Major health insurers commit to streamlining prior authorization for Medicare Advantage, commercial plans 

WASHINGTON – In a landmark move to improve health care access and reduce administrative burdens, major U.S. health insurers have pledged six key reforms to prior authorization processes across Medicare Advantage, Medicaid Managed Care, the Health Insurance Marketplace and commercial health plans.  

These reforms, announced by the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS), aim to benefit nearly 80% of Americans covered by these plans. 

Key prior authorization reforms announced 

The initiative focuses on cutting red tape, accelerating care decisions, and enhancing transparency for both patients and healthcare providers. Participating insurers have committed to: 

• Standardizing electronic prior authorization submissions using Fast Healthcare Interoperability Resources (FHIR)-based APIs. 
• Reducing the number of services requiring prior authorization by January 1, 2026. 
• Honoring existing authorizations during insurance transitions to ensure continuity of care. 
• Improving transparency and communication around authorization decisions and appeals. 
• Expanding real-time responses to minimize care delays, with most requests receiving real-time approvals by 2027. 
• Ensuring clinical denials are reviewed by medical professionals. 

“These commitments represent a step in the right direction toward restoring trust, easing burdens on providers, and helping patients receive timely, evidence-based care,” said CMS Administrator Dr. Mehmet Oz. “We applaud these voluntary actions by the private sector, which is how these types of issues should be solved. CMS will be evaluating progress and driving accountability toward our shared goals, as we continue to champion solutions that put patients first.” 

Industry-wide collaboration 

The reforms were unveiled during a roundtable discussion on June 23, with participation from leading health insurers and organizations, including: 

• Aetna, Inc. 
• AHIP 
• Blue Cross Blue Shield Association 
• CareFirst BlueCross BlueShield 
• Centene Corporation 
• The Cigna Group 
• Elevance Health 
• GuideWell 
• Highmark Health 
• Humana, Inc. 
• Kaiser Permanente 
• UnitedHealthcare 

Impact on patients and providers 

According to AHIP, the national trade association for the health insurance industry, the reforms are expected to deliver significant improvements: 

• For patients: Faster, more direct access to appropriate treatments and medical services, with fewer administrative hurdles. 

• For providers: Streamlined workflows and a more efficient, transparent prior authorization process, enabling a stronger focus on delivering evidence-based care. 

“The health care system remains fragmented and burdened by outdated manual processes, resulting in frustration for patients and providers alike,” said AHIP President and CEO Mike Tuffin. “Health plans are making voluntary commitments to deliver a more seamless patient experience and enable providers to focus on patient care, while also helping to modernize the system.”