CMS prior-auth overhaul

The Centers for Medicare & Medicaid Services wants health plans to answer many drug prior-authorization requests within 24 hours for urgent cases and 72 hours for standard ones. (cms.gov) CMS released the proposed rule on April 10, 2026, and it was published in the Federal Register on April 14 with a public comment deadline of June 15, 2026. The proposal covers Medicare Advantage, Medicaid fee-for-service and managed care, the Children’s Health Insurance Program, and Qualified Health Plans on the federally facilitated exchanges. (federalregister.gov) Prior authorization is the insurer’s yes-or-no checkpoint before a plan agrees to pay for a treatment. CMS says its 2024 rule sped up that process for non-drug items and services, and this new proposal would extend many of the same electronic requirements to prescription drugs. (cms.gov) The proposal would require affected payers to support electronic prior authorization for drugs instead of relying on phone calls, portals, and fax machines. It would also require plans to report application programming interface endpoints and usage data to CMS so the agency can track whether the digital systems are actually being used. (cms.gov) The rule reaches beyond CMS programs into the plumbing of the broader insurance system. Under the Health Insurance Portability and Accountability Act, the Department of Health and Human Services is proposing to adopt Health Level Seven Fast Healthcare Interoperability Resources standards for prior-authorization transactions used by HIPAA-covered entities that exchange those requests electronically. (federalregister.gov) CMS is also proposing more public reporting on drug prior authorization, including approval rates, denial rates, appeal outcomes, and decision timeframes. The agency said those disclosures would apply across federal programs and give patients, doctors, and policymakers a clearer view of how plans handle requests. (cms.gov) Another piece of the proposal targets Open Payments, the federal database that tracks payments from drug and device companies to doctors and teaching hospitals. The Federal Register notice says CMS would add a definition of “failure to report,” allowing civil monetary penalties if applicable manufacturers or group purchasing organizations do not give CMS timely access to documents during an audit. (federalregister.gov) CMS is also proposing to add small-group Qualified Health Plans sold through the federally facilitated Small Business Health Options Program to the list of payers subject to these interoperability rules. In its summary, the agency said public reporting for those issuers would begin in 2028 if the rule is finalized. (cms.gov) Hospitals backed the direction of the proposal. The American Hospital Association said April 10 that electronic standards for drug prior authorization could help reduce administrative burden and speed care, while the details now move through the federal comment process. (aha.org) For now, nothing changes until CMS reviews comments and issues a final rule. But the proposal sets out a measurable test for plans: faster answers, digital transactions, and public data showing whether those promises are being met. (federalregister.gov)