Ensuring Continuity of Stabilizing Care

The Continuity of Stabilizing Treatment Act of 2026 is a federal healthcare reform proposal that addresses treatment delays caused by pre-service administrative review processes such as prior authorization and utilization review. While these tools play an important role in managing costs and ensuring medical necessity, they can create harmful interruptions when applied before clinically necessary stabilizing treatment begins.

The proposal establishes a continuity-first framework for narrowly defined medications, therapies, and treatments where delay or interruption could reasonably result in physiological destabilization, emergency intervention, or escalation of care. Under this model, eligible treatment may begin immediately based on the good-faith clinical judgment of a licensed participating provider, while insurer or plan review occurs afterward.

The Act applies to federally regulated health programs including Medicare Advantage, Medicaid managed care, and qualified health plans offered through federally facilitated marketplaces. It does not alter underlying benefit mandates or eliminate utilization review authority. Instead, it reforms the timing of review in order to better protect patients during medically vulnerable periods.

By prioritizing treatment continuity in time-sensitive cases, the proposal seeks to improve patient outcomes, reduce avoidable high-acuity utilization, clarify administrative standards, and preserve responsible oversight within existing federal healthcare systems.

1. Administrative review can delay clinically necessary stabilizing treatment.

Prior authorization and utilization review procedures, while intended to ensure medical necessity and cost control,

can create harmful delays when applied before treatment begins in time-sensitive clinical situations. 

2. Treatment delays may increase the risk of patient deterioration and higher-acuity care.

When stabilizing therapies are postponed, patients may face avoidable physiological decline, greater reliance on

emergency services, and escalation to inpatient or other higher-intensity interventions. 

3. The core policy problem is sequencing, not the existence of utilization review itself.

The proposal does not argue for eliminating insurer oversight. Instead, it identifies the timing of review as the

central issue and proposes that review occur after treatment initiation in narrowly defined circumstances. 

4. A continuity-first model can preserve both patient protection and administrative oversight.

Allowing continuity-critical treatment to begin immediately, while maintaining post-initiation utilization review, offers

a middle-ground framework that protects clinical stability without broadly expanding coverage mandates. 

5. Federal healthcare programs are an appropriate jurisdiction for targeted reform.

Because Medicare Advantage, Medicaid managed care, and federally facilitated marketplace plans already

operate under federal regulatory authority, they provide a legally and administratively viable setting for continuity-

first treatment protections. 

6. Patient financial protection is a necessary component of treatment continuity reform.

Even when treatment begins appropriately, patients may otherwise be exposed to retroactive liability arising from

insurer-provider disputes. The proposal addresses this by protecting patients from recoupment beyond ordinary

cost-sharing obligations.

7. The proposal is designed as an administrative reform, not a new entitlement expansion.

The Act does not create a new benefit category or require coverage of elective services. It modifies utilization

management sequencing within existing federal program structures. 

8. Implementation is feasible through HHS rulemaking and existing program oversight mechanisms.

The proposal can be operationalized through federal guidance, compliance standards, documentation

requirements, and program monitoring without requiring the creation of a wholly new administrative system. 

How can federal healthcare programs reform prior authorization and utilization review processes to ensure timely access to medically necessary stabilizing treatment without weakening cost controls, medical necessity standards, or administrative oversight?

Prior authorization and utilization review are established tools of healthcare administration, intended to promote medical necessity, cost control, and program integrity. The policy problem addressed in this proposal is not the existence of those tools, but the risk created when administrative review delays treatment that is needed to maintain clinical stability. The underlying legislative proposal identifies this as a sequencing failure: in some time-sensitive cases, treatment review occurs too early in the process, before medically necessary stabilizing care can begin. 

Recent evidence suggests that prior authorization remains a significant operational barrier in clinical practice. The American Medical Association’s 2024 physician survey reports that practices complete an average of 39 prior authorizations per physician per week, and that physicians continue to associate prior authorization with delays in necessary care, treatment abandonment, and negative effects on clinical outcomes. These findings do not by themselves prove that every delay causes patient harm, but they strongly support the conclusion that administrative review can function as a meaningful barrier to timely treatment in routine practice. 

The proposal is particularly relevant in federally regulated health programs where utilization management is widespread and federal administrative authority is already well established. CMS’s prior authorization rulemaking applies to Medicare Advantage organizations, state Medicaid and CHIP fee-for-service and managed care programs, and Qualified Health Plans offered on the federally facilitated exchanges. CMS has framed these reforms as part of a broader effort to improve prior authorization processes and keep patients at the center of care. That existing regulatory footprint strengthens the legal and administrative case for a targeted federal continuity standard, because Congress would not be creating an entirely new oversight domain. It would instead be modifying how prior authorization operates within programs already subject to federal standards. 

Available federal and policy data also suggest that prior authorization is not a marginal issue in Medicare Advantage. KFF reported that Medicare Advantage insurers made 52.8 million prior authorization determinations in 2024, including 4.1 million full or partial denials, and that only 11.5% of denied requests were appealed. Those figures do not establish that all denied requests were improper or clinically harmful, but they do show the scale of administrative gatekeeping in a program the proposal would cover. They also support the brief’s concern that patients often lack the practical ability to navigate utilization review disputes during medically vulnerable periods. That concern is consistent with the proposal’s patient-protection rationale. 

