What Are the New CMS and ONC Interoperability Rules for Payers?

By Mike Penich, Partner, Cumberland Payer Division

On March 9, 2020, two rules were issued by the HHS Office of the National Coordinator for Health Information Technology (ONC) and Centers for Medicare and Medicaid Services (CMS) to implement interoperability and patient access provisions of the bipartisan 21st Century Cures Act (Cures Act). The objective is to drive interoperability and improve patient access to their own medical information so they can make better health care decisions.

The CMS Interoperability Patient Access final rule (CMS-9115-F) applies to federally regulated health plans, including Medicare Advantage, Medicaid, CHIP and Qualified Health Plans on federal exchanges. The regulations are outlined across nearly 500 pages and include many intricacies that will greatly impact how healthcare organizations operate over the coming years. Notable policies within the rule that impact payers include:

  • Patient Access API: Enable patients to access their own data via third-party applications. Payers are required to implement and maintain a secure, standards-based API (HL7 FHIR Release 4.0.1). Claim and encounter data – as defined in U.S. Core Data for Interoperability (USCDI) v1 to be made available. Deadline for compliance is January 1, 2021. As a result of COVID-19, CMS has announced the new requirements will not be enforced until July 1, 2021.  
  • Provider Directory API: CMS regulated payers, with the exception of Qualified Health Plans, are required to make information about their provider networks available via a standards-based publicly accessible API. Deadline for compliance is January 1, 2021. As a result of COVID-19, CMS has announced the new requirements will not be enforced until July 1, 2021.
  • Payer-to-Payer Data Exchange: Required to exchange clinical data as requested by the individual. Data requirements and standards are consistent with the Patient Access API. Deadline for compliance is January 1, 2022.

Other policies noted in the final rule include:

  • Increased Frequency of Federal-State Data Exchanges for dual eligible (Medicare and Medicaid) enrollee data.
  • Public Reporting of eligible providers and organizations that may be information blocking or do not list their digital contact information in NPPES.
  • Admission, Discharge and Transfer (ADT) Notification Requirements defined in Medicare and Medicaid Conditions of Participation for providers to send electronic notification to other providers when an ADT event occurs.

January 2021 is right around the corner and there is a lot of work to do to prepare for the new interoperability rules – that’s where Cumberland can help. We will meet you where you are in the process and provide you with the support you need – whether that’s with an initial assessment, strategic planning, technology vendor selection or implementation leadership. Over the next several weeks, we’ll share more information about the actions health plans can take now to ensure compliance and to position themselves for future success.

If you’re interested in learning more about the final rule and what you should do next, please email info@cumberlandcg.com.