Continuity of Stabilizing Treatment Act of 2026

The Continuity of Stabilizing Treatment Act of 2026 is a federal legislative proposal designed to ensure uninterrupted access to medically necessary stabilizing treatment within federally regulated health programs.

Administrative authorization procedures such as prior authorization and utilization review play an important role in maintaining medical necessity standards and managing healthcare expenditures. However, when administrative approval is required before therapy begins in clinically time-sensitive situations, treatment delays may unintentionally expose patients to avoidable physiological deterioration.

The proposal establishes a continuity-first sequencing standard for defined stabilizing treatments. Under this framework, clinicians may initiate continuity-critical therapies immediately when delay or interruption would reasonably risk destabilization. Utilization review authority is preserved, but review occurs after therapy initiation rather than before, preventing administrative processes from interrupting clinically necessary stabilization.

The Act applies to federally administered and federally regulated health programs, including Medicare Advantage plans, Medicaid managed care programs, and qualified health plans offered through federal health insurance marketplaces. Oversight and regulatory implementation would be administered through the Department of Health and Human Services.

Importantly, the proposal does not expand underlying coverage mandates or eliminate insurer oversight mechanisms. Instead, it modifies the sequencing of utilization review in narrowly defined circumstances where treatment interruption poses a predictable clinical risk. Patients receiving therapy under this framework are protected from retroactive financial liability arising solely from administrative disputes between insurers and providers.

By reinforcing stabilization as the foundational principle of time-sensitive care, the Continuity of Stabilizing Treatment Act of 2026 seeks to reduce avoidable escalation of medical conditions, support responsible utilization oversight, and strengthen patient protection within existing federal healthcare programs.

Administrative Authorization and Treatment Delays

Healthcare utilization review and prior authorization procedures are widely used across federal healthcare programs to ensure medical necessity, manage costs, and maintain program integrity. While these administrative safeguards serve an important function, they can create unintended barriers when applied prior to the initiation of clinically necessary stabilizing treatment.

In time-sensitive clinical situations, delays associated with administrative approval processes may interrupt or postpone therapies that physicians determine are necessary to maintain physiological stability. When treatment initiation is delayed, patients may experience avoidable deterioration in health status, increased reliance on emergency services, or escalation to higher-intensity medical interventions.

Federal Program Context

These challenges are particularly relevant within federally regulated health programs, including Medicare Advantage plans, Medicaid managed care programs, and health insurance marketplace plans operating under federal standards. Although these programs maintain utilization review systems designed to promote efficiency and accountability, current regulatory frameworks do not consistently prioritize continuity of stabilizing therapy when administrative review is pending.

As a result, the sequencing of utilization review may inadvertently function as a barrier to timely stabilization rather than as a safeguard of appropriate care. Patients receiving treatment from participating providers often rely on uninterrupted access to prescribed therapy but may lack the practical ability to navigate complex administrative authorization processes during medically vulnerable periods.

Policy Sequencing Challenge

The policy challenge is therefore not the existence of utilization review itself, but the timing of administrative review in relation to clinically necessary treatment. Establishing a continuity-first standard for narrowly defined stabilizing therapies can ensure that patients receive immediate care when interruption poses a predictable medical risk, while still preserving the oversight and cost-management functions of utilization review systems.

Addressing this sequencing issue within federal healthcare programs offers an opportunity to strengthen patient protection, reduce avoidable escalation of care, and maintain responsible program administration without expanding underlying benefit mandates.

The Continuity of Stabilizing Treatment Act of 2026 is designed for structured implementation within existing federal healthcare regulatory authority. Implementation would occur through coordinated regulatory guidance issued by the Department of Health and Human Services and administered through relevant federal healthcare programs.

The rollout is structured in phases to ensure clarity for healthcare providers, insurers, and program administrators.

Phase I — Legislative Enactment and Federal Regulatory Guidance

Following enactment, the Secretary of Health and Human Services shall initiate rulemaking to establish regulatory standards necessary for implementation.

Regulatory guidance will clarify:

• Definitions and documentation standards for continuity-critical treatment determinations

• Administrative sequencing requirements for utilization review

• Compliance expectations for participating health plans

• Patient protection and disclosure requirements

• Reporting standards for program oversight

This phase ensures that continuity standards are implemented consistently across applicable federal healthcare programs.

Phase II — Program Administration and Operational Alignment

Federal health programs subject to the Act will adjust administrative procedures to incorporate continuity-first sequencing for defined stabilizing treatments.

