Health Plans Must Share Data Faster – No More Waiting Games
Published Date: 4/14/2026
Proposed Rule
Summary
Starting soon, Medicare Advantage, Medicaid, CHIP, and health plans on federal exchanges will need to use better tech to share health info and speed up drug approval requests. This means less waiting and smoother care for patients, while plans and agencies will update their systems to meet new rules. These changes aim to save time and money by making health data work together more easily, with deadlines coming in the next couple of years.
Analyzed Economic Effects
7 provisions identified: 6 benefits, 0 costs, 1 mixed.
Electronic prior authorization for all drugs
Medicare Advantage plans, Medicaid and CHIP programs and plans, and Qualified Health Plans on the federal exchanges must support electronic prior authorization (ePA) for all drugs. The rule proposes using HL7 FHIR implementation guides for drugs under a medical benefit and NCPDP standards for drugs under a pharmacy benefit, with an October 1, 2027 compliance date for these ePA requirements.
Faster prior-auth timelines for exchange plans
Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (including small-group FF-SHOP plans) would have stricter provider notification timeframes: for non-drug standard requests notify provider no later than 7 calendar days and expedited requests remain 72 hours; for drugs notify provider for standard requests no later than 72 hours and for expedited drug requests no later than 24 hours. The proposal sets an October 1, 2027 compliance date.
Must give specific denial reason for drug denials
Impacted payers must provide the requesting provider a specific reason when denying a prior authorization request for any drug. The proposal sets an October 1, 2027 compliance date for requiring denials to include a specific reason.
Medicaid/CHIP drug prior-auth decision timeframes
For state Medicaid fee-for-service programs, Medicaid managed care plans, and CHIP managed care entities, the decision timeframe for covered outpatient drugs is 24 hours; the proposal would align decision timeframes for drugs and proposes an October 1, 2027 compliance date for these drug prior authorization timing requirements.
API usage and prior-authorization metrics reporting
Impacted payers must report API usage metrics (Patient Access, Provider Access, Payer-to-Payer, Prior Authorization, and Provider Directory APIs) and post prior authorization metrics (including numeric counts and several new metrics) publicly. The proposal sets reporting and public-posting compliance beginning in 2028, with MA and state Medicaid/CHIP FFS programs reporting prior calendar-year metrics by March 31, and Medicaid managed care/CHIP managed care reporting to states within 90 days after each rating period; QHP issuers would report aggregated, de-identified metrics within QHP certification timeframes.
Small-group FF-SHOP QHP issuers added as impacted payers
The rule proposes to apply existing interoperability and prior authorization API requirements to small group market Qualified Health Plan (QHP) issuers on the Federally-facilitated Small Business Health Options Program (FF-SHOPs). The proposal sets compliance for Patient Access API and other interoperability rules to plan years beginning on or after January 1, 2028 for these small-group QHP issuers.
Payers must report API endpoints to CMS
The proposal would require impacted payers to report their Patient Access, Provider Directory, Provider Access, Payer-to-Payer, and Prior Authorization API endpoints and related information to CMS so CMS can publish a centralized directory of endpoints.
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Key Dates
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