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Disability, Accessibility, and Civil Rights

Nothing Changed But the Calendar: Recurring Prior Authorization as a Methods of Administration Violation Under Section 504 and Section 1557

Publisher: Real Safety AI Foundation

Legal research article.

Written
July 2026
Version
v0.9
Pages
34
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Abstract

Medicaid beneficiaries on stable drug regimens are required to obtain prior authorization for the same medication, at the same dose, year after year. Federal law permits states to impose prior authorization on covered outpatient drugs and conditions that permission on a response within 24 hours and the dispensing of a 72 hour emergency supply. Federal law says nothing about how often an authorization must be renewed. The interval is a state choice driven by formulary review cycles and supplemental rebate contracts, and it interrupts therapy for a population whose disabilities make each interruption most costly and each renewal hardest to complete. Title III of the Americans with Disabilities Act fails against payers on three settled grounds: the access and content line drawn in Doe v. Mutual of Omaha, the holding that a benefit plan is not a place of public accommodation, and McCarran-Ferguson reverse preemption. Developing each ground identifies what it does not reach. Neither the insurance safe harbor nor McCarran-Ferguson engages a utilization control applied to an already enrolled beneficiary, since both are addressed to the assumption and classification of risk. And a pharmacy sits on the statutory list of public accommodations by name.

Keywords

  • disability law
  • administrative law
  • meaningful access
  • disparate impact
  • reasonable modification
  • utilization management
  • Alexander v. Choate
  • Medicaid pharmacy benefit
  • maintenance medication
  • administrative burden
  • ordeal mechanisms
  • health insurance

Plain language slides

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Suggested citation

Gilly, Travis. "Nothing Changed But the Calendar: Recurring Prior Authorization as a Methods of Administration Violation Under Section 504 and Section 1557." Real Safety AI Foundation Legal Research Article, July 2026. https://realsafetyai.org/research/nothing-changed-calendar/

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SSRN version

References (48)

