Confused about Data Availability Requirements as a Result of the Interoperability Rule and the Real Time Benefit Tool? BluePeak has you Covered!

Over the course past year, CMS issued several different proposed and final rules that address making certain data available in a real-time or near real-time manner.  The table below summarizes these rules and what they require.

  Interoperability and Patient Access Real Time Benefit Tool (RTBT)
Prescriber Member
Relevant Rule(s) Interoperability and Patient Access

(CMS-9115)

Modernizing Part D and MA to Lower Drug Prices and Reduce Out-of-Pocket Expenses

(CMS-4180)

Contract Year 2021 and 2022 Policy and Technical Changes to the MA and Medicare Prescription Drug Benefit Program

 

Change Finalized? Yes, final rule issued on March 9, 2020 Yes, final rule issued on May 23, 2019 Not at this time
Implementation Date Patient Access API
January 1, 2021 (enforcement starting July 1, 2021)
Provider Directory API
January 1, 2021 (enforcement starting July 1, 2021), though CMS strongly encourages earlier implementationPayer-to-Payer Exchange
January 1, 2022
January 1, 2021 (though CMS strongly encourages earlier implementation)

 

Proposed: January 1, 2022
Purpose To move the health care ecosystem in the direction of interoperability, and to signal CMS and HHS commitment to improve the quality and accessibility of information that Americans need to make informed health care decisions, including data about health care prices and outcomes, while minimizing reporting burdens on affected health care providers and payers To enhance medication adherence and lower overall drug costs by providing Part D prescribers information in real time when lower-cost alternative drugs are available

 

To empower enrollees with information like that in the prescriber RTBT to help them initiate conversations with their prescriber about medication options, and give them the ability to access this information either at their computer or using a mobile device, so they need not depend on prescribers to pull up the information
 Requirements Patient Access API
Implement and monitor a Patient Access API to which third party software applications can connect, so the enrollee can view their electronic health information can be displayed by enrollees on their mobile device
Provider Directory API

Implement and monitor a Provider Directory API to which third party software applications can connect, so the information can be displayed by enrollees on their mobile devicePayer-to-Payer Exchange
With the approval and at the direction of any current/former enrollee, health plans must electronically send the enrollee’s electronic health information (requires same data as Patient Access API) to another payer identified by the enrollee
Part D Plans must implement at least one electronic RTBT capable of integrating with at least one of prescribers’ e-Prescribing (eRx) or electronic health record (EHR) systems to provide complete, accurate, timely, clinically appropriate, and patient-specific real-time formulary and benefit information to the prescriber Would require Part D Plans to implement a beneficiary RTBT to allow enrollees to view subset of the information included in the prescriber RTBT system

To encourage enrollees to use the beneficiary RTBT, CMS will allow Part D Plans to offer rewards and incentives to enrollees who log onto the beneficiary RTBT or seek to access this information via the plan’s customer service call center.

 

Who it applies to Patient Access API

  1. MA Plans
  2. Medicaid Plans (both Fee-for Service (FFS) and Managed Care Plans (MCP))
  3. CHIP Plans (both FFS and MCP)
  4. QHP issuers on Federally Facilitated Exchanges

Provider Directory API

  1. MA Plans
  2. Medicaid Plans (both FFS and MCP)
  3. CHIP Plans (both FFS and MCP)

Payer-to-Payer Exchange

  1. MA Plans
  2. Medicaid Plans (MCP only)
  3. CHIP Plans (MCP only)
  4. QHP issuers on Federally Facilitated Exchanges

Does NOT apply to:

  • Standalone Part D Plans (PDPs)
  • Cost Plans
  • PACE Organizations
  • Stand-Alone Dental Plans (SADPs)
  • QHPs in the federally facilitated Small Business Health Options Program Exchanges (FF-SHOPs)
  • State-based exchanges on the Federal platform (SBE-FPs)
Medicare Part D Plans Medicare Part D Plans
Data Involved Patient Access API
Must use data standards published in 21st Century Cures Act final rule with dates of service on or after January 1, 2016, including:

  1. Adjudicated claims, including:
    • Claims data for payment decisions that may be appealed, were appealed, or are in the process of appeal
    • Part D claims
    • Provider remittances
    • Cost-sharing
  2. Encounters data, including:
    • Medicare Part A and Part B items and services
    • Part D prescription drugs, if covered by the MA plan
    • Any supplemental benefits
  3. Clinical Data (but only required when the MA organization receives and maintains this clinical data as part of its normal operations)
  4. Formularies or preferred drug lists

Provider Directory API

  1. Provider names, addresses, phone numbers, and specialties
  2. MAOs that offer MA-PD plans must also make available pharmacy directory data: Pharmacy name, address, and phone number, number of pharmacies in the network, mix of pharmacies in the network (e.g., retail, mail order)

Payer-to-Payer Exchange
Same data as in Patient Access API

  1. Benefit information about the drug the provider intends to prescribe
  2. Beneficiary-specific utilization management requirements (e.g. Prior Authorization or Step Therapy Requirements) that have yet to be satisfied
  3. Formulary alternatives (e.g., medication(s) with the same therapeutic efficacy but that may have different coinsurance than the drug being considered)
  4. Beneficiary cost-sharing at the selected pharmacy
  5. Each drug’s full negotiated price (this is encouraged but not required)

 

  1. A plan-defined subset of the information included in the Prescriber RTBT
  2. Each drug’s full negotiated price (this is encouraged but not required)