The rule puts access to information in patients’ hands but also puts some burdens on states and providers.
The interoperability final rule reveals the goals of enabling patients to access their health information electronically through an application programming interface (API), ensuring that health care providers have ready access to health information about their patients, and requiring that payers make enrollee electronic health information held by the payer available through an API. According to CMS, patients should have the ability to move from health plan to health plan, provider to provider, and have both their clinical and administrative information move with them. Under the rule, CMS will require that information is easily accessible to patients enrolled in government-funded health care programs, as well as those enrolled in qualified health plans (QHPs) under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), through open APIs. The APIs will allow third-party applications to connect and make information publicly available in accordance with privacy regulations (Final rule, 85 FR 25510, May 1, 2020).
Data availability. Through a standard Patient Access API, payers must, at a minimum, make available adjudicated claims (including provider remittances and enrollee cost-sharing), encounters with capitated providers, and clinical data, including laboratory results. Data must be made available no later than one business day after a claim is adjudicated or encounter data are received. Also, beginning January 1, 2021, impacted payers must make available through the Patient Access API the specified data they maintain with a date of service on or after January 1, 2016. Medicare Advantage (MA) organizations, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs) must coordinate care between payers by exchanging, at a minimum, specific data elements outlined in the rule as well as vocabulary finalized in the 21st Century Cures Act final rule. By January 1, 2022, this payer-to-payer data exchange must be implemented.
Standardized information. MA organizations, Medicaid and CHIP fee-for-service (FFS) programs, Medicaid managed care plans, and CHIP managed care entities must make standardized information about their provider networks available through a Provider Directory API. The Provider Directory API must conform with the technical standards finalized in the 21st Century Cures Act final rule. Payers must make available, at a minimum, provider names, addresses, phone numbers, and specialties through the Provider Directory API. Also, access to the published Provider Directory API must be fully implemented by January 1, 2021.
States. All states must participate in the daily exchange of buy-in data. That includes sending data to CMS and receiving responses from CMS daily. All states submit the Medicare Modernization Act (MMA) file data to CMS daily by April 1, 2022. States must implement and maintain a standards-based Application Programming Interface (API) that permits third-party applications to retrieve, with the approval and at the direction of a current beneficiary or the beneficiary’s personal representative, certain medical data, such as laboratory results, through the use of common technologies and without special effort from the beneficiary.
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