For health plans
Payer-to-payer exchange and patient access are distinct.
CMS-0057-F requires specified payers to implement a Payer-to-Payer API, with compliance dates generally beginning January 1, 2027. Flexpa's current Patient Access API workflow lets members authorize retrieval from supported plans. That workflow is distinct from the rule's payer-to-payer obligations and should not be treated as proof of compliance.
Updated 2026-11-11
How it works
- Member authorizes a supported plan
- Patient Access API retrieval
- Application reviews available history
Which payers and when
The rule covers Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and specified Qualified Health Plan issuers on the Federally Facilitated Exchanges. It is not a mandate for every commercial or employer-sponsored plan.
API compliance is due January 1, 2027 for Medicare Advantage and state Medicaid and CHIP fee-for-service programs; the first rating period beginning on or after that date for Medicaid managed care plans and CHIP managed care entities; and plan years beginning on or after that date for affected exchange issuers. CMS provides certain extension, exemption, and exception processes. Some operational provisions generally began January 1, 2026.
The exchange scope excludes issuers offering only stand-alone dental plans or only plans through the federally facilitated small-business exchanges. State-based exchanges, including those using the federal platform, are not Federally Facilitated Exchanges for this rule.
What payer-to-payer exchange requires
- A patient opt-in process.
- Claims and encounter data, excluding provider remittances and enrollee cost-sharing information.
- USCDI data classes and elements and specified prior authorization information, excluding drug prior authorizations.
- Required exchange of data with service dates within five years of the request.
Using patient access now
A member can authorize a supported plan through Flexpa Consent, and your integration can retrieve available records. Check the specific prior plan's endpoint and former-member access conditions before relying on it during onboarding. Do not assume every previous plan remains accessible.
Questions
When must payers comply with CMS-0057-F's Payer-to-Payer API requirements?
CMS-0057-F sets Payer-to-Payer API compliance dates generally beginning January 1, 2027, with exact timing varying by payer type. The requirements cover specified Medicare Advantage, Medicaid, CHIP, and Federally Facilitated Exchange plans, not every health plan. Other operational provisions generally began in 2026.
Does using Flexpa's Patient Access API workflow satisfy payer-to-payer compliance?
Do not treat Flexpa's member-authorized Patient Access API workflow as proof of CMS-0057-F Payer-to-Payer API compliance. Patient access can supply available history from supported plans; the rule has separate payer-to-payer requirements.