In February 2019, the Centers for Medicare and Medicaid Services (CMS) issued new requirements for Medicaid, the Children’s Health Insurance Program, Medicare Advantage plans and Qualified Health Plans, mandating they provide enrollees with immediate electronic access to health data by 2020. So what do these new requirements mean for those payers?


Authored by Chip Terhune, SVP and General Manager, Government Programs & Accounts

The new year is just weeks away, and its arrival will bring significant changes for the healthcare industry. In 2018, Seema Verma, administrator for the Centers for Medicare and Medicaid Services (CMS), announced the launch of MyHealthEData, during the Healthcare Information and Management Systems Society (HIMSS) annual conference in 2018. MyHealthEData is an initiative aimed to give patients the ability to control their healthcare data and decide how that data will be used.

Since that announcement, CMS has been working to improve patients’ access to their personal healthcare data, while also simultaneously advancing care coordination and communication across the industry. Therefore, it didn’t come as a big surprise when CMS released new regulations related to interoperability and patient access on February 11, 2019, at the 2019 HIMSS conference.

For the first time, CMS has proposed requirements that Medicaid, the Children’s Health Insurance Program (CHIP), Medicare Advantage plans and Qualified Health Plans (QHP) in the Federally Facilitated Exchanges (FFE) must provide enrollees with immediate electronic access to medical claims and other health information by 2020. These rules, essentially, “reiterated that patients own their health data and have the right to access it,” explains Nan Sloan, vice president of compliance at Medecision.

“We believe this is an important step in advancing interoperability, putting patients at the center of their health care and ensuring they have access to their health information,” the proposed rule from CMS states. “We are committed to solving the issue of interoperability and achieving complete access to health information for patients in the U.S. health care system.”

Shaking Up the Industry

CMS wasn’t the only federal agency to recommend new rules about interoperability and data sharing in early 2019. The Office of the National Coordinator for Health IT (ONC) also proposed new regulations about interoperability and information blocking in early 2019, seeking to “advance interoperability and support the access, exchange and use of electronic health information.”

CMS’ and ONC’s proposed rules—different, yet connected—indicate a commitment to the 21st Century Cures Act, a law designed to “help accelerate medical product development and bring new innovations and advances to patients.” The 21st Century Cures Act also defines interoperability, prohibits information blocking and sets requirements around API (application programming interface) design. The ONC is proposing the healthcare industry adopt standardized APIs—specifically the Fast Healthcare Interoperability Resources (FHIR) standard—to allow individuals to securely and easily access their electronic health information.

In the proposed rules set forth by CMS, CMS-run programs (such as Medicaid, CHIP, Medicare Advantage plans and QHP issuers in the FFE programs) must make patient claims and other health-related information available to members through a standardized, open API that also permits third-party applications to retrieve the data.

Other CMS requirements for payers include:

  • Transferring patient data if a patient is switching providers or moving to a new payer or health plan
  • Allowing electronic access to healthcare providers via APIs
  • Enabling participation in exchange networks for exchanging data

After several weeks of allowing comments, questions and suggestions from the public and industry stakeholders, ONC delivered its interoperability and information blocking rule to the Office of Management and Budget (OMB) on October 28, 2019. Despite many industry organizations requesting a change in the timeline, ONC is moving ahead with finalizing the rule.

“The risk of delaying this is that the American public is not in charge of their healthcare, are paying more for their care, and not getting as good care as they could get,” said Don Rucker, M.D., national coordinator for Health IT, at a May 2019 meeting for the Senate Health, Education, Labor and Pensions (HELP) Committee.

Likewise, CMS also submitted its proposed rules to the OMB on September 26, 2019, and they are currently under review.

A final rule is likely to be issued in the first few months of 2020, Sloan explains. But most regulations take 18 to 24 months to actually go into effect. Payers who don’t comply with the new regulations from CMS, however, could face substantial penalties, she says.

“Their contracts can be suspended or revoked, or they could be pulled out of a health exchange, be fined or have to pay a penalty,” Sloan says. “Not complying can end up costing payers a significant amount of money.”

Better Access Means Better Care

When CMS’ rules are finalized, more than 125 million patients will have electronic access to their healthcare data and claims information.

“These proposed rules strive to bring the nation’s healthcare system one step closer to a point where patients and clinicians have the access they need to all of a patient’s health information, helping them in making better choices about care and treatment,” Alex Azar, secretary of the U.S. Department of Health and Human Services, said in a February 2019 press release.

“By outlining specific requirements about electronic health information, we will be able to help patients, their caregivers, and providers securely access and share health information,” he continued. “These steps forward for health IT are essential to building a healthcare system that pays for value rather than procedures, especially through empowering patients as consumers.”

The more data that can be shared—quickly and easily—can allow patients to receive better care, Sloan explains. “Patients can have their health information readily accessible across the entire continuum of care, which can only mean better care as they get the services they need,” she says.

Looking Forward

So what does this mean for employer-sponsored insurance plans? Though employer plans are currently exempt from these new regulations, Sloan believes that they will eventually have to comply as well.

“Employer-sponsored plans are self-funded,” Sloan explains. “CMS had to start somewhere. You don’t want to boil the ocean, so it’s easier for the government to mandate the plans they reimburse. Employer plans should look at these regulations as a warning ticket. Regulations—and likely shorter implementation cycles—will be issued for them in the next few years.”

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