The case for continuity protections is also supported by patient-safety and care-coordination research. AHRQ describes care coordination as the deliberate organization of patient care activities and information-sharing to achieve safer and more effective care, emphasizing that care should be delivered at the right time and in a way that reflects patient needs. AHRQ materials on outpatient and transition-related safety similarly note that failures in continuity, communication, and follow-up can contribute to preventable harm, including medication-related events and avoidable hospital use. Applied to this proposal, that literature supports the core inference that continuity has independent clinical value, especially when patients are being stabilized after diagnosis, discharge, or acute deterioration. 

The policy’s strongest analytical feature is that it does not propose to abolish utilization review. Instead, it narrows reform to a specific class of cases in which delay itself may create foreseeable medical risk. The proposal’s continuity-first model preserves post-initiation review, maintains medical necessity standards, and leaves broader benefit design intact. In policy design terms, that makes this an administrative sequencing reform rather than a benefit expansion. This distinction matters because it improves legal defensibility, limits fiscal exposure, and makes implementation more realistic within Medicare Advantage, Medicaid managed care, and federally facilitated marketplace plans. CMS has already imposed continuity-related and process-streamlining requirements in Medicare Advantage rulemaking, which suggests that more targeted sequencing reforms are not conceptually outside existing federal practice. 

At the same time, the proposal would benefit from acknowledging several implementation risks. First, the concept of “continuity-critical” treatment will need careful regulatory definition to prevent overbroad application. Second, plans will likely seek documentation standards robust enough to distinguish legitimate stabilization needs from routine utilization disputes. Third, non-pharmacologic treatments are likely to present more operational complexity than medications, because scheduling, provider capacity, and treatment setting vary more widely. The uploaded proposal anticipates this by assigning greater regulatory development to HHS for non-pharmacologic therapies. That is a sound design choice because it allows the statute to establish the principle while leaving category-specific operational rules to program administrators.

On balance, the available evidence supports the brief’s central conclusion: prior authorization can delay needed care, continuity of care is a recognized patient-safety value, and federal programs already have the regulatory infrastructure to implement more protective sequencing rules. The proposal therefore appears analytically strongest when framed not as an attack on utilization management, but as a targeted correction to the timing of administrative review in a narrow set of clinically sensitive situations. That framing is more credible, more administratively feasible, and more likely to withstand fiscal and legal scrutiny.

1. Continuity-First Treatment Sequencing

Requires certain medically necessary stabilizing treatments to begin immediately when delay or interruption would

reasonably risk physiological deterioration, with administrative review occurring after treatment initiation.

2. Definition of Continuity-Critical Treatment

Establishes a statutory standard for medications, therapies, or services that, in the good-faith clinical judgment of a

licensed provider and consistent with accepted medical practice, are necessary to prevent destabilization or

escalation of care.

3. Immediate Initial Access to Eligible Medications

Prohibits participating health plans from delaying the first dispensing of qualifying continuity-critical medications

pending prior authorization or utilization review.

4.Preservation of Utilization Review Authority

Maintains insurer and plan authority to conduct post-initiation utilization review, determine ongoing

appropriateness of care, and manage future treatment pathways.

5.Non-Interruption of Active Therapy

Prevents treatment already initiated under the Act from being abruptly terminated solely because review occurs

after therapy begins. Any clinically appropriate transition must occur without interruption of care.

6.Patient Financial Protection

Bars retroactive financial liability or recoupment against patients arising solely from insurer-provider coverage

disputes related to treatment initiated under the Act, beyond normal cost-sharing obligations.

7. Federal Program Applicability

Applies to Medicare Advantage, Medicaid managed care programs, and qualified health plans offered through

federally facilitated marketplaces.

8. ERISA Boundary Protection

Clarifies that the Act does not regulate self-funded employer-sponsored health plans governed by Employee

Retirement Income Security Act of 1974.

9.HHS Rulemaking Authority

Directs U.S. Department of Health and Human Services to issue regulations, documentation standards,

compliance rules, and oversight procedures necessary for implementation.

10. Reporting and Compliance Monitoring

Authorizes federal oversight of plan compliance, treatment continuity outcomes, review patterns, and

administrative performance within covered programs.

The Continuity of Stabilizing Treatment Act of 2026 has broader policy significance beyond the specific treatments it covers. It reflects a growing recognition that healthcare regulation must evaluate not only whether oversight mechanisms exist, but whether they are structured in ways that protect patients during clinically vulnerable periods. In that sense, the proposal represents a shift from purely administrative cost-control models toward a more balanced framework that integrates patient safety, continuity of care, and program accountability. 

First, the proposal could establish a new federal standard for sequencing-based reform in healthcare administration. Much of the current debate over prior authorization is framed as a binary choice between maintaining insurer controls or eliminating them. This legislation suggests a third path: preserving utilization review while changing when review occurs in narrowly defined circumstances. If successful, that model could influence future reforms involving step therapy, discharge transitions, durable medical equipment approvals, or specialty medication access.

