Michigan Healthcare Freedom Forum - Recent Posts

Michigan Number 4 For Catastrophic Health Plan Growth

10x25mm — Tue, 14 Apr 2026 17:15:59 +0000

Michigan residents are beginning to select catastrophic only ObamaCare plans to reduce their monthly premiums. Michigan had the fourth greatest growth in catastrophic plans - in the entire nation - albeit from a low base:

https://www.beckerspayer.com/payer/aca/states-ranked-by-catastrophic-plan-enrollment-growth-in-2026/

https://www.kff.org/affordable-care-act/state-indicator/marketplace-plan-selections-by-metal-level-2/

States ranked by catastrophic plan enrollment growth in 2026
By Jakob Emerson - Friday, April 10th, 2026

Montana saw the largest increase in catastrophic plan enrollment from 2025 to 2026, while Pennsylvania saw the largest decrease, according to CMS data analyzed by KFF.

Catastrophic plan enrollment grew nearly 25% nationally, from 54,000 to almost 68,000, even as total ACA enrollment fell 5% to 23.1 million in 2026.

States ranked by catastrophic plan enrollment growth in 2026

Montana
2026: 3,238
2025: 296
Change: +994%

Delaware
2026: 1,123
2025: 177
Change: +534%

South Dakota
2026: 1,672
2025: 290
Change: +477%

Michigan
2026: 8,045
2025: 1,657
Change: +386%

Oklahoma
2026: 1,127
2025: 261
Change: +332%

New Hampshire
2026: 1,343
2025: 355
Change: +278%

Arizona
2026: 737
2025: 235
Change: +214%

Iowa
2026: 184
2025: 84
Change: +119%

Kentucky
2026: 999
2025: 464
Change: +115%

North Dakota
2026: 791
2025: 373
Change: +112%

Massachusetts
2026: 889
2025: 432
Change: +106%

Go to the hyperlinks for more states' data

MDHHS Encourages STD Testing

10x25mm — Tue, 14 Apr 2026 09:24:41 +0000

The Michigan Department of Health and Human Services (MDHHS) is urging Michigan residents to get tested for STDs regularly.Sexually Transmitted Infections (STDs) Awareness Week is April 12th through the 18th. MDHHS appear to be particularly concerned about syphilis:

https://www.michigan.gov/mdhhs/inside-mdhhs/newsroom/2026/04/13/mdhhs-encourages-residents-to-get-tested-during-sti-awareness-week

MDHHS encourages residents to get tested during STI Awareness Week
By Laina Stebbins - April 13, 2026

Cases of symptomatic, infectious syphilis increased 50% over last decade

LANSING, Mich. – As part of Sexually Transmitted Infections (STIs) Awareness Week, April 12-18, the Michigan Department of Health and Human Services (MDHHS) reminds residents to advocate for their sexual health and get tested for STIs regularly. Syphilis is a key focus this year, and MDHHS is emphasizing the importance of awareness, early detection and timely treatment.

“Syphilis is preventable and treatable,” said Dr. Natasha Bagdasarian, chief medical executive. “Regular testing, open conversations with partners and providers, and timely treatment are critical to protecting your health and preventing serious complications. Taking these steps is essential to reversing current trends and safeguarding the health of our communities.”

In Michigan, preliminary 2025 data show that rates of symptomatic and infectious syphilis have increased 50% over the past 10 years. If left untreated, syphilis can affect one’s organs and nervous system, and increase the risk of acquiring other STIs, including HIV. While most syphilis cases occur among gay and bisexual men, the proportion of syphilis cases among straight men and women has risen rapidly.

There also has been an increase in syphilis among pregnant women, leading to a rise in congenital syphilis. Congenital syphilis occurs when the infection passes to babies during pregnancy. If left untreated, this can lead to serious health complications for the baby, including death. There were 58 congenital syphilis cases reported in 2024, which was the highest total number of cases in Michigan in more than 30 years.

Syphilis testing and treatment are available at little to no cost through local health departments and other providers. MDHHS encourages residents to get tested for syphilis regularly if they are sexually active. To prevent cases of congenital syphilis, pregnant women should seek early prenatal care with recommended syphilis screening in the first and third trimesters to help ensure timely treatment and partner notification when diagnosed.

In addition, doxycycline post-exposure prophylaxis (doxy PEP) is an emerging prevention strategy that may reduce the chances of acquiring syphilis among some individuals when taken within 24 hours and no longer than 72 hours after a potential exposure. Doxy PEP should be considered in consultation with a health care provider as part of a comprehensive sexual health care approach. For more information visit Michigan.gov/doxyPEP.

More information about syphilis testing, treatment, prevention resources and partner services are available by visiting the MDHHS Stop Syphilis website. Information and resources on other STIs can be found at Michigan.gov/HIVSTI.

Iran War Creates Water Treatment Fluoride Shortage

10x25mm — Tue, 14 Apr 2026 09:06:39 +0000

Israel is the worlds largest net exporter of fluorosilicic acid ( H₂SiF₆ ), the chemical used by water utilities to fluoridate drinking water. The Israeli suppliers are declaring force majeure on their fluorosilicic acid contracts. Officially, the producers have lost many of their workers to military call ups, however the Iranians have launched devastating missile strikes on the Israeli chemical industry during the war.

