Health Plans Must Share Data Faster Under New Interoperability Push
Published Date: 4/14/2026
Proposed Rule
Summary
This new rule will help Medicare, Medicaid, CHIP, and health plan companies share patient info more easily and speed up drug approval requests. It affects Medicare Advantage, Medicaid, CHIP, and health plans on federal exchanges, aiming to make care smoother and faster. These changes will start soon and could save time and money by cutting red tape.
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Analyzed Economic Effects
8 provisions identified: 8 benefits, 0 costs, 0 mixed.
Electronic Prior Authorization for All Drugs
If you have coverage through Medicare Advantage, Medicaid/CHIP, or a Qualified Health Plan on the federal exchange, your insurer would be required to support electronic prior authorization for all drugs. CMS proposes that payers use HL7 FHIR implementation guides for drugs covered under medical benefits and NCPDP standards for drugs covered under pharmacy benefits, with a compliance date of October 1, 2027.
Part D Sponsors Must Adopt NCPDP Standards
Medicare Part D sponsors (including Medicare Advantage plans with drug coverage) must implement unexpired versions of the NCPDP Formulary & Benefit (F&B) and Real-Time Prescription Benefit (RTPB) standards beginning January 1, 2027. These standards support real-time drug coverage, formulary, and cost-sharing information at prescribing time.
24-Hour Rule for Medicaid/CHIP Drug Decisions
For state Medicaid fee-for-service programs, Medicaid managed care plans, and CHIP managed care entities, decision timeframes for covered outpatient drugs are 24 hours. CMS proposes October 1, 2027 as the compliance date and is proposing to require state CHIP FFS programs to make decisions on prescription drugs no later than 24 hours after a request.
Shorter Prior Authorization Timelines for QHPs
Qualified Health Plan issuers on the Federally-Facilitated Exchanges (including small-group FF-SHOP plans) would have new time limits to notify providers: standard non-drug requests no later than 7 calendar days, expedited non-drug requests within 72 hours; for drugs, standard requests no later than 72 hours and expedited requests no later than 24 hours. CMS proposes an October 1, 2027 compliance date for these timeframes.
Clear Reasons Required for Drug Denials
Impacted payers (Medicare Advantage, Medicaid/CHIP, and QHP issuers on the federal exchanges) would be required to tell the requesting provider a specific reason when they deny a prior authorization request for any drug. CMS proposes an October 1, 2027 compliance date for this requirement.
API Usage Reporting Starts in 2028
Impacted payers would be required to report usage metrics for Patient Access, Provider Access, Payer-to-Payer, and Prior Authorization APIs beginning in 2028. MA organizations and state Medicaid/CHIP FFS programs would report the previous calendar year's metrics by March 31 of each year; Medicaid managed care plans and CHIP managed care entities would report metrics to states no later than 90 days after each rating period; QHP issuers report aggregated, de-identified metrics per Secretary timelines.
Public Posting of Prior Authorization Metrics
Impacted payers would have to publicly post numeric counts and additional metrics about prior authorizations for non-drug items and services and for all drugs (excluding certain Part D drugs for MA-PD plans). Reports must be posted no later than March 31 following a calendar year for MA organizations, state Medicaid/CHIP FFS programs, and QHP issuers; Medicaid managed care plans and CHIP managed care entities must post no later than 90 days after each rating period. Compliance is proposed to begin in 2028.
Small-Group FF-SHOP QHPs Added as Impacted Payers
CMS proposes to include small group market QHP issuers on the Federally-Facilitated SHOP Exchanges as impacted payers. These issuers would need to implement and maintain Patient Access APIs and other interoperability requirements; CMS proposes implementation by plan years beginning on or after January 1, 2028 (for Patient Access and for Provider Access/Payer-to-Payer APIs unless excepted).
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