The U.S. Centers for Medicare & Medicaid Services (CMS) released new rules overhauling the nation’s prior authorization process, as the administration pushes on with TrumpRx.
The agency introduced several new changes that will reshape provider workflows and payer operations during the rest of 2026 through 2027. While not part of any formal ‘TrumpRx’ initiative, the updates align with broader policy efforts to streamline access.
“Patients should not have to wait days or weeks for approval to start the medication their doctor prescribed,” CMS Administrator Dr. Mehmet Oz said in a recent statement. “We are standardizing the process, increasing transparency and ensuring providers can focus on caring for patients instead of navigating red tape.”
The agency shared that these proposed rule changes would prompt faster prior authorization decisions. Per the CMS, the changes will expand electronic prior authorization for drugs and increase transparency across federal programs.
New Mandate For Drug Prior Authorizations
The new CMS rules would overhaul the current prior authorization process, requiring a standardized timeframe for faster decisions. Based on the proposed changes, insurance companies must answer urgent prior authorization requests within 24 hours. For standard requests, the rules give them a longer leeway time, requesting a response within 72 hours.
This is a dive away from the former process, where timelines often varied by plan type and program. Under the previous prior authorization rules, expedited requests had 72 hours for review, while standard non-urgent requests had up to seven days.
Medical Group Management Association released an official statement in support of the new prior authorization rules.
“This newly proposed rule builds on the Administration’s positive momentum to hold Medicare Advantage, Medicaid, and other insurers accountable for abusive prior authorization tactics, ” said organization spokesman Anders Gilberg.
How Will The New Rules Impact The Healthcare Industry?
New Digital System Requirements For Insurers
Under the new rules, the CMS requires health plans to implement interoperable, standardized digital systems for prior authorizations. Clinicians and insurers are required to use specialized software connectors, known as APIs. These can link medical records directly to the insurance company’s system. This allows real-time submission, tracking, and coverage decisions.
“This proposal moves prior authorization into the digital age, replacing fax machines and fragmented systems with real-time electronic workflows,” Oz said.
Beyond prior authorization digitization, the rule standardized clinical data submissions. Clinicians must now use standardized formats across all patents when submitting data to insurers.
Increased Reporting Oversight
The proposed rule created the first fully standardized, nationwide framework focused on prior authorization performance reporting across multiple programs.
The CMS expanded reporting requirements for health plans, requiring submission of a standard annual report on prior authorization–related metrics. Plans must report on key performance indicators, including approval and denial rates, appeal outcomes and average decision timelines.
In past years, the CMS required health plans, particularly Medicare Advantage plans, to report utilization management data. However, reporting requirements were not in a single, uniform prior authorization–specific reporting structure across all plans.
New Rates And Medicare Advantage Requirements
The CMS finalized updates to Medicare quality metrics and payment rates, with a strong emphasis on behavioral health integration. A new Depression Screening and Follow-Up measure has been added to the Part C Star Ratings for next year as part of broader changes to the quality system.
They also finalized a 2.48% average payment increase for Medicare Advantage plans in 2027. This increase is projected to result in roughly $13 billion in additional federal payments to insurers.
