Prior Authorization and APIs for Medicaid, CHIP and QHPs Proposed Rule Summary

On December 14, 2020, CMS placed on public display a proposed rule imposing new requirements on 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. Medicare Advantage organizations are not affected by this rule. The proposals aim to improve the electronic exchange of health care data and streamline prior authorization by building on previously adopted requirements pertaining to Application Programming Interfaces. Also in this rule, the Office of the National Coordinator for Health Information Technology of the DHHS proposes adoption of specific implementation guides needed to support the CMS policies proposed in this rule. The proposed rule is scheduled to be published in the December 17, 2020, Federal Register.