The Centers for Medicare & Medicaid Services (CMS) last week sent a letter to state Medicaid directors about the steps they will need to take to implement the CMS Interoperability and Patient Access final rule, including creating a patient access application programming interface (API). The letter also notes that some of the activities could be eligible for 90/10 federal matching funds.
State Medicaid agencies face a daunting challenge to meet federal deadlines for making their data available to third-party developers through standard APIs. The compliance deadline for the patient access API and provider directory API provisions is January 2021, just a few short months away. However, CMS has released guidance saying it would exercise enforcement discretion for a period of up to six months with connection to those two API provisions.
During a recent presentation, Colorado Medicaid IT officials outlined their planned approach to overcome the obstacles they face, including a budget crisis related to the COVID pandemic.
“To be frank, based on state timelines and shifting resources to mitigate the COVID virus, it will likely be incredibly difficult for many states, Colorado included, to implement by July 1, 2021,” said Micah Jones, health IT coordinator for the Colorado Department of Health Care Policy and Financing.
Several new requirements in the final rule apply to Medicaid and CHIP, including the following:
• Maintaining a standards-based Patient Access API will enable beneficiaries to have access to their health data on their internet-enabled devices (such as smartphones).
• Payer-to-Payer Data Exchange. Medicaid systems will have to coordinate care between payers by exchanging, at a minimum, the information contained in the United States Core Data for Interoperability (USCDI). The CMS Interoperability and Patient Access final rule requires Medicaid managed care plans and CHIP managed care entities to comply with a beneficiary’s request to have their health data transferred from payer to payer by Jan. 1, 2022.
• Make standardized information about provider networks available via a FHIR-based Provider Directory API: The final rule requires Medicaid agencies, CHIP agencies, Medicaid managed care plans and CHIP managed care entities to provide current provider directory information via an API. CMS is exercising enforcement discretion and does expect to enforce this requirement prior to July 1, 2021.
• Improving the Dual-Eligible Experience: The rule requires state Medicaid agencies, by April 1, 2022, to exchange certain data with CMS daily on beneficiaries who are dually eligible for Medicaid and Medicare. Currently, many states and CMS exchange these data as infrequently as monthly, which delays coverage status changes and leads to inaccuracies, recoupments, and poor customer experiences. Improving the accuracy and timeliness of data on dual eligibility status is a strong first step in improving how these systems work together for beneficiaries, providers, and payers.
The letter states that State Medicaid agencies implementing the API requirements might be able to claim the enhanced federal financial participation (FFP) for the design, development, installation, or enhancement of mechanized claims processing and information retrieval systems, provided that they meet all other requirements applicable to claiming those enhanced federal matching rates. In those cases, the federal government typically pays 90 percent of the cost, and the states pay 10 percent.
The letter also highlights the potential role of health information exchanges (HIEs). States may be best able to compile all data elements described for the Patient Access API through connections to health information exchanges or public health agencies, or human services agencies, CMS said. “Specifically, the required data in the United States Core Data for Interoperability (USCDI) … might include information residing in health information exchanges or public health agencies (for immunization data, lab test and result data, etc.), or human service agencies, and states should review if establishing such connections would be appropriate. If so, enhanced FFP might be available…to support such connections.”
