ASE has been working to fight prior authorization on behalf of our members and joined several coalitions, including the Alliance of Specialty Medicine, to advance this issue. There has been progress with Centers for Medicare & Medicaid Services (CMS) action today! The CMS Interoperability and Prior Authorization Final Rule has been finalized. The rule sets requirements for Medicare Advantage (MA) organizations, Medicaid and the Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and issuers of Qualified Health Plans (QHPs) offered on the Federally-Facilitated Exchanges (FFEs), to improve the electronic exchange of health information and prior authorization processes for medical items and services. Most of these changes will take effect in 2026.
Please see the CMS press release for more information, https://www.cms.gov/newsroom/press-releases/cms-finalizes-rule-expand-access-health-information-and-improve-prior-authorization-process
The fact sheet for this final rule is available here: https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f