Introduction
The CMS Patient Access Final Rule (CMS-9115-F) was introduced to jumpstart interoperability in the payer space. For many health plans, that meant building a FHIR API, ensuring compliance, and checking off a regulatory box.
But then came the next question: Now what? Where's the business value?
That’s exactly what Chris from Chinese Community Health Plan (CCHP) asked in a recent conversation with Flexpa. His team had built the API; now he wanted to understand how that investment could translate into meaningful outcomes for members, business operations, and the broader healthcare ecosystem.
Here are the top questions from that conversation—questions we know many payers are quietly asking themselves. If you're looking to unlock value from CMS-9115-F, you're not alone. These answers are for you.
- Isn’t CMS 9115F the same information they can get in the member portal?
- Where’s the business leverage? How can I make this more than a compliance checkbox (even if the ROI isn’t immediate)?
- How do we market this to members?
Isn’t CMS 9115F the same information they can get in the member portal?
The data might be the same, but the delivery is transformative. The Patient Access API gives members what they've never truly had before: automated, secure, portable, and real-time access to their health information through third-party applications they choose.
Traditional methods for getting access to this data often involve calling the plan, navigating portals, downloading PDFs, sending faxes or worse—filling in medical history by hand. In contrast, the API enables members to authorize apps or services to connect directly to their claims and clinical history, seamlessly and instantly.
This matters most when it matters most. Imagine a member managing a chronic illness, switching to a new plan, enrolling in a clinical trial, or needing documentation for disability pay. In these high-friction moments, timely access to accurate data is everything. The Patient Access API turns what used to be a bottleneck into a frictionless experience.
This isn’t just an upgrade. It’s a completely new model for health data access—and a huge leap forward in meeting member expectations.
Where’s the business leverage? How can I make this more than a compliance checkbox (even if the ROI isn’t immediate)?
The Patient Access API may not deliver a substantial financial return on its own—at least not today. But it is foundational in a very real, technical sense. The FHIR standards and implementation guides required under CMS-9115-F form the backbone of the upcoming CMS-0057 regulation for payer-to-payer exchange. These specifications—like the CARIN Blue Button IG for patient access and the Payer-to-Payer IG—aren’t isolated efforts; they’re part of an evolving interoperability framework that’s already being built into CMS’s next wave of mandates.
By implementing 9115-F, you’ve done more than check a box. You’ve laid down infrastructure—FHIR servers, consent frameworks, token-based auth flows—that you can now extend to support payer-to-payer exchange and related workflows.
Seen this way, CMS-9115-F isn't the end of the road. It's the first mile of a longer road. CMS-0057 picks up and expands where this regulation leaves off, and payers who treat the API as a strategic foundation—not just a compliance artifact—will be better prepared for what’s next. Payers can leverage payer-to-payer based patient access by:
- Pulling prior claims for new members at enrollment, shortcutting the time to value
- Automating HEDIS gap closures and risk scoring
- Powering care coordination and continuity of care
- Reducing manual processes and improving provider network recommendations
- Improving MA Stars ratings through patient satisfaction
Some of these benefits may not yield immediate financial ROI~~—and that’s worth acknowledging.~~ But that doesn’t mean they’re not valuable. Strategic readiness, infrastructure reuse, and regulatory momentum all matter. CMS-0057 builds directly on the API foundation laid by 9115-F. Embracing that continuity now puts your organization in a better position for what’s coming.
And the good news: You don’t have to build new infrastructure to enable it. If done with this forward momentum in mind, you can extend what you’ve already built.
Beyond compliance, this is about positioning your plan for the future: agile, integrated, and member-centered, with clear value propositions for the business.
How do we market this to members?
You don’t. Not in the traditional sense.
Members don’t care about APIs—they care about experiences. And those experiences come from apps and services that use your API under the hood.
Instead of trying to explain interoperability to your member base, focus on enabling the ecosystem:
- Ensure developers can find and connect to your API (CMS requires this anyway)
- Enable third-party apps that are building products to improve member experiences
- Promote member-facing apps that integrate with your API to create tangible value
Think of it like Apple’s App Store. Apple doesn’t market the APIs to users; they market the products built on top. The same applies here. Like CMS’s own Medicare Connected Apps Directory, the best "marketing" is showing up where your members already are—and enabling better care through the app ecosystem.
How Flexpa Can Help
You built the Patient Access API. That was the hard part.
Now is the moment to turn that compliance requirement into a real strategic asset. One that supports member engagement, drives operational efficiency, and sets your organization up for future interoperability initiatives like CMS-0057. But to fully participate in what's next—CMS-0057 and the future of seamless data exchange—you need two essential capabilities:
- A network of connectivity to other payers
- A consent management system that ensures data flows securely and compliantly, and keeps a record of every consent interaction.
Flexpa can help with both. We are a consent management system that connects patient-consented claims data from every health plan. At Flexpa, we specialize in building the connective tissue between payers and the growing ecosystem of healthcare applications, ensuring that your investment in interoperability pays off.
Our infrastructure gives you plug-and-play access to a payer network already in place. With our existing connectivity to 320+ health plans, we are the largest network of Payer FHIR endpoints in the United States, giving you instant access to all those members.
We help you unlock that data securely, compliantly, and meaningfully. Whether you're preparing for CMS-0057, enabling value-based care, or just trying to make use of the infrastructure you've already built, we're here to help.
Interested in unlocking more value from your API?
Contact Flexpa to learn how your organization can make the most of CMS-9115-F and prepare for CMS-0057. Learn more about how we support payers at flexpa.com/solutions/payers, or schedule a demo.
Let’s make your API work for you—and for the members you serve.
