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BLOG. 4 min read

The Game Changer: 3 Interoperable Data Types Required of Health Plans

Government interoperability mandates are coming to health plans. Mobile and web access to individual health claims data, clinical data, and health provider information may finally be entering the 21st Century. While you can instantly change your flight, check the status of a package you ordered, reserve a hotel room, and view your concert tickets on your mobile phone, you still need to wait a month or more for health plans to mail a paper notice advising you if your medical treatment was covered. Recently proposed federal regulations from the Trump Administration, through CMS and the HHS Office of National Coordinator (ONC) for Health IT, aim to change that. They are the first nationwide interoperability compliance requirements for health plans and states administering coverage under government programs, to generate personal health and provider data over the web and on mobile devices for the consumer.

What Interoperable Data Would Plans Have to Produce?

CMS and state Medicaid agencies have required electronic X12 data transactions for over 20 years. These data standards started with the 1996 Health Insurance Portability and Accountability Act (HIPAA), which set enrollment, claims, payment, coverage, and authorization transaction standards. However, these transaction standards govern data exchanges between health plans, providers, and the government for batches of electronically transmitted transactions only. HIPAA did not require electronic data sharing with individuals but rather set up individual privacy and security protection over the release of individual data. Until now, plans have not been required to make individual claims data available to members, their families, caregivers, or providers via the internet or mobile devices. 

Under the new CMS1 and ONC2 proposed interoperability regulations, new requirements for digital data-sharing with members will be established. CMS would require health plans to connect to a trusted exchange network and make three types of data available to the member through open Application Programming Interface (API): claims data, plan possessed clinical data, and current provider directory data.

Claims data: Under the proposed rule, health plans that offer government program coverage would make medical and drug claims available via API to the web or mobile devices, only if requested and authorized by a plan enrollee, with members selecting who receives the data. Plans would have to send the member claims on a rolling basis, within 1 day after a claim is adjudicated, and can use the data content from HIPAA transaction standards. To accomplish this, health plans would be required to allow third-party applications to retrieve the following data upon approval by the enrollee: adjudicated claims (including provider remittance and beneficiary cost-sharing), encounters from capitated providers and approved and denied claims. 

Clinical data: As an alternative to claims data, plans could instead release clinical data, including laboratory results, vital signs, clinical notes, and assessments via API to the member and their designated stakeholders. For such clinical information, plans would need to use the U.S. Core Data for Interoperability (USCDI) version 1 content and vocabulary standards, which were created for 2015 edition electronic health record (EHR) certification. 

In order to adhere to the requirements, plans can choose to release either claims or clinical data layouts as appropriate. 

Provider Directories:  Within 30 calendar days after changes are made, provider directory data would need to be available via API to third-party applications for consumption, aggregation, and display for different contextual uses, such as comparison of plan provider networks for individual needs. In addition to basic provider information like name, phone number, location, and specialty, CMS is seeking expanded information to possibly include hours of operation, languages spoken, and availability for new patients. 

Who’s impacted?

The two interwoven HHS-ONC and CMS interoperability and patient access rules require the following types of plans to implement, test, and monitor APIs so that provider directories, patient claims, and other electronic health information (EHI) are electronically available to patients through third-party applications:

  • Medicare Advantage
  • Children’s Health Insurance Programs (CHIP)
  • Medicaid Fee-for-service programs and managed care entities
  • Qualified health plans (QHPs) on the Federally-Facilitated Exchange (FFE)

In addition to open API requirements, these plans must also connect to a trusted exchange network to further assist with care coordination. 

If finalized, CMS estimates up to 125 million lives could request EHI access to their claims, clinical, and provider directory data.  CMS initially proposed an effective date starting in January 2020 for MA and FFE plans, and July 2020 for Medicaid and CHIP; however, it appears CMS will delay these dates while it considers comments received on the proposed regulation.  The comment period ended June 3, 2019.

Be aware that CMS estimates an average one-time cost to implement health plan API requirements will be around $790,000 per health plan or state; the annual cost to maintain, upgrade, and test with third-party applications is estimated to come in around $158,000.[1]

In Summary

Health plans will need to consider these new interoperability requirements very thoughtfully. The devil is in the details. For instance, since plans will be required to receive and store USCDI v1 clinical data, will you need a data warehouse? Are there other use cases that these new technical abilities can help solve?  

The timelines for compliance are expected to shift, and we are proactively using our API experience to develop a solution to assist plans with compliance of these new interoperability requirements. Contact SS&C Health today to learn more about our solutions and expertise. Let us help you prepare for a more patient-connected tomorrow.




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