CMS Patient Access Rule

In 2020, CMS introduced new interoperability mandates for health plans that went into effect on July 1, 2021. The CMS Patient Access Rule is designed to make health information more easily available to patients by implementing new industry standards like HL7 FHIR® APIs and by deterring information blocking.

Understanding the Ruling

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.

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. 

Overview of What's Required

1) Patient Access API: Patients must be able to share claims, encounter, clinical & formulary data data via FHIR APIs & developers must be able to access.

2) Provider Directory API: Public API provider directory for in-network doctors & pharmacies.

1upHealth’s Solution

1upHealth provides a fully managed solution to cover all new mandates. Today, hundreds of apps use 1up FHIR APIs to manage user directed connectivity across thousands of health systems. Impacted health plans can use the same infrastructure to meet all patient access and interoperability requirements.

Compliant, Secure, Easy

1up has marketing leading tools to help customer control the incoming and outgoing data with field-level privacy as well as authorization and consent management. More than 60 health plans are now live with our CMS APIs.


Our solution is already built and fully managed


No additional integrations needed


Implementation is the fastest in the industry (10 weeks or less)


Simple pricing (per member per year) without license fees