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

HHS has published a proposed rule that would expand electronic prior authorization requirements to include drugs across Medicare Advantage, Medicaid, CHIP, and qualified health plans. The proposal also seeks to mandate specific HL7 FHIR implementation guides, require payers to report API endpoint data to CMS, and collect API usage metrics to reduce administrative burden on patients and providers. Physical therapists may be affected insofar as these changes streamline prior authorization workflows and interoperability standards across payers who also cover PT services.

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