By Elena Eyber, J.D.
CMS released guidance on how state Medicaid agencies, Medicaid managed care plans, CHIP agencies, and CHIP managed care entities should implement the CMS Interoperability and Patient Access final rule (published in the Federal Register on May 1, 2020) in a manner consistent with existing guidance and the recently published ONC 21st Century Cures Act final rule. The CMS letter details several new requirements with key compliance dates from the CMS Interoperability and Patient Access final rule, relating to Patient Access API, Payer-to-Payer Data Exchange, Provider Directory API, Dual Eligible Experience, and provisions of the ONC 21st Century Cures Act final rule (CMS Letter, SHO: 20-003, August 14, 2020).
Patient Access API. The CMS Interoperability and Patient Access final rule requires state Medicaid agencies, Medicaid managed care plans, CHIP agencies, and CHIP managed care entities to make certain health information about Medicaid and CHIP beneficiaries accessible through a Patient Access application program interface (API) by January 1, 2021 (see Interoperability final rule makes information easier to get, increases requirements, April 27, 2020). This policy enables beneficiaries to have access to their health data on their smart phones. However, due to the COVID-19 public health emergency (PHE), CMS is exercising enforcement discretion and does not expect to enforce this requirement prior to July 1, 2021.
Payer-to-Payer Data Exchange. The CMS Interoperability and Patient Access final rule requires Medicaid managed care plans and CHIP managed care entities to comply with a beneficiary’s request to have their health data transferred from payer to payer by January 1, 2022. This new policy may reduce the need for unnecessary letters of medical necessity, prior authorization requests and calls or faxes to pharmacies or health plans if the receiving plan decides to use the information shared from the prior plan in administering the beneficiary’s coverage.
Provider Directory API. The CMS Interoperability and Patient Access final rule requires Medicaid agencies, CHIP agencies, Medicaid managed care plans and CHIP managed care entities to provide current provider directory information via an API by January 1, 2021. Having this information available through an API will facilitate public access to accurate information about which managed care providers are in-network or accepting new patients, as well as current contact information for providers. However, due to the COVID-19 PHE, CMS is exercising enforcement discretion and does not expect to enforce this requirement prior to July 1, 2021.
Dual Eligible Experience. The CMS Interoperability and Patient Access final rule requires state Medicaid agencies to exchange certain data with CMS daily on beneficiaries who are dually eligible for Medicaid and Medicare by April 1, 2022. Currently, many states and CMS exchange these data as infrequently as monthly, which delays coverage status changes and leads to inaccuracies, recoupments, and poor customer experiences. Improving the accuracy and timeliness of data on dual eligibility status is a strong first step in improving how these systems work together for beneficiaries, providers, and payers.
ONC 21st Century Cures Act final rule. CMS urged Medicaid agencies, CHIP agencies, Medicaid managed care plans, and CHIP managed care entities to review the final rule, particularly the sections on the definition of health information network (HIN) or health information exchange (HIE) and the information blocking exceptions. CMS also urged the entities to review existing contractual and financial relationships (especially those related to API usage and access) to evaluate potential compliance implications regarding the ONC 21st Century Cures Act final rule.
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