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This proposed rule would place new requirements on Medicare Advantage (MA) organizations, Medicaid managed care plans, Children’s Health Insurance Program (CHIP) managed care entities, state Medicaid and CHIP fee-for-service (FFS) programs, 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. This proposed rule would also add a new measure for eligible hospitals and critical access hospitals under the Medicare Promoting Interoperability Program and for Merit-based Incentive Payment System (MIPS) eligible clinicians under the Promoting Interoperability performance category of MIPS. These policies taken together would play a key role in reducing overall payer and provider burden and improving patient access to health information.

Statement of Need:

The proposed changes further support CMS’ efforts to improve the electronic exchange of healthcare data and streamline processes related to prior authorization, while continuing CMS’ drive toward interoperability in the healthcare market.  The proposals in this rule build on the foundation we laid out in the CMS Interoperability and Patient Access final rule to move the healthcare system toward increased interoperability and reduced burden by proposing to enhance the data sharing capabilities of impacted payers and providers through the use of innovative technologies. The proposals also empower patients by making health-related data more easily available through standards-based technology.

Summary of the Legal Basis:

This rule addresses multiple sections of the Social Security Act, as well as Executive Order 13985, Advancing Racial Equity and Support for Underserved Communities Through the Federal Government.

Alternatives:

We carefully considered alternatives to the policies we are proposing in this rule and concluded that none of the alternatives would adequately or immediately begin to address the critical issues related to patient access to health information and interoperability or help to address the processes that contribute to payer, provider, and patient burden.  Alternatives considered will be included in the proposed rule.

Anticipated Costs and Benefits:

We believe that the proposed policies, if finalized, would result in some financial burdens for impacted payers and providers. We have weighed these potential burdens against the potential benefits, and believe the potential benefits outweigh any potential costs.  We anticipate the long-term savings to be significant. As we move toward publication, estimates of costs and benefits will be included in the proposed rule. 

Risks:

Risks of the proposals in this rule are still under development and will be included in the published rule for comment.