Participating health plans will be required to:

• Permit immediate dispensing of continuity-critical medications prescribed by participating providers

• Conduct utilization review following therapy initiation when applicable

• Maintain documentation of review outcomes for regulatory compliance

• Ensure that any transition in therapy occurs without interruption to patient treatment

Operational alignment during this phase will allow insurers and program administrators to adapt existing utilization review systems without disrupting care delivery.

Phase III — Oversight and Compliance Monitoring

The Department of Health and Human Services will oversee implementation through program monitoring and reporting requirements.

Oversight may include:

• Review of continuity-critical treatment determinations

• Monitoring patterns of post-dispensing utilization review

• Evaluation of patient protection compliance

• Analysis of treatment escalation trends associated with administrative delays

Periodic summary reports may be issued to evaluate the effectiveness of continuity protections within federal healthcare programs.

Phase IV — Regulatory Guidance for Non-Pharmacologic Stabilizing Treatments

Implementation of continuity protections for non-pharmacologic stabilizing therapies will occur through structured regulatory guidance issued by the Department of Health and Human Services.

Guidance will define:

• Qualifying treatment categories

• Documentation and clinical standards

• Program administration requirements

• Operational readiness benchmarks

This staged approach ensures that continuity protections are implemented carefully for therapies involving greater clinical and operational complexity.

Ongoing Program Review

Federal agencies responsible for program administration may conduct ongoing evaluations of the policy’s impact on treatment continuity, healthcare utilization patterns, and administrative performance.

———————————————————

Fiscal & Administrative Considerations

The Continuity of Stabilizing Treatment Act of 2026 is designed to operate within existing federal healthcare regulatory frameworks and does not establish new entitlement programs or expand underlying coverage mandates.

Instead, the proposal modifies the sequencing of utilization review for defined stabilizing treatments, allowing therapy initiation prior to administrative authorization when clinical judgment indicates that treatment interruption may pose a predictable risk of physiological deterioration.

Because the legislation addresses administrative sequencing rather than benefit eligibility, the Act is not expected to create large structural changes in overall program expenditures.

Administrative Costs

Implementation of the Act would primarily involve regulatory guidance, compliance oversight, and reporting requirements administered by the Department of Health and Human Services.

These responsibilities would be integrated into existing program oversight mechanisms governing Medicare Advantage plans, Medicaid managed care programs, and federally regulated health insurance marketplace plans.

Any incremental administrative costs associated with regulatory implementation and compliance monitoring are expected to be absorbed within existing federal healthcare program administration structures.

Healthcare Utilization Effects

In situations where stabilizing treatment is delayed due to administrative authorization procedures, patients may experience deterioration requiring higher-intensity medical intervention such as emergency department treatment or hospitalization.

Allowing continuity-critical therapies to begin immediately may reduce the probability that administrative delays lead to avoidable escalation of care.

Where escalation events are prevented, episode-of-care costs may be lower than those associated with delayed treatment pathways.

Actuarial Evaluation

Formal fiscal scoring and actuarial evaluation would be conducted through the Congressional Budget Office during legislative review.

Such analysis would examine:

• potential changes in utilization review patterns

• administrative impacts on federal healthcare programs

• healthcare utilization trends related to treatment continuity

• potential cost offsets associated with reduced escalation of care

The Act is structured to support patient stability while preserving existing utilization management authority and cost-control mechanisms.

———————————————————

American Medical Association. 2023 AMA Prior Authorization Physician Survey.

This national survey of practicing physicians documents the frequency with which prior authorization requirements delay medically necessary care and the potential clinical consequences associated with treatment delays.

American Medical Association. Fix Prior Authorization Reform Toolkit.

The toolkit outlines administrative barriers associated with prior authorization and proposes policy approaches designed to improve timely access to care.

Centers for Medicare & Medicaid Services. Improving Prior Authorization Processes.

Federal guidance recognizing that delays associated with administrative authorization may interfere with timely access to medically necessary treatment.

Health Affairs. Administrative Barriers and Health Care Utilization.

Research examining the relationship between treatment authorization delays and increased emergency care utilization.

Agency for Healthcare Research and Quality (AHRQ). Care Coordination and Patient Safety.

Federal research highlighting the role of treatment continuity in preventing avoidable escalation of care and improving patient outcomes.

U.S. Department of Health and Human Services. Medicare Advantage and Managed Care Oversight Framework.

Federal regulatory framework governing participating plans within federal healthcare programs.

———————————————————————

Institutional Note

This proposal was developed and published by Public Reason Institute as part of its independent research and legislative development program. The draft is offered for public discussion and potential consideration by policymakers.