U.S. water utilities are starting to curtail fluorosilicic acid additions and lower fluoride levels in water. This situation will be aggravated as we get to the high water consumption periods of summer. The fluorosilicic acid will also crimp solar panel output in China, which will affect RPS electricity generation here as well:

https://apnews.com/article/fluoride-teeth-decay-dentist-iran-israel-cavities-cc1127d5278674498fe580be9f88a243

https://www.epa.gov/system/files/documents/2023-03/Fluorosilicic%20Acid%20Supply%20Chain%20Profile.pdf

Iran war has some US water utilities facing a fluoride shortage
By Devi Shastri - April 13, 2026

It’s not just gas prices: Some U.S. water utilities are reporting the Middle East war is disrupting their ability to maintain recommended fluoride levels in the drinking water.

Over the past few weeks, a few water utilities have said their supply had been disrupted, according to the Association of Metropolitan Water Agencies. Fluoride is used in water systems as a public health measure to prevent tooth decay.

Here’s what to know.

What’s driving the fluoride shortage?

Israel is one of the world’s top exporters of fluorosilicic acid, according to the U.S. Environmental Protection Agency. EPA data also shows the U.S. is among the world’s top five importers of the product.

At least one Israeli supplier has been facing workforce challenges because many employees have been called into active military service, said Dan Hartnett, chief policy officer for the Association of Metropolitan Water Agencies.

“That has led to decreased production, and supply shortages for the U.S. market,” he said.

Not every water system is affected

The number of water utilities affected so far is small, but the shortage is affecting hundreds of thousands of people. As the conflict continues, “there will likely be additional stressors placed on the supply chain, leading to shortages in additional communities,” Hartnett said.

The country’s eighth largest water and wastewater utility, WSSC Water in Maryland, is among those facing a shortage. On April 7, utility officials said they were lowering the level of fluoride in the water to 0.4 milligrams per liter, down from the recommended 0.7 milligrams per liter.

Chuck Brown, spokesperson for the utility serving 1.9 million customers, said officials did not know how long the shortage would last, “but we feel confident that we’ll be able to stretch that out for a couple more months.”

In Pennsylvania, the borough of Lititz told its water customers it had to halt fluoridation for a couple weeks last month because of supply issues.

What dentists say you should do

Water utilities add fluoride voluntarily to improve communities’ oral health, so lower levels have no effect on drinking water safety.

A few months’ drop in fluoride levels is probably not a cause for concern for most people, said Dr. Scott Tomar, an American Dental Association community water fluoridation expert.

Research from places that stopped fluoridating their water — Calgary, Canada; Juneau, Alaska; and Israel — has found that lower levels can have an impact over the span of years.

“Based on the best available information we have, below about 0.5 milligrams per liter, you’re probably not going to see effective preventive exposure,” he said.

Tomar said younger children would be the first to experience tooth decay, because the fluoride strengthens enamel as their teeth are developing and once they’ve grown in.

He recommends people in shortage areas brush twice a day with a fluoride toothpaste and keep up with their routine dental appointments. If people are concerned they aren’t getting enough fluoride, they should talk to their dentist before taking a fluoride supplement or other treatment.

What else should I know about fluoride in the water?

Research shows water fluoridation is beneficial even when it is also available through toothpaste and other means. Nearly two-thirds of the U.S. population gets fluoridated drinking water, according to CDC data.

The addition of low levels of fluoride to drinking water was long considered one of the greatest public health achievements of the last century. The American Dental Association credits it with reducing tooth decay by more than 25% in children and adults.

However, misinformation about fluoride’s safety has proliferated. Last year, Utah became the first state to ban public water fluoridation. And Health Secretary Robert F. Kennedy Jr. has repeatedly sown doubt about its safety and restricted the use of fluoride for dental health.

“The levels we use in the United States is perfectly safe,” Tomar said. “Despite a lot of the misinformation, there are no adverse health effects associated with the levels we use in our drinking water.”

___

RE: The IRA's "Dessert First, Spinach Later" Budgeting Has Failed

10x25mm — Tue, 14 Apr 2026 01:04:54 +0000

Michael F. Cannon's different approach:

https://www.cato.org/books/recovery

https://www.cato.org/sites/cato.org/files/ebookfiles/michael-f-cannon-recovery.pdf

Recovery
A Guide to Reforming the U.S. Health Sector

A quick-reference guide to reforms that state and federal policymakers must enact to make health care better, more affordable, more secure, and more universal.
By Michael F. Cannon • October 2023 • Published By Cato Institute

About the Book

Health care in the United States is not a free market. In many ways, U.S. residents are less free to make their own health decisions than residents of other nations. Government controls a larger share of health spending in the United States than in Canada, the United Kingdom, and most other advanced nations. State and federal governments subsidize low-quality medical care and penalize high-quality care. They block innovations that would otherwise reduce medical prices. Congress even funds veterans benefits in a way that increases the likelihood of war.

Fortunately, there are corners of the U.S. health sector where market forces have had room to breathe. In those areas, markets have made health care better, more affordable, and more secure. They have made health care more universal—both in the United States and in nations that supposedly already had universal health care. Sometimes, market forces develop such innovations despite government policies that exist explicitly to block them.

Those sorts of innovations should be exploding across the United States and the world, bringing affordable health care to low-income patients and driving high-cost and low-quality providers and insurers out of business. But they aren’t.

Recovery shows that making health care as universal as possible requires ending all barriers that government places in the way of better, more affordable, and more secure health care.

About the Author

Michael F. Cannon is the Cato Institute’s director of health policy studies. Cannon is “an influential health‐care wonk” (Washington Post), “ObamaCare’s single most relentless antagonist” (New Republic), “ObamaCare’s fiercest critic” (The Week), “the intellectual father” of King v. Burwell (Modern Healthcare), and “the most famous libertarian health care scholar” (Washington Examiner). Washingtonian magazine named Cannon one of Washington, DC’s “Most Influential People” in 2021, 2022, 2023, 2024, and 2025.

The IRA's "Dessert First, Spinach Later" Budgeting Has Failed

10x25mm — Tue, 14 Apr 2026 01:00:05 +0000

The 2022 Inflation Reduction Act (IRA) failed - spectacularly - to reduce health care costs. Michael F. Cannon, the Director of Health Policy Studies at the Cato Institute, explains why and details the Center for American Progress' (CAP) latest plan to limit drug prices and increase drug subsidies for Medicare enrollees. CAP and its lovely and gracious Director Neera Tanden were the most active promoters of both ObamaCare and the IRA:

https://mfcannon.substack.com/p/cap-health-care-proposal-regulation

https://www.americanprogress.org/article/a-patients-bill-of-rights-to-lower-health-care-costs/

CAP Health Care Proposal: Regulation Hasn’t Delivered Affordability, So Let’s Try Regulation
To make health care more affordable and universal, we need a different approach.
Michael F. Cannon - April 10, 2026

In 2022, under the banner, “How the Inflation Reduction Act Reduces Health Care Costs,” the left-leaning Center for American Progress predicted that that law’s provisions to limit drug prices and increase drug subsidies for Medicare enrollees “will improve health care affordability for Americans” and “translate into lower premiums for Part D plans.”

Fast forward to 2024, the year before most of the IRA’s drug provisions took effect. The Congressional Budget Office (CBO) announced that insurer bids for Part D plans rose by 42 percent—16 percentage points more than the CBO expected. In 2026, the CBO announced that Part D plan bids increased by another 35 percent, leading to a whopping increase in the agency’s spending projections:

Part D spending per beneficiary in 2035 is now projected to be more than $4,000, up from less than $3,000 in the January 2025 baseline.

The agency correspondingly increased its 10-year spending projection for Part D by $600 billion. Repealing the enhanced matching rate for Obamacare’s Medicaid expansion (10-year savings: $561 billion), at which Republicans balked during last year’s budget debate, would not offset that much additional spending. The only non-health care, CBO-scored budget option that would involves cutting Social Security for 75 percent of new recipients (10-year savings: $607 billion).

According to the CBO, much of the cause of this increase in Part D spending is that the IRA’s drug provisions turned out to be a lot more expensive than the agency previously projected. Bundling long-term spending restraints with near-term subsidies—what I call “dessert first, spinach later” budgeting—hasn’t had the effect CAP predicted.

The IRA experience came to mind when I read CAP’s new health care affordability proposal, which would pair broader and tighter health care price controls with a prohibition on certain spending restraints. Specifically, the CAP authors propose:

Tightening price controls on health insurance premiums by lowering the threshold for individual-market premium increases that regulators may reject, and imposing “rate review” regulation on employer plans as well.
Indirect, Medicare-based price controls on hospitals in highly concentrated markets, that limit prices to three times what Medicare sets.
Additional indirect price controls on hospitals whose prices exceed the statewide median, that prohibit price increases greater than the rate of general inflation plus one percentage point.
Tightening indirect regulation of insurer profits, by limiting administrative expenses to a percentage of industry-average premiums (rather a figure that individual insurers can manipulate) for purposes of “medical loss ratio” (MLR) regulation.
Imposing indirect regulation of insurer profits on self-funded employer plans. (MLR again.)
Prohibiting integration, specifically banning health insurance companies from owning “providers, pharmacies, and PBMs,” to prevent insurers from maximizing government subsidies by acquiring downstream providers and then overcharging themselves.
Additional indirect regulation of insurer profits, where regulators determine whether provider-subsidiaries are overcharging parent insurers, and count the excess against administrative expenses rather than claims.
Prohibiting prior authorization for “routine, emergency, and essential care” and requiring insurers to obtain permission from a government agency before denying any other claim.

These proposals double down on the very ideas that are currently making health care so unaffordable. Contrary to conventional wisdom, the US health sector already suffers from extensive government price-setting, which more often than not increases health care prices, in both government programs and private markets, including by encouraging inefficient market concentration.

To their credit, the authors admit, implicitly and explicitly, that many such regulations have failed. Obamacare already regulates premiums via both “community rating” (which links price floors to price ceilings) and “rate review” (which imposes subjective price ceilings). If those regulations were making health insurance affordable, there would be no need for additional proposals. Yet Obamacare premiums have grown at three times the rate of inflation and increased 26 percent in 2026, so here we are. Despite Obamacare’s “protections” for patients with preexisting conditions, the authors write, “health insurance companies can still discriminate against sick people by requiring prior authorization of claims.” It’s worse than that: research shows those Obamacare provisions are increasing prior authorization hurdles.

The authors explicitly admit that MLR regulation is increasing prices and premiums. Thanks to those regulations, “insurers are insensitive to increases in provider prices” because “higher prices translate to higher premiums and higher profits,” which counterproductively encourages insurers to “boost profits by increasing spending and premiums.” The authors acknowledge that MLR regulation encourages insurers to acquire downstream providers, who then overcharge their parent-insurers, leading to still-higher prices, claims, and premiums. We’ve come a long way since the Obama administration boasted that MLR regulation “has saved consumers a lot of money” because insurance companies “are charging lower premiums and operating more efficiently.”

Where the authors claim that regulation has succeeded, they set the bar very low. They cite one study finding that after Rhode Island introduced price caps, regulated (fully insured) and unregulated (self-insured) hospital prices both fell by 9 percent relative to prices in comparator states. (See Exhibit 1.) Curiously, the authors interpret this to mean that regulation reduced even the unregulated prices. Obviously, that’s not the only available interpretation. The authors claim that rate-review regulation “clearly” reduced Obamacare premiums. Yet the data they cite can’t rule out that insurer gaming defeated this regulation too.

