CMS Newsroom

2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule

CMS has released the 2026 CMS Interoperability Standards and Prior Authorization for Drugs proposed rule (CMS-0062-P), which would extend electronic prior authorization requirements to cover drugs for Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan issuers. The rule also proposes adding small group market QHP issuers on the FF-SHOP as impacted payers and would require impacted payers to adopt specific HL7 FHIR standards for electronic prior authorization transactions under HIPAA.

CMS Proposes CJR Model National Expansion to All Hospitals

CMS announced a proposed rule to expand the Comprehensive Care for Joint Replacement (CJR-X) Model nationwide through the FY2027 Hospital IPPS and LTCH PPS proposed rule. Beginning October 1, 2027, the model would be mandatory for most hospitals, making it the first nationwide test of an episode-based payment model for joint replacements. The model holds hospitals responsible for Medicare spending on joint replacement surgery, hospital stay, and 90 days of post-acute recovery care.

Proposes Faster Drug Prior Authorization Decisions with 24-Hour Urgent Deadline

CMS proposes a rule establishing mandatory prior authorization decision deadlines for drugs: 24 hours for urgent requests and 72 hours for standard requests. The rule would expand electronic prior authorization requirements to include drugs under Medicare Advantage, Medicaid, CHIP, Qualified Health Plans, and FF-SHOP. Impacted payers would be required to publicly report prior authorization metrics including approval rates, denial rates, appeal outcomes, and decision timeframes.

FY 2027 Medicare Hospital Inpatient and Long-Term Care Payment Rates Proposed Rule

CMS issued a proposed rule on April 10, 2026, updating Medicare payment policies and rates for inpatient hospitals and long-term care hospitals for FY 2027. The proposed rule would expand the Comprehensive Care for Joint Replacement (CJR-X) model nationwide, covering hip, knee, and ankle replacements in inpatient and outpatient settings, effective October 1, 2027. The rule also includes proposed changes to Organ Acquisition and Reimbursement Appeals policies.

CMS Launches First Wave HealthTech Ecosystem Tools, 700+ Orgs Pledged

CMS announced the First Wave Launch of its HealthTech Ecosystem, featuring interoperable digital tools for patient data access and streamlined care. Over 700 organizations have pledged support for the initiative, which aims to modernize healthcare delivery by replacing traditional paperwork with digital-first solutions.

CMS Issues Guidance on New Medicaid and CHIP Funding Limits for Noncitizens

CMS issued guidance implementing new limits on federal Medicaid and CHIP matching funds for certain noncitizens under Public Law 119-21 Section 71109. States must implement system changes by October 1, 2026, including updates to eligibility systems, applications, verification, and claims processing. Exceptions exist for emergency medical conditions and coverage of lawfully residing children and pregnant women.

2027 Medicare Advantage and Part D Rate Announcement

CMS released the CY 2027 Medicare Advantage and Part D Rate Announcement, finalizing capitation rates and payment policies. The final policies result in a 2.48% average payment increase, representing over $13 billion in additional payments to Medicare Advantage plans. The announcement includes risk model revisions, Star Ratings changes, and updated normalization factors affecting plan payment calculations.

CMS Finalizes 2027 Medicare Advantage and Part D Payment Policies

CMS released the Calendar Year 2027 Medicare Advantage and Part D Rate Announcement, finalizing payment policies projected to result in a net average increase of 2.48%, representing over $13 billion in additional MA payments. The finalized policies address coding differentials between MA and Original Medicare and establish three guiding principles for risk adjustment: simplicity, competition, and payment accuracy.

Hospice Scoring System for Fraud Detection and Transparency

CMS announced a proposed rule (FY 2027 Hospice Wage Index and Payment Rate Update) introducing a new Hospice Service and Spending Variation Index (SSVI) to publicly score hospice providers based on indicators of inappropriate utilization, quality of care, and compliance concerns. The scoring system aims to combat fraud in the Medicare hospice program, with enhanced oversight already resulting in over 200 enrollment revocations in Arizona, California, Nevada, and Texas, now expanding to additional states.

FY 2027 Skilled Nursing Facility Prospective Payment System Proposed Rule

CMS issued a proposed rule (CMS-1843-P) updating Medicare payment policies and rates for skilled nursing facilities under the SNF Prospective Payment System for FY 2027. The proposed payment update is 2.4%, based on a 3.2% market basket update offset by a 0.8% productivity adjustment. CMS also proposes changes to the SNF Quality Reporting Program and Value-Based Purchasing Program.

Medicare Inpatient Psychiatric Facility Payment System Updates for FY 2027

CMS issued a proposed rule to update Medicare payment policies for Inpatient Psychiatric Facilities (IPF) for FY 2027, proposing a 2.3% payment rate update representing a $50 million increase in total payments. The rule includes proposals to reform outlier payment policy, remove two measures from the IPF Quality Reporting Program, and implement a standardized IPF patient assessment instrument.

