About one in eight adults (12%) say they have taken one of an increasingly popular class of prescription drugs known as GLP-1s that are used for weight loss and to treat diabetes and reduce the risk of heart disease and stroke, a new KFF Health Tracking Poll finds. This includes 6% of adults who say they are currently taking one of these drugs, which include Ozempic, Wegovy and MounjaroThe shares of adults who report ever taking these drugs is highest among people with diabetes (43%), followed by those with heart disease (26%) and those who have obesity or overweight (22%), the poll finds. Among those who report ever taking the drugs, most (61%) say that they took the drugs to treat a chronic condition such as diabetes or heart disease – either alone (39%) or in combination with losing weight (23%). Nearly four in ten (38%) say that they took the drugs solely to lose weight.

List prices for GLP-1 drugs can top $1,000 for a month’s supply prior to insurance coverage, rebates, and discount coupons. About half (54%) of those who report ever taking the drugs say it was difficult to afford them, including one in five (22%) who say it was “very difficult.”  Having insurance coverage makes little difference to patients’ perceptions of the drugs’ affordability, with similar shares of those covered by insurance saying the drugs were difficult (53%) or very difficult (23%) to afford.

Most of the Public Favors Medicare Coverage of Weight-Loss Drugs Even After Hearing Competing Arguments 

While 9% of older adults ages 65 and older report ever taking the drugs, few (1%) say they did so solely for weight loss – likely reflecting Medicare’s prohibition on the coverage of prescription weight-loss drugs. Medicare covers some of the drugs for diabetes and other conditions.

About six in ten adults (61%) say that Medicare should cover these drugs when prescribed for weight loss for people who are overweight. This includes similar shares across age groups, and more than half of Democrats, independents, and Republicans.The poll also tested the impact of arguments for and against Medicare coverage, with short descriptions explaining that it could increase premiums for people with Medicare and place financial pressure on the Medicare program and the federal budget, but that it could help more people afford the medications and improve the health and quality of life of people who are overweight.Those arguments did little to change the public’s views, with similar shares of the public overall and the various subgroups continuing to favor Medicare coverage. 

Other findings include:•    About eight in ten (82%) adults say they have heard at least “a little” about these drugs, including about three in ten (32%) who say they have heard “a lot” about them. Awareness is up since July 2023, when about one in five (19%) said they heard a lot about the drugs.•    About eight in ten (79%) adults who have taken GLP-1 drugs report getting these drugs or a prescription for them from their primary care doctor or a specialist. Fewer report getting them from an online provider or website (11%), a medical spa or aesthetic medical center (10%), or somewhere else (2%). 

Designed and analyzed by public opinion researchers at KFF. The survey was conducted April 23-May 1, 2024, online and by telephone among a nationally representative sample of 1,479 U.S. adults in English and in Spanish. The margin of sampling error is plus or minus 3 percentage points for the full sample. For results based on other subgroups, the margin of sampling error may be higher.

This analysis examines the share of new mothers who have significant medical debt (in excess of $250), compared to other young women who did not recently give birth, using data from the Survey of Income and Program Participation (SIPP).

New mothers are twice as likely to have medical debt as young women who did not recently give birth. Among women ages 18-35, 14.3% of those who gave birth in the last year and a half have medical debt in excess of $250, compared to 7.6% of women in the same age group who did not have a child recently. This comparison group (7.6%) includes some women who have older children, so there could still be residual debt from an earlier birth.

KFF’s earlier survey of people experiencing health care debt also found that parents generally are significantly more likely than non-parents to report having health care debt from their own or someone else’s medical or dental bills.

The analysis is available through the KFF-Peterson Health System Tracker, an online information hub that monitors and assesses the performance of the U.S. health system.

On May 8, 2024, KFF submitted this letter in response to the Centers for Medicare & Medicaid Services request for information about research data requests and access policy changes.  As KFF currently uses several CMS Research-Identifiable File datasets and would be affected by the changes, the letter outlines a number of concerns and options for CMS to consider.

View the letter [PDF]

A new analysis of data from KFF’s Survey on Racism, Discrimination, and Health shows Black women are more likely than other groups to report being treated unfairly by a health care provider in recent years because of their race and ethnicity and that these experiences have health consequences.

For example, among Black women who used health care in the past three years, 34% report at least one of three consequences because of a negative experience with a health care provider for any reason: worse health (13%), being less likely to seek care (19%), or switching providers (27%).

The findings shift with Black women’s health status: Black women who describe their physical and/or mental health as fair or poor are more likely than those who report better health to say that a negative experience resulted in worse health, being less likely to seek care, or switching providers in the past three years. In fact, about half (49%) of Black women with fair or poor mental health status say they experienced at least one of these consequences.

Although overall, most Black women report positive experiences receiving health care, they are more likely than other groups to report being treated unfairly by a health care provider because of their race and ethnicity (21%) and to say they prepare for possible insults or must be very careful about their appearance to be treated fairly during health care visits (61%).  The survey suggests such preparations—behaviors documented in other research areas as “heightened vigilance”—may be a response to past experiences.

