2022-26479: Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Advancing Interoperability and Improving Prior Authorization Processes for Medicare Advantage Organizations, Medicaid Managed Care Plans, State Medicaid Agencies, Children's Health Insurance Program (CHIP) Agencies and CHIP Managed Care Entities, Issuers of Qualified Health Plans on the Federally-Facilitated Exchanges, Merit-Based Incentive Payment System (MIPS) Eligible Clinicians, and Eligible Hospitals and Critical Access Hospitals in the Medicare Promoting Interoperability Program

Summary

This proposed rule would place new requirements on Medicare Advantage (MA) organizations, state Medicaid fee-for-service (FFS) programs, state Children's Health Insurance Program (CHIP) FFS programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs) to improve the electronic exchange of healthcare data and streamline processes related to prior authorization, while continuing CMS' drive toward interoperability in the healthcare market. This proposed rule would also add a new measure for eligible hospitals and critical access hospitals (CAHs) under the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System (MIPS) eligible clinicians under the Promoting Interoperability performance category of MIPS. These policies taken together would play a key role in reducing overall payer and provider burden and improving patient access to health information.

The agency’s own summary, as published.

What this changes

Amends 7 parts of the Code of Federal Regulations — the standing rules this notice rewrites.

• 42 CFR 422 Medicare Advantage Program
• 42 CFR 431 State Organization and General Administration
• 42 CFR 435 Eligibility in the States, District of Columbia, the Northern Mariana Islands, and American Samoa
• 42 CFR 438 Managed Care
• 42 CFR 440 Services: General Provisions
• 42 CFR 457 Allotments and Grants to States
• 45 CFR 156 Health Insurance Issuer Standards Under the Affordable Care Act, Including Standards Related to Exchanges