Expert Perspective

May 11, 2020

Valuable Insights: May Regulatory Updates

Kathleen Gravelle – Chief Risk Officer

Interoperability Final Regulations

On March 9, the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator of Health Information Technology (ONC) released the long-awaited final rules on interoperability in IT health regulations. Together the rules implement provisions of the 21st Century Cures Act meant to improve patient access to their personal electronic health data and prevent health care systems from engaging in "information blocking." Notably, ONC’s final regulation implements eight exceptions to the information blocking ban, which generally involve protecting patient safety and privacy, protecting providers from unreasonable or infeasible requests, and allowing actors to charge certain fees for accessing or transmitting electronic health information.

Due to COVID-19, CMS also recently extended some of the implementation dates, but in general the CMS regulation requires payers to implement a secure, standards-based interface that allows patients to easily access claims and encounter information, including costs. It also requires provider directory information be publicly available via the same interface. Payers must exchange certain clinical data at the patient's request, allowing the patient to take their information with them as they move from payer to payer over time, to create a cumulative health record. CMS will also publicly report eligible clinicians, hospitals, and critical access hospitals that may be blocking information based on how they attested to program requirements. In addition, CMS will report providers who do not list or update their digital contact information in the National Plan and Provider Enumeration System.

Why Is This Important?

The CMS rule puts new requirements on all CMS-regulated payers, including Medicare Advantage Organizations (MAO), Medicaid fee-for-service and managed care plans, CHIP programs, and Qualified Health Plan issuers participating in health insurance exchanges. Both the CMS and ONC rules may require payers to make significant investments in new technology to be in compliance with the new standards, or they may face monetary penalties.

Final Rate Announcement

On April 6, CMS released the CY 2021 Final Medicare Advantage (MA) and Part D Rate Announcement, which provides an update of the proposed changes to the current MA risk adjustment model and Star Rating methodology, and includes the county-by-county MA rates that plans will bid against. On average, plans will see a 1.66 percent increase in payment in 2021, although individual plans will be affected by how the regulation influences rates in each individual county. Overall, CMS finalized the proposals it made in Part I and Part II of the Advance Notice published on January 6 and February 5, respectively.

2020 Presidential Election Spotlight

Due to the COVID-19 pandemic, the Democratic National Convention was moved to August 20, and will be in Milwaukee, Wisconsin. At the convention the party will formally nominate their presidential candidate and adopt the official 2020 Democratic Party platform. On April 8, Bernie Sanders dropped out of the Democratic race, meaning Joe Biden will likely be nominated as the candidate. For Medicare, Biden’s plan supports negotiating drug prices and “reference pricing” to set prices for drugs launching with no competition. Biden also proposes a public option to be available alongside the individual health insurance exchange options, but he does not propose a single-payer Medicare-for-all plan. This proposal would also allow people participating in employer-based insurance to opt out of their coverage and select the public option.


Access the latest resources and information from CareAllies during this uncertain time:

Quality Payment Program Scientific Research Incentive

CMS is encouraging clinicians who participate in the Quality Payment Program (QPP) to contribute to scientific research around COVID-19, with the goal of driving data to help with improvements in patient care and developing best practices to manage the spread of COVID-19 within communities. Clinicians can earn credit in the Merit-based Incentive Payment System (MIPS) by attesting to the new COVID-19 Clinical Trials improvement activity. To earn the credit, clinicians must attest that they participate in a COVID-19 clinical trial utilizing a drug or biological product to treat a patient with a COVID-19 infection and report their findings through a clinical data repository or clinical data registry for the duration of their study.

COVID-19 Legislative and Regulatory Update Timeline


To learn more...

For more information about the interoperability final regulations, visit the CMS website:

Read the CMS fact sheet for more information on the final rate announcement:

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