The authors’ proposals are not likely to perform any better than existing government interventions. Take the proposal to limit hospital prices to three times what Medicare pays. Medicare is not a good price negotiator. In the words of former administrator Tom Scully, Medicare is just “a big, dumb price fixer.” It overpays hospitals for cataract removal by 100 percent. It overpays long-term care hospitals by more than 200 percent. Under the CAP proposal, private insurers could (use government subsidies to) overpay long-term care hospitals by 800 percent—i.e., three times the Medicare-set price—and supporters would still call this idea a success on which Congress should build.

The fact that the authors also propose to prohibit prior authorization—a spending restraint—will win them favorable attention from doctors, hospitals, and pharmaceutical companies. The proposal would effectively require insurers to pay more invalid claims and then seek repayment from providers later. In Medicare, we call it “pay and chase.” It doesn’t work very well. And, as with the IRA, it all but guarantees that this package would increase rather than reduce health care spending and health insurance premiums.

If we’re going to make health care more affordable and universal, we need a different approach.

Health Policy Apr : medical debt, mental health licenses, pediatric insurance mandate, facility license

Abigail Nobel — Mon, 13 Apr 2026 23:12:57 +0000

Yet another mental health limited license work-around proposes X revisions:

add time to licensing terms, and renewals
empower LARA with discretion to "toll" certain licenses if hardship is proven "to the satisfaction of the department."

At what point do we just admit that limited licensing is a failed experiment?

It extends shortages; it keeps control with the "in" crowd and state government instead of the patient and clinician at the point of care; and in the end, one either qualifies for full licensing (even to a lower standard), or one does not.

Equally disturbing are bills that set up pediatric care for higher costs and shortages through insurance mandates (4% added to each premium per mandate) and facility licensing (restricting market supply).

Medical debt facts posted in previous senate bill hearings.

Wednesday, April 15, 2026 9:00 AM

AGENDA

HB 5074 (Rep. Thompson)
Health occupations: mental health care professionals; number of renewals of temporary or limited licenses; modify.

HB 5251 (Rep. VanderWall)
Human services: medical services; coverage for prescribed pediatric extended care; require.

HB 5252 (Rep. Rogers)
Health facilities: licensing; licensing of prescribed pediatric extended care facilities; provide for.

HB 5254 (Rep. Rigas)
Consumer credit: interest rates; maximum interest rate allowed for medical debt; modify.

HB 5255 (Rep. Pohutsky)
Civil procedure: foreclosure; foreclosure or garnishment of wages for medical debt; prohibit.

SB 449 (Sen. Anthony)
Health facilities: hospitals; hospital financial assistance act; enact.

SB 450 (Sen. Lindsey)
Health facilities: hospitals; certain hospital financial assistance policies; make subject to the hospital financial assistance act.

SB 451 (Sen. Anthony)
Consumer credit: credit reports and reporting agencies; collection and reporting of medical debt information; regulate.

OR ANY BUSINESS PROPERLY BEFORE THIS COMMITTEE

RE: Senate FICP Cmte Jan-Feb: cap interest rates, ban foreclosure, garnishment of wages for medical debt

Abigail Nobel — Mon, 13 Apr 2026 22:43:48 +0000

Medical debt provisions in SB 449-451 passed the senate, as summarized by MPRN.

https://www.michiganpublic.org/health/2026-03-12/michigan-senate-passes-medical-debt-bills

Michigan Senate passes medical debt bills

Colin Jackson | March 12, 2026

The Michigan Senate passed five bills to help with medical debt Wednesday.

The package would require hospitals to create financial assistance programs to help some low-income patients. Those would be available to people whose unpaid bills in one year total more than 30% of their annual income.

Another bill would stop medical debt from affecting someone’s credit score. Right now, the major credit bureaus still consider debts $500 and larger that are more than a year overdue.

State Senator Sarah Anthony (D-Lansing) co-sponsors the package. She said it’s an issue that can affect everyone, even if they have health insurance.

“For far too many, medical debt isn’t just a one-time bill. It can damage credit, threaten housing, and wages, and turn a health crisis into a long-term financial stress,” she said in a floor speech Wednesday.

The bills received pushback during the committee process from the credit reporting industry.

In a letter to the Senate Health Policy Committee, Consumer Data Industry Association director Zachary Taylor said the bills could conflict with federal law.

“aintaining alignment between state consumer reporting laws and federal consumer reporting laws is more critical than ever. State legislation that attempts to regulate credit reporting can unleash many unintended consequences,” Taylor wrote.

Beyond one’s credit score, the bills would also limit medical debt collection practices. Home foreclosures… liens… or wage garnishment related to medical debt would largely face bans.

Meanwhile, larger medical facilities would no longer be allowed to charge late fees on debt within 90 days of a due date, or charge more than 3% interest on outstanding debt in a single year.

The bills were among the policies Governor Gretchen Whitmer called for in her State of the State speech last month. They passed the Senate with bipartisan support.

Senator Jonathan Lindsey (R-Coldwater) co-sponsored the bills. He said the job isn’t done without also passing hospital price transparency bills.

"We have an opportunity to not only address medical costs when they become a crisis for people, when they face medical debt. But to also help them in getting care in ways that are the most economically feasible for those people,” Lindsey said.

The legislation now moves to the House of Representatives, where Speaker Matt Hall (R-Richland Twp) is also calling for hospital transparency bills to make it across the finish line.

When asked if he’d support the Senate bills during a press conference Wednesday, he talked at length about other medical cost measures he wanted to see. Those included the creation of a hospital oversight board and a deeper look at the growth of Michigan’s hospital systems.

“I like this issue,” Hall said regarding the medical debt bills, before adding, “It’s incomplete and we want to see these other things go into place too.”

While talking to reporters, Anthony didn’t rule out the possibility of more legislation down the line. But she said the Senate bills made sense as a starting point.

“What people like to see is when we have concrete proposals that meet the needs of the people and I think this bill package before us does that,” she said.

In a written statement, the Michigan Health and Hospital Association didn’t take an expressed position on the bills, saying it’s willing to work with lawmakers on new policies.

“Ensuring patients have access to high-quality hospital care in their communities is deeply important to Michigan hospitals, and we look forward to continued collaboration with all stakeholders to find solutions that preserve vital services close to home,” association spokesperson Elise Gonzales said.

RE: Senate Appropriations Subcommittee on LARA/DIFS March 3 2026: Governor's budget recommendations

Abigail Nobel — Mon, 13 Apr 2026 16:58:54 +0000

We have bills!

LARA/DIFS appropriations, as writ by the senate.

Tuesday, April 14, 2026 1:30 p.m.

AGENDA

SB 871 (Cavanagh) Appropriations: department of licensing and regulatory affairs; appropriations for fiscal year 2026-2027; provide for.

SB 872 (Cavanagh) Appropriations: department of insurance and financial services; appropriations for fiscal year 2026-2027; provide for.

And any other business properly before the committee.

RE: Families and Veterans March 17 2026: Medical Examiner tuition grants, youth restraint ban during transport to residential treatment

Abigail Nobel — Mon, 13 Apr 2026 15:21:21 +0000

Youth restraints are back, plus oxygen therapy for the military.

Non-health bills in italics.

Tuesday, April 14, 2026 12:00 PM

AGENDA

HB 5456(Rep. Schmaltz)
Military affairs: other; hyperbaric oxygen treatment pilot program; establish.

HB 5457 (Rep. Schmaltz)
Military affairs: other; hyperbaric oxygen therapy pilot program; establish.

HB 5514 (Rep. Cavitt)
Children: other; prohibition of use of certain restraints while transporting youths to certain qualified residential treatment programs; provide for.

HB 5715 (Rep. Schmaltz)
Military affairs: other; direct deposit for compensation of Michigan national guard members; provide for.

OR ANY BUSINESS PROPERLY BEFORE THIS COMMITTEE

RE: Proposed CMS Rule Speeds Up Drug Access, Increases Transparency, and Reduces Bureaucracy

10x25mm — Mon, 13 Apr 2026 13:18:46 +0000

The proposed CMS 2026 Interoperability Standards and Prior Authorization for Drugs rule is still under construction but we do have their fact sheet:

https://www.cms.gov/newsroom/fact-sheets/2026-cms-interoperability-standards-prior-authorization-drugs-proposed-rule

https://www.federalregister.gov/public-inspection/2026-07205/medicare-and-medicaid-programs-patient-protection-and-affordable-care-act-interoperability-standards

2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule
Press Release - April 10, 2026

Fact Sheet

The Centers for Medicare & Medicaid Services (CMS) continues its efforts to improve prior authorization so patients and providers can benefit from a more expeditious, transparent, and reliable process. Today, CMS released the 2026 CMS Interoperability Standards and Prior Authorization for Drugs proposed rule (CMS-0062-P).

This proposed rule builds on the 2020 CMS Interoperability and Patient Access final rule and the 2024 CMS Interoperability and Prior Authorization final rule, which together require Medicare Advantage (MA) organizations, state Medicaid and Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs) (collectively “impacted payers”) to implement Patient Access, Provider Directory, Provider Access, Payer-to-Payer, and Prior Authorization Application Programming Interfaces (APIs) (collectively “interoperability APIs”). In this rule, CMS is proposing to add small group market QHP issuers offering plans on the Federally-facilitated Small Business Health Options Program (FF-SHOP) as an impacted payer subject to the interoperability requirements of the previous rules and these proposals.

While the prior authorization requirements in the 2024 final rule focused on non-drug items and services, the 2026 CMS Interoperability Standards and Prior Authorization for Drugs proposed rule extends many of those requirements to cover prior authorizations for drugs. Specifically, CMS now proposes to require impacted payers to support electronic prior authorization, to make decisions on requests within shorter timeframes that align CMS programs, and to increase transparency for the prior authorization of drugs. In addition, CMS is proposing to require impacted payers to update health information technology (health IT) standards and to report interoperability API endpoints and API usage metrics to CMS.

Furthermore, under the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Department of Health and Human Services (HHS) is proposing to adopt certain Health Level Seven® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) standards and implementation specifications for transactions related to prior authorizations. These HHS proposals would apply to all HIPAA covered entities (health care providers, health plans, and health care clearinghouses) that electronically exchange prior authorization requests and decisions for items and services.

Electronic Prior Authorization for Drugs

The 2024 final rule requires impacted payers to implement and maintain a Prior Authorization API to facilitate electronic prior authorization for non-drug items and services. CMS now proposes to require impacted payers to incorporate coverage and documentation requirements into those APIs to support the electronic prior authorization of drugs covered under a medical benefit beginning October 1, 2027. Aligning the technology and standards for all items, services, and drugs covered under a medical benefit would streamline the prior authorization process for providers and patients, enable real-time data exchange, improve electronic documentation submission, and accelerate payers’ ability to make decisions.

