By Nolan Kelly, Chief Customer Officer, 1upHealth
LinkedIn: Nolan Kelly
LinkedIn: 1upHealth, Inc.
There is a well-known Chinese Proverb that says “the best time to plant a tree was 20 years ago. The second best time is now.” In January 2024, CMS published the 0057 Final Rule. That was the best time for health plans to get serious about interoperability. Now, nearly two years since the rule’s publishing and with many health plans only just beginning to grapple with meeting the January 1, 2027 deadline, the second best time is now.
Why the urgency?
The CMS-0057 Final Rule isn’t simply a new set of APIs to stand up — it’s a multi-year transformation mandate that reshapes how data, workflows, and partnerships should function across a health plan. That’s exactly why CMS gave health plans three full years to comply. This wasn’t meant to be a two-year warm-up followed by a frantic sprint in the final months. It was recognition that true interoperability at this scale requires deep, deliberate, cross-functional change — the kind that absolutely cannot happen overnight.
Many health plans have examined the utilization of their CMS-9115 Patient Access APIs and written off the importance and associated complexity of CMS-0057 compliance. What makes these rules so complex isn’t only the adoption of FHIR standards or building compliant endpoints; it’s the layered operational engineering required to support those standards in real-world environments. Health plans must design member-appropriate and provider-appropriate workflows, orchestrate a functioning network of payer-to-payer data exchange, and integrate with utilization management vendors, care management platforms, quality programs, identity-matching tools, and downstream analytics systems.
Each requirement triggers a cascading set of decisions:
- How will provider attribution be validated and refreshed?
- How will consent and identity be applied consistently?
- What workflows will operational teams follow when data arrives, when it fails, or when it conflicts?
- How will connections be established, monitored, scaled, and maintained across an entire payer network?
These aren’t side projects – they require organizational choreography crossing IT, operations, clinical programs, vendor ecosystems, and compliance. This all takes time and is precisely why CMS provided a three-year runway.
It’s time to stop thinking “compliance only”.
Compliance is table stakes. If your only ambition is “get the APIs up by 1/1/27 and check the box,” you will miss the far greater prize. Interoperability, via these APIs, is the foundation of the elusive digital shift that is required for healthcare modernization.
Without reliable, standards-based, real-time data exchange, health plans remain stuck in legacy modes: flat files, proprietary interfaces, and hand-offs rife with delays and inefficiencies. Worse, when a member moves from Plan A to Plan B, their clinical/claims history often stays behind. When a provider seeks to understand care gaps or care history, important data is locked up at the health plan. When a member seeks care that requires prior authorization, they wait days, weeks, or months with no transparency into the archaic process for approval or denial. It’s time for all of that, and more, to change.
The bottom line.
The 1/1/27 deadline is real. Health plans can no longer delay. They’ve had almost two years since the announcement of the CMS-0057 Final Rule and yet many are still stuck in early stages. Now is the time to pivot from “we need to build APIs” to “we will leverage APIs to transform our operations, drive efficiency, reduce waste, and gain competitive advantage.”
The “check the box” mentality is losing. Markets don’t reward mere compliance — they reward performance. Payers who view interoperability as an enabler of business value (not just a regulatory burden), will be better positioned to thrive in the era of real-time data, value-based care, and member-centric operations.
It’s time to double down and get serious about interoperability. It’s time to plant the tree.