Understanding the Ruling
Patients and their healthcare providers will have the opportunity to be more informed, which can lead to better care and improved patient outcomes, while at the same time reducing burden. In a future where data flows freely and securely between payers, providers, and patients, we can achieve truly coordinated care, improved health outcomes, and reduced costs.
The CMS Interoperability and Patient Access final rule (CMS-9115-F) is intended to put patients first by giving them access to their health information when they need it most and in a way they can best use it. The interoperability rule applies to government regulated health plans including Medicare Advantage (MA), Medicaid, CHIP, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs).
Lack of seamless data exchange in healthcare has negatively impacted patient care which leads to poor health outcomes, and higher costs. The CMS Interoperability and Patient Access final rule establishes policies that break down barriers in the nation’s health system to enable better patient access to their health information, improve interoperability and unleash innovation, while reducing burden on payers and providers.
Patient Access Application Programming Interface
In order to better facilitate coordination of care, and support movement toward value-based payment models, we are proposing to require impacted payers to build and maintain a Provider Access API to share patient data with in-network providers with whom the patient has a treatment relationship. We are proposing that they make patient claims and encounter data (excluding cost information), data elements identified in the United States Core Data for Interoperability (USCDI) version 1, and prior authorization requests and decisions available to in-network providers beginning January 1, 2026.
Policies and Technology for Interoperability and Burden Reduction
The CMS Advancing Interoperability and Improving Prior Authorization Processes proposed rule (CMS-0057-P) is now available in the Federal Register and open for public comment. This proposed rule builds on the policies finalized in the CMS Interoperability and Patient Access final rule (CMS-9115-F) published May 2020 and policies introduced in the CMS Interoperability proposed rule (CMS-9123-P) published December 2020, which we are withdrawing in this proposed rule. The newly proposed rule considers stakeholder feedback and includes Medicare Advantage plans.
Payer-to-Payer Data Exchange
In December 2021, CMS announced enforcement discretion for this policy until identified implementation challenges could be addressed in future rule making;
In an effort to ensure a patient’s data can follow them throughout their health care journey, we are proposing to require that payers would exchange patient data when a patient changes health plans with the patient’s permission. Those data would include claims and encounter data (excluding cost information), data elements identified in the USCDI version 1, and prior authorization requests and decisions. For all impacted payers, we are considering a proposal that would require this exchange only if the patient opts in to data sharing.