CMS, HHS: Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Interoperability Standards and Prior Authorization for Drugs for Medicare Advantage Organizations, Medicaid Managed Care Plans, State Medicaid Agencies, Children's Health Insurance Program (CHIP) Agencies and CHIP Managed Care Entities, and Issuers of Qualified Health Plans on the Federally-Facilitated Exchanges

Federal Register

Apr 14, 2026

Notice of proposed rule from the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) proposing to improve the electronic exchange of healthcare data and streamline processes related to prior authorization by increasing the interoperability of systems used across the healthcare industry. Among other things, this rule proposes new requirements for Medicare Advantage (MA) organizations, state Medicaid fee-for-service (FFS) programs, state Children's Health Insurance Program (CHIP) FFS programs, Medicaid managed care plans, CHIP managed are entities, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs) to make electronic prior authorization for drugs available; to report their application programming interfaces (API) endpoints and related information for the Patient Access, Provider Directory, Provider Access, Payer-to-Payer, and Prior Authorization APIs to CMS; and extend many existing interoperability requirements for the prior authorization of non-drug items and services to include prior authorizations for drugs. In addition, ONC proposes adopting updated versions of certain health information technology (health IT) standards and specifications for HHS use. Comments are due by June 15, 2026.

Health information technology · Health insurance · Healthcare business and finance · Healthcare facilities · Legislation and regulations · Medicare · Pharmacy and prescription drugs