Reflecting the importance of racial and ethnic diversity in the health care workforce, a shared racial and ethnic background between provider and patient is associated with more positive interactions for Black women. The survey finds that Black women who have more health care visits with providers who share their racial and ethnic background report more frequent positive and respectful interactions.

KFF’s  Survey on Racism, Discrimination and Health is a probability-based survey conducted online and by telephone, June 6-August 7, 2023, with a total of 1,306 women who identify as Black. Respondents were contacted via mail or telephone; and had the choice to complete the survey in English, Spanish, Chinese, Korean, or Vietnamese. The survey methodology was developed by KFF researchers in collaboration with SSRS and SSRS managed sampling, data collection, weighting, and tabulation. The margin of sampling error is plus or minus four percentage points for results based on the sample of Black women.

Additional resources from the Survey on Racism, Discrimination and Health:

• Survey on Racism, Discrimination and Health: Experiences and Impacts Across Racial and Ethnic Groups
• KFF Survey on Racism, Discrimination and Health: Views on Racism and Trust in Key U.S. Institutions
• LGBT Adults’ Experiences with Discrimination and Health Care Disparities: Findings from the KFF Survey of Racism, Discrimination, and Health
• Five Facts About Older Adults’ Health Care Experiences by Race and Ethnicity

Black women account for one in seven women in the U.S. today and play an integral part of our workforce and communities. Despite making significant advances and contributions to U.S. society, Black women continue to face high levels of unfair treatment and systemic discrimination, making up disproportionate shares of people living in poverty and working in low-wage jobs. Reflecting the intersectional nature of their identity, Black women experience the combined impact of discrimination based on their gender in addition to their race. KFF’s 2023 Racism, Discrimination, and Health Survey is a major effort to document the extent and implications of racism and discrimination, particularly with respect to people’s interactions with the health care system. As reported in the overview report, a majority (54%) of Black women say they experienced at least one form of discrimination asked about in the survey in the past year, such as receiving poorer service than others at stores or restaurants.

In addition to these everyday forms of discrimination, Black women also report experiencing disproportionate levels of unfair treatment in health care settings. For example, about one in five (21%) Black women say they have been treated unfairly by a health care provider or their staff because of their racial or ethnic background and a similar share (22%) of Black women who have been pregnant or gave birth in the past ten years say they were refused pain medication they thought they needed. These experiences may contribute to ongoing disparities in health for Black women, including stark divides in maternal health.

Below are five key facts about Black women’s experiences in health care drawing on the survey. The findings highlight that while overall most Black women report positive interactions in health care settings, experiences with discrimination and unfair treatment due to race are pervasive among Black women of all backgrounds. Having more health care visits with a racially concordant provider is associated with increased reports of positive experiences in health care settings among Black women, illustrating the opportunities to increase high-quality and culturally competent care which may mitigate disparities in health.

Although overall most Black women report positive experiences receiving health care, they are more likely than other groups to report being treated unfairly by a health care provider due to their race and ethnicity and to say they prepare for possible insults or must be very careful about their appearance to be treated fairly during health care visits. Overall, similar to other groups, the majority of Black women report positive interactions when receiving health care in the past three years, such as a doctor spending enough time with them during their visit or explaining things in a way they can understand. However, compared to other groups, Black women are more likely to report being treated unfairly by a health care provider in the past three years. For example, Black women (21%) are more likely to say they have been treated unfairly by a health care provider because of their racial or ethnic background than are Black men (13%) and are seven times as likely to say this than are White women (3%). In another example, about six in ten (61%) Black women say they are very careful about their appearance or prepare for possible insults when seeking health care, similar to the share of Black men (57%), but roughly twice the share of White men (28%) who say the same.

Reports of unfair treatment by a health care provider due to race and ethnicity persist among Black women with higher incomes and are particularly high among those who are younger and those with darker skin tones. Across income groups, at least one in six Black women say they have felt they were treated unfairly or with disrespect because of their race or ethnic background during a health care visit in the past three years. There are some differences in experiences with unfair treatment among Black women by age and skin tone. Younger Black women are more likely than older Black women to say they have had this experience, with about a quarter of Black women ages 18-29 (23%) and 30-49 (26%) and one in five ages 50-64 (19%) reporting this compared with about one in ten (11%) Black women ages 65 and over. Black women who describe their skin tone as “very dark” or “dark” are also more likely to report these experiences compared to those who describe their skin tone as “light” or “very light” (27% vs. 17%).

Black women who are younger or who have self-reported darker skin tones are more likely than their counterparts to say they prepare for possible insults or feel they must be very careful about their appearance to be treated fairly during health care visits. Vigilant behaviors, such as preparing for insults or considering one’s appearance, are sometimes adopted by people who experience discrimination as a means of protection from the threat of possible discrimination and to reduce exposure. Research has shown that heightened vigilance is associated with poor physical and mental health outcomes, including hypertension, sleep difficulties, and depression. While about half or more Black women regardless of income, age, and skin tone say they do one or both of these things at least some of the time, the share of Black women who report these vigilant behaviors is higher among those who are younger and have darker skin tones. For example, seven in ten (71%) Black women with self-reported darker skin tones say they have to be very careful about their appearance and/or prepare for insults at least most of the time, whereas about half (56%) of Black women with self-reported lighter skin tones say the same.

