Prior Authorization Reform

Current understanding

Legislative and regulatory efforts to modify prior authorization requirements imposed by insurers and public payers, including timelines, transparency, and disease-specific carve-outs. Prior authorization directly affects whether and when patients can access prescribed treatments, making it a recurring target of federal legislation.

Evidence log

• 2026-03-19 — Safe Step Act: cross-connection with safe-step-act-step-therapy: Both address utilization-management barriers (step therapy and prior authorization) that delay patient access to prescribed treatments under group health plans. (novelty: 2)
• 2026-07-15 — Improving Seniors’ Timely Access to Care Act of 2025: 2025 — Improving Seniors’ Timely Access to Care Act of 2025 (introduced): would codify electronic PA, CMS timeliness/quality standards, and public reporting of approval rates and response times specifically for Medicare Advantage plans, with a directive to study AI’s effect on access. (novelty: 2)
• 2026-05-19 — Providing for congressional disapproval under chapter 8 of title 5, United States Code, of the rule submitted by the Centers for Medicare & Medicaid Services of the Department of Health and Human Services relating to “Medicare Program; Implementation of Prior Authorization for Select Services for the Wasteful and Inappropriate Services Reduction (WISeR) Model”.: 2026 — Failed CRA disapproval of CMS’s WISeR Model (46–50) signals congressional split over AI-assisted, shared-savings prior authorization in Medicare fee-for-service, keeping the pilot in place as a live policy testbed. (novelty: 3)
• 2026-07-16 — A joint resolution providing for congressional disapproval under chapter 8 of title 5, United States Code, of the rule submitted by the Centers for Medicare & Medicaid Services of the Department of Health and Human Services relating to “Medicare Program; Implementation of Prior Authorization for Select Services for the Wasteful and Inappropriate Services Reduction (WISeR) Model”.: cross-connection with wiser-model-prior-authorization: WISeR expands prior authorization into fee-for-service Medicare via third-party AI review, running counter to broader legislative efforts to constrain prior authorization burdens. (novelty: 3)
• 2026-02-03 — Prior Authorization Relief Act: 2025 — Prior Authorization Relief Act (S3762, introduced): Senate companion-style proposal referred to Senate Finance Committee aimed at reducing prior authorization burdens in healthcare coverage. (novelty: 2) (novelty: 2)
• 2026-07-07 — Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; and Quality Reporting Programs; Including the Hospital Outpatient Quality Reporting Program and Ambulatory Surgical Center Quality Program; Request for Information on Strengthening the Standardization and Comparability of Hospital Price Transparency (HPT) Data; Prior Authorization; Accrediting Organization (AO) Deeming for Emergency Medical Treatment and Labor Act (EMTALA); and Notices of Closure of Teaching Hospitals and Opportunities To Apply for Available Slots: cross-connection with medicare: The CY 2027 OPPS proposed rule expands Medicare prior authorization to Botulinum Toxin Injection services, connecting outpatient payment policy to prior authorization scope. (novelty: 2)
• 2026-06-25 — Prior Authorization Accountability Act: HR9396 (Prior Authorization Accountability Act) was forwarded by subcommittee to the full committee by voice vote in the 119th Congress, advancing one procedural step toward a floor vote. (novelty: 2)
• 2025-02-06 — Alternatives to PAIN Act: 2026 — Alternatives to PAIN Act (introduced): would prohibit prior authorization and step therapy requirements in Medicare Part D specifically for non-opioid pain management drugs. (novelty: 3) (novelty: 3)

Open questions

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