Stay Informed. Stay Compliant. Stay Ahead.
Evolving regulations, compliance requirements, and technology mandates continuously shape the healthcare industry. At HealthAxis, we recognize that staying current with these changes is essential for maintaining operational excellence and protecting the integrity of your organization.
Our Regulatory Updates page provides timely insights into the latest federal and state developments that impact health plans, insurers, and third-party administrators (TPAs). From CMS and HHS rulings to data privacy standards and interoperability requirements, HealthAxis helps you understand what’s changing and what it means for your business.
Federal Regulatory Highlights
Major federal agencies continue to drive standards that shape the administrative, data and operational side of health insurance and TPA services:
- CMS Releases 2026 Readiness Checklist: What Plans Need to Have Locked In Before January 1.
- The Centers for Medicare & Medicaid Services (CMS) finalised its CMS Interoperability and Prior Authorization Final Rule (CMS‑0057‑F) on January 17 2024, which requires impacted payers—including Medicare Advantage, Medicaid/CHIP managed‐care entities and Qualified Health Plan issuers—to implement HL7® FHIR®-based APIs for patient access, provider access and prior authorization processes, plus tighter timelines for PA decisions. Impacted payers are required to implement certain provisions by January 1, 2026. However, in response to stakeholder comments on the proposed rule, impacted payers have until January 1, 2027, to meet the application programming interface (API) requirements in this final rule.
- 2026 CMS Call Center Monitoring: What Medicare Plans Need to Know Now
- CMS also continues to expand its interoperability agenda via its broader initiatives: enabling secure, standardized electronic health information exchange and enforcement of data-access obligations.
- Implications for your organization include: ramping up API readiness and data exchange capabilities; adjusting workflows for prior authorization and claims data sharing; assessing timing for compliance; updating vendor contracts and data governance policies.
- CMS also released its 2026 Policy and Technical Changes to the Medicare Advantage and Part D Programs (CMS-4208) — applicable beginning January 1, 2026 — which include updates affecting Medicare Advantage and Prescription Drug Benefit programs.
- CY 2026 Medicare Physician Fee Schedule (PFS) Final Rule
State-Level Developments
While federal rules set the baseline, states are increasingly active in regulating network adequacy, prior-authorization reform, payment transparency and consumer protection. Some examples for payers and TPAs to monitor:
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New state statutes requiring specific prior-authorization turnaround times or denying retroactive denials.
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Transparency requirements around in-network vs out-of-network claims, provider directories, and surprise-billing protections.
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State data-reporting mandates for payers and TPAs regarding utilization, appeals, and grievances.
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Effective dates vary widely by state; early awareness can enable a smoother transition and reduce implementation strain.
- For plans offered via the ACA Marketplace, new 2026 rules under the 2026 Notice of Benefit and Payment Parameters (CMS-9888-F) revise premium-payment thresholds, risk-adjustment policies, and enforcement authority over brokers/agents — all of which may impact plan pricing, compliance burden, and consumer notices.
Data Privacy and Security Updates
Data protection continues to be a frontline issue for health plans, TPAs and their vendor ecosystems:
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Upcoming changes to the Health Insurance Portability and Accountability Act (HIPAA) Security Rule proposed by the Office for Civil Rights (OCR) would impose enhanced technical and administrative safeguards for electronic protected health information (ePHI).
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Cybersecurity incidents remain a concern and regulators expect stronger vendor oversight, multifactor authentication, encryption, and incident-response documentation.
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For payers and TPAs, this means revisiting risk assessments, vendor oversight frameworks, data-mapping, incident response plans, and compliance documentation.
Technology and Interoperability
Technology standards and interoperability mandates are no longer optional; they are central to regulatory compliance and operational efficiency:
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The CMS interoperability rules (for example, the CMS-0057-F final rule) require payers to build Patient Access APIs, Provider Access APIs, Prior Authorization APIs, and exchange data in standardized formats such as FHIR®.
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CMS’s Interoperability Framework outlines network connectivity, directory requirements, standards for federated networks, and identity/security/trust protocols.
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In practice, this means payers and TPAs must leverage their IT architecture, vendor interfaces, data governance, and operations to support electronic data exchange, real-time interfaces, and comprehensive audit/logging capabilities.
Best Practices and Readiness Guidance
To translate regulatory obligation into practical readiness, consider these actions:
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Conduct a gap assessment: compare your current state (APIs, workflows, data exchange, prior authorization timelines, vendor contracts) against upcoming regulatory requirements
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Update vendor agreements and contracts to incorporate regulatory timelines, data-exchange obligations, audit rights, and security expectations.
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Engage cross-functional teams (compliance, IT, operations, vendor management) early to build an integrated implementation plan.
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Monitor state developments in your jurisdictions of operation to align federal and state readiness.
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Leverage HealthAxis: our platform, subject-matter expertise, and evolving architecture are designed to support compliance, data exchange, and operational agility.
Taking a Stand: Reporting Violations Responsibly with HealthAxis
Any suspected or confirmed violations can be reported to any of the following: