Bill Details
HR.639 - 119th Congress
Status
Latest action
2025-01-22 - Referred to the Committee on Energy and Commerce, and in addition to the Committee on Oversight and Government Reform, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Introduced Date
2025-01-22
Policy Area
Health
Committees
View committees (2)
8
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AI Summary This summary was generated by AI from the bill text. AI can get information wrong.
This bill would stop health plans and government health programs from requiring patients to get approval ahead of time for covered care. It would also ban insurers and programs from using common delay or denial methods, such as step therapy, fail-first rules, utilization management, and medical necessity reviews, for services that are already covered. The goal is to make it easier for patients to get the treatment their doctor recommends without waiting for extra approval from an insurer or program.
- Private group health plans and health insurance companies could no longer require prior authorization for covered items or services.
- Those private plans and insurers would also be barred from using utilization management methods, including step therapy and fail-first protocols.
- Federal health care programs, including the federal employee health program, would face the same limits starting January 1, 2026.
- The change for private plans would apply to plan years beginning on or after January 1, 2026.
Official Summaries
Doctor Knows Best Act of 2025
This bill prohibits health insurance plans (including federal health care programs) from imposing a prior authorization requirement, utilization management technique (e.g., step therapy or fail-first protocol), or medical necessity review for any item or service for which benefits are available under the plan.
The prohibition is effective for plan years beginning on or after January 1, 2026.
Current Full Text
[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 639 Introduced in House (IH)]
<DOC>
119th CONGRESS
1st Session
H. R. 639
To prohibit group health plans, health insurance issuers, and Federal
health care programs from applying prior authorization requirements,
utilization management techniques, and medical necessity reviews.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
January 22, 2025
Mr. Van Drew introduced the following bill; which was referred to the
Committee on Energy and Commerce, and in addition to the Committee on
Oversight and Government Reform, for a period to be subsequently
determined by the Speaker, in each case for consideration of such
provisions as fall within the jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To prohibit group health plans, health insurance issuers, and Federal
health care programs from applying prior authorization requirements,
utilization management techniques, and medical necessity reviews.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Doctor Knows Best Act of 2025''.
SEC. 2. PROHIBITING PRIOR AUTHORIZATION REQUIREMENTS, UTILIZATION
MANAGEMENT TECHNIQUES, AND MEDICAL NECESSITY REVIEWS.
(a) Private Insurers.--Subpart II of part A of title XXVII of the
Public Health Service Act (42 U.S.C. 300gg-11 et seq.) is amended by
adding at the end the following new section:
``SEC. 2730. PROHIBITION ON PRIOR AUTHORIZATION REQUIREMENTS,
UTILIZATION MANAGEMENT TECHNIQUES, AND MEDICAL NECESSITY
REVIEWS.
``A group health plan, and a health insurance issuer offering group
or individual health insurance coverage, may not impose any prior
authorization requirement, any utilization management technique
(including any step therapy or fail-first protocol), or any medical
necessity review on any item or service for which benefits are
available under such plan or coverage.''.
(b) Federal Health Care Programs.--Beginning January 1, 2026, a
Federal health care program (as defined in section 1128B of the Social
Security Act (42 U.S.C. 1320a-7b) and the health program established
under chapter 89 of title 5, United States Code, including a State or
any entity carrying out such Federal health care program or health
program, may not impose any prior authorization requirement, any
utilization management technique (including any step therapy or fail-
first protocol), or any medical necessity review on any item or service
for which benefits are available under Federal health care program or
health program (as applicable).
(c) Effective Date.--The amendment made by subsection (a) shall
apply with respect to plan years beginning on or after January 1, 2026.
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