The CMS Interoperability and Patient Access Final Rule (CMS-9115-F) aims to enhance the accessibility and exchange of patient health data. Implemented by the Centers for Medicare & Medicaid Services (CMS), it requires health insurers to provide patients with easy access to their health information through standardized application programming interfaces (APIs). The CMS Interoperability and Patient Access Final Rule (CMS-9115-F) took effect on July 1, 2021. Compliance with the rule’s requirements was phased in, with certain provisions becoming mandatory over time, including those related to patient access and data sharing. This rule mandates that health plans share data with patients, their providers, and other third parties to promote coordinated care and improve health outcomes. It supports transparency and empowers patients by allowing them to manage their health information more effectively, fostering a more integrated healthcare system.

Phases

The CMS Interoperability and Patient Access Final Rule (CMS-9115-F) includes several phased-in requirements:

• July 1, 2021
  • Health plans must provide patients with electronic access to their claims and encounter data through a patient access API.
• January 1, 2022
  • Providers and health plans must implement the standards for the Patient Access API and the Provider Directory API. Health plans must also provide information on drug formulary and costs through a payer-to-payer data exchange.
• July 1, 2022
  • Health plans are required to comply with the regulations for the Interoperability and Patient Access API. This includes making information about covered services, cost-sharing, and network provider directories available electronically.
• January 1, 2023
  • Health plans must begin to provide information on cost-sharing and drug formulary through the payer-to-payer data exchange, making this data available to other health plans and to patients.

These phased-in requirements are designed to ensure a smooth transition and provide ample time for organizations to implement the necessary changes to achieve compliance.

Intent

The intent of the CMS Interoperability and Patient Access Final Rule (CMS-9115-F) is to improve the flow and accessibility of healthcare data for patients and providers. By mandating that health insurers use standardized APIs to share patient health information, the rule aims to:

1. Empower Patients: Provide patients with easier access to their health data, allowing them to make informed decisions about their care.
2. Enhance Care Coordination: Facilitate the exchange of information between different healthcare providers and organizations to improve care coordination and reduce inefficiencies.
3. Increase Transparency: Promote transparency in healthcare data to help patients understand their health status and treatment options better.
4. Support Innovation: Encourage the development of new tools and applications that leverage patient data to improve health outcomes and system efficiency.

Organizations, Individuals and the Rule’s Impact

Payer

A payer is an entity responsible for covering or reimbursing the cost of healthcare services and products. In the context of healthcare, payers typically include:

1. Health Insurance Companies: These are private companies that provide health insurance plans and are responsible for paying claims related to covered medical services and treatments.
2. Government Programs: Public programs such as Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) act as payers by providing health coverage and funding for eligible individuals.
3. Employers: Some employers directly provide health benefits to employees through self-funded health plans, acting as payers for the medical services their employees receive.
4. Third-Party Administrators (TPAs): These organizations manage health insurance claims and administrative services on behalf of employers or insurers, but they do not assume financial risk themselves.

Payer Impact

Under the CMS Interoperability and Patient Access Final Rule (CMS-9115-F), payers (health insurers) have several key responsibilities:

1. Data Sharing: Payers must make patient health information available to patients, providers, and third parties using standardized APIs. This includes information related to claims, encounters, and clinical data.
2. Patient Access: Payers are required to provide patients with easy access to their health information through a secure, online portal or app. This portal should be user-friendly and allow patients to view and manage their health data.
3. Provider Directory: Payers must maintain and share an up-to-date directory of in-network providers and facilities, ensuring that patients and providers can easily find and access necessary care.
4. Interoperability: Payers must use standardized data formats and APIs to ensure that health information can be exchanged seamlessly across different systems and platforms.
5. Data Security: Payers must ensure that patient data is protected and secure, complying with privacy and security regulations to safeguard sensitive information.
6. Compliance: Payers need to comply with the specific requirements and timelines set forth in the rule, including regular reporting and updates on their data-sharing practices.

The CMS Interoperability and Patient Access Final Rule (CMS-9115-F) enhances patient access to health data, promotes care coordination, increases transparency in costs, and supports patient-centered care. By improving data sharing and reducing administrative burdens, it fosters better healthcare outcomes and encourages innovation in the industry.