Prior Authorization and Interoperability for Medicare Advantage, Medicaid, CHIP, and QHPs Proposed Rule Summary

On December 6, 2022, CMS placed on public display a proposed rule imposing new requirements on Medicare Advantage organizations, Medicaid and the state Children’s Health Insurance Program (CHIP) fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and qualified health plans in the federally-facilitated exchanges. The proposals are designed to improve the electronic exchange of health care data and streamline prior authorization processes, while continuing to encourage interoperability in the healthcare market. Also in this rule, CMS proposes the addition of a new measure for eligible hospitals and critical access hospitals under the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System (MIPS) eligible clinicians under the MIPS Promoting Interoperability performance category. As has been the norm for most CMS rulemaking over the past few years, numerous requests for information are included. The proposed rule is scheduled to be published in the Federal Register on December 13, 2022. The 90-day public comment period closes on March 6, 2023.