Interoperability

Issuers seeking certification of their QHPs must meet CMS requirements for data interoperability as implemented by the Interoperability and Patient Access Final Rule. Issuers must attest to the organization’s compliance with the following requirements:

  • The implementation of an application programming interface (API) that enables enrollees to access their health data via a third-party application of the enrollee's selection.
  • The inclusion of claims, encounter, cost, and clinical data within timeframes detailed in the regulation.
  • The public posting of complete technical documentation to guide successful interaction with the API.
  • The public posting of educational resources for enrollees that advise on the protection of personal health information, which organizations are likely to be Health Insurance Portability and Accountability Act (HIPAA)-covered entities, and how to submit formal complaints.
Note: CMS has decided to exercise enforcement discretion not to take action against certain payer-to-payer data exchange provisions of the May 2020 Interoperability and Patient Access final rule. Further details are available on the Additional Regulatory Guidance webpage linked below. 

In addition to attesting to compliance, issuers must also supply 1-2 URLs where the public posting of technical documentation and educational resources for enrollees may be found. These URLs should lead to live, active webpages and include key terms indicating the issuer has included required technical information and education resources. Issuers are advised to refer to CMS URL guidance documents listed at the bottom of this webpage. 

Another key change for PY2023 is the collection of interoperability data. In PY2022, issuers were required to complete a supporting document and upload it to HIOS or SERFF. Beginning PY2023, issuers will complete a webform on the interoperability tab of the supplemental submission module of HIOS. Issuers are encouraged to review the QHP Issuer Application Instructions for further detail. 

Key Changes for PY2023: 
  • If you are applying to certify Medical QHPs, you must still submit an Interoperability Attestation and Justification Form as was included in PY2022. This year, the form will be available in the Supplemental Submission Module as a web-based form as opposed to last year when it was a supporting document uploaded to the Program Attestations Section.
Tips for the Interoperability Section
  • Respond to all questions on the web-based form to attest to compliance with each requirement. If you respond “No” to any attestation or do not provide a URL documenting compliance, you must submit a narrative justification at the end of the form. 

Application Resources