  1. A.W. ex rel. J.W. v. Coweta County School District, 110 F.4th 1309 (11th Cir. 2024).
  2. Advancing Interoperability and Improving Prior Authorization Processes, 89 Fed. Reg. 8758 (Feb. 8, 2024).
  3. Alexander v. Choate, 469 U.S. 287 (1985).
  4. Alexander v. Sandoval, 532 U.S. 275 (2001).
  5. Americans with Disabilities Act of 1990, 42 U.S.C. §§12133, 12181, 12182, 12201.
  6. Bendtsen, K.-E. (2026). Increasing take-up of social benefits: A meta-analysis of field experiments. Journal of Policy Analysis and Management, 45(2), e70085.
  7. Carparts Distribution Center, Inc. v. Automotive Wholesaler’s Association of New England, Inc., 37 F.3d 12 (1st Cir. 1994).
  8. Chino, F., Baez, A., Elkins, I. B., Aviki, E. M., Ginex, P. K., & Ferrell, B. (2023). The patient experience of prior authorization for cancer care. JAMA Network Open, 6(10), e2338182.
  9. Christensen, J., Aarøe, L., Baekgaard, M., Herd, P., & Moynihan, D. P. (2020). Human capital and administrative burden: The role of cognitive resources in citizen-state interactions. Public Administration Review, 80(1), 127–136.
  10. Chudnovsky, M., & Peeters, R. (2021). The unequal distribution of administrative burden: A framework and an illustrative case study for understanding variation in people’s experience of burdens. Social Policy & Administration, 55(4), 527–542.
  11. Crowder v. Kitagawa, 81 F.3d 1480 (9th Cir. 1996).
  12. Cummings v. Premier Rehab Keller, P.L.L.C., 596 U.S. 212 (2022).
  13. Doe v. CVS Pharmacy, Inc., 982 F.3d 1204 (9th Cir. 2020).
  14. Doe v. Mutual of Omaha Insurance Co., 179 F.3d 557 (7th Cir. 1999).
  15. Ford v. Schering-Plough Corp., 145 F.3d 601 (3d Cir. 1998).
  16. Fox, A., Feng, W., & Reynolds, M. (2023). The effect of administrative burden on state safety-net participation: Evidence from food assistance, cash assistance, and Medicaid. Public Administration Review, 83(2), 367–384.
  17. Goldberg v. Kelly, 397 U.S. 254 (1970).
  18. Gotlieb, E., Blank, L. J., & Jetté, N. (2026). Barriers and consequences of prior authorization for neurologic medications. JAMA Neurology, 83(2), 181–192.
  19. Halling, A., & Van de Walle, S. (2025). Do justifications affect tolerance for administrative burdens? Evidence from a survey experiment among policymakers. Social Policy & Administration, 60(1), 12–26.
  20. Heinrich, C. J., Camacho, S., Henderson, S. C., Hernandez, M., & Joshi, E. (2022). Consequences of administrative burden for social safety nets that support the healthy development of children. Journal of Policy Analysis and Management, 41(1), 11–44.
  21. Humana Inc. v. Forsyth, 525 U.S. 299 (1999).
  22. Illinois Department of Healthcare and Family Services. Criteria and forms. https://hfs.illinois.gov/medicalproviders/pharmacy/criteriaandforms.html
  23. Illinois Department of Healthcare and Family Services. Four prescription policy. https://hfs.illinois.gov/medicalproviders/pharmacy/fourprescriptionpolicy.html
  24. Interoperability Standards and Prior Authorization for Drugs, 91 Fed. Reg. 19890 (proposed Apr. 14, 2026).
  25. K.M. ex rel. Bright v. Tustin Unified School District, 725 F.3d 1088 (9th Cir. 2013).
  26. Kleinman, R. (2026). Transaction costs and the take-up of social safety net programs: Evidence from the Combined Application Project. Journal of Policy Analysis and Management, 45(2), e70086.
  27. Madsen, J. K., Mikkelsen, K. S., & Moynihan, D. P. (2022). Burdens, sludge, ordeals, red tape, oh my!: A user’s guide to the study of frictions. Public Administration, 100(2), 375–393.
  28. McCarran-Ferguson Act, 15 U.S.C. §§1011–1012.
  29. Medicaid: Payment for Covered Outpatient Drugs, 42 U.S.C. §§1396a(a)(30)(A), 1396r-8(d)(5).
  30. Nichols, A. L., & Zeckhauser, R. J. (1982). Targeting transfers through restrictions on recipients. American Economic Review, 72(2), 372–377.
  31. Nondiscrimination in Health Programs and Activities, 89 Fed. Reg. 37522 (May 6, 2024); 45 C.F.R. pt. 92.
  32. Nondiscrimination on the Basis of Disability by Public Accommodations, 28 C.F.R. §§36.204, 36.301.
  33. Nondiscrimination on the Basis of Disability in Programs or Activities Receiving Federal Financial Assistance, 89 Fed. Reg. 40066 (May 9, 2024); 45 C.F.R. §84.68.
  34. Nondiscrimination on the Basis of Disability in State and Local Government Services, 28 C.F.R. §35.130.
  35. North Carolina Medicaid. Pharmacy frequently asked questions. https://medicaid.ncdhhs.gov/providers/programs-and-services/pharmacy-frequently-asked-questions
  36. Parker v. Metropolitan Life Insurance Co., 121 F.3d 1006 (6th Cir. 1997).
  37. Patient Protection and Affordable Care Act §1557, 42 U.S.C. §18116.
  38. Payan v. Los Angeles Community College District, 11 F.4th 729 (9th Cir. 2021).
  39. Payan v. Los Angeles Community College District, 169 F.4th 971 (9th Cir. 2026).
  40. Rehabilitation Act of 1973 §504, 29 U.S.C. §794.
  41. Rescinding Portions of the U.S. Department of Health and Human Services Title VI Regulations To Align With the Statutory Text and Conform to Executive Order 14281, 91 Fed. Reg. 46746 (July 24, 2026).
  42. State Plans for Medical Assistance: Amount, Duration, and Scope of Services, 42 C.F.R. §440.230.
  43. State Plans for Medical Assistance: Fair Hearings, 42 C.F.R. §§431.220, 431.230.
  44. Tennessee v. Becerra, No. 1:24-cv-161 (S.D. Miss.).
  45. Texas v. Becerra, No. 6:24-cv-211 (E.D. Tex.).
  46. Wallace, Z. S., Harkness, T., Fu, X., Stone, J. H., Choi, H. K., & Walensky, R. P. (2020). Treatment delays associated with prior authorization for infusible medications: A cohort study. Arthritis Care & Research, 72(11), 1543–1549.
  47. Wang, Y., Levy, J., & Mattingly, T. J. (2026). Prior authorization and associated delays and denials of branded medication dispensation. JAMA Health Forum, 7(4), e260760.
  48. Weyer v. Twentieth Century Fox Film Corp., 198 F.3d 1104 (9th Cir. 2000).

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