The Centers for Medicare and Medicaid Services (CMS) released two proposed rules on April 10: the fiscal year 2027 Inpatient Prospective Payment System (IPPS) proposed rule and another on interoperability and prior authorization for drugs for Medicare Advantage organizations and Medicaid Managed Care plans.

The 2027 IPPS proposed rule includes a net increase to inpatient hospital payment of 2.4%, reflecting a 3.2% increase in the hospital market basket reduced 0.8% by the productivity adjustment.

After initial review, ACC Advocacy staff have identified the following provisions as noteworthy for cardiology:

• The proposed rule modifies five mortality measures including 30-day all-cause risk-standardized mortality rates for acute myocardial infarction (AMI), heart failure (HF) and CABG surgery.
• CMS proposes adding Medicare Advantage patient data and shortening performance periods from three years to two years for Excess Days in Acute Care after AMI and HF measures.
• A proposal regarding graduate medical education payments was added requiring an approved medical residency training program "not discriminate, or promote or encourage discrimination, on the basis of race, color, national origin, sex, age, disability, or religion, including the use of those characteristics or intentional proxies for those characteristics as a selection criterion for employment, program participation, resource allocation, or similar activities, opportunities, or benefits."

For more on the 2027 IPPS proposed rule, access the full text and accompanying press release and fact sheet.

The proposed rule on interoperability and prior authorization aims to make drug prior authorization more electronic, standardized, faster and transparent by extending existing interoperability and prior authorization requirements to prescription drugs. Some key points include:

• The proposed rule expands electronic prior authorization for drugs across specific payers including Medicare Advantage organizations, state Medicaid and Children's Health Insurance Program (CHIP) Fee-for-Service programs, Medicaid Managed Care plans, CHIP Managed Care entities, Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchange (FFE), and newly added QHP issuers on the FFE SHOP. Impacted payers will support electronic prior authorization using Fast Healthcare Interoperability Resources (FHIR)-based standards for drugs under the medical benefit and National Council for Prescription Drug Programs standards for drugs under the pharmacy benefit.
• Payers would have to make drug prior authorization decisions within shorter timeframes (24 hours for urgent requests, 72 hours for standard requests) and give providers a specific reason when a request is denied so providers can fix, resubmit or appeal the request more easily. These updated timeframes align with current prior authorization requirements for decision times on medical procedures and the ACC's past recommendations for drug prior authorization decision times.
• Impacted payers would also have to share prior authorization status and decision details through CMS-required interoperability application programming interfaces (APIs) that use HL7 FHIR-based standards and implementation guides, in addition to publicly reporting prior authorization metrics.
• Most proposed requirements are planned to take effect around Oct. 1, 2027, with additional public reporting and API usage metrics phased in starting in 2028.

For more on the proposed rule, access the full text as well as the accompanying press release and fact sheet.

ACC Advocacy staff are currently reviewing both proposed rules and will submit formal comments to CMS in the coming weeks. Explore ACC's Regulatory Affairs Roadmap for more on how the College develops formal policy positions.

Keywords: Prospective Payment System, Centers for Medicare and Medicaid Services, U.S., Prescription Drugs, Inpatients, Prior Authorization, Policy, ACC Advocacy