Health

Proposed Rule on Interoperability Standards and Prior Authorization for Medicare and Medicaid Programs

🇺🇸United States··Proposed Rule·Medium Impact·View source ↗

AI-generated summary for informational purposes only. Not legal advice. See the original source for the authoritative text.

🇬🇧 English

This proposed rule aims to enhance the electronic exchange of healthcare data, focusing on prior authorization processes across Medicare Advantage, Medicaid, and related programs. It will require impacted payers to implement electronic prior authorization for drugs, expand API requirements, and adopt specific interoperability standards by October 2027. The rule affects insurers and healthcare providers, aiming to streamline processes and reduce administrative burdens.

AI-generated summary. May contain errors. Refer to official sources for legal decisions.

Key Changes

  • Requires electronic prior authorization for drugs in Medicare and Medicaid by October 2027.
  • Mandates expanded API reporting and interoperability standards.
  • Introduces penalties for non-compliance in data reporting.

Obligations

What this law requires

high

Implement electronic prior authorization for drugs for Medicare Advantage organizations, state Medicaid FFS programs, state CHIP FFS programs, Medicaid managed care plans, CHIP managed care entities, and QHP issuers on FFEs by October 2027

Medicare Advantage organizations, state Medicaid FFS programs, state CHIP FFS programs, Medicaid managed care plans, CHIP managed care entities, and QHP issuers on Federally-facilitated Exchanges
operational
high

Extend existing interoperability requirements for prior authorization of non-drug items and services to include prior authorizations for drugs

Medicare Advantage organizations, state Medicaid FFS programs, state CHIP FFS programs, Medicaid managed care plans, CHIP managed care entities, and QHP issuers on Federally-facilitated Exchanges
operational
high

Report API endpoints and related information for Patient Access, Provider Directory, Provider Access, Payer-to-Payer, and Prior Authorization APIs to CMS

Medicare Advantage organizations, state Medicaid FFS programs, state CHIP FFS programs, Medicaid managed care plans, CHIP managed care entities, and QHP issuers on Federally-facilitated Exchanges
reporting
medium

Collect and report API usage metrics to CMS for Patient Access, Provider Directory, Provider Access, Payer-to-Payer, and Prior Authorization APIs

Medicare Advantage organizations, state Medicaid FFS programs, state CHIP FFS programs, Medicaid managed care plans, CHIP managed care entities, and QHP issuers on Federally-facilitated Exchanges
reporting
high

Implement required HL7 FHIR implementation guides that are currently recommended for health information exchange

Medicare Advantage organizations, state Medicaid FFS programs, state CHIP FFS programs, Medicaid managed care plans, CHIP managed care entities, and QHP issuers on Federally-facilitated Exchanges
operational

Affected Parties

Medicare Advantage OrganizationsMedicaid Managed Care Plans

Tags

Medicare,Medicaid,Interoperability…

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