Prior Authorization Reform Bills Gain Momentum in Legislature
Two bills to reform prior authorization are advancing in the Legislature: AB 512 would shorten health plan response times for authorization requests, while SB 306 would eliminate prior authorization for routinely approved services and require health plans to report data for transparency. SB 306 passed the Senate unanimously and AB 512 is headed to the Senate floor.
CMA and SSVMS Push Back on Cigna’s Unlawful Downcoding PolicyCMA and SSVMS are urging physicians and medical groups to demand that Cigna rescind its new “Evaluation and Management Coding Accuracy” reimbursement policy, set to take effect October 1, 2025, which would automatically downcode higher-level E/M services and force physicians into costly, time-consuming appeals. The policy appears to violate state law, conflicts with AMA and CMS coding standards, and creates unnecessary administrative burdens; physicians are encouraged to contact Cigna directly by phone at (800) 88-Cigna (882-4462) or via the provider portal to request the withdrawal of the downcoding policy. CMA has prepared talking points to support physicians in pushing back against this harmful measure.
FDA’s Narrow COVID-19 Vaccine Approval Creates Confusion and Barriers
The FDA has approved updated COVID-19 vaccines from Moderna, Pfizer, and Novavax but restricted their use to adults 65+ and those with undefined “high-risk” conditions, a move which undermines science and creates confusion that could limit access during respiratory virus season. While physicians may still prescribe vaccines “off label,” CMA and SSVMS urge reliance on guidance from specialty societies such as AAP and ACOG, which continue to recommend broad vaccination, and pledges to advocate for evidence-based policies and protections that safeguard access to critical vaccines.
West Coast States Form Alliance to Safeguard Science-Based Vaccine Guidance
In response to federal actions undermining the CDC and raising concerns about politicized public health, California, Oregon, Washington, and now Hawaii have launched the West Coast Health Alliance to provide unified, evidence-based vaccine recommendations. State leaders stressed the coalition will restore trust, align guidance with respected medical organizations, and ensure decisions are grounded in science, transparency, and public safety. CMA and SSVMS welcomed the move, emphasizing that safeguarding evidence-based policy is essential to protecting patients and restoring confidence in public health.
New Federal Rule Embeds Real-Time Drug Costs and e-Prior Authorization in EHRs
Beginning October 1, certified EHR systems will be required to integrate real-time prescription drug cost tools, modernized e-prescribing, and electronic prior authorization under a new federal interoperability rule from HHS, reducing administrative burdens and improving patient care. The policy will allow physicians to see patient-specific drug prices, submit and track prior authorizations within their workflows, and reduce errors through standardized data sharing between EHRs, payors, and pharmacies. The California Medical Association, alongside AMA and other physician groups, hailed the rule as a major win, calling it a long-sought reform that will replace phones, faxes, and portal-hopping with streamlined, interoperable systems that free physicians to focus more on patients.
Federal Regulators Extend QPA Enforcement Discretion Under No Surprises Act
Federal regulators have extended their “enforcement discretion” on how insurers calculate the Qualified Payment Amount (QPA) under the No Surprises Act, allowing health plans to continue using the original 2021 methodology until at least February 1, 2026, and possibly through August 2026. The move follows ongoing legal challenges which struck down portions of the QPA methodology and created uncertainty around federal rules. While the extension provides short-term stability, the California Medical Association warns the current approach gives insurers an unfair advantage in out-of-network disputes, driving down physician reimbursement and threatening patient access to care, and will continue advocating for a fair, balanced system that protects both patients and physicians.
CMA Urges Congress to Act on Critical Health Care Priorities Before Year-End
As Congress reconvenes, the California Medical Association is calling for urgent action to protect patient access and physician sustainability, warning that without reforms millions could lose coverage, seniors may face worsening barriers to care, and physician shortages will deepen. CMA is pressing lawmakers to extend ACA premium tax credits, stabilize Medicare with payment updates and sequestration relief, make telehealth waivers permanent, fund workforce programs, and pass bipartisan bills reforming prior authorization and pharmacy benefit managers to reduce delays and drug costs. Stressing that delays only heighten uncertainty and strain practices, CMA urged California’s delegation to move quickly to ensure affordable coverage, sustain physician practices, and safeguard access to care statewide.
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