CMS is also proposing to require that state Medicaid and CHIP FFS programs, Medicaid managed care plans, CHIP managed care entities, and QHP issuers on the FFEs support electronic prior authorization for drugs covered under a pharmacy benefit, which aligns with existing requirements for Medicare Part D sponsors. Specifically, CMS is proposing to require those impacted payers to support three National Council for Prescription Drug Programs (NCPDP) standards—the SCRIPT, Formulary & Benefit (F&B), and Real-Time Prescription Benefit (RTPB) standards–beginning October 1, 2027. The proposed standards allow providers to query formulary information, determine real-time coverage information, and exchange electronic prior authorization requests and decisions for drugs.

HIPAA Administrative Simplification: Adoption of the FHIR Standard for Prior Authorization Related Transactions

HHS is proposing to modify the current HIPAA Administrative Simplification standards for dental, professional, and institutional transactions related to prior authorization. Specifically, HHS is proposing to adopt the FHIR standard and certain FHIR implementation guides (IGs) as the standards for the “referral certification and authorization” and the “eligibility for a health plan” transactions related to prior authorization. Alternatively, we propose to also adopt the FHIR standard and applicable FHIR IGs to also include transactions for referral certifications. These modifications would improve transparency for patients, streamline provider workflows, increase transaction speed and accuracy, and reduce costly administrative inefficiencies.

HHS also proposes to adopt the HL7 FHIR Da Vinci Clinical Data Exchange (CDex) IG as the standard for attachments accompanying prior authorization transactions. The CDex IG is used to exchange files in various formats such as Consolidated Clinical Document Architecture (C-CDA) documents, PDF, and text files. This flexibility allows documents containing relevant patient data to be shared seamlessly across health IT systems. The CDex IG also allows health plans to be explicit with the data they are requesting, which would help health care providers avoid spending time gathering and sending more information than necessary.

HHS proposes that HIPAA covered entities (health care providers, health plans, and health care clearinghouses) that engage in those electronic transactions would be required to comply with these proposals no later than 24 months after the final rule’s effective date. Small health plans would have 36 months after the final rule’s effective date to comply with these proposals. HIPAA covered entities who do not engage in electronic prior authorization transactions would not be required to adopt these standards.

Payer Reporting of API Endpoints and Associated Information

CMS is proposing to require impacted payers to report their API endpoints for each of the interoperability APIs for CMS to publish in a centralized location. In addition, CMS is proposing to require impacted payers to submit to CMS a direct URL to their interoperability APIs’ FHIR capability statements and URL(s) with required technical documentation—about authorization and authentication protocol and implementation details and API registration information—for each of their interoperability APIs.

CMS is proposing that existing impacted payers report this required information to CMS no later than 60 days after the effective date of a final rule and that new impacted payers report this information no later than 60 days before they begin covering patients under the applicable CMS program. In addition, impacted payers would be required to update the information within one week of any changes and verify that the reported information is still correct at least annually.

Alternatively, CMS is proposing that impacted payers report the proposed information for each interoperability API using the National Directory of Healthcare Providers & Services (NDH) IG Endpoint Profile resources.

HHS Adoption of Updated Health IT Standards and Specifications

This proposed rule includes proposals from the Office of the National Coordinator for Health Information Technology (ONC) to adopt updated versions of certain health IT standards and specifications on behalf of HHS related to the interoperability APIs. Adopting these updated versions would support the continued development of a nationwide health IT infrastructure and ongoing federal alignment of standards for interoperability and health information exchange. In addition, ONC proposes that certain currently adopted versions of the proposed standards in 45 CFR 170.215 would expire on January 1, 2028.

Updates to Standards and IGs for Interoperability APIs

CMS proposes to cross-reference versions of the required standards adopted by the Secretary in 45 CFR 170.215. This would allow industry to move to newer versions of the required standards (see the 2024 final rule fact sheet for a list of required standards), as adopted by ONC, rather than necessitating additional CMS rulemaking. In addition, impacted payers would have the flexibility to use updated versions of the required standards under the following conditions: (1) the updated version of the standard is required by other applicable law or the updated version of the standard is not prohibited under other applicable law, (2) the National Coordinator has approved the updated version for use in the ONC Health IT Certification Program, and (3) the updated version does not disrupt an end user’s ability to access the data required to be available through the API.

In addition, building upon the 2024 final rule and in conjunction with the ONC proposals, CMS is proposing to require impacted payers to use a set of currently recommended IGs, as applicable to each of the interoperability APIs. Impacted payers’ interoperability APIs would be required to conform with the proposed, additional IGs beginning October 1, 2027. Requiring these IGs would promote interoperability by further aligning industry standards and best practices for how patient data should be structured and exchanged.

Specifically, CMS is proposing to require impacted payers to use versions of the below IGs that are currently recommended under the 2024 final rule:

HL7 FHIR CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®) IG, Version 2.0.0—STU 2, proposed to expire on January 1, 2028, or Version 2.2.0—STU 2.2*
HL7 FHIR Da Vinci—Payer Data Exchange (PDex) IG, Version 2.1.0—STU 2.1
HL7 FHIR Da Vinci—Payer Data Exchange (PDex) US Drug Formulary IG, Version 2.0.1—STU 2*, proposed to expire on January 1, 2028, or Version 2.1.0—STU 2.1*
HL7 FHIR Da Vinci—Payer Data Exchange (PDex) Plan Net IG, Version 1.1.0—STU 1.1 US*, proposed to expire on January 1, 2028, or Version 1.2.0—STU 1.2*
HL7 FHIR Da Vinci—Coverage Requirements Discovery (CRD) IG, Version 2.0.1—STU 2*, proposed to expire on January 1, 2028, or Version 2.2.1—STU 2.2*
HL7 FHIR Da Vinci—Documentation Templates and Rules (DTR) IG, Version 2.0.1—STU 2*, proposed to expire on January 1, 2028, or Version 2.2.0—STU 2.2*
HL7 FHIR Da Vinci—Prior Authorization Support (PAS) IG, Version 2.0.1—STU 2*, proposed to expire on January 1, 2028, or Version 2.2.1—STU 2.2*