About one in three (34%) Black women who used health care in the past three years report that a negative experience with a health care provider resulted in worse health (13%), them being less likely to seek care (19%), and/or them switching providers (27%). Younger Black women are more likely than those ages 65 and over to report that a negative experience resulted in one of these consequences. In addition, Black women who describe their own physical and/or mental health as “fair” or “poor” are more likely than those who report better health to say that a negative experience resulted in worse health, being less likely to seek care, or switching providers in the past 3 years.

Black women who had at least half of their health care visits with a racially concordant provider report more positive interactions with their health care providers. For example, Black women who had at least half of recent visits with a provider who shares their racial or ethnic background are more likely than those who have fewer of these visits to say that their doctor spent enough time with them during their visit (80% vs. 66%), explained things in a way they could understand (90% vs. 82%), involved them in decision-making about their care (84% vs. 76%), understood and respected their cultural values or beliefs (84% vs. 75%), or asked them about social and economic factors (39% vs. 27%) during recent visits. However, about six in ten (63%) Black women say that less than half or none of their health care visits in the past three years have been with a provider who shared their racial or ethnic background. This suggests that increasing the diversity of the health care workforce may help increase positive interactions for Black women and points to importance of training and education among all providers to provide culturally competent and respectful care.

Maternal and infant mortality rates in the U.S. are far higher than those in similarly large and wealthy countries, with people of color at increased risk for poor maternal and infant health outcomes compared to their White peers. As a result, policy makers at both the federal and state levels are increasingly focusing on improving maternal and infant health outcomes and reducing disparities. At the federal level, the Consolidated Appropriations Act made permanent the option for states to extend Medicaid postpartum coverage to 12 months. As of April 2024, 46 states have implemented the 12-month extension. In addition, the Biden administration has identified maternal health as a priority, and their recent budget proposal includes enhanced efforts to improve maternal care. The nation’s governors, acting through the National Governors Association, have recognized the urgent need for action releasing the Tackling the Maternal and Infant Health Crisis: A Governor’s Playbook in July 2023. Also, in the 2023 Medicaid budget survey, conducted by KFF and Health Management Associates (HMA), nearly a third of all responding states mentioned initiatives to improve maternal and child health as a top priority for the year ahead.

The Medicaid program has potential to influence maternal and infant health outcomes as it finances about 4 in 10 U.S. births. While Medicaid’s coverage of maternity care has traditionally focused on prenatal and postpartum physician visits and labor and delivery care, a growing number of states have added new pregnancy or postpartum benefits in recent years, such as doula services, lactation services, and home visiting programs, to promote better maternal and infant health outcomes and reduce racial/ethnic health disparities.

To better understand state initiatives to expand Medicaid coverage of these less commonly covered pregnancy-related services, the 23^rd annual Medicaid budget survey, conducted by KFF and HMA asked states about strategies and challenges in promoting access to “non-traditional pregnancy-related care and services” and included childbirth education classes, doula services, home births, and home visits by lactation consultants as examples. The budget survey question was limited to services that were separately reimbursed as of July 1, 2023, outside of a hospital bundled payment and not as a component of an office or clinic visit. Maternity care is often reimbursed as a bundled payment that covers all professional services provided during the perinatal period, including prenatal care, labor and delivery, and postpartum care. These bundled payments do not typically cover non-traditional services. A previous KFF survey collected additional detail on pregnancy-related services included in bundled rates as of July 2021 and also identified specific pregnancy-related services provided by each state – detail that was not collected by the 2023 budget survey.

Forty-eight states (including DC) responded to the survey, although response rates for specific questions varied. The full report highlights state action to expand pregnancy and postpartum benefits including doula services, lactation supports, and home visiting programs.

What types of non-traditional (less commonly covered) pregnancy-related services are states separately reimbursing for?

As of July 1, 2023, more than two-thirds of responding states (32 of 47) reported coverage of at least one separately reimbursed, non-traditional pregnancy-related service. The following list describes services mentioned in state responses. A broader group of states may provide these services (like doula services) through a bundled payment.

• Doula services. Doula services were the most frequently mentioned non-traditional service. Doulas are professionals who support pregnant and postpartum people by providing a variety of services throughout the pregnancy and postpartum period, including visits during the prenatal period, labor coaching and support at the time of delivery, and postpartum care and assistance. Doula services are linked to more positive delivery outcomes, including reductions in C-sections, premature deliveries, and length of labor.¹ 
• Childbirth and/or parenting classes. There are a variety of education-related support services that can aid pregnant and postpartum individuals with pregnancy, delivery, and childrearing. These include childbirth education classes, infant and parenting education classes, and group prenatal care (e.g., Centering Pregnancy group prenatal care). While some states cover these services through their Medicaid programs, some states offer these services through other public health programs.
• Outpatient lactation supports. Lactation support can be provided in multiple settings in the postpartum period, including in the hospital before discharge, at outpatient visits, or at home. Many Medicaid enrollees are also eligible for WIC, which provides lactation support.
• Lay or “direct entry” midwife services as a non-traditional covered service. Midwives use a holistic, person-centered care model that has been linked to better maternal and infant outcomes. Most states only include certified nurse-midwives (CNMs) in their provider networks, as required by federal law, but recent state action has extended Medicaid coverage to other midwife providers, including midwives who may be credentialed to provide childbirth support and services despite not having a formal nursing education. States use various terms to refer to midwives without a nursing degree, including licensed midwife, direct entry midwives, licensed lay midwife, certified midwives, certified professional midwives, traditional midwife, and verifiable midwife.
• Home births. International studies suggest that home births may be as safe as hospital births for low-risk pregnant individuals and infants when they are part of an integrated and regulated system. Nevertheless, home births account for a small share of births in the U.S., although there has been growing interest since the start of the COVID-19 pandemic. Doulas, midwives, or physicians may be in attendance for home births.
• Other services. Other covered pregnancy-related services mentioned by at least one state as “non-traditional” include specialized care management or care coordination programs, home visiting programs, and pregnancy care via telehealth.