Second, the proposal may strengthen beneficiary protections in federally regulated programs such as Medicare Advantage, Medicaid managed care, and marketplace plans. These programs increasingly rely on private plan administration and utilization management. A continuity-first standard would reaffirm that public healthcare programs retain an obligation to ensure timely access to medically necessary care even when services are delivered through managed care structures. 

Third, the legislation could reduce avoidable downstream spending if treatment continuity prevents escalation into emergency department use, hospitalization, or more intensive interventions. While formal budget scoring would be required, the policy logic is that modest increases in immediate treatment access may offset larger costs associated with delayed care episodes. This makes the proposal relevant not only as a patient-protection measure, but also as a value-based administrative reform.

Fourth, the Act may improve regulatory clarity for providers and insurers. Current prior authorization disputes often arise because treatment urgency, clinical necessity, and administrative timelines are not aligned. By establishing statutory continuity rules, Congress or regulators would provide clearer expectations for clinicians, health plans, and beneficiaries regarding when immediate treatment takes precedence over pre-service review.

Fifth, the proposal has implications for federalism and health law. By limiting application to programs already under federal regulatory authority and excluding self-funded employer plans governed by Employee Retirement Income Security Act of 1974, the legislation demonstrates how targeted federal healthcare reform can be structured to avoid unnecessary jurisdictional conflict while still reaching millions of covered lives. 

Finally, if implemented effectively, the proposal could contribute to a broader policy principle: administrative systems should not create foreseeable medical harm through delay when narrower, more balanced alternatives are available. That principle may become increasingly important as healthcare delivery becomes more complex and utilization management tools continue to expand.

Overall, the policy implications of the proposal extend beyond prior authorization reform. It offers a potential template for modernizing healthcare administration so that oversight mechanisms remain intact while patient stabilization and continuity of care receive greater priority.

The Continuity of Stabilizing Treatment Act of 2026 addresses a specific but consequential weakness in modern healthcare administration: medically necessary stabilizing treatment can be delayed when pre-service utilization review occurs before clinically urgent care begins. While prior authorization and utilization review remain legitimate tools for promoting medical necessity, cost control, and program integrity, their design can produce harmful outcomes when administrative timing conflicts with patient need. 

This proposal offers a targeted alternative. Rather than eliminating insurer oversight or broadly expanding coverage mandates, it restructures the sequencing of review for narrowly defined continuity-critical treatments. Under a continuity-first model, eligible therapy may begin immediately when delay would reasonably risk destabilization, while post-initiation review preserves accountability and utilization management authority. That balance is the proposal’s central strength. 

The legislation is also notable for its practical scope. By applying to Medicare Advantage, Medicaid managed care, and federally facilitated marketplace plans, it operates within existing federal jurisdiction and established administrative systems. This improves implementation feasibility while avoiding broader legal conflicts involving self-funded employer plans governed by Employee Retirement Income Security Act of 1974.

If properly designed through statute and rulemaking, the policy could improve treatment continuity, reduce avoidable deterioration, lower some downstream acute-care costs, and provide clearer standards for plans, providers, and beneficiaries. It would not solve every challenge associated with prior authorization, but it directly addresses one of the most important operational failures: delays that create foreseeable clinical risk.

Ultimately, the proposal demonstrates that healthcare reform need not be framed as a choice between unrestricted access and rigid administrative control. More durable reforms often come from redesigning systems so that oversight remains intact while patient safety is better protected. In that respect, the Continuity of Stabilizing Treatment Act presents a credible and potentially scalable model for modernizing federal healthcare administration.

• American Medical Association. 2023 AMA Prior Authorization Physician Survey. Survey documenting physician-reported delays in medically necessary care, treatment abandonment, and administrative burden associated with prior authorization.
• American Medical Association. Fix Prior Authorization Reform Toolkit. Policy resource outlining common utilization management barriers and reform options to improve timely access to care.
• Centers for Medicare & Medicaid Services. Improving Prior Authorization Processes. Federal guidance and rulemaking addressing streamlining of prior authorization in Medicare Advantage and related federal programs.
• U.S. Department of Health and Human Services. Medicare Advantage and Managed Care Oversight Framework.Regulatory standards governing participating plans, beneficiary protections, and plan administration.
• Agency for Healthcare Research and Quality. Care Coordination and Patient Safety. Research examining continuity of care, treatment adherence, and prevention of avoidable escalation in patient conditions.
• Health Affairs. Studies on administrative barriers, delayed care, and the relationship between treatment interruption and emergency utilization.
• Congressional Budget Office. Budget scoring methodologies and federal healthcare program cost estimation frameworks relevant to utilization management reform.
• Employee Retirement Income Security Act of 1974. Federal statutory framework governing employer-sponsored self-funded health plans and preemption boundaries.
• Public Reason Institute, LLC. Continuity of Stabilizing Treatment Act of 2026. Legislative proposal and policy framework.