CMS is also requesting comments on the following IGs for consideration in future rulemaking:

HL7 FAST Security for Scalable Registration, Authentication, and Authorization Release (FAST Security IG), Version 2.0.0—STU 2
HL7 FHIR Da Vinci Member Attribution (ATR) List IG, Version 2.1.0—STU 2.1
HL7 FHIR Da Vinci Clinical Data Exchange (CDex) IG, Version 2.1.0—STU 2.1

For a complete list of required standards and proposed IGs, please refer to the proposed rule here: www.federalregister.gov

Improving Communications and Decision Timeframes for Prior Authorizations

Timeframes for Prior Authorization Decisions

Prior Authorizations for Drugs

To ensure prompt notification and align prior authorization decision processes across different CMS programs, CMS proposes that certain payers be required to provide notice of drug-related prior authorization decisions within specific timeframes.

To align patient protections and create consistent requirements across the Medicaid and CHIP programs, state Medicaid FFS programs, Medicaid managed care plans, and CHIP managed care entities would be required to make prior authorization decisions for all drugs within a timeframe that aligns with existing decision timeframe requirements for covered outpatient drugs (no later than 24 hours after receiving a prior authorization request) or items and services (7 days for standard requests, 72 hours for expedited requests).
State CHIP FFS programs would be required to provide notice of a prior authorization decision no later than 24 hours after receiving a prior authorization request for any prescription drugs for which Federal Financial Participation (FFP) is available.
QHP issuers on the FFEs would be required to provide notice of a prior authorization decision to the requesting provider as expeditiously as the enrollee’s health condition requires, but no later than 72 hours after standard prior authorization requests and no later than 24 hours for expedited prior authorization requests for all drugs.

CMS proposes compliance dates beginning October 1, 2027 for these decision timeframe proposals. Shortening and aligning decision timeframes for prior authorization across CMS programs could improve timely access to medications, which is essential for maintaining health and preventing complications in these populations.

Prior Authorization for Non-Drug Items and Services

Under this proposed rule, CMS is proposing that beginning October 1, 2027, QHP issuers on the FFEs be required to provide notice of prior authorization decisions to the requesting provider for non-drug items and services as expeditiously as the enrollee’s health condition requires, but no later than seven calendar days after receiving a standard prior authorization request and no later than 72 hours after receiving an expedited prior authorization request. This proposal would align prior authorization decision timeframe requirements for QHP issuers on the FFEs with those that finalized for other impacted payers under the 2024 final rule and should mitigate administrative burden with consistent requirements across impacted payers.

Expanding Communication of Prior Authorization Denials for Drugs

CMS proposes that beginning October 1, 2027, state Medicaid and CHIP FFS programs, Medicaid managed care plans, CHIP managed care entities, and QHP issuers on the FFEs be required to provide providers with a specific reason for denying prior authorization requests for any drugs. These proposals would improve communication between payers and providers when a prior authorization request is denied, align prior authorization requirements across payers, and support providers by giving them the information they need to resubmit or appeal prior authorization denials.

Prior Authorization Metrics

New and Updated Prior Authorization Metrics for Non-Drug Items and Services

The 2024 final rule requires that impacted payers annually report prior authorization metrics for non-drug items and services on their public websites. CMS is proposing to add requirements for impacted payers to report the numeric counts in addition to percentages for certain existing metrics, as well as for impacted payers to publicly report additional prior authorization metrics on non-drug items and services. These proposed requirements would begin on the effective date of the final rule.

The proposed reporting deadlines vary by payer type:

MA organizations, state Medicaid and CHIP FFS programs, and QHP issuers on the FFEs would be required to report by March 31 of the following year.
Medicaid managed care plans and CHIP managed care entities would be required to report no later than 90 days after the end of each rating period.

See the proposed rule for more information on new metrics proposed as well as proposed updates to current metrics.

CMS is also proposing that Medicaid managed care plans and CHIP managed care entities report prior authorization metrics for non-drug items and services finalized in the 2024 final rule, as well as prior authorization metrics for non-drug items and services introduced in this proposed rule at both the program and plan levels.

Other impacted payers’ reporting levels would not change:

MA organizations would still report at the MA contract level,
State Medicaid and CHIP FFS programs would still report at the state level, and
QHP issuers on the FFEs would still report at the issuer level.

New Prior Authorization Metrics for Drugs

In addition, CMS proposes to require impacted payers to annually report prior authorization metrics for drugs on their public websites. The proposed compliance dates for reporting these new metrics are in 2028 for data from the 2027 reporting period, with specific deadlines and reporting level varying by payer type, as described in the “New and Updated Prior Authorization Decision Metrics for Non-Drug Items and Services” section above. See section II.C.7. of the proposed rule for more information on the specific metrics proposed for impacted payers.

Publicly reporting these data would provide transparency and accountability in payer prior authorization processes across drugs and non-drug items and services. The additional metrics for non-drug items and services would provide context that would make existing metrics both more complete, as well as useful to the public. Making these data available should build trust with patients and providers and showcase commitment to improving services.

API Usage Metrics (Provider Access, Payer-to-Payer, and Prior Authorization APIs)

Under the 2024 final rule, CMS requires that impacted payers annually report certain Patient Access API usage metrics to CMS. CMS is now proposing that impacted payers also annually report certain Provider Access, Payer-to-Payer, and Prior Authorization APIs usage metrics to CMS. Please refer to the Proposed Metrics Updates document for a full list of the new metrics.