In addition to state efforts, there are federal efforts to expand access to non-traditional pregnancy-related services. In June 2022, the White House identified workforce expansion and diversification as one of its five goals for addressing the nation’s maternal health crisis. This goal includes, in part, promotion of doulas, midwives, and community health workers. Subsequently, CMS announced the Transforming Maternal Health (TMaH) Model in December 2023. The new model aims to improve maternal and infant health outcomes and reduce disparities by providing technical assistance and grant funding to up to 15 state Medicaid agencies. TMaH will help participating states improve access to care, including care from doulas and perinatal community health workers. The Biden Administration’s recently proposed budget also directs more than $300 million to improving maternal health, including an additional $5 million to grow and diversify the doula workforce. The proposed budget also includes an optional Medicaid maternal health support benefit aiming to address equity issues in maternal health outcomes. The benefit would include coverage of doulas, community health workers, and peer support workers. However, with a divided Congress, those budget proposals are not likely to be passed this year.

What are challenges and strategies to expand access to non-traditional pregnancy-related services?

While non-traditional pregnancy-related services have the potential to improve maternal health outcomes and reduce disparities, access-related challenges may limit utilization, despite state efforts to establish coverage and encourage take-up. Documented access-related barriers include workforce shortages, restrictive provider training/licensure requirements, low reimbursement rates, billing complexities, and quantity limitations. The 2023 Medicaid budget survey asked states about these challenges and initiatives to address them. The survey divided these challenges into six categories: 1) workforce shortages, 2) provider enrollment//training/certification/licensing needs, 3) low reimbursement rates, 4) billing challenges, 5) quantity limitations on hours/visits allowed, and 6) “other.”

Twenty-five states reported a challenge in at least one specified category. The following section describes the challenges most frequently mentioned by states and the approaches cited for addressing those challenges, if any. In some cases, initiatives to respond to challenges involve collaborative efforts between Medicaid agencies and managed care organizations (MCOs), state-level provider licensing boards, and/or private licensing entities.

The most frequently cited challenges related to provider enrollment, training, certification, or licensing. Eighteen states reported challenges in this category. States have varying approaches and standards for certifying or licensing non-traditional providers. For example, doulas have not historically received state medical board licenses, though many do receive certifications from private entities (which may involve significant training and cost). However, to receive Medicaid reimbursement, doulas must enroll as Medicaid providers and meet the state Medicaid department’s relevant qualification standards. Some doulas find this process to be challenging as it can involve costly and administratively burdensome training standards. Also, midwives can have varying levels of education and training (as described above) which could impact their ability to meet Medicaid enrollment requirements or limit the settings for which they can receive Medicaid reimbursement, particularly those who have not received nursing degrees.

Only a few states mentioned initiatives to address these challenges: Michigan has developed provider support materials, trainings, and toolkit information; Montana reported developing an outreach and education plan; New Jersey Medicaid staff are working with MCOs and the New Jersey Department of Health-funded Doula Learning Collaborative to provide technical assistance; in Virginia the Department of Health and the Virginia Certification Board are working to increase the number of doula training entities; and Wisconsin reported that it planned to update the state’s administrative code to allow additional non-traditional providers to become certified.

Seventeen states reported workforce shortage challenges. Several states reported that broader health care workforce shortages were also affecting the non-traditional pregnancy-related services workforce. States specifically mentioned shortages of doulas, lactation consultants, and providers of childbirth classes. In addition to widespread shortages brought on by the COVID-19 pandemic, states cited training requirements (discussed above) as a barrier to growing the non-traditional workforce. A few states noted specific initiatives to address workforce shortages in rural areas. For example, Kansas allows access to lactation consultants via telehealth to help improve access in rural areas, and New Mexico uses midwife services to improve access to care in rural areas with existing physician/OBGYN shortages.

At least four states described efforts to increase their doula workforce: New Jersey is working with non-profits, MCOs, and their sister agencies to increase access to accepted doula trainings; Virginia is recruiting more doulas to create an adequately sized doula workforce for their expected number of pregnant enrollees; Michigan is financing doula training courses, and Maryland is collaborating with their state’s Maternal and Child Health Bureau to recruit more doulas.

