CMS-0057-F, payer type by payer type
Medicare Advantage Organizations
Medicare Advantage organizations are impacted payers under CMS-0057-F. Since January 1, 2026 they must decide expedited prior-auth requests in 72 hours and standard requests in 7 calendar days, give specific denial reasons, and publicly report PA metrics. By January 1, 2027 they must run FHIR Prior Authorization, Provider Access, and Payer-to-Payer APIs.
Medicaid Managed Care Plans
Medicaid managed care plans are impacted payers under CMS-0057-F. From January 1, 2026 they face 72-hour expedited and 7-calendar-day standard prior-auth decision timeframes, specific denial reasons, and public PA metrics reporting; by January 1, 2027 they must operate FHIR Prior Authorization, Provider Access, and Payer-to-Payer APIs alongside Patient Access enhancements.
CHIP Fee-for-Service and Managed Care
CHIP agencies and CHIP managed care entities are impacted payers under CMS-0057-F, on essentially the same track as Medicaid: 72-hour expedited and 7-calendar-day standard prior-auth decisions plus specific denial reasons from January 1, 2026, public PA metrics from March 31, 2026, and the FHIR API stack by January 1, 2027.
Qualified Health Plan Issuers on the Federally-Facilitated Exchanges
QHP issuers on the Federally-facilitated Exchanges are impacted payers under CMS-0057-F for denial-reason, metrics-reporting, and API requirements — but CMS did not extend the rule's 72-hour/7-day decision timeframes to QHPs. API obligations apply for plan years beginning on or after January 1, 2027; specific denial reasons and public metrics start with 2026 plan years.