CMS Qualified Health Plan (QHP) Directory Pilot

As part of its ongoing work to improve access to care, reduce clinician burden, and support interoperability throughout the health sector, the Centers for Medicare & Medicaid Services (CMS) announced on September 17, 2024, a partnership with the state of Oklahoma on a first-of-its-kind directory pilot. One goal of this pilot is to develop an automated, single, statewide centralized directory for Qualified Health Plans (QHPs) and providers in Oklahoma to improve data accuracy, lessen burden on providers and payers, lower administrative costs, support interoperable data exchange, and ultimately improve patient and provider experiences. CMS believes that this pilot will serve as a proof-of-concept and help inform any future development of an National Directory of Healthcare (NDH) that can serve as a centralized database for provider information. For questions, please contact QHPDirectorypilot@cms.hhs.gov.

Additional Information:

• Qualified Health Plan (QHP) Directory Pilot Frequently Asked Questions (12/20/24) (PDF)

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HHS Releases Information Bulletin on Publication of Final Rule CMS-0056-F

The Department of Health and Human Services (HHS) has released an Information Bulletin informing stakeholders of the Federal Register publication of the final rule CMS-0056-F. This final rule adopts updated versions of the retail pharmacy standards for electronic transactions adopted under the Administrative Simplification subtitle of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Stakeholders can review a fact sheet that provides additional information on this final rule, including relevant background, major provisions, and an implementation timeline.

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Optimizing Care Delivery: A Framework for Improving the Health Care Experience

CMS has a critical role in advancing health system efficiency and improving the experience of delivering and receiving health care. Administrative burden is a persistent challenge that can come in many forms and be a factor in limiting a patient’s ability to access quality, timely care. Such frictions can take time away from clinicians and their patients, contribute to inequities in care, and negatively affect the health and well-being of the nation’s health care workforce.

Optimizing Care Delivery: A Framework for Improving the Health Care Experience is CMS’ five-year strategy for improving health care delivery and the care experience by addressing administrative burdens and other frictions in the programs it oversees as well as the health system more broadly.

CMS Finalizes Rule to Expand Access to Health Information and Improve the Prior Authorization Process

The CMS Interoperability and Prior Authorization final rule is now available to review here (PDF).

As part of the Biden-Harris Administration’s ongoing commitment to increasing health data exchange and strengthening access to care, the Centers for Medicare & Medicaid Services (CMS) finalized the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) today. The rule sets requirements for Medicare Advantage (MA) organizations, Medicaid and the Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and issuers of Qualified Health Plans (QHPs) offered on the Federally-Facilitated Exchanges (FFEs), (collectively “impacted payers”), to improve the electronic exchange of health information and prior authorization processes for medical items and services. Together, these policies will improve prior authorization processes and reduce burden on patients, providers, and payers, resulting in approximately $15 billion of estimated savings over ten years. (Click here for fill Press Release)

Recordings Now Available From the 2023 CMS Conference on Optimizing Healthcare Delivery to Improve Patient Lives

All session recordings of the 2023 CMS Conference on Optimizing Healthcare Delivery to Improve Patient Lives are now available! 

The conference was a step ahead in fostering a collaborative, inclusive approach to addressing health worker burnout, advancing interoperability, and reducing or eliminating unnecessary administrative burdens. It served as a forum for sharing ideas and best practices and demonstrated the value of coming together and learning from each other. We look forward to continuing the work with all of you.

CMS Releases the Barriers to Oral Health Care Illustration

In the spring of 2022, CMS conducted the Oral Health Human-Centered Design Customer Engagement to understand barriers to oral health care access for Medicaid or dual (Medicare-Medicaid) eligible children and adults. CMS engaged directly with a broad range of external customers, including people with Medicaid, oral health providers, state representatives, and advocates, through interviews and onsite visits to capture their lived experience.

As a product of our research, we co-created the “Barriers to Oral Health” illustration with our external customers to represent their perspective and highlight the most prominent obstacles individuals’ face as they seek to access or provide oral health care.

The Oral Health Customer Engagement supports CMS’ Oral Health Cross-Cutting initiative (PDF), a priority for CMS.

View the Barriers to Oral Health Care Illustration (PDF).

2022 Compliance Review Findings Report Now Available

The Centers for Medicare & Medicaid Services’ (CMS) National Standards Group (NSG), on behalf of the U.S. Department of Health & Human Services (HHS), has released the 2022 Compliance Review Findings Report (PDF), identifying common standard and operating rule violations found during compliance reviews. This report expands on previously published reports, adding insights based on violation findings discovered in an additional 24 compliance reviews completed between April 2022 and March 2023.

CMS is sharing the updated findings to inform and educate the health care industry, encourage compliance, and assist covered entities with preparing for compliance reviews.

The Compliance Review Program aims to promote compliance with HIPAA Administrative Simplification rules for electronic health care transactions. Since the program launched in April 2019, NSG has initiated 63 compliance reviews with 53 health plans, four clearinghouses, and six providers.

Find out more about the Compliance Review Program with the Compliance Review Program Information Bulletin, (PDF) Compliance Review Infographic, (PDF) or on the Administrative Simplification website.