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.

Tips for the Interoperability Section

  • Issuers should consult the following CMS resources: 
  • Issuers must complete the Interoperability Attestation and Justification Form as part of their QHP Application(s), and either upload it to the Program Attestations section of the Health Insurance Oversight System (HIOS) for Federally-facilitated Exchange (FFE) issuers, or submit it to the System for Electronic Rates & Forms Filing (SERFF) for issuers in states performing plan management functions. The following types of issuers are not required to complete the form:
    • Stand-alone dental plan-only issuers
    • Federally-facilitated Small Business Health Options Program (SHOP) issuers
    • State-based Exchange on the Federal Platform (SBE-FP) issuers
  • The four attestations in the Interoperability Attestation and Justification Form describe requirements for issuers to complete by January 1, 2021, but with enforcement discretion extended until July 1, 2021. Issuers must respond to each attestation and select “July 1, 2021” if they are on track to implement the requirement by that deadline. Issuers that are unable to meet that deadline must select an alternate deadline that reflects the earliest date by which they will have implemented each requirement; if issuers cannot meet any listed deadline, they must report the applicable timeline for implementation.
    • New issuers, defined as issuers that did not offer a plan on the Exchange in the prior year, are not required to implement the interoperability requirements until January 1, 2022.
  • Issuers that have not selected “July 1, 2021” for each of the four attestations in the Interoperability Attestation and Justification Form must complete the Justification section. These issuers will select from a list of implementation challenges (e.g., insufficient internal resources to complete implementation) applicable to their situation and provide a narrative justification. The narrative justification must include:
    • Additional detail on reasons for non-compliance, including both the challenges captured above and challenges not listed;
    • The impact of non-compliance on enrollees;
    • The current/proposed means of providing health information to enrollees; and
    • A proposed interim mitigation strategy to address current implementation challenges.

Application Resources