Fifteen states cite billing challenges for non-traditional pregnancy-related service providers. Several states noted that these providers are not familiar with Medicaid and MCO billing processes, which may be complex and time-consuming resulting in delays in payments as well as frustrations working with Medicaid agencies and MCOs. For example, Michigan reported that providers don’t always have the technology needed for Medicaid billing and New Jersey reported that doulas are not accustomed to the amount of paperwork for Medicaid billing. Some states are providing technical assistance, resources, and training to help providers navigate billing. For example, New Mexico reported exploring ways to streamline the billing process and Virginia is working with MCOs to provide support to doulas in Medicaid and MCO billing.

Eleven states reported low reimbursement rates for non-traditional providers as a challenge. Low reimbursement rates can disincentivize providers from enrolling in Medicaid, limiting access for Medicaid enrollees. This has been a barrier for perinatal professionals for many years. For example, in California implementation of Medicaid coverage for doula services was delayed due to disputes between the state and doula organizations over reimbursement rates. Non-traditional providers emphasize patient education and support, which means that they often spend extensive time with patients, and many have reported that Medicaid rates are not sufficient for covering their costs. Some states reported actions to address low reimbursement rates. Iowa and Indiana are evaluating their current reimbursement rates; Ohio is matching reimbursement rates to other programs, like the federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program; Kansas has plans to increase reimbursement rates for lactation services, and Wisconsin recently increased rates for prenatal care coordination services.

Five states reported challenges related to quantity limitations on hours or visits for doula services, childbirth education classes, and/or lactation supports. For example, while Virginia Medicaid currently reimburses doula services for up to eight prenatal/postpartum visits (90 minutes for the initial prenatal visit and one hour for other visits), the state reported that doulas have expressed the desire to have more allowed visits – e.g., a total of 12-16 visits, 6-8 prenatal and 6-8 postpartum visits — and longer visits. Also, Indiana reported that efforts were underway to develop doula-specific service limitations as the Community Health Worker benefit currently used to reimburse doula services was subject to visit limits that were “not conducive to doula activities.”

Four states commented on “other” challenges: California commented on working with hospitals to allow doulas access during birth; Georgia cited access to services in rural areas as a challenge; Missouri noted as a challenge the need to disenroll members from MCOs for a home birth to be covered through fee-for-service reimbursement payment; and Oklahoma commented on the challenge of structuring the doula services benefit in a way that allows doulas and patients to be matched on the basis of race, ethnicity, and language.

1. According to the National Health Law Program, 21 states covered or were implementing Medicaid coverage of doula services as of February 2024 (which could include services reimbursed through a bundled payment). ↩︎

In a new brief, KFF explores how abortion bans and restrictions in the aftermath of the Supreme Court’s 2022 Dobbs decision can further complicate pregnancy loss. 

Pregnancy loss, which includes miscarriage and stillbirth, is common, and for many people, it is a physically, mentally, and emotionally taxing experience. The medical interventions used to manage miscarriages and stillbirths are often the same medicines and procedures used in abortions, which means abortion bans and restrictions can end up limiting care for pregnancy loss. 

Further, the threat of criminalization and penalties for clinicians who provide abortions in states with bans can create a chilling effect on clinical care. Four in 10 OBGYNs who practice in states with abortion bans report that management of miscarriages and pregnancy-related emergencies has become worse since the Dobbs ruling.  While all state abortion bans have exceptions for cases of life endangerment of the pregnant person, they don’t account for the wide range of circumstances people may face when experiencing a pregnancy loss. Meanwhile, the growing record of documented cases of people experiencing pregnancy-related emergencies who have been denied care highlights what abortion restrictions can mean for pregnancy loss management. 

As concerns continue to be raised about consumer barriers to care resulting from prior authorization requirements, the federal government issued a final regulation aimed at streamlining and automating the prior authorization process and improving transparency for certain payers. Over the past two years, research and investigations into the use of prior authorization in Medicare Advantage and Medicaid managed care plans have brought renewed attention to the prior authorization process. For private commercial coverage, a growing number of states have passed wide-ranging prior authorization changes. This Issue Brief discusses the final regulation issued by the Centers for Medicare and Medicaid Services (CMS), how it might address some of the current consumer concerns, and the areas that are left for further evaluation. Key takeaways include:

• The new regulation will apply largely uniform prior authorization standards across almost all insurance programs that CMS oversees: Affordable Care Act (ACA) Marketplaces run by the federal government, Medicaid, and Children’s Health Insurance Program (CHIP) fee-for-service and managed care plans, and Medicare Advantage plans. These rules do not apply to prescription drug prior authorization, or prior authorization processes for most employer-sponsored health plans.
• The use of electronic processes to share the data needed for prior authorization review promises to improve the speed and efficiency of the process, but hurdles could exist that limit actual use of these technologies including patient awareness, limited education about how to use these features, and data privacy and security concerns.
• New transparency requirements will provide information to enrollees and the public about the specific services that require prior authorization by their health plan, and aggregate information about prior authorization claim denials. Claim denial information about the specific types of services denied is not included.
• The regulation will require some plans to shorten time frames for making prior authorization decisions but does not address how plans figure out what services require prior authorization; the clinical coverage criteria plans decide use to make prior authorization decisions; or the appeals structures in place that allow consumers to appeal a prior authorization denial to the plan and independent appeal entities.

