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What the CMS proposed interoperability and patient access proposed rule means for payers

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To promote data sharing, CMS released a proposed rule on March 4, 2019 with the goal of ensuring that every American can, without special effort or advanced technical skills, see, obtain, and use all electronically available information that is relevant to his or her health and care. The rule covers information on choices of plans, providers, and specific treatment options as well. These rules go into effect in January of 2020 for Medicare Advantage Plans and July of 2020 for Medicare Plans. They include two types of information:

  • Personal information that requires appropriate diligence to protect each individual’s privacy, such as their current and past medical conditions and care received
  • General interest information that should be widely available, such as plan provider networks, the plan’s formulary, and coverage policies

What payers are impacted by this rule?
Medicare Advantage (MA) plans, Medicaid state agencies, Medicaid managed care plans, Children’s Health Insurance Program (CHIP) agencies, CHIP Managed Care entities, and issuers of qualified health plans in Federally-Facilitated Exchanges, except for stand-alone dental plans.

What are payers required to do under this proposed rule?
The rule requires covered Health Plans to provide patients access to their data through “open” Application Programming Interfaces (APIs). APIs should be published such that patients can use third-party applications to access that data, subject to the provision of HIPAA.

  • Data to be shared includes:
    • All of the provider directory (the names of providers, addresses, phone numbers, and specialty plan coverage information)
    • Adjudicated claims X837 (including cost X835 – payment/advice), encounters with capitated providers, provider remittances, enrollee cost-sharing, and clinical data, including laboratory results (where available)
    • Drug benefit data, including pharmacy directory information and formulary or preferred drug list data
    • MA Part D – pharmacy directory data, including the number, mix, and addresses of pharmacies in the plan network, as well as formulary data including covered Part D drugs and any tiered formulary structure or utilization management procedure which pertains to those drugs
  • APIs must be compliant with ONC API standards (HL7® FHIR® – Fast Healthcare Interoperability Resources) published in the companion ONC proposed rule

The rule also requires payers to support beneficiaries in coordinating their own care via payer to payer care coordination, and to share information with a Trusted Exchange Network.

What standards need to be supported under this rule?

  • FHIR DSTU 2
  • United States Core Data for Interoperability (USCDI)

What type of data will be shared?

  •  X12 message types X837, X835, and other
  • Clinical data if already managed by the plan
  • Pharmacy benefit, directory, and formulary data
  • Provider Directory information

Customers use our solutions to bring together patient and member data from EMRs, insurance claim systems, and other sources across the healthcare ecosystem. InterSystems interoperability technology has been at or near the top of KLAS rankings for over a decade.

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Digital transformation is a strategic imperative that payers need to embrace if they want to maintain a leading edge. Not only will it help payers envision new approaches to care delivery at lower cost, but will also help steer members to the lowest-cost high-quality provider, thereby optimizing the care setting for their needs and enabling them to better manage their health. And that is at the heart of the CMS proposed rule.

No data management vendor has a greater commitment to healthcare or more relevant experience than InterSystems. Globally, more than half a billion health records are managed by solutions built on our technology. The most sophisticated private and government providers depend upon devices, records, and IT powered by InterSystems.

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