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CMS Proposed Rule on Interoperability and Patient Access

On February 11, 2019, CMS Administrator Seema Verma announced the release the Centers for Medicare & Medicaid Services (CMS) proposed rule on patient access to data and interoperability.

What is CMS Proposing?

For health plans that do business with the federal government, like Medicare Advantage and individual market exchange plans, CMS is proposing that they make electronic information available to their enrollees – like provider directories, lab results and patient claims.
CMS is also proposing that Medicare-participating hospitals send electronic notifications when a patient is admitted, discharged or transferred to a different care facility.
To make sure that Americans have access to their medical records in a digital format and increase the seamless flow of health information between health care organizations.

What is the Proposed Rule For?

When Are Comments Due?

CMS will accept comments until June 3, 2019.

When Will the Rule Be Finalized?

It seems likely that some or all of this proposed rule will be finalized very soon after comments are reviewed (~September 2019), though some more controversial parts may be delayed for future rulemaking this year.

(Remember, this only applies to plans that contract with the federal government, like Medicare Advantage, Medicaid managed care and federal individual market exchange plans)

What Do Plans Have to Do?

1. Use APIs -


Plans need to use an open API (application programming interface that permits third-party apps to retrieve data) when enrollees request their electronic data. Plans will also need to facilitate the portability of this data -- allowing patients to take the information with them if they switch health plans.

2. Send Electronic Data to Enrollees -


Health plans must make specific data accessible to enrollees electronically, including approved or denied adjudicated claims, clinical data including lab results, and provider directories.

3. Join a Trusted Exchange Network -


Plans must participate in a trusted exchange network – a group of different organizations that share health data in a standardized and secure system – effective beginning January 1, 2020.


In its proposal, CMS refers to the ONC’s draft trusted exchange framework here, which will be updated in the next few months.

What Other Related Rules Are Coming After This One?

CMS is asking for comments on specific issue areas for the purposes of informing future rulemaking. The biggest issues are:
  • Patient matching (making sure Jane Doe’s medical records are the correct Jane Doe across multiple databases),

  • Improving health IT adoption in post-acute care settings,

  • Information sharing between payers and providers via APIs,

  • Interoperability between Medicare and Medicaid dual-eligible populations, and

  • Advancing interoperability through new payment models.

Who Should Review These Rules?

  • Legal and Regulatory Teams, particularly privacy experts

  • Technology Teams, anyone else who is familiar with APIs

  • Business Operational Teams who oversee claims and encounter data, provider directories, and other enrollee data

  • If you are an MA Part D plan, your pharmacy team or whomever oversees your drug benefit data, pharmacy directories information, and formularies

Want to know more?


Contact Julie Barnes at​

Text or call 703-304-1756

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