Final Rules Focus on Electronic Processes and Increased Transparency

The major aim of the final rule is to improve the speed and efficiency of making prior authorization decisions through the standardized electronic exchange of information. It applies to payers (insurers and in the case of Medicaid fee-for-service, states) for the following plans: Medicare Advantage plans, Medicaid and CHIP fee-for-service and managed care plans, and qualified health plans (QHPs) on the federal Affordable Care Act (ACA) Marketplace. These payers will be required to make prior authorization information available through four different application programming interfaces (APIs). This will allow providers, payers, and consumers to know what medical items and services require prior authorization, what documentation is required for the plan to make a prior authorization decision, and the current status of a prior authorization decision (Box 1). The rule does not apply to most employer-sponsored health plans.

Four APIs are included in the final rule (Table 1). The Patient Access, Provider Access, and Payer-to-Payer APIs facilitate exchange of claims and clinical information about a patient so that it is more easily accessible electronically to make prior authorization decisions. This could also include information about past prior authorization decisions useful for a patient that is required to obtain prior authorization again for the same service when switching health plans. The Prior Authorization API will be used in the prior authorization process to pass information between the provider and payer.

Effective Date: The effective date of these new functionalities was changed from the January 2026 effective date in the proposed regulation to January 2027, giving payers extra time to implement what may be new processes for some of these plans. While nothing prevents these plans from putting these standards in place before then, the delay means that providers and consumers might not see noticeable changes soon.

Limits of API standards. The final rules will likely result in improvements where the API processes are utilized by providers and patients. Notably, these rules put requirements on payers to make certain information available so it can be accessed through an API. However, it will still require providers and patients to voluntarily use these API processes to take advantage of these efficiencies. Third party applications—consumer applications for the Patient Access API and electronic health record software for the Provider Access API—will likely need to be available to make this happen.

Patient use. CMS indicates in the final rule that consumers have been slow in utilizing the existing Patient Access API functionalities and may require additional education and resources to take advantage of the Patient Access API. CMS will be tracking consumer use of the Patient Access API through annual reporting requirements including the total number of unique enrollees whose data are transferred using the Patient Access API. While this number might help gauge traction of the API overall, it may not accurately reflect patient engagement in the prior authorization process. This API may be used for purposes other than monitoring prior authorization, such as downloading a clinical history. Additionally, consumer interaction with the insurer where the API is not used, either through insurance portals or telephone, would not be considered in the metrics even if conveying information on prior authorization.

Providers will be able to access their patient’s information through the Provider API. Patients that do not want their information accessed in this way can opt out to prevent this exchange. Payers must provide educational resources written in plain language to patients describing the Provider Access API and instructions for opting out (or back in) to the data exchange. Since multiple mechanisms exist apart from the new APIs for disseminating patient clinical information (such as through a health information exchange), it may be confusing for some consumers that opting out of the Provider Access API may not prevent their information from being shared.

For the Payer-to-Payer API, a patient’s information will not be shared between payers unless a patient opts in with both their previous and new insurers for data to be exchanged. One potential value of this API is to allow a patient’s new health plan to access information about a prior authorization approval from the patient’s previous health insurer. This might eliminate the time a patient and their doctor must spend to obtain a new prior authorization for the same treatment when a patient must change their health insurance. Given the opt in requirement, lack of awareness of this API could limit its use.

Provider use. Use of the API for providers is voluntary and might not be up to individual practitioners todecide, as increasing numbers of providers are employed by large health systems that make these business decisions. Use of the Provider Access API is broadly available to all in-network providers that treat a given patient, such as specialists who have recently received a referral but have not yet seen the patient. Unless querying the payer through the Provider Access API is enabled by information technology infrastructure and is part of the established provider workflow, use of the API could be somewhat limited. Also, since support of APIs is not universally required of all payers, a provider would need to determine whether their patient has a payer required to provide this information through the API. The final rules do add a new Electronic Prior Authorization measure for providers under the Merit-based Incentive Payment System (MIPS) to encourage providers to use the Prior Authorization API.

Other Changes Required in the Final Rule

The remaining standards in the final prior authorization regulation would make changes to what CMS calls “business process” rules. Payers will need to make these changes by January 2026 whether API processes are used or not:

Shortened Timeframes. Medicare Advantage plans and Medicaid and CHIP (both fee-for-service and managed care plans) will have to make standard prior authorization decisions within 7 calendar days and expedited decisions within 72 hours of prior authorization requests for medical treatment. Shorter timeframes could apply to programs that are subject to state law, but the rules provide a federal floor of protections. This would tighten some decision-making standards. For example, currently Medicare Advantage timeframes are 14 calendar days for standard decisions. The final regulations do not change timeframes for QHPs on the federal Marketplace (generally, 15 days to make standard prior authorization decisions and 72 hours for expedited requests, although states may have shorter timeframes). See Table 2 for current and new timeframes.

Reasons for denial. Plans must give a specific reason for a denial to the provider and the patient through their APIs. This does not change existing notice rules that may already require notice to patients (and in some case providers). This requirement is meant to align all program standards to make sure providers have the information about a denial so that they can take whatever necessary steps are needed for their patient—whether that is an appeal of the decision and/or a recommendation for an alternative treatment.

