CMS Issues Interoperability and Prior Authorization Final Rule and Medicare Advantage RFI

Earlier this month, the Centers for Medicare and Medicaid Services (CMS) finalized the Interoperability and Prior Authorization Rule, which is intended to promote health information sharing among payers, providers, and patients, and improve prior authorization times for all CMS-funded payers. CMS also published a Request for Information (RFI) seeking input into the collection and publication of Medicare Advantage (MA) data.

The Interoperability and Prior Authorization Rule applies to Medicaid fee-for-service, Medicaid managed care, Child Health Plus, MA, and federal health insurance exchange Qualified Health Plans. The Rule imposes new application programming interface (API) requirements for all covered payers. The compliance dates for the API requirements are generally Jan. 1, 2027, although the deadlines vary somewhat by type of payer.

The Rule also imposes new prior authorization standards and timeframes for all covered payers. It requires notice to providers and patients of prior authorization decisions within 72 hours for expedited requests and within 7 calendar days for standard requests, unless state law requires shorter timeframes. It also requires covered payers to provide a reason for denials of prior authorization requests. In addition, it requires those payers to publicly report certain prior authorization metrics annually on their website. The prior authorization requirements are generally effective Jan. 1, 2026.

The RFI applies only to MA data. It seeks input from the public regarding data needed in relation to access to care, prior authorization, provider directories, and networks; supplemental benefits; marketing; care quality and outcomes; value-based care arrangements and equity; and healthy competition in the market. CMS is also seeking comments on improving MA data collection and publication methods. Comments are due on May 29, 2024, and LeadingAge National will be engaging members to gain insights and feedback for its comments.

Contact: Karen Lipson, klipson@leadingageny.org