In March 2020, the Centers for Medicare & Medicaid Services (CMS) and Office of the National Coordinator for Health Information Technology (ONC) released separate but related final rules which are designed to drive interoperability through data sharing and empower patients through increased access to data.

The CMS Interoperability and Patient Access Rule places new requirements on state Medicaid and CHIP fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally-facilitated Exchanges (FFEs) to improve the electronic exchange of health care data, and streamline processes related to prior authorization, while continuing CMS’ drive toward interoperability, and reducing burden in the health care market. Several new requirements include the following:

  • Implement and maintain a standards-based Patient Access API
  • Payer-to-Payer Data Exchange
  • Make standardized information about provider networks available via an FHIR-based Provider Directory API
  • Improve Dual Eligible Experience
  • Compliance with ONC 21st Century Cures Act final rule

The ONC 21st Century Cures Act final rule applies more generally to healthcare providers that are participating in CMS funded health IT programs, such as Promoting Interoperability, as well as to a broader definition of providers listed in the Public Health Service Act. This final rule will implement certain provisions for example, conditions and maintenance of certification requirements for health information technology (health IT) developers under the ONC Health IT Certification Program (Program), the voluntary certification of health IT for use by pediatric health care providers, and reasonable and necessary activities that do not constitute information blocking. The implementation of these provisions will advance interoperability and support the access, exchange, and use of electronic health information. The final rule also modifies the 2015 Edition health IT certification criteria and Program in additional ways to advance interoperability, enhance health IT certification, and reduce burden and costs.