Health Reform WK-EDGE Medicaid proposed rule would require specified implementation guides for APIs, other changes
Friday, January 8, 2021

Medicaid proposed rule would require specified implementation guides for APIs, other changes

By Cathleen Calhoun, J.D.

The Medicaid proposed rule would mean changes for some payers, Medicaid managed care plans, and CHIP managed care entities when using application programming interfaces (APIs), including sharing certain information on patients.

CMS is proposing several initiatives that would have an impact on Medicaid and the Children’s Health Insurance Program (CHIP) programs, along with qualified health plan (QHP) issuers on the federally facilitated exchanges (FFEs). Specifically, the proposals would involve Medicaid fee-for-service (FFS) programs, Medicaid managed care plans, state CHIP FFS programs, CHIP managed care entities, and QHP issuers on the FFEs. In the CMS Interoperability and Patient Access final rule, certain payers were required to implement and maintain standards-based patient access and provider directory application programming interfaces (APIs). In this proposed rule, CMS is expanding on that rule to enhance the patient access API for impacted payers by proposing the use of specific implementation guides (IGs), proposing that certain payers implement a standards-based provider access API that makes patient data available to providers, and by proposing payers include information about pending and active prior authorization decisions, among other proposals (Proposed rule, 85 FR 82586, December 18, 2020).

Patient Access API. Beginning January 1, 2023, under the proposed rule, and applicable to Medicaid managed care plans and CHIP managed care entities, impacted payers would be required to ensure their APIs are conformant with certain IGs. The IGs are: CARIN IG for Blue Button, the PDex IG, and the PDex US Drug Formulary IG, and the US Core IG that was adopted by HHS in the Office of the National Coordinator for Health Information Technology (ONC) 21st Century Cures Act final rule. CMS notes that since it is requiring compliance with specific IGs, and that evolving IGs will outpace its ability to amend regulations, it proposes that regulated entities would be permitted to use an updated version of any or all IGs proposed for adoption. However, the use of the updated IG cannot disrupt an end user's ability to access the data through any of the specified APIs. Payers could use new standards as they are available.

CMS is also proposing the requirement that information must be available to patients about prior authorization decisions through the Patient Access API, in addition to the accessible content finalized in the CMS Interoperability and Patient Access final rule.

Provider Access API. CMS stated that while the use of the patient access API is a first step in facilitating sharing individual patient health information, it believes the benefits of making patient data available through a standards-based API would be enhanced if providers had direct access to their patients’ data. CMS is proposing that providers be allowed to request the claims and encounter data for patients they provide services to for treatment purposes. CMS proposes to require that certain payers implement a standards-based provider access API that makes patient data available to providers both on an individual patient basis and for one or more patients at once using a bulk specification, as permitted by law, with the reasoning that providers could use data on their patients for facilitating treatment and ensuring their patients receive better, more coordinated care. HIPAA concerns are discussed in the proposed rule.

Other proposals. The extension of patient-initiated payer-to-payer data exchange requirements to state Medicaid and CHIP FFS programs are proposed by CMS. Impacted payers must implement the payer-to-payer API to support exchanging patient data, including but not limited to adjudicated claims and encounter data (not including cost information), clinical data as defined in the United States Core Data for Interoperability (USCDI), and information related to pending and active prior authorization decisions. On prior authorization, CMS is proposing requirements for payers to implement APIs that are conformant with certain implementation guides that would facilitate the exchange of information between payers and providers and allow providers to integrate the prior authorization process more easily within their clinical workflow. CMS is also proposing several policies that would require impacted payers, except for QHP issuers on the FFEs, to respond to prior authorization requests within certain timeframes. In addition, on behalf of HHS, ONC is proposing to adopt the implementation specifications described in the proposed rule at 45 CFR 170.215—Application Programming Interfaces—Standards and Implementation Specifications, as standards and implementation specifications for health care operations.

MainStory: TopStory ProposedRules CHIPNews GeneralNews HealthInformationTechnologyNews HealthInsuranceExchangeNews MedicaidNews NewsFeed

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