What health plans can do today to prepare for the new patient access and interoperability rules

What health plans can do today to prepare for the new patient access and interoperability rules

September 15, 2020
Business Affairs
John D’Amore
By John D’Amore

Although the COVID-19 pandemic led the federal government to delay enforcement of new patient access and interoperability rules, that doesn’t mean health insurers should lose focus on these important and groundbreaking regulations.

These two “transformative” rules – one from the Office of the National Coordinator for Health Information Technology (ONC) and the other from the Centers for Medicare & Medicaid Services (CMS) – are intended to “put patients first” by giving patients safe and secure access to their own health data, according to the U.S. Department of Health and Human Services (HHS).

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A key objective of both rules is to provide patients and members the ability to use third-party apps on their smartphones, effectively letting them exercise the same control over their health data as they do over financial, retail, and other consumer transactions. The CMS rule holds payers who offer Medicare Advantage and Managed Medicaid plans accountable for sharing “claims and other health information with patients in a safe, secure, understandable, and user-friendly electronic format through the Patient Access application programming interface (API).” Additionally, the ONC rule requires the provision of clinical data using the new standard for data access called Fast Healthcare Interoperability Resources (FHIR) Version 4.

For health plans, which have the most urgent deadlines, there is no time to waste. Now is the time for action.

Know your deadlines
As it stands today, the first step related to the new rules that health plans should take is to mark their calendars for near-term deadlines. While some industry observers previously expected these deadlines to be a few years out, HHS had other ideas, initially establishing an aggressive target of Jan. 1, 2021, for payer compliance. As a result of the pandemic, enforcement of payer compliance has been pushed back to July 1, 2021, but the following deadlines still need to be top-of-mind for payers.

July 1, 2021
• Patient Access API: Payers must provide members with access to their claims and clinical data using new API standards.
• Provider Directory API: Payers must provide public-facing directory services for provider networks and drug formularies.

January 1, 2022
• Payer-to-Payer Data Exchange: Payers must make data available through APIs to other payers as members change plans.

Early-to-Mid 2022
• Improving the Dual Eligible Experience: Additional data sharing requirements will enable better coordination for members covered under both Medicare and Medicaid.

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