Onyx Blog
What 2027 asks of health plans: four pressures, one data foundation
By Susheel Ladwa, Onyx CEO
January 1, 2027 is a crowded date for health plans. The four FHIR APIs required under CMS-0057-F go live. Medicaid expansion adults move to six-month redeterminations and work requirements. A new Medicare Advantage payment year starts under revised risk adjustment rules. All of it lands during the steepest commercial cost trend in 17 years.
Most planning conversations I hear treat these as four separate projects, with four budgets and often four vendors. I think that is the expensive way to read 2027. Each pressure comes down to one capability: getting accurate, current member data to the right place in time to act on it.
PwC projects a 9% medical cost trend for the commercial group market in 2027 and 8.5% for the individual market. Its actuaries cite pharmacy, behavioral health use, provider consolidation, and a newer factor: provider-side AI documentation and coding tools. Those tools are raising paid amounts per claim and widening variation in coding intensity.
PwC’s first recommended action is payment integrity: review high-dollar claims before payment and track severity drift by provider. That work depends on having clinical context next to the claim when it is adjudicated. Chasing overpayments after the fact is slower and adds appeals work on both sides.
In HealthScape’s early-2026 survey of MA executives, just 7% said their MA business was currently profitable. Most expect a two-to-three-year path back. Risk adjustment, medical cost, and Star Ratings topped their priorities.
The 2027 rules raise the bar on all three. CMS will exclude diagnoses from unlinked chart review records from risk scores, so a diagnosis needs to trace to a documented encounter. Four new measures enter the 2027 Star Ratings. Plans whose risk and quality programs work from a complete, current clinical record are better placed than plans that rely on year-end chart sweeps.
One regional payer we work with moved HEDIS computation onto integrated claims, clinical, and pharmacy data. It saw a 20% lift in its Medicare Advantage Star Ratings.
Starting January 1, 2027, states must redetermine eligibility for expansion adults every six months instead of annually. They must also verify work or community engagement requirements and cut retroactive coverage from 90 days to 30. More members will lose coverage and come back, sometimes to a different plan.
Each transition breaks the care record unless the data moves with the member. Open care gaps, active authorizations, and chronic condition history otherwise have to be rebuilt by the next plan. The Payer-to-Payer API was built for this handoff, which makes it more useful in Medicaid than its compliance label suggests.
As of September, CMS had not announced a broad extension of the January 1, 2027 API deadline. Readiness is uneven. In WEDI’s most recent readiness survey, from February, 35% of payers said they were only a quarter of the way through Patient Access API work, and 16% expected to be mostly done by the deadline.
CMS-0057-F is not the last rule; it is the first of several on the same data. Medicare Advantage directories go public on Medicare Plan Finder for 2027 enrollment, CMS-0053 sets claims attachment standards due by May 2028, and the proposed CMS-0062 would extend electronic prior authorization to drugs as early as October 2027. A plan that builds each one separately pays for integration again with every rule.
It is tempting to treat the APIs as a compliance line item to close out. But Patient Access, Provider Access, Payer-to-Payer, and Prior Authorization carry the same data that payment integrity, risk adjustment, quality, and member transitions depend on. Built once, on standards, they feed every program downstream. That is what we mean by continuous compliance: infrastructure that stays current with the rules and keeps paying back.
In practice, each new mandate becomes an extension of work already done instead of a new project, and the same data starts improving the decisions a plan makes every day. Compliance is the starting point, not the outcome: as Onyx Chief Interoperability Officer Mark Scrimshire explains, health plans are already running the Provider Access API in production for value-based care contracts, using access controls on the same API to give at-risk providers the full cost picture those contracts require.
Providers feel the difference quickly. One provider organization using FHIR-based prior authorization inside its existing EMR workflow cut average approval time from 15 days to 48 hours.
Buyers have set a clear bar. In a recent Bain & Company survey, organizations with a formal return target most often set it at 3 to 3.9 times the initial investment. Executives said they want a specific use case, measurable returns, and short time to value. That 3X target is a starting point, not a ceiling. Third-party economic studies of healthcare data platforms have measured three-year returns of up to 5 times the investment, with the highest returns where data previously split across systems was brought into one place.
Here is the test I would add for 2027: does each investment reuse the member data you already have, or rebuild it? A payment integrity tool with its own clinical feed, a risk program with its own chart retrieval, and an API build that sits apart from both each pay the integration cost again. Plans that run these programs on one longitudinal record pay that cost once, and each added program raises the return on the ones before it.
The January deadline is fixed. How much the work pays back is still up to each plan.
If you want a baseline before January, our CMS-0057 Readiness Check gives you a scored view of where your plan stands across all four APIs and the data underneath them, in about a week.
