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May 14, 2026 – Reforming prior authorization processes has been on the regulatory menu for a while. Both patients and providers have argued that prior authorization is a complex and burdensome process that too often results in patients being denied coverage for care they and their doctors believe is necessary to maintain and improve health. In response to these criticisms, the Centers for Medicare & Medicaid Services (CMS) has put forth several regulations in recent years aimed at ensuring that Medicare Advantage (MA) plans use prior authorization appropriately, and that certain health plans develop technology to facilitate electronic prior authorization, which promises to be faster and less burdensome on providers and allow for better tracking of the process. But these regulations are limited in some respects, and health plans have decided to complement these regs with voluntary commitments that go above and beyond the regulatory requirements. To help me describe this mixture of regs and voluntary commitments and what it could ultimately produce in the way of prior authorization reform, I’m bringing in my colleague Lynn Nonnemaker.
Prior authorization reform overarchingly can be broken down into two components:
Both CMS and health plans have looked to address each component. Let’s take a closer look.
Process improvements have been a key focus of CMS’s regs. In the Advancing Interoperability and Improving Prior Authorization Processes final rule published in early 2024, CMS imposed new requirements on certain health plans in three key areas: technology to support electronic prior authorization, timelines for prior authorization approvals, and public reporting on prior authorization decisions. The 2024 rule applied to medical services only, and CMS recently proposed a complementary rule to extend similar policies and requirements to medications covered under a health plan’s medical benefit (these requirements would largely not apply to prescription drugs obtained from a pharmacy).
While these requirements could help speed the prior authorization timeline and streamline the process, health plans themselves have voluntarily committed to processing some prior authorizations more quickly. As discussed in a previous Regs & Eggs blog post, in June 2025 health plan members of AHIP and the Blue Cross Blue Shield Association (BCBSA) announced a series of steps that a broad swath of health insurers will take to improve the prior authorization experience. One of those commitments includes delivering at least 80% of prior authorization approvals in real time when providers submit requests electronically and include the required clinical documentation. While “real time” is not defined, these approvals theoretically would be much quicker than CMS’s minimum requirements.
Health plans also committed to process improvements in the following areas:
In April 2026, AHIP and the BCBSA announced commitments from a coalition of 49 health plans to adopt a standardized approach to submitting prior authorization requests for a range of medical services, including services commonly subject to prior authorization such as orthopedic surgeries and imaging. Statements from several health plans suggest that the initiative will affect a large majority of medical services by the end of 2026.
These commitments in many cases go above and beyond CMS’s regulatory requirements and also apply to plans that don’t fall under CMS’s regulatory jurisdiction. CMS has the authority to regulate MA, Medicaid, Children’s Health Insurance Program (CHIP), state Medicaid and CHIP fee-for-service programs, and qualified health plan issuers operating on the Affordable Care Act marketplace. A significant chunk of the market not regulated by CMS are commercial plans— which are generally regulated by states.
The 2025 industry pledge also included a commitment to reduce the volume of medical services subject to prior authorization and to report data to demonstrate that the industry is meeting this goal. In recent weeks, both CMS and the industry have touted health plans’ progress towards this goal. AHIP announced in April 2026 that since making the commitment in 2025, “leading health plans eliminated 11% of prior authorizations across a range of medical services, representing 6.5 million fewer prior authorizations for patients.” A large national plan also stated that it is planning to eliminate authorization requirements for 30% of healthcare services. CMS called out these updates in a May 5, 2026, press release, stating that these actions are helping to move prior authorization into the 21st century.
While CMS has not weighed in on the specific services that may be subject to prior authorization, it has used its regulatory authority to clarify when prior authorization is allowed. In a 2023 rule, CMS imposed new requirements on MA plans to ensure they abide by Medicare coverage rules when they exist. When Medicare coverage criteria are absent, the rule allows plans to develop their own internal coverage criteria but restricts plans to using clinical evidence in support of those criteria. CMS specified that prior authorization may be used only to confirm the presence of a diagnosis or condition when coverage criteria apply, or to ensure medical necessity. CMS also mandated that plans publish their criteria on the plan website so providers and patients have ready access.
CMS has taken steps to gather more data from MA plans about prior authorization requests, denials, and appeals and to make that information more available to patients. As of earlier this year, MA plans are required to publicly post data on their websites specifying which services are subject to prior authorization, the share of prior authorization requests approved or denied, and the average time it takes to process a prior authorization request.
With a mix of regulations and voluntary commitments, stakeholders might wonder what successful prior authorization reform will ultimately look like. Many of the regulatory reforms included in CMS’s 2024 rule don’t kick in until 2027, and health plans have stated that they are still working on addressing all of the commitments they made in 2025. Thus, it will be a while until we fully understand what this mix actually yields.
Regulatory requirements are more prescriptive than voluntary commitments, and it is unclear in some cases what final targets health plans are voluntarily setting for themselves. For example, if health plans state that they are making progress by eliminating 11% of prior authorizations, what is their ultimate goal: 30%, 40%, 50%? Even once every regulatory requirement and voluntary commitment goes into effect, some stakeholders might claim that the final product didn’t go far enough in terms of streamlining the process or reducing the number of services subject to prior authorization. In other words, defining success may prove difficult, and “achieving success” may be in the eye of the beholder.
Another potential question is whether the regulatory requirements and voluntary commitments will operate as intended, since they depend on both health plans and providers taking specific actions. When new requirements around electronic prior authorization go into effect in 2027, not only will health plans have to update their processes, but providers will also need to be positioned to take advantage of the new systems. For some providers, particularly smaller provider groups or those working in rural areas or with fewer resources, actually making use of the new technologies may be challenging. As with most technologies, there may be growing pains that limit how effective the systems are initially. We will need to monitor how quickly and effectively providers adjust their systems once health plans are required to modify theirs.
These are just some of the questions we are considering as the public and private sectors continue to work together to reform prior authorization processes.
Until next week, this is Jeffrey (and Lynn) saying, enjoy reading regs with your eggs.
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