Proposed Health Record Regs Could Loosen Up the Medicare Plan Market

Because of those restrictions, the payer rules proposed in the new draft regulations would have a direct effect only on:

• Medicare Advantage plans.
• Medicaid managed care plans.
• State Medicaid agencies.
• The Children's Health Insurance Program (CHIP).
• Insurers  that issue "qualified health plans," or Affordable Care Act public exchange plans, through HealthCare.gov.

The traditional Medicare program already comes a separate, similar set of "Blue Button" patient record access program requirements.

HHS set up HealthCare.gov to provide ACA exchange program account setup and administration services for states that are unable or unwilling to provide all ACA public exchange services themselves.

Officials say in the preamble that they hope other health finance system players, including state-based ACA exchange programs and providers of private health insurance, will move voluntarily toward adopting the standards and rules described in the new regulations.

3. How the Draft Regulations Could Change the Rules for the Affected Payers

HHS officials want the new draft regulations to require the affected payers to make basic enrollee data available to the enrollees through a standardized "application programming interface," or API.

Health plans would have to use the API to share enrollee data with the enrollees.

To an enrollee, the API would be similar to the "Blue Button" health record system that the traditional Medicare program now uses: The enrollee could click on a button connected to the API and get health records.

The payer would have to provide information about any:

• Fee-for-service claims that have already been processed, including how much was paid to the providers and how much the enrollee had to pay.
• Patient encounters with health care providers who receive a flat monthly or annual fee for each patient served.
• Clinical data, such as laboratory results, managed by the payer.

HHS officials also want payers, such as Medicare Advantage plans, to use the API data pipes to share enrollee data with other payers.

"We propose that a plan must, if asked by the beneficiary, forward his or her information to a new plan or other entity designated by the beneficiary for up to five years after the beneficiary has disenrolled with the plan," officials say.

For a HealthCare.gov plan enrollee, an issuer would have to give an enrollee online access to information about how much the plan is paying the provider, and how much the enrollee has to pay the provider, within one day after processing the provider's claim.

4. A New Sin: Health Care Provider 'Data Blocking'

HHS officials say they will try to deal with providers who engage in at least one common form of data blocking — failing to provide digital contact information in a key government provider directory — by publicly identifying the providers who have failed to send that digital contact information to the directory.

5. Cost Estimates

Officials predict that the cost of implementing the draft regulations would be only about $3.81 per commercial health plan enrollee over the five-year period starting in 2020.

The five-year cost for Medicare Advantage plan enrollees would be $4.08 per enrollee, officials estimate.

6. Reasons to Be Skeptical

HHS and private organizations have tried to improve U.S. health information system interoperability many times before.

HHS officials have included a history of federal efforts in that area in the preamble to the new draft regulations.

The new efforts will face many challenges, such as privacy concerns that have gotten in the way of providing every patient with a "unique patient identifier," and long-term care providers' delays in adopting and using standardized patient health information exchange systems, officials say.

7. Possible Effects on the Medicare Plan Market

If the regulations take effect as written and work as HHS officials hope, agents who help clients deal with health insurance claim problems could have any easier time getting claim information, especially for clients who have Medicare Advantage plan or HealthCare.gov coverage.

If payers really use the new API infrastructure to send enrollee data to other payers, agents could also have an easier time moving a Medicare Advantage plan enrollee to another Medicare Advantage plan, or shift a Medicare Advantage plan enrollee into a combination of traditional Medicare coverage with a Medicare supplement insurance plans.

Officials do not discuss life insurance or other medically underwritten products in the preamble to the draft regulations, but the API could also make it easier for clients to share their health records with life insurance, disability insurance or long-term care insurance underwriters.

Resources

A copy of the proposed regulations is available here.

— Read Intel Executive: Let My Health Records Go, on ThinkAdvisor.

— Connect with ThinkAdvisor Life/Health on LinkedIn and Twitter.