HHS wants to boost interoperability for Medicaid and CHIP


HHS wants to make it easier for beneficiaries covered by Medicaid, the Children’s Health Insurance Program or individual market plans to access and share their health information and speed up prior authorization for such plans, according to a proposed rule on Monday.

The proposal would require covered payers to follow specific implementation guidelines for application programming interfaces that increase access to patient health information and provider directories. It would also mandate that impacted payers force third-party app developers to agree to specific privacy requirements to access patient data and notify CMS about patient data requests every quarter. The proposal would apply to state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities and qualified health plans available through federal marketplaces.

The agency believes Medicaid, CHIP and people with individual market plans could disproportionately benefit from the changes because they’re more likely to switch insurers or plans or lose coverage.

“This proposed rule emphasizes improving health information exchange and achieving appropriate and necessary access to complete health records for patients, providers and payers, while simultaneously reducing payer, provider and patient burden by improving prior authorization processes, and helping to ensure that patients remain at the center of their own care,” HHS wrote.

The agency wants the changes to go into effect Jan. 1, 2023. Comments will be due on the proposal on Jan. 4, 2021.

HHS would require state Medicaid and CHIP fee-for-service programs to adopt new payer-to-payer data exchange policies using the Fast Healthcare Interoperability Resources—FHIR—standard. The agency said it didn’t require them to do it in its earlier interoperability rule so they could focus on implementing application programming interfaces for patient information and provider directories. The move is supposed to support the sharing of claims and encounter data, clinical data and information about prior authorization decisions.

“To better facilitate the coordination of care across the care continuum and in support of a move to value-based care, we are proposing to require that impacted payers implement and maintain (an application programming interface that allows) the exchange of current patient data from payers to providers,” the proposed rule said.

In addition, covered payers would have to enable providers to directly look up documentation and prior authorization requirements through their electronic health records, respond to prior authorization requests within specified timeframes and publicly report metrics about their prior authorization processes.

HHS isn’t proposing similar changes for Medicare Advantage plans, but the agency noted that nothing in the proposed rule should prevent payers from adopting the changes across their business lines.

“We are aware that these proposals, if finalized, would create misalignments between Medicaid and Medicare that could affect dually eligible individuals enrolled in both a Medicaid managed care plan and an MA plan,” the proposed rule said. According to HHS, the agency is evaluating whether Medicare Advantage plans should have to adopt similar interoperability and prior authorization changes.

HHS included several requests for information in the proposed rule that address the control and sharing of patient health information and prior authorization.



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