What is Centers for Medicare & Medicaid Services (CMS) Patient Access and Payer Data exchange Rule?

The Interoperability and Patient Access Rule calls on Medicare, Medicaid, and CHIP health plans, as well as those sold on the federal exchanges, to grant electronic access to patient claims and clinical data. The Rule puts patients first, giving them access to their health information when they need it most and in a way they can best use it.
Additionally, the Payer to Payer rule allows patients to take their clinical data with them when they switch insurance companies and retain access to their data from their prior payer.
The rule is part of the cross-agency MyHealth eData initiative started in 2018 to facilitate data-sharing across public payers and provider organizations.

Who is it for?

Users of Medicare Advantage (MA) plans, state Medicaid programs both fee-for service (FFS) and managed care, Children’s Health Insurance Plans (CHIP) including FFS and managed care, and Qualified Health Insurance Plan (QHP) in the health insurance exchanges established by the Affordable Care Act (ACA).

How will it work?

Last year, CMS established an “open” Application Programming Interface (API) for developers to create apps that can help beneficiaries access their data and to help health care systems exchange information in an interoperable format. The API is like an app store for a smart phone except it is designed for health care systems instead. Openly published APIs are accessible to third-party applications, developers, and payers. CMS says that over 1,500 developers are building apps with various purposes within this API.
The CMS and ONC proposed rules would require Medicare Advantage (MA) organizations, state Medicaid and CHIP FFS programs, Medicaid managed care plans, CHIP managed care entities, and health insurers issuing plans on the Federal Health Insurance Exchange to implement an API using the HL7 Fast Health Care Interoperability Resources (FHIR) programming standard. The Administration is not proposing to require state CHIP programs that do not operate an FFS program to establish an API.

What do you need to do?

Learn about how you can prepare yourself
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  • Stay informed about ways to ensure the apps protect your privacy.
  • Select the app of your choice once available in accordance with the security and privacy guidelines.
  • Always initiate your Payer to Payer date exchange request with your current payer.


Why is CMS doing it? / Why is it important?

To promote interoperability and patient empowerment.
CMS describes the intent of the API, “Consumers routinely perform many daily tasks on their mobile phones – banking, shopping, paying bills, scheduling – using secure applications. We believe that obtaining their health information should be just as easy, convenient, and user-friendly.”
The interoperability rules call for healthcare organizations to give patients better access to their personal health data and clearer information about cost, empowering them to make informed decisions about what care they receive and where.
With secure, standards-based application programming interface (API) requirements, you could have access to and control over your health information, through whatever device or app you choose. The goal is to foster choice and competition in health care.

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