CMS Interoperability and Patient Access Proposed Rule

The Centers for Medicare & Medicaid Services (CMS) Interoperability and Patient Access rule 1,2 released in February 2019 aims to improve patient access and advance electronic data exchange and care coordination. The proposed rule would require health plans to provide enrollees with immediate electronic access to medical claims and other health information via APIs.

How 1upHealth is Assisting Health Plans’ Compliance

To address this regulation, health plans are using 1up to:

  • Normalize internal data including claims, provider networks, and other health information to the canonical FHIR format accessible via a single FHIR endpoint
  • Aggregate internal data with external sources in FHIR Bulk Data format to enable downstream reporting and population health analytics
  • Implement, test, and monitor HL7 FHIR APIs to make data available to patients and their authorized applications

By enabling health plans to share information with apps via FHIR APIs, payers can gain deep insights into healthcare quality and cost, and patients can access numerous tools and applications to help improve their outcomes.

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How CMS Patient Access Rule Intersects ONC NPRM

Released in tandem in February 2019 with the CMS Patient Access rule, the ONC Notice of Proposed Rulemaking (NPRM) rule aims to enable patients to access all of their health information electronically at no cost via FHIR APIs. Both rules tie back to the 21st Century Cures Act, under which ONC and CMS have closely collaborated to advance interoperability.

Interoperability and Patient Access Rule Details

“We will not stop until we ensure that patients will always be able to get their records, to utilize them, and to share them as they wish. Not only for patient empowerment, but because the future of our healthcare system depends on it—for data is the fuel of healthcare innovation” - Seema Verma, Administrator of CMS 3

The proposed rule from CMS directly supports its broader MyHealthEData initiative to empower patients by giving them control of their healthcare data. The rule received over 1600 comments over the summer. While the rule has yet to be finalized, it remains clear that CMS is committed to driving forward patient access to electronic health information, and that it’s a matter of ‘when’, not ‘if’, health plans will need to meet these new requirements.

Some specific stipulations include requiring Medicare Advantage (MA) organizations, state Medicaid and Children's Health Insurance Program (CHIP) Fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers in FFEs to:

  • Implement, test, and monitor HL7 FHIR APIs to make patient claims and other health information available to patients through third-party applications and developers
  • Support electronic exchange of data for transitions of care as patients move between health plans. This data includes information about diagnoses, procedures, tests and providers seen and provides insights into a beneficiary’s health and healthcare utilization.
  • Make provider networks data available to enrollees and prospective enrollees through APIs
  • Participate in trust networks to improve interoperability.

References

  1. https://www.cms.gov/newsroom/fact-sheets/cms-advances-interoperability-patient-access-health-data-through-new-proposals
  2. https://www.federalregister.gov/documents/2019/03/04/2019-02200/medicare-and-medicaid-programs-patient-protection-and-affordable-care-act-interoperability-and
  3. https://www.cms.gov/newsroom/press-releases/speech-remarks-administrator-seema-verma-2019-himss-conference