The Centers for Medicare & Medicaid Services (CMS) Interoperability and Patient Access Final Rule aims to bridge digital divides within the healthcare ecosystem. The Application Programming Interface (API) policies will improve patient, provider and payer access to interoperable patient data and reduce the burden of the prior authorization processes by requiring all CMS-backed plans to grant members access to their own health records. The core objective is to enhance the flow of healthcare information and empower members with access to their data. However, meeting the proposed effective date of Jan. 1, 2026, involves addressing several technology specifications.


Interoperability Requirements and API

The overarching goal is to streamline communication, reduce administrative burdens, and enhance overall care coordination for patients across the healthcare continuum. The CMS interoperability mandate includes:

  1. Patient Access API
  2. Provider API
  3. Payer-to-payer data exchange system

The interoperability requirements outlined by CMS are underpinned by APIs. An API serves as the standardized gateway through which external applications can access data and play a pivotal role in achieving the broader objectives of the mandate. Through improved connectivity, members who consent will gain greater control over their health data via a Patient Access API. The Provider API enables healthcare providers to access patient health data electronically, including prior authorization information. Patient information, such as medical history, prescriptions, and treatment plans, can be efficiently and securely shared between health plans and providers. Finally, the Payer-to-Payer data exchange ensures a member’s data remains with them – even if they switch health plans.


Technology Hurdles

Revamping existing technology infrastructure to meet these new requirements poses a significant challenge for many payers. Substantial investments in new technology and the integration of existing systems are necessary to implement patient access APIs, provider APIs, and payer-to-payer data exchange systems. Payers must navigate the complex healthcare IT landscape to ensure seamless data exchange without compromising security or member privacy.


Data Governance and Security

The flow of data across systems necessitates robust data governance and security measures with payers holding the responsibility. Safeguarding sensitive patient information is not only a legal obligation but also a matter of trust. Payers must implement stringent protocols to protect against data breaches and unauthorized access, all while adhering to evolving CMS regulatory frameworks.


Provider Engagement

The success of interoperability relies on the active engagement of healthcare providers. Payers must foster collaboration and communication with a diverse array of providers, each operating with their own set of systems and protocols. Achieving a standardized approach to data exchange requires open communication channels and user-friendly technology between payers and providers.


Improved Care Coordination

Interoperability can facilitate improved care coordination by dismantling silos in healthcare information. Payers can collaborate more effectively with providers, leading to streamlined care pathways, reduced redundancies, and ultimately, improved patient outcomes. This collaborative approach has the potential to enhance the quality of care within the healthcare ecosystem.


Empowering Patients

At the heart of the CMS Interoperability and Patient Access Final Rule is patient empowerment. Providing members access to their health data through user-friendly APIs fosters a more informed and engaged patient population, enhancing the overall patient experience, and laying the groundwork for a more patient-centric healthcare model.


Innovation and Integration

Payers can leverage data exchange systems to fuel advancements in healthcare analytics, population health management, and personalized medicine. The interconnected healthcare landscape allows for the integration of innovative solutions, such as telehealth platforms and wearable technologies, fostering a more comprehensive and holistic approach to healthcare delivery.


Interconnected Healthcare Ecosystem

As payers grapple with challenges and seize opportunities presented by the CMS Interoperability and Patient Access Final Rule, the future of healthcare appears poised for transformation. The industry is on the cusp of a paradigm shift towards a more connected, patient-centric, and technologically advanced ecosystem. 



Standardized data exchange protocols and the refinement of interoperability frameworks will continue to evolve with the healthcare landscape. Payers will play a pivotal role in shaping this future by embracing emerging technologies, collaborating with stakeholders, and championing the cause of patient empowerment.

UST HealthProof closely monitors regulation changes. Contact us to learn how we can help navigate these changes while helping solve the complex operational challenges health plans can face. 


About UST HealthProof

UST HealthProof, a UST company, is on a mission to play a role in shaping how the future of healthcare is delivered. Focused on consumer-centric and cloud-based solutions to reduce administrative cost, UST HealthProof administers and serves over 6 million members across multiple lines of business including Medicare, Medicaid, Commercial, Individual and self-funded employer groups. Its proven core administration solutions and business process-as-a-service (BPaaS) provide transparency and improve operational efficiency, breaking down operational barriers to scale and drive strategic growth. 

UST HealthProof closely monitors regulation changes. Contact us to learn how we can help navigate these changes while helping solve the complex operational challenges health plans can face.