What Is Prior Authorization Reform?
Prior authorization has long been one of the sharpest friction points between health insurers and care providers. Fortunately, 2026 is bringing real change. Insurers are cutting requirements, federal regulators are expanding oversight, and state governments are stepping in with their own rules.
Together, these developments mark a turning point in how the U.S. healthcare system handles treatment approvals. This article breaks down where prior authorization reform stands today — across voluntary industry pledges, CMS mandates, and actions taken by major payers.
Voluntary Payer Commitments
The 2025 Industry Pledge
The current reform cycle started in June 2025, when roughly 50 insurers pledged to simplify and reduce prior authorization requirements. These plans cover commercial, Medicare Advantage, and managed Medicaid populations — totalling approximately 257 million Americans.
Since that pledge, participating insurers have collectively cut 11% of prior authorization requirements, according to an April 2026 survey from AHIP and the Blue Cross Blue Shield Association. That translates to 6.5 million fewer requests. Medicare Advantage plans saw an even larger drop — more than 15%.
Continuity of Care and Standardization Goals
Participating plans also introduced a 90-day continuity of care policy. This policy honors existing approvals for benefit-equivalent, in-network services when patients switch plans mid-treatment. That change directly reduces care disruption for patients.
Looking ahead, the next phase of voluntary commitments takes effect in 2027. By then, payers in this cohort must implement standardized electronic prior authorization submissions. Moreover, they must process at least 80% of electronic approvals in real time. These standards will apply to commonly authorized services, including imaging and orthopedic surgeries.
- Aetna has already standardized 88% of its prior authorization volume.
- UnitedHealthcare has committed to standardizing at least 70%.
- Cigna has similarly committed to a 70% standardization target.
Federal and State Regulatory Changes
CMS Interoperability and Prior Authorization Rule
At the federal level, CMS has steadily layered new requirements onto payers. Under the 2024 Interoperability and Prior Authorization Rule, payers must publicly post their prior authorization metrics for the first time. The first reports, covering 2025 data, were due March 31, 2026.
Required disclosures include approval rates, denial rates, decision turnaround times, and appeals outcomes for medical items and services. Medicare Advantage plans report at the contract level. Medicaid programs report at the state level.
Additionally, the same rule requires plans to issue decisions on standard prior authorization requests within seven calendar days. Urgent requests must receive a decision within 72 hours — effective in 2026.
Concerns About Data Transparency
However, an April 2026 analysis by KFF found that the initial data offers limited insight. The information is aggregated across all items and services, with no breakdown by service type. Furthermore, payers are not required to report reasons for denials. KFF identified Massachusetts and Washington as states providing more granular data — including service-category metrics and prescription drug data — which could serve as models for future collection.
CMS Expands the Coalition
On May 5, 2026, CMS Administrator Mehmet Oz, MD, announced the next phase of this initiative. The expansion goes beyond insurers to include hospitals, physician practices, EHR vendors, and digital health developers. This broader coalition will align on interoperability rule deadlines and address workflow gaps.
Under the 2024 rule, payers must also build out API capabilities by January 1, 2027. These capabilities cover patient access, provider access, payer-to-payer record transfers, and electronic prior authorization submission and response. CMS estimates these policies will save approximately $15 billion over 10 years.
Proposed Drug Coverage Extension
CMS also proposed a rule in April 2026 extending interoperability requirements to cover drugs for the first time. Under this proposal, Medicaid, CHIP, and ACA plans must support three pharmacy data standards by October 2027. These standards will enable providers to query formulary information, check real-time coverage, and submit electronic requests for drugs.
ACA plans must respond to standard drug requests within 72 hours and expedited requests within 24 hours. The proposal also expands public reporting to include drugs and requires payers to give specific denial reasons for drug requests. In addition, it adopts HL7 FHIR standards for prior authorization transactions under HIPAA across all covered entities.
State-Level Action
At the state level, at least five states have enacted their own prior authorization reforms taking effect in 2026, adding another layer of accountability for insurers operating in those markets.
Latest Insurer Updates
UnitedHealthcare
UnitedHealthcare has steadily reduced prior authorization requirements over recent years. The insurer eliminated 20% of requirements in 2023 and launched a gold carding program in 2024 that exempts certain high-performing providers from authorization for specific services.
In April 2026, UnitedHealthcare announced exemptions for roughly 1,500 rural hospitals and critical access facilities. Then, in May 2026, it announced an additional 30% reduction targeting outpatient surgeries, diagnostic tests such as echocardiograms, outpatient therapies, and chiropractic care — with completion expected by year-end. Prior authorizations now apply to just 2% of medical services, and over 90% of submitted requests receive approval within 24 hours.
Aetna
Aetna has standardized 88% of its prior authorization volume. More than 83% of its requests process in real time, and 95% of eligible requests get approved within 24 hours. Additionally, Aetna is the first large payer to integrate medical and pharmacy decisions into single, condition-specific reviews.
Cigna
Cigna has reduced overall medical prior authorization volume by approximately 15%. During its April 30 first quarter earnings call, Cigna disclosed it is exploring strategic alternatives for EviCore — its Evernorth subsidiary that provides utilization management and prior authorization services to other payers. Incoming CEO Brian Evanko cited industrywide progress on standardization and automation as key factors behind the strategic review.
Elevance Health
Elevance Health reported in April 2026 that its Health OS platform and other AI tools have lowered prior authorization denials by nearly 70%. The company also operates a “PA Pass” program that waives requirements for approximately 400 outpatient procedure codes for qualifying large health systems. Currently, 16 health systems across seven states are enrolled. A parallel program offers real-time approval for roughly 250 outpatient procedure codes for smaller medical groups.
What Providers Actually Think
Despite the reported progress from payers, provider sentiment remains cautious. An inaugural Aetna provider survey released in April 2026 — covering 827 hospital executives, physicians, nurses, pharmacists, and health IT leaders — revealed notable gaps in trust.
Only 36% of providers believe payers reliably deliver on their promises. Only 44% believe the payers they work with prioritize clarity and patient well-being. These numbers suggest that voluntary commitments, while meaningful, have not yet translated into broad confidence at the care delivery level.
Interestingly, 65% of providers said they believe prior authorization is necessary in some form — to assess medical need, hold parties financially accountable, and reduce low-value care. That nuance matters. The goal of reform is not to eliminate oversight but to make it faster, fairer, and less burdensome.
What Comes Next
Prior authorization reform is moving on multiple tracks simultaneously. Voluntary pledges from insurers, CMS regulatory mandates, a new multi-stakeholder coalition, proposed drug coverage rules, and state-level legislation are all advancing at the same time.
The 2027 deadline for electronic prior authorization standardization will be a critical milestone. Industry observers will watch closely to see whether payers meet their commitments on real-time processing — and whether provider trust improves as a result. For now, 2026 represents the most active period of prior authorization reform in recent memory.
