Baltimore, Maryland — For nursing home residents waiting days — sometimes weeks — for insurance approval to start a prescribed medication, help may be on the way.
The Centers for Medicare & Medicaid Services proposed a sweeping overhaul of how insurance plans approve prescription drugs this month, setting hard deadlines that would require decisions on urgent drug requests within 24 hours and standard requests within 72 hours. The proposed rule, released April 10, would apply across Medicare Advantage, Medicaid, the Children’s Health Insurance Program, and plans sold through ACA marketplaces.
“Patients should not have to wait days or weeks for approval to start the medication their doctor prescribed,” CMS Administrator Dr. Mehmet Oz said in a statement. “This proposal moves prior authorization into the digital age, replacing fax machines and fragmented systems with real-time electronic workflows.”
What the Rule Would Do
Prior authorization — the process insurers use to approve medications before coverage kicks in — has long frustrated nursing home operators and clinicians. Delays tied to the system routinely slow treatment for residents who need fast adjustments to pain regimens, antibiotics, or psychiatric medications. A 2026 systematic review found that prior authorization delays were associated with disease progression and preventable hospitalizations across multiple specialties.
The new rule would expand electronic prior authorization requirements to include drugs for the first time, aligning medication approvals with processes already in place for medical services. Plans would be required to use FHIR-based digital standards, replacing the outdated X12N 278 transaction that some insurers still rely on.
It’s part of a broader pattern of pressure on payers to move faster. Last year, CMS reached a voluntary agreement with 80 percent of the insurance industry to eliminate prior authorization for common medical services including physical therapy and outpatient surgery. This proposed rule pushes that effort into prescription drug coverage — territory that hadn’t been addressed until now.
Transparency Requirements Added
Beyond faster timelines, the rule would require insurers to publicly report detailed prior authorization metrics: approval and denial rates, appeal outcomes, how quickly decisions were made, and how often electronic systems are being used. That data would give providers — and regulators — a clearer picture of which plans are actually modernizing and which are still creating bottlenecks.
For nursing home operators, the stakes are real. Residents on Medicare Advantage plans already face significant friction around drug coverage, particularly as insurer acuity demands keep rising. Industry groups have long pointed to growing access problems at the long-term care pharmacies that facilities depend on, with reimbursement gaps and coverage delays squeezing both operators and residents.
CMS said compliance dates would generally begin in 2027, with the goal of getting patients faster access as quickly as possible. The agency is also seeking public comment on five additional areas, including step therapy reform and prior authorization for lab tests and durable medical equipment.
Health and Human Services Secretary Robert F. Kennedy Jr. said the proposal builds on last year’s voluntary agreement. “This rule builds on that agreement by making it easier for patients to get the medications they need by minimizing delays and enabling real-time decisions,” Kennedy said.
The proposed rule is open for public comment. Comments are due through the Federal Register process.
