Sunday, April 26, 2026

CMS issued a proposed rule on April 14, 2026, to apply new prior authorization interoperability and decision timelines to drugs covered by Medicare Advantage, Medicaid, CHIP, and federally-facilitated exchange plans. The rule aims to enforce the ACA's electronic prior auth standards, potentially streamlining approval workflows for prescribed medications. A 60-day comment period closes in mid-June. The proposed policy signals a regulatory push to reduce administrative burden, but the final rule's scope and effective date remain unknown. Monitor the docket (CMS-2025-XXXX) for the final rule later this year, as it will define new operational requirements for drug authorizations.

A CMS AI-driven prior authorization pilot for Medicare Advantage plans in Washington state is causing significant care delays, according to a report cited by Senator Maria Cantwell. The program uses automated systems to review and deny requests, with providers reporting increased administrative appeals and slower patient access to services. This follows broader industry concerns about opaque AI decision-making in utilization management. For practices with Medicare Advantage patients in Washington, expect longer resolution times on auth requests flagged by the system. Document all clinical rationale thoroughly and initiate appeals immediately upon denial to protect patient care timelines and revenue.

CMS and the FDA jointly announced the RAPID Coverage Pathway, a new coordinated process to accelerate Medicare coverage for FDA-designated breakthrough medical devices. The program aims to reduce the lag between FDA approval and Medicare reimbursement, potentially bringing novel technologies to patients faster. For practices that adopt new devices, this could mean more predictable coverage timelines and reduced uncertainty about reimbursement for cutting-edge treatments. The pathway is voluntary for device sponsors and will initially focus on a select group of breakthrough products. This represents a structural shift in how Medicare evaluates new technology, moving toward parallel review.

Representatives Pramila Jayapal (D-WA) and Ro Khanna (D-CA) introduced federal legislation, the 'Improving Seniors' Timely Access to Care Act,' which would prohibit the use of prior authorization for medically necessary services under Medicare Advantage plans. The bill is a direct response to rising denial rates and administrative delays documented in CMS data and congressional hearings. It has significant backing from physician and patient advocacy groups but faces strong opposition from payer lobbyists. This is an early-stage bill; it has not been scheduled for committee markup. Its introduction, however, elevates prior authorization as a live legislative issue for the 119th Congress. Monitor the bill's progress (H.R. XXXXX) for any movement, as a ban would radically simplify billing workflows for MA patients.