New public reporting on prior authorization. All payers covered by the final rule will have to report information about prior authorization determinations. See call out box. The goal is that new transparency of aggregate information about prior authorization will “allow for objective evaluation of the efficiency of prior authorization practices of each organization.”  Public reporting information for prior authorization will be available directly for consumers to review on a payer’s website but will not be aggregated by CMS. While there is an expectation that patients could use the information when selecting among plan or organization options, it is not clear whether consumers understand that prior authorization data will be available, how to access them, and how these data could inform their decisions of selecting an insurer. At a minimum, the information posted on the website could be a resource for better information about what items and services require prior authorization.

Issues Remain

The final regulation is a first step toward addressing existing challenges, including those that unnecessarily delay prior authorization decisions, causing patients and providers to scramble to obtain medically necessary care they thought was covered by insurance. This regulation, however, does not get to many of the patients affected by prior authorization and many of the issues raised about prior authorization. This includes the following:

Prescription drugs

Only medical items and services are covered by the final regulation, not prior authorization requirements for drugs, whether self-administered, administered by a provider, dispensed by a pharmacy, or purchased over the counter. CMS cited operational complexities in applying API and other standards, but the agency received many comments objecting to the exclusion of drugs and in response says they will consider options for future rulemaking. Examples of concerns often arising for prescription drug prior authorization include:

• Step therapy. While not limited to pharmacological treatments, step therapy is often a limitation to immediate access to a medication that a provider recommends. Step therapy is where a plan requires a patient to take another medication or treatment and determine it is not effective before it will authorize coverage for a specific medication. Some states require commercial plans with step therapy requirements to have an exceptions process for enrollees whose condition warrants receiving the prescribed and covered medication without trying an alternative beforehand. These state laws do not apply to self-insured employer-sponsored plans, which represent a majority of those covered through employers.
• Claim review timing. Time is often of the essence for medications such as chemotherapy oral medications to treat cancer. CMS points out in the new regulation that some existing programs already have expedited timeframes for review of an initial claim specific to prescription drugs. For example, Medicare Advantage plans must respond within 24 hours to an expedited prior authorization request for a Medicare Part B drug. Medicaid contracting rules require a response within 24 hours of a prior authorization request of a covered outpatient drug if the state requires prior authorization. These expedited timeframes might not apply to commercial insurance provided on the Marketplace unless state law requires it. Federal claims review standards that are part of the Affordable Care Act (ACA) were taken from existing ERISA internal claims standards and timeframes issued in a U.S. Department of Labor (DOL) claims and appeals regulation from 2000. These rules do not include timeframes specific to prescription drugs.

Large employer-sponsored plans

CMS does not regulate large private employer plans that are subject to ERISA requirements administered by the DOL. As a result, these rules do not change any of the current requirements for most Americans who are covered by large insured and self-insured employer plans. Even most small employer plans are not covered, unless they obtain their insurance through the Small Business Health Options Program (SHOP) with an insurer that offers coverage to both individuals and small employers on a federal Marketplace. For these private employer plans not covered by the CMS prior authorization rules, federal standards for “internal” claim review and appeal (where a health plan makes an initial coverage decision and then reviews the decision again if a consumer appeals) for prior authorization and other claim decisions have not been updated since 2000. The ACA applied these rules from 2000 to most non-grandfathered individual and group health plans (including Marketplace plans) in 2010.

Prior authorization requirements have been a focus of DOL oversight for mental health parity standards. A 2023 DOL enforcement report noted that these were the top issues where the agency found violations. Also, concerns about the failure to provide adequate notice of the reasons for a denial was the subject of a recent federal appeals court decision that has garnered some attention.

In addition, continuing an already approved prior authorization for those changing employer-sponsored plan benefit options from year to year or transitioning to Marketplace or Medicaid coverage can put a halt to the preauthorized care at the beginning of the plan year (or due to a midyear formulary change). ERISA does not address these types of transitions. Last year, CMS adopted changes for Medicare Advantage coordinated care plans that require a minimum 90-day transition period when an enrollee currently undergoing a course of treatment is new to Medicare or switches Medicare Advantage plans. Plans cannot require reauthorization of care during this 90-day period.

Plan processes for prior authorization decision making

The final regulation does not address how prior authorizations decisions are made within a health plan, including any plan processes for deciding what types of services warrant prior authorization, the clinical and other coverage criteria a plan uses to make these decisions, the individuals and technologies utilized to make prior authorization decisions, and how these prior authorization processes are updated over time as research results in more information about the effectiveness and cost of a service.

Rationale for applying prior authorization. Some point to the wide variation across different health plans of the services that require prior authorization. Scrutiny of this plan variation might uncover unnecessary or outdated use of prior authorization resulting in a high volume of prior authorization requests and the resulting administrative burden on providers and patients. One study of over 200 Medicaid managed care plans that covered buprenorphine (a medication used to treat opioid use disorder) found large variation within and across states on whether plans required prior authorization for the drug.

