Prior authorizations should follow a patient to a new plan. Consider a patient halfway through a course of physical therapy after a knee replacement, or a few weeks into home health care after a hospital stay, who changes health plans. The first plan approved the care. The new plan has no record of it. Unless someone tells the new plan, the provider has to submit a new request, and treatment already judged appropriate stops while the question is asked again.
The rules already say this should not happen. Making them work depends on whether the approval, and the reasons for it, travel with the patient.
Continuity rules need data to work
Several layers of policy now protect patients who switch plans mid-treatment. Medicare Advantage rules require coordinated care plans to provide a transition period of at least 90 days for enrollees in an active course of treatment, during which the new plan may not require prior authorization for that course, as we described in February. In June 2025, health plans pledged to honor existing prior authorizations for benefit-equivalent in-network services during a 90-day transition starting in January 2026, and states including Montana and Indiana have written similar protections into law.
Each of these protections assumes the new plan knows what was approved. Today, that knowledge usually arrives through the patient or the provider, often as a phone call or a faxed approval letter. If no one calls, or the information arrives incomplete, the new plan treats the request as new. The protection exists on paper and fails in practice.
The failure is quiet. A patient whose therapy is interrupted for a week while a new authorization is processed may never know that a transition rule was supposed to prevent it. The new plan may not know either.
What the payer-to-payer requirement does
CMS’s January 2024 interoperability and prior authorization rule creates the infrastructure that continuity rules have been missing. By January 2027, impacted payers must implement a Payer-to-Payer API. They include Medicare Advantage organizations and qualified health plan issuers on the federal exchanges, along with Medicaid and CHIP programs and their managed care plans. According to the CMS fact sheet, the API must make 3 kinds of data available.
- claims and encounter data, excluding provider remittances and enrollee cost-sharing information
- the clinical data classes and elements in the US Core Data for Interoperability
- information about certain prior authorizations, excluding those for drugs
Payers must share data with dates of service within the previous 5 years, and patients must opt in to the exchange.
That last element is important for continuity. When a new plan receives a list of the patient’s prior authorizations from the previous plan, it can see which courses of treatment were approved and for how long, without waiting for the patient or provider to tell it.
A plan cannot honor an approval it does not know exists.
The requirement has limits. It does not apply to employer-sponsored plans, so a patient moving from employer coverage to Medicare Advantage, one of the most common transitions, may arrive with nothing. It also excludes drugs, and it works only when the patient opts in, which means plans have to ask clearly and early.
What good continuity looks like
The API is necessary, not sufficient. A plan that receives prior authorization data still has to use it.
- Ask at enrollment. The opt-in should be part of enrollment, explained in plain terms, so that the exchange can begin before the patient’s first claim.
- Request promptly. Data that arrives after the patient’s first appointment is too late to prevent a gap. The request to the previous plan should go out as soon as coverage begins.
- Load active approvals as approvals. An incoming prior authorization for an active course of treatment should appear in the new plan’s utilization management system as an approval to honor during the transition, not as background information for a reviewer to rediscover.
- Carry the reasons. The approval is more useful with the criteria and documentation behind it. When the transition period ends and the new plan has to decide whether to continue coverage, it should start from what the previous plan knew, not from nothing.
- Tell the provider. The treating provider should learn that the new plan has the approval and will honor it, so the office does not resubmit out of caution.
- Measure the gaps. A plan can track how many new members arrive in active treatment and how many of them it identified in the first week. Avoided resubmissions are the other number worth counting.
Until 2027, much of this will still depend on manual work. Plans can prepare by deciding now how incoming approvals will appear in their systems and who will act on them. The plans that design those steps before the API arrives will be able to use it on the first day.
What we build for
We build tools health plans use in utilization review, and continuity is one of the clearest places where software can help without making a hard judgment. An incoming approval for an active course of treatment, received from the previous plan, is the kind of request a machine can say yes to during the transition period. A machine can say yes. Only a person can say no. If the new plan believes the course of treatment should change, a clinician should make that call, with the previous plan’s approval and its reasons in view.
We also think the record of what was carried over should be kept. Every decision we help record can be reconstructed, and that record should show what the previous plan approved and what the new plan did with it. When a patient asks why a treatment continued or stopped after a plan change, the answer should be in the record.
The point of a transition rule is that a patient’s care should not depend on which plan they happen to be in that month. Data that moves with the patient is how that promise is kept.