CMS issues Medicaid guidance for states on implementing interoperability rule

Doctor computer medical records
The timeline for compliance with CMS' interoperability final rule is "aggressive" according to a CMS official. The agency issued new guidance Friday to help states get into compliance. (Getty/BrianAJackson)

A new federal regulation requires state Medicaid agencies to make it easy for patients to access their health information via smartphone by January 1.

To help with the heavy lift, the Centers for Medicare and Medicaid Services (CMS) issued guidance (PDF) Friday to help states implement the Interoperability and Patient Access final rule in Medicaid and the Children's Health Insurance Program (CHIP).

"The timeline for compliance with the CMS Interoperability and Patient Access final rule is aggressive, and CMS is committed to providing states with the necessary technical assistance to implement these advancements in improving patient access to their data and interoperability," said Calder Lynch, deputy administrator and director of the Center for Medicaid and CHIP Services in the guidance.

Lynch advised that states should seriously consider leveraging existing state and federal investments in health information exchanges (HIEs) to implement these new requirements.

The Department of Health and Human Services issued two major rules in March to implement interoperability and patient access provisions of the bipartisan 21st Century Cures Act. 

RELATED: CMS' new interoperability rule requires major changes for payers, hospitals. Here are 6 key elements

The regulations require major changes for payers and hospitals to provide patients access to their health information.

Among other things, the rule requires that Medicaid, CHIP, Medicare Advantage (MA) plans and qualified health plans make enrollee data immediately accessible through a standards-based patient access application programming interface (API) by January 2021. 

That gives beneficiaries access to their claims and encounter information, including cost, through a third-party  mobile app of their choosing. 

Due to the COVID-19 pandemic, CMS said it won't enforce those requirements for an additional six months, which means enforcement begins July 1, 2021.

Medicaid managed care plans and CHIP managed care entities also will have to provide current provider directory information via an API by January 1, 2021. CMS enforcement will not begin until July.

RELATED: Americans will have 'access to their health information on their smartphones': Trump admin on HHS rules

Under the rule, Medicaid managed care plans and CHIP managed care entities must enable payer-to-payer data exchange so a beneficiary's health data can be transferred from one payer to another. That requirement goes into effect January 1, 2022.

The guidance outlines key steps that Medicaid agencies should take now to come into compliance with the interoperability rules, including:

  • Evaluate implementation guides developed by HHS and CMS to help implement the API policies;
  • Consider what contract amendments might need to be put in place with managed care plans and entities and what advance planning documents might be necessary;
  • Develop a project plan in coordination with the appropriate CMS Medicaid Enterprise System (MES) state officers to address funding and data infrastructure issues; and
  • Assess the organization's ability to create the appropriate data sets and the ability to send and receive that data.