HIT Policy & Standards Committees Enrollment Workgroup

1. HIT Policy & Standards Committees Enrollment Workgroup Aneesh Chopra, Chair Chief Technology Officer (CTO), Office of Science and Technology Policy (OSTP) Sam Karp, Co-Chair California Healthcare Foundation June 30, 2010

2. Workgroup Members Members: Ex Officio/Federal: Cris Ross SureScripts Sharon Parrott, O/S, HHS James Borland Social Security Administration Nancy DeLew, HHS Jessica Shahin U.S. Department of Agriculture Penny Thompson, CMS/HHS Stacy Dean Center on Budget & Policy Priorities Henry Chao, CMS/HHS Steve Fletcher Chief Information Office (CIO), Utah Gary Glickman, OMB Reed V. Tuckson UnitedHealth Group John Galloway, OMB Ronan Rooney Curam David Hale, NIH Rob Restuccia Community Catalyst Paul Swanenberg, SSA Ruth Kennedy Louisiana Medicaid Department David Hansell, Administration for Ray Baxter Kaiser Permanente Children & Families, HHS Deborah Bachrach Consultant Julie Rushin, IRS Paul Egerman Businessman Farzad Mostashari, ONC Gopal Khanna CIO, Minnesota Doug Fridsma, ONC Bill Oates CIO, City of Boston Claudia Williams, ONC Anne Castro Blue Cross/Blue Shield South Carolina Oren Michels Mashery Wilfried Schobeiri InTake1 Bryan Sivak CTO, Washington, DC Terri Shaw Children’s Partnership Elizabeth Royal Service Employees International Union (SEIU) Sallie Milam West Virginia, Chief Privacy Officer Dave Molchany Deputy County Executive, Fairfax County Chair: Aneesh Chopra, Federal CTO Co-Chair: Sam Karp, California Healthcare Foundation

3. Section 1561 of Affordable Care Act §1561. HIT Enrollment, Standards and Protocols. Not later than 180 days after the enactment, the Secretary, in consultation with the HIT Policy and Standards Committees, shall develop interoperable and secure standards and protocols that facilitate enrollment in Federal and State health and human services programs through methods that include providing individuals and authorized 3rd parties notification of eligibility and verification of eligibility.

4. Enrollment Workgroup Charge Inventory of standards in use, identification of gap, recommendations for candidate standards for federal and state health and human service programs in following areas: Electronic matching across state and Federal data Retrieval and submission of electronic documentation for verification Reuse of eligibility information Capability for individuals to maintain eligibility information online Notification of eligibility

5. Potential Deliverables • Inventory of standards-based data exchange in use today to enroll in health and human services • Candidate standards for data elements and messaging • Proposed process to fill in gaps to rapidly turn "requirements" into working prototypes/live implementations to deliver world class eligibility and enrollment services

6. Potential Candidate Standards Core data elements Name, address, residence, income, citizenship, etc. Messaging Checking eligibility and enrollment Consumer matching across systems Retrieving and sending “packages” of verification information including income, employment, citizenship Communicating enrollment information Privacy and security Secure transport Authentication

7. Standards Requirements We need to conceptualize standards that might be useful and work across a variety of use cases or architectures which might include: Front end user-facing consumer portal* to conduct initial eligibility checks and obtain and forward verification information Comprehensive eligibility system for Health and Human Services programs State or Federal exchange portals *online, mail and telephone based systems

8. Draft Policy Principles - Reprise Standards and technologies must support and be in service to our policy goals: Consumer at the center Make enrollment process less burdensome; simplify eligibility process and make it seamless Enter/obtain information once, reuse for other purposes Make it easier for consumers to move between programs Focus on 2014 world

9. Draft Standards Principles - Reprise Keep it simple - Think big, but start small. Recommend standards as minimal as required to support necessary policy objective/business need, and then build as you go. Don’t rip and replace existing interfaces that are working (e.g., with SSA etc.) Advance adoption of common standards where proven through use (e.g., 270/271). Don’t let “perfect” be the enemy of “good enough” Go for the 80 percent that everyone can agree on. Opportunity to standardize the core, shared data elements across programs. Cannot represent every desired data element. Keep the implementation cost as low as possible May be possible to designate a basic set of services and interfaces that can be built once and used by or incorporated by states. Opportunity to accelerate move to web services Do not try to create a one-size-fits-all standard that add burden or complexity to the simple use cases Opportunity to describe data elements and messaging standards that would be needed regardless of the architecture or precise business rules selected.

10. Base Use Case – Draft – Under Discussion Consumer-facing web portal that allows applicants to: Identify available services for which they might be eligible Conduct initial screening and enrollment checks Retrieve electronic verification information from outside sources Determine eligibility or forward eligibility “packet” (screening information and verification information) to programs for final determination Store and re-use eligibility information

11. This Base Use Case Supports Several Eligibility and Enrollment Scenarios in 2014 – Draft Under Discussion Makes recommendations more flexible, durable and useful Scenario One: Exchange portal Screening, verification and eligibility for 2014 Modified Adjusted Gross Income (MAGI)-eligible group: Medicaid, Children’s Health Insurance Program (CHIP) and exchange Send/receive applicant information “packets” with Medicaid Scenario Two: Medicaid/Temporary Assistance for Needy Families (TANF) TANF/ Supplemental Nutrition Assistance Program (SNAP) portal Screening, verification and eligibility for residual Medicaid, TANF, and SNAP. Send/receive applicant information “packets” with exchange Re-use eligibility information to screen for other programs Scenario Three: Combined portal All of Medicaid, CHIP, Exchange; other combinations

12. Medicaid MAGI, MA, Exchange, State systems Check Current Enrollment: Check other systems for existing coverage; first match using single identifier, probabilistic formula, or other method; then obtain enrollment info 2 Initial Screening: Applicant provides basic demographic info 1 Obtain Verification Info: Electronically verify identity, residency, citizenship, household size, income, etc. 3 IEVS VR IRS DMV SSA DHS 4b Portal makes eligibility decision State systems Determine Eligibility: Method will depend on system capabilities. 4 4a Portal sends eligibility packet to program 5 Enrollment Notification to Portal Send eligibility info to other programs (human services, etc.) Program makes eligibility decision 6 Send enrollment information to plans