Prior authorization (PA) has long been one of the heaviest administrative burdens facing family physicians. A patient needs a medication, procedure or referral, but before care can move forward, everyone must wait. That wait has real consequences, including delayed treatment, frustrated patients who may not receive needed care in a timely manner and increased administrative burden for physicians.
Over the past two years, Minnesota and the federal government have taken meaningful steps to reform the PA system. Here is what has changed, what is coming next and what family physicians need to know.
Minnesota’s 2024 Prior Authorization Reforms Are Now in Effect
Prior authorization reform was a top priority for the Minnesota Academy of Family Physicians (MAFP) during the 2024 legislative session. The legislation, included in the Health and Human Services (HHS) omnibus bill that passed in the final hours of the session, took effect in 2026 and represents a significant win for Minnesota patients and family physicians.
What the 2024 law does:
- Expands the law’s scope. For the first time, all PA requirements now apply to Medical Assistance (MA) and MinnesotaCare. Previous state law had excluded these public programs.
- Protects patients with chronic conditions. A PA approval for a chronic condition does not expire unless the standard of care changes.
- Prohibits PA for certain services outright. Health plans may no longer require PA for preventive services (including those recommended by the U.S. Preventive Services Task Force), pediatric hospice care, pediatric neonatal abstinence syndrome programs, non-medication treatments for cancer, outpatient mental health and substance use disorder care.
- Speeds up some medication decisions. Medications used to treat cancer, mental health conditions and substance use disorder may still require PA, but insurers must now issue a decision within 48 hours — down from five days.
- Requires annual transparency reporting. Health plans and pharmacy benefit managers (PBMs) must report annually to the Minnesota Department of Health on how often they require, approve and deny prior authorizations.
- Requires electronic PA systems. Health plans must implement automated processes — consistent with new federal requirements — to determine whether PA is required and what documentation is needed.
- Closes retroactive denial loopholes. Health plans are prohibited from denying coverage after the fact simply because PA was not obtained, if PA was not required at the time of service. Plans also may not deny coverage solely due to lack of PA if they would have otherwise covered the service.
It is important to note that Minnesota’s PA law applies only to state-regulated insurance products, including fully insured employer-sponsored plans, Medical Assistance, MinnesotaCare and state employee plans. It does not cover self-insured employer plans (roughly 35% of the market) or Medicare, which are governed by federal law.
The Minnesota Medical Association (MMA) has published a detailed Physicians’ Guide to Minnesota’s Prior Authorization Law (updated January 2026) that summarizes every provision, decision deadline and appeals pathway, including how to file complaints with state regulators when plans fall out of compliance.
Federal Action: CMS Streamlines PA for Medicare and Medicaid
In January 2024, the Centers for Medicare & Medicaid Services (CMS) finalized a rule — Advancing Interoperability and Improving Prior Authorization Processes — that reflected years of advocacy by the American Academy of Family Physicians (AAFP). The rule began rolling out January 1, 2026, and covers Medicare Advantage (MA) plans, state Medicaid and Children’s Health Insurance Program (CHIP) plans and qualified health plan issuers on federal exchanges.
Key provisions of the 2024 CMS final rule:
- Requires electronic PA systems to streamline how physicians submit requests and receive decisions.
- Sets standard decision deadlines: seven calendar days for routine requests and 72 hours for expedited requests.
- Requires insurers to provide specific reasons for PA denials and instructions for appeals.
- Mandates public reporting of PA metrics to increase transparency.
- Ensures that once a PA is approved, it remains valid as long as medically necessary.
The AAFP called the rule “significant progress to address care delays and the administrative burden physicians and their patients face daily.”
One important limitation: the 2024 rule applies only to non-drug items and services. Prescription drugs are explicitly excluded.
What’s Next: A Proposed Rule for Prescription Drugs
In April 2026, CMS issued a new proposed rule — Interoperability Standards and Prior Authorization for Drugs — to extend the 2024 framework to prescription medications. If finalized, the rule would apply to the same programs as the 2024 rule and would:
- Require electronic PA for drugs covered under both medical and pharmacy benefits.
- Set PA decision deadlines for prescription drugs modeled on existing Medicare timelines.
- Require annual transparency reporting for drug-specific PA metrics.
- Target implementation by October 1, 2027.
A May 2026 analysis in Health Affairs noted that while the proposed rule would meaningfully reduce administrative burden, it ends at the initial coverage decision and largely leaves the appeals process unaddressed — an important gap to watch as the rule is finalized.
On the Congressional Front
The Improving Seniors’ Timely Access to Care Act, reintroduced in 2024, would codify many of the CMS reforms into law for Medicare Advantage and add additional protections, including real-time decision requirements for routinely approved services. The AAFP has urged Congress to pass the bipartisan legislation, noting that regulatory reforms alone cannot make these changes permanent.
Your Voice Matters: Take Action on PA Reform
The CMS proposed rule on PA for prescription drugs is open for public comment through June 15, 2026.
This is a direct opportunity for family physicians to weigh in on federal regulations that will shape how PA works for the medications your patients need. The AAFP has long championed these reforms, and your comments as a Minnesota family physician add an important frontline perspective.
For physicians seeking additional information or support:
- The MMA provides a detailed Physicians’ Guide to Minnesota’s Prior Authorization Laws, including current requirements and instructions for filing complaints with regulators when plans are out of compliance.
- For questions or assistance navigating state insurance regulators, you can also contact the Minnesota Department of Commerce at 651-539-1600.