FY 2027 Inpatient Rehabilitation Facility Prospective Payment System Proposed Rule

CMS issued a proposed rule updating Medicare payment policies for Inpatient Rehabilitation Facilities for FY 2027, proposing a 2.4% payment rate increase based on a 3.2% market basket update less a 0.8% productivity adjustment. The rule includes an estimated $355 million increase in IRF payments, updates to outlier thresholds and case-mix weights, and proposes clarifying that all therapies must be initiated within 36 hours of IRF admission.

FY 2027 Hospice Wage Index Payment Rate Update and Quality Reporting Program Proposed Rule

CMS issued proposed rule CMS-1851-P to update Medicare hospice payments for FY 2027, proposing a 2.4% payment rate increase ($785M estimated impact). The rule includes new Service and Spending Variation Index (SSVI) for oversight, mandatory hospice election addendum requirements, and changes to physician designee discharge authority.

Medicare Advantage and Part D Contract Year 2027 Final Rule

CMS issued a final rule updating Medicare Advantage and Part D programs for Contract Year 2027. The rule modifies the Star Ratings system by removing 11 administrative measures and adding a depression screening measure, while codifying Inflation Reduction Act provisions including elimination of the coverage gap phase and reduced annual out-of-pocket thresholds. The rule impacts Medicare Advantage organizations, Part D sponsors, and approximately 66 million Medicare beneficiaries.

CMS Hemp-Derived Products Beneficiary Engagement Incentive

CMS announced a new Substance Access Beneficiary Engagement Incentive (BEI) allowing participating Accountable Care Organizations in the ACO REACH and Enhancing Oncology Models to offer eligible hemp-derived products valued at up to $500 per year per beneficiary. Five ACOs have submitted implementation plans for CMS review, with approved participants able to begin offering the incentive starting April 1, 2026.

Exchange Coverage Remains Near Record High with 23.1 Million Enrolled in 2026

The Centers for Medicare & Medicaid Services (CMS) reported that 23.1 million consumers selected or were automatically re-enrolled in coverage through the Health Insurance Exchanges for plan year 2026. The report highlights the impact of CMS enforcement actions to prevent fraud, which resulted in the removal of nearly 1.5 million improper enrollments.

HHS and CMS Announce Healthcare Advisory Committee Members

HHS and CMS have announced the members of the new Healthcare Advisory Committee, a federal advisory body composed of healthcare leaders. The committee will provide non-binding recommendations to improve and modernize U.S. healthcare financing and delivery across Medicare, Medicaid, and other programs.

CMS Rule Phases Out Fax, Mail for Electronic Transactions

CMS has issued a final rule to phase out fax and mail for healthcare claims attachments, replacing them with standardized electronic transactions and electronic signatures. This rule is projected to save the healthcare industry approximately $781 million annually by reducing administrative burdens and improving efficiency.

CMS Finalizes Health Care Claims Attachments and Electronic Signatures Standards

CMS has finalized a rule adopting new HIPAA-adopted standards for health care claims attachments transactions and electronic signatures. This rule aims to enable secure electronic exchange of clinical documentation and is projected to save the healthcare industry approximately $781 million annually.

Medicare Drug Price Negotiation: Manufacturer Participation in Third Cycle

CMS announced that 15 drug manufacturers have chosen to participate in the third cycle of Medicare drug price negotiations. These negotiations, part of the Inflation Reduction Act, will determine prices for selected high-expenditure drugs, with negotiated prices effective beginning in 2028.

Medicare.gov Enhanced Login Options

The Centers for Medicare & Medicaid Services (CMS) has introduced new login options for Medicare.gov, including ID.me, CLEAR, and Login.gov, to enhance user security and protect beneficiary information from fraud and identity theft. These services are free and offer various verification and support methods.

CMS Extends GENEROUS Model Application Deadline

The Centers for Medicare & Medicaid Services (CMS) has extended the application deadline for the GENEROUS Model, a drug pricing initiative for Medicaid, from March 31, 2026, to April 30, 2026. This extension provides additional time for prescription drug manufacturers to apply to participate in the model, which aims to lower drug spending and improve health outcomes.

Crackdown on Health Care Fraud

The Trump Administration announced a major crackdown on health care fraud, including deferring $259.5 million in federal Medicaid funding to Minnesota and imposing a nationwide moratorium on Medicare enrollment for certain DMEPOS suppliers. The initiative aims to prevent fraud before it occurs and protect taxpayer dollars.

HHS Proposed Rule for Health Insurance Exchanges 2027 Payment Parameters

HHS, through CMS, has issued a proposed rule outlining benefit and payment parameters for Health Insurance Exchanges for the 2027 plan year. The proposal includes changes to risk adjustment programs, user fees, marketing practices, and plan options, with a public comment deadline of March 13, 2026.