State Legislation Update
ACR tracks hundreds of healthcare-related bills each state legislative cycle.
Read moreThe Centers for Medicare and Medicaid Services (CMS) released the CMS Interoperability and Prior Authorization Final Rule Jan. 17. It defines requirements to streamline health information exchange and the prior authorization process for impacted payers, including Medicare Advantage (MA) organizations, state Medicaid and Children’s Health Insurance Program (CHIP) programs, Medicaid managed care plans, CHIP managed care entities, and qualified health plan issuers on the federally facilitated exchanges.
This rule builds upon policies outlined in the CMS Interoperability and Patient Access final rule, where CMS required these payers to implement and maintain a Patient Access Application Programming Interface (API), allowing patients to download health information to a third-party application of their choosing. This rule adds the requirement of adding information about prior authorizations to the API, which must be implemented by Jan. 1, 2027. Impacted payers must also annually report certain metrics to CMS about patient data requests made via the API starting Jan. 1, 2026.
In addition to the Patient Access API, CMS requires the following APIs to be implemented by impacted payers:
To improve the prior authorization process, CMS requires impacted payers (excluding qualified health plan issuers on the federally facilitated exchanges) to send prior authorization requests within 72 hours for expedited requests and seven calendar days for standard requests. Beginning in 2026, payers must provide a specific reason for denials, regardless of which method was used to send the request. To enhance transparency, CMS requires impacted payers to publicly report certain prior authorization metrics on an annual basis by posting them on their website. The compliance date for these policies is Jan. 1, 2026, with initial metrics being reported publicly by March 31, 2026. These requirements complement the requirements set forth in the Contract Year 2024 Medicare Advantage and Part D Final Rule.
For questions related to this rule, contact Kimberly Greck, ACR Senior Economic Policy Analyst.
State Legislation Update
ACR tracks hundreds of healthcare-related bills each state legislative cycle.
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