HHS Secretary Sebelius Adopts Initial Enrollment Recs

On Friday, HHS Secretary Kathleen Sebelius adopted, with minor edits, recommendations from the Health IT Standards and Policy committees that aim to improve the enrollment process for health and human services programs.

The recommendations, developed by the Standards and Policy committees’ enrollment work group, include initial standards and protocols designed to encourage the adoption of modern IT systems and processes to allow consumers to obtain and maintain health and human services benefits.

Background on Enrollment Recommendations

The enrollment work group was formed in June in response to Section 1561 of the Patient Protection and Affordable Care Act, which tasks Sebelius and the Health IT Policy and Standards committees to “develop interoperable and secure standards and protocols that facilitate enrollment in federal and state health and human services programs.”

Since its inception, the work group faced an extremely tight deadline, holding eight public meetings in two-and-a-half months. The Policy Committee approved the work group’s recommendations on Aug. 19, and the Standards Committee gave its okay on Aug. 30. On Sept. 7, the recommendations were sent on to National Coordinator for Health IT David Blumenthal and HHS.

Under the health reform law, Sebelius has the power to require states to implement these enrollment standards in order to receive federal funding for health IT investments. The law also requires the HHS secretary to award grants to eligible entities to develop new or adapt existing health IT to ensure compliance with enrollment standards. Grant recipients then are required to share any developed technology or other information.

Enrollment Work Group’s Charge, Challenges

The enrollment work group was charged with recommending standards to support a health and human services eligibility and enrollment process that:

  • Features a transparent, understandable and easy-to-use online process that allows consumers to make informed decisions about applying for and managing benefits;
  • Accommodates the range of user capabilities, language and access considerations;
  • Offers seamless integration between private and public insurance options;
  • Connects consumers with health coverage and other human services, such as the Supplemental Nutrition Assistance Program and the Temporary Assistance for Needy Families program; and
  • Provides strong privacy and security protections.

Several work group members cited tight time constraints as one of biggest challenges in developing recommendations for enrollment standards.

The other challenge — according to Stacy Dean, a work group member and director of food assistance policy at the Center on Budget and Policy Priorities — “was that this process was happening simultaneously with HHS and CMS deliberating how the policy would work.” She said, “So we had to make a lot of recommendations not completely sure what the Medicaid and exchange eligibility rules would be.” 

However, Dean added, “I think that was also an opportunity because it forced us to focus on creating standards for incredibly flexible systems. They had to encