Compliance News Week Ending June 27, 2025

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Insurers' Pledge to Simplify Prior Authorizations

Final Rule - 2025 Marketplace Integrity and Affordability

Insurers’ Pledge to Simplify Prior Authorizations

Health insurers that are part of America’s Health Insurance Plans (AHIP), a national trade association representing health insurance companies, have pledged to simplify the prior authorization process through several key reforms.

They aim to implement standardized electronic prior authorization systems by January 1, 2027, reduce the number of services requiring prior authorization by January 1, 2026, and ensure continuity of care by honoring existing prior authorizations for 90 days when patients switch plans mid-treatment.

Some of these things are not new and may already be required of insurers, but perhaps with this pledge and the agreement to post data publicly about prior authorization, we will see improvements for patient access to care and a reduction in administrative burdens for providers over time.

Final Rule – 2025 Marketplace Integrity and Affordability 

The Centers for Medicare & Medicaid Services (CMS) finalized a rule that may have a significant impact on individual health coverage available through public Marketplaces beginning in 2026.

Amongst other things, the rule shortens the open enrollment window to Nov. 1 – Dec. 15 for federally-run Marketplaces and requires that no Marketplace offer an open enrollment longer than Nov. 1 – Dec. 31; increases eligibility verification and reconciliation requirements for premium tax credits; and adjusts the methodology used to set premiums.

It is estimated that some of these changes may result in lower overall premiums and will reduce improper enrollments and payment of premium tax credits. However, the changes might also make it more difficult to obtain individual coverage and qualify for premium tax credits through public Marketplaces.

In addition to the Marketplace changes, the rule prohibits individual and small group fully-insured plans from providing coverage for specified sex-trait modification procedures and provided the 2026 out-of-pocket (OOP) maximums for ACA group health plans. The 2026 maximum OOP is $10,600 for self-only coverage and $21,200 for other than self-only coverage (currently $9,200 and $18,400 for 2025).

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