CMS Releases Updated Interoperability of Health Plans and Prior Authorization Requirements Proposed Rule

In December 2020, the Trump Administration proposed a rule on Medicare Interoperability and Prior Authorization, but it received overwhelming comments against implementation, including from ISASS. Most of the opposition revolved around its implementation timeframe, its short comment period, and its lack of inclusion of Medicare Advantage programs. Subsequently, CMS fully withdrew that proposed rule and issued a new proposed rule, which was released December 6, 2022.

Highlights include the following:

• Most of the implementation dates do not start until 2026
• Impacted payers will be required to include information about prior authorizations in the data that are available through the Patient Access API (application program interface)
• Previous payer-to-payer data exchange requirements will be replaced with a new policy that would require impacted payers to build a payer-to-payer API to facilitate the exchange of patient information between payers, both at a patient’s request and at the start of coverage with a new payer
• Patient data requests via the Patient Access API must be annually reported to CMS
• The rule includes five requests for information: (1) information on barriers to adopting standards, and opportunities to accelerate the adoption of standards, for social risk data; (2) comments on how CMS could leverage APIs (or other technology) to facilitate electronic data exchange between and with behavioral healthcare providers; (3) comments regarding how Medicare Fee-for-Service could support improved medical documentation exchange between and among providers, suppliers, and patients; (4) comments on how using data standards and electronic health records can improve maternal health outcomes; and (5) comments regarding how to encourage providers and payers to enable exchanges under the Trusted Exchange Framework and Common Agreement to make patient information more readily available for access and exchange in a variety of circumstances

ISASS is pleased with the Advancing Interoperability and Improving Prior Authorization Processes proposed rule and is particularly supportive of its proposal to place new requirements on Medicare Advantage plans, state Medicaid and Children’s Health Insurance Program (CHIP) Fee-for-Service programs, Medicaid and CHIP managed care plans, and Qualified Health Plan issuers on the Federally Facilitated

Exchanges to streamline prior authorization (PA) processes to reduce physician practice burdens and prevent patient care delays.

The rule reflects ISASS’s successful advocacy to address PA programs in Medicare Advantage plans, as they were excluded from the previous iteration of the rule that CMS released in late 2020. The rule will bring much-needed transparency to plans’ PA requirements and program metrics, such as approval/denial rates and average PA processing time.

ISASS looks forward to providing our feedback to CMS within the 90-day comment period.

To read the rule, see the link here