CMS proposes to require impacted payers to submit these metrics beginning in 2028 with data from the 2027 reporting period. Reporting these metrics would offer valuable insight into how the APIs are being used, who is using them, and whether data are flowing as intended. This information will enable CMS to identify potential issues and target areas for improvement.

New Proposed Reporting Levels and Deadlines for API Usage Metrics

Proposed reporting requirements for Provider Access, Payer-to-Payer, and Prior Authorization API usage metrics vary by payer type in both reporting level and deadline:

MA organizations: Contract level, by March 31 each year
Medicaid and CHIP FFS: State level, by March 31 each year
Medicaid managed care plans and CHIP managed care entities: Plan and program levels, no later than 90 days after the end of each rating period. (Note: Medicaid managed care plans and CHIP managed care entities would be required to report API usage metrics to states.)
QHP issuers on the FFEs: Issuer level, by the FFE QHP certification deadline in the subsequent year.

Updates to Patient Access, Provider Access, and Payer-to-Payer APIs

CMS is proposing a new requirement for impacted payers to make detailed information about prior authorization requests and decisions for all drugs available through the Patient Access, Provider Access, and Payer-to-Payer APIs.

For the Patient Access and Provider Access APIs, this would include, as applicable:

The status of the prior authorization,
The date the prior authorization was approved or denied,
The date or circumstance under which the authorization ends,
The drug or drugs approved (including dosage),
A specific reason the request was denied (if applicable), and
Related structured administrative and clinical documentation submitted by a provider.

For the Payer-to-Payer API, the required information would include:

The status of the prior authorization,
The date the prior authorization was approved,
The date or circumstance under which the authorization ends,
The drug or drugs approved (including dosage), and
Related structured and unstructured administrative and clinical documentation submitted by a provider, excluding denied prior authorization requests.

Impacted payers would be required to comply with this proposal beginning October 1, 2027. This proposal aims to ensure that patients, providers, and payers have consistent and comprehensive access to prior authorization information, improving transparency and care coordination.

Open Payments Program Proposal

Section 1128G of the Social Security Act and implementing regulations require “applicable manufacturers” and “applicable group purchasing organizations” (GPOs) to annually submit certain payments or transfers of value made during the previous calendar year to specified “covered recipients,” originally defined as physicians and teaching hospitals. CMS is proposing to add a definition for “Failure to Report” in 42 CFR 403.902, which would be foundational to enabling us to impose a civil monetary penalty (CMP) on applicable manufacturers or GPOs if either of those entities fail to grant timely access (within 30 calendar days of the audit request) to documents for the purposes of an Open Payments program audit authorized by 42 CFR 402.912(e)(2). CMS proposes this new requirement to begin on the effective date of the final rule.

Requests for Information (RFIs)

This proposed rule includes five standalone RFIs that are distinct from the policy proposals. CMS will collect public responses to these RFIs to analyze and determine steps the agency can take to improve related issues in the health care industry. The RFIs are as follows:

Electronic Event Notifications for Value-Based Care and Care Coordination

Electronic event notifications (often referred to as admission, discharge, and transfer, or “ADT” notification) are valuable tools for coordinating care in the modern health care environment, and CMS seeks comments on ways to improve this process with expanded use and content of ADT notifications. CMS solicits comments on the types of providers or other entities that should receive ADT notifications, along with technical approaches that are currently in use or that could be used for patient event notifications. CMS also seeks comments on health IT certification criteria for notification capabilities and strengthening enforcement of ADT notification requirements.

Increasing Health Care Resiliency

Hacking, ransomware, and other cybersecurity attacks on health care systems and electronic protected health information (ePHI) present an ever-increasing threat. These attacks have already caused, and could continue to cause, significant disruption to the health care industry, potentially resulting in significant harm to patients, providers, payers, and the health care ecosystem at large. CMS seeks feedback on opportunities to strengthen, protect, and increase the resiliency of our health care system in cybersecurity spaces to prevent and better handle future threats. Additionally, CMS would like to hear about existing standards and technologies, as well as the current role of point-to-point connections within the health care system.

Improving Implementation of Payer Application Programming Interface Technology

Monitoring compliance and technical conformance with standards is critical to effective interoperability within the health care ecosystem based on the API requirements that CMS has established for impacted payers. CMS is seeking comments on steps that we could take to improve oversight of payer APIs, for instance, through strengthening testing and transparency requirements. CMS is also exploring opportunities to leverage existing programs, such as the ONC Health Information Technology (IT) Certification Program, to help ensure that API technology used by payers meets the technical requirements CMS establishes.

Step Therapy

CMS also seeks comments on ways to streamline the step therapy process through technology and data sharing (such as the Payer-to-Payer API) to allow payers access to historical patient information. CMS seeks comment on how technology may facilitate step therapy determinations and improve current step therapy processes. This includes the role of technology in evaluating and applying step therapy use criteria and how payers evaluate and honor step therapy use criteria from other payers.

Laboratory Tests and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Items

Prior authorization requirements from health insurers for laboratory tests and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items have emerged, in some instances, as a barrier to care and coverage that impacts both patients and providers. The primary issues associated with prior authorization for laboratory tests and DMEPOS items are coordination between providers and laboratories or DMEPOS suppliers and the length of time approval takes for tests and equipment. CMS solicits public comments on how prior authorization for laboratory tests and DMEPOS items impact patient care and provider burden and what can be done to mitigate that burden.

The proposed rule is available for public comment at: www.federalregister.gov

To view the Press Release, please visit: https://www.cms.gov/newsroom/press-releases/cms-proposes-major-reforms-speed-up-patient-access-drugs-increase-transparency-reduce-administrative.