New Drug PA Requirements In Government Programs
Notwithstanding the voluntary prior authorization reforms, the Centers for Medicare and Medicaid Services (CMS) issued a new proposed rule that extends recent non-pharmacy prior authorization requirements to retail drug requests. In the case of retail drugs, urgent requests would have to be fulfilled in government programs within 24 hours, with all others in 72 hours. The requirement is within a broader Interoperability Standards and Prior Authorization for Drugs rule. The PA requirements are effective October 1, 2027.
The rule would also require insurers to publicly report certain metrics around prior authorization, including approval and denial rates, appeal outcomes, and decision timeframes. As well, CMS is proposing to require payers to support three National Council for Prescription Drug Programs (NCPDP) standards—the SCRIPT, Formulary & Benefit (F&B), and Real-Time Prescription Benefit (RTPB) standards–beginning October 1, 2027. The proposed standards allow providers to query formulary information, determine real-time coverage information, and exchange electronic prior authorization requests and decisions for drugs.
The proposed rule would additionally:
- Update health IT standards and implementation guides to align with current versions adopted by ONC for HHS use.
- Expand existing interoperability requirements to small group market QHP issuers on Exchange.
- Add a regulatory definition for “Failure to Report” to strengthen CMS’ oversight authority under the Open Payments program.
CMS is also seeking public input through five Requests for Information on:
- Improving electronic event notifications for care coordination.
- Strengthening healthcare cybersecurity and system resilience.
- Enhancing oversight of payer APIs.
- Streamlining step therapy processes.
- Improving prior authorization for laboratory tests and durable medical equipment, prosthetics, orthotics, and supplies.
Additional articles: https://www.fiercehealthcare.com/regulatory/proposed-cms-rule-would-set-prior-auth-deadlines-drugs and https://www.cms.gov/newsroom/press-releases/cms-proposes-major-reforms-speed-up-patient-access-drugs-increase-transparency-reduce-administrative and https://www.cms.gov/newsroom/fact-sheets/2026-cms-interoperability-standards-prior-authorization-drugs-proposed-rule
#priorauthorization #medicareadvantage #medicaid #managedcare
CMS Issues Proposed Rule For Hospital Rates and Various VBC Reform Pilots
The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule for various inpatient rates in Medicare as well as quality and other changes to various value-based-care models. Medicare beneficiaries undergoing knee, hip, and ankle replacements could soon experience more coordinated care and lower costs. CMS is looking to expand the Comprehensive Care for Joint Replacement (CJR) Model nationwide.
CMS says the nationwide implementation would create strong incentives for hospitals to coordinate care more effectively, avoid unnecessary services like avoidable re-hospitalization and emergency care, and focus on delivering the best outcomes for patients. It would specifically encourage better communication with post-acute care providers to support recovery.
The proposed increase in IPPS payment rates is projected to be 2.4%. This reflects a projected FY 2027 hospital market basket percentage increase of 3.2%, reduced by a 0.8 percentage point productivity adjustment.
It makes changes and updates to the following programs:
Hospital Inpatient Quality Reporting Program
PPS-Exempt Cancer Hospital (PCH) Quality Reporting Program
Hospital Readmissions Reduction Program
Hospital-Acquired Condition Reduction Program
Hospital Value-Based Purchasing Program
Long Term Care Hospital Quality Reporting Program (LTCH QRP)
The TEAM Model, a mandatory alternative payment model finalized in last year’s rule, is also updated to modify policies affecting episode category triggers, quality measure assessment and the construction of target prices.
As well, various interoperability changes and mandates are proposed.
Additional articles: https://www.cms.gov/newsroom/press-releases/cms-improve-patient-care-experience-lower-costs-hip-knee-ankle-replacements and https://www.cms.gov/newsroom/fact-sheets/fy-2027-hospital-inpatient-prospective-payment-system-ipps-long-term-care-hospital-prospective
#hospitals #medicare
CMS Promotes Digital Technology
The Centers for Medicare and Medicaid Services (CMS) showcased dozens of health technology innovations as part of the agency’s ambitious tech and data sharing initiative. The Health Tech Ecosystem aims to ease data interoperability and patient access to their own health information. It also wants to promote digital health and artificial intelligence tools. Over 700 organizations have pledged to support the initiative, and over 120 have said their products are ready for use or close to completion.
#digitalhealth #cms #healthcare #technology
— Marc S. Ryan
