The Centers for Medicare & Medicaid Services (CMS) requires reporting of data related to program operations, expenditures, and outcomes. These requirements include regular submission of financial reports, eligibility and enrollment data, claims and utilization information, and performance metrics tied to federal standards and initiatives. Through these reports, CMS monitors compliance with federal regulations, assesses program integrity, evaluates quality of care, and ensures appropriate use of federal funds, while also supporting transparency and accountability across the Medicaid program.
Prior Authorization Process Changes and Metrics
The Centers for Medicare & Medicaid Services (CMS) requires reporting of data related to program operations, expenditures, and outcomes. These requirements include regular submission of financial reports, eligibility and enrollment data, claims and utilization information, and performance metrics tied to federal standards and initiatives. Through these reports, CMS monitors compliance with federal regulations, assesses program integrity, evaluates quality of care, and ensures appropriate use of federal funds, while also supporting transparency and accountability across the Medicaid program.
The Centers for Medicare & Medicaid Services (CMS) issued the Advancing Interoperability and Improving Prior Authorization Processes Final Rule (CMS-0057-F). This Final Rule requires Alabama Medicaid to process prior authorization (PA) requests under the medical benefit within seven calendar days, and expedited PA requests within 72 hours, effective January 1, 2026. Metrics about processed PAs must also be made available on a public website annually, effective March 31, 2026. These timelines and public reporting requirements apply to PAs for medical items and services only, excluding Pharmacy PAs. To learn more, visit Prior Authorization Changes and Metrics.
Ensuring Access to Medicaid Services
The Centers for Medicare and Medicaid Services (CMS) published the Ensuring Access to Medicaid Services Final Rule, 89 FR 40542 (2024 Access Final Rule) on May 10, 2024. The provisions of the 2024 Access Final Rule were organized into three main subsections: 1. The Medicaid Advisory Committee (MAC) and Beneficiary Advisory Council (BAC), 2. Home and Community Based Services (HCBS), and 3. Documentation of Access to Care and Service Payment Rates.
The Access rule addresses critical dimensions of access across both Medicaid FFS and managed care delivery systems, including HCBS. Overall, these improvements seek to increase transparency and accountability, standardize data and monitoring, and create opportunities for states to promote active beneficiary engagement in their Medicaid programs with the goal of improving holistic access to care. This section has information on, “documentation of access to care and service payment rates,” which is specific to fee-for-service (FFS) delivery systems and rates. To learn more, visit Ensuring Access to Medicaid Services.