Clinical coverage criteria. Attention has also focused on the clinical criteria that plans use to make prior authorization decisions. Issues include whether the criteria are transparent to patients and providers, appropriate for the specific claim being evaluated, or whether the criteria are evidence-based. A report from the U.S. Department of Health and Human Services’ Office of the Inspector General (OIG) on improper use of a Medicare Advantage plan’s internally-developed clinical criteria for prior authorization decisions led to a 2023 CMS regulation and recent guidance clarifying when such criteria can be used. These rules are limited to Medicare Advantage plans. How clinical coverage criteria are applied has been the subject of litigation involving employer-sponsored plans covered under ERISA, including an ongoing case on the alleged improper use of a plan’s own coverage criteria and a recent case questioning the use of an independently developed clinical guideline.

Use of automated processes. How plans process the millions of prior authorization requests and other claims filed every year has also become the subject of scrutiny. A DOL case filed last summer accused a large third-party administrator of automatically denying certain types of claims without human review, in violation of ERISA rules. In addition, the use of artificial intelligence (AI) in claims review has triggered additional private litigation involving Medicare Advantage plans and private  plans. It is unclear whether streamlining data collection through the API will facilitate application of such technologies to the prior authorization process and whether similar litigation will result.

Appeals of prior authorization decisions

KFF research indicates that few patients engage the appeals process, whether for prior authorization in Medicare Advantage plans or for claims from federal Marketplace plans denied for lacking prior authorization. A denial of prior authorization is a “claim denial.” Many are not aware they have a right to appeal, according to the KFF 2023 Consumer Survey. Some consumers may not have the time or ability to navigate a complicated appeals process. Others may be relying on their provider to take action. A KFF analysis of Medicare Advantage prior authorization denials found that of the small number of denials that were appealed to the health plan (an internal appeal), a large percentage (82%) were either partially or completely overturned. Increased use of appeals processes might uncover improper prior authorization claim denials, whether resulting from an administrative mistake or more systemic problems in a claims review system.

Limited appeal information in final rule. The CMS final prior authorization rule will provide some new and ongoing information about prior authorization, but limited information about appeals of prior authorization denials. Plans must publicly report the percentage of prior authorization requests that were approved after appeal but does not require that plans provide any other information about the specific service involved in the appeal, the reason for the initial denial, or the rate of appeal to health plans. While some information is reported to CMS or states for Medicare Advantage and Medicaid, currently there are few sources for information about appeals in private coverage available. The Market Conduct Annual Statement (MCAS), developed by the National Association of Insurance Commissioners (NAIC), can provide most states with uniform market-related commercial health plan information and data including on prior authorization requests, approvals, denials, and external appeals requests for adverse benefits determinations which are reported in aggregate and not publicly available. CMS also releases data on claims denials and appeals for QHPs offered on the federal Marketplace, including for prior authorization.

No information on the use of independent and automated systems of appeal. The CMS final regulations appear to require plans to report on their own appeals outcomes—those appeals reviewed by plans internally—but not the outcome of independent external review of prior authorization denials. All appeals systems have some form of independent external appeal entity. For private coverage, including Marketplace and employer-sponsored coverage, the ACA added the option for independent appeals for certain claims. Patients must individually request to appeal a denied prior authorization claim to external appeal. By contrast, Medicare Advantage plans require automatic review of a claim denial by an external entity (an Independent Review Entity or IRE) following the denial of a claim on appeal to the health plan. For consumers in Medicaid managed care plans, state fair hearing and access to independent appeal entities is available, but an HHS OIG report found these enrollees in Medicaid managed care plans are less likely to have access to an external, automated review process compared to Medicare enrollees.

Looking Forward

Prior authorization will continue to be an important tool for health insurers. Many insurers have announced that they have reduced the volume of prior authorization requirements, but with few specifics on where these reductions are being made. Congress is starting to focus on prior authorization reforms, with pending legislation that would make changes for Medicare Advantage plans (for example, H.R. 4822) and an investigation by at least one Congressional committee on prior authorization practices of Medicaid managed care plans. A recent Medicare Advantage and Medicare Part D final regulation will require plan utilization management committees to issue an annual plan level health equity analysis of prior authorization policies.

Even for electronic processes, there is more to come. Further actions will likely involve including API functionality in the provider’s electronic health record to make it easier to use these automated electronic processes. More streamlined processes might also focus not just on business processes, but on how patients use the system, allowing them to appeal a prior authorization or claim denial to an independent entity through a simple process on their smart phones so that they can also get the benefit of innovation. Enhanced visibility into the prior authorization process by patients, through means enabled by the patient access API, could increase patient engagement in the process and contribute to a higher appeal rate.

As the number of health apps using the patient access API grows, there is increasing opportunity for monetization of patient information, with potential security and privacy risk to the payers’ systems. While payers must provide information to their subscribers on steps to protect their privacy, this limited education might not be sufficient to prevent users from authorizing the collection of commercially valuable patient information by app developers, who may not be covered entities under HIPAA privacy rules. Inclusion of prior authorization information could make mining for certain conditions easier. Questions surrounding security also exist in addition to privacy concerns. The recent cybersecurity breach at UnitedHealthcare is a reminder of the limits of the sole reliance on electronic systems. There may be renewed attention to the importance of enhanced security and privacy protections as systems of data exchange become more interoperable.