Upcoming Prior Authorization Reforms: What Will Change, What Won’t, and What's Left Out

Prior authorization reform has been a long time coming. After many calls for change, a wave of new policies and industry commitments are hoped to finally overhaul the process that requires clinicians to get insurer approval before certain treatments or medications are covered.

For patients, providers, and payers, the immediate challenge is understanding what is changing, when those changes will take effect, and how much they will address the core issues around prior authorization. Most importantly, will the reforms truly make it easier for patients to get the care they need?

Why prior authorization has become a policy priority

A major criticism of prior authorization as it is today is that it creates substantial administrative work for providers. In the 2025 American Medical Association (AMA) survey, about 40% of physicians reported employing staff who worked exclusively on prior authorization. Despite that effort, 95% said the process delays care at least sometimes, 79% said it can lead patients to abandon treatment, and 26% reported that it had contributed to a serious adverse event.

Claims data show what those reported delays can look like in practice. One study followed more than 205,000 branded prescriptions after they triggered a prior authorization-related rejection at the pharmacy. Only 35% received a final decision within one day. The rest took a median of six days, and just 54% were ultimately approved. Clearly, many patients experience a significant wait when trying to start or continue treatment.

The prior authorization reform timeline

Prior authorization reform is unfolding in stages, on a number of different timelines. Here’s what has already changed and what changes are forecasted for the future.

In effect now: Federal prior authorization rules for medical services

At the start of 2026, new Centers for Medicare & Medicaid Services (CMS) prior authorization requirements took effect for medical items and services, requiring CMS-regulated payers to provide prior authorization decisions within 72 hours for urgent requests and within seven days for standard requests. Payers must also provide a specific reason when a request is denied and publicly report selected prior authorization metrics each year.

What this changes: Prior authorization decisions for covered medical care should arrive on a more predictable schedule and include clearer explanations when denied. Required reporting should also make approval rates, denial rates, and response times more visible.

What this doesn’t change: The requirements don’t apply to prescription drugs. They also don’t affect which medical services require prior authorization or what clinical criteria payers use to approve or deny care.

Rolling out through 2027: Voluntary insurer reforms for medical services

Major insurers committed to reforms, some beginning in June 2025, and others in January 2026. These include clinical review of non-approved requests, fewer services subject to prior authorization, continuity protections when patients change plans, and clearer communication about decisions. Insurers also pledged to standardize electronic prior authorization and expand real-time responses by January 1, 2027.

What this changes: If insurers follow through, fewer services may require prior authorization, patients may be less likely to lose an existing authorization when switching plans, and providers may receive clearer information about decisions. The 2027 commitments could also reduce the need to navigate different forms, portals, and manual workflows.

What this doesn’t change: Because the commitments are voluntary, their impact depends on insurers following through. According to the AMA survey, only 24% of physicians believe medical-necessity denials are being reviewed by a licensed and qualified clinician as insurers had pledged. But AHIP, the health insurance industry association, reports early progress, including an 11% reduction in prior authorization requirements.

Due January 1, 2027: Electronic prior authorization for medical services

Additional CMS prior authorization requirements will take effect at the start of next year, requiring CMS-regulated payers to support electronic prior authorization for covered medical items and services. They must provide digital connections, called application programming interfaces (APIs), that allow a provider’s electronic health record (EHR) to check whether prior authorization is required, identify and submit needed documentation, and receive a decision or request for more information within the same workflow.

CMS is also trying to make sure those technical requirements work in practice. In May 2026, it announced 29 early adopters who are working on the workflow and technical issues that have slowed electronic prior authorization adoption.

What this changes: Prior authorization workflows should require less manual work as they become more automated and digital, while also helping providers receive decisions more quickly.

What this doesn’t change: The requirements apply to medical items and services, not prescription drugs. Electronic infrastructure will be made available, but that doesn’t guarantee that every EHR will integrate it smoothly or that every provider will adopt it immediately.

Proposed for October 2027: Electronic prior authorization for prescription drugs

CMS has proposed a separate rule to bring prescription drugs into the electronic prior authorization framework. It would establish electronic standards for checking drug coverage requirements, submitting authorization requests, exchanging supporting information, and receiving decisions.

What this could change: Clinicians could learn earlier whether a medication requires prior authorization, receive more real-time information about coverage, alternatives, and patient costs, and submit supporting documentation electronically.

What it leaves out: While CMS has proposed that the requirements take effect October 1, 2027, the rule has to be finalized.

Where prior authorization reform still falls short

The current wave of reform could bring about changes physicians and patients have sought for years. If the proposed measures are fully implemented, prior authorization should become faster and less labor-intensive. Fewer requests may be required overall, and for medical services, patients and clinicians should be able to expect urgent decisions within 72 hours.

But at Cinnamon, we believe speed and automation are only part of the answer. Beyond the fact that much of this work is still being implemented or merely considered, the expected reforms still sidestep many of the questions at the heart of the debate: when prior authorization should be required, what clinical standards payers should follow, and how a denial can be challenged.

We also need better data that shows what happens after a denial. How often do appeals succeed? How many patients give up on treatment in the meantime? How long does it ultimately take to receive care?

We believe the answers to those questions are the standard by which reform should be judged. We need not just a faster prior authorization process, but a better chance for patients to get the treatment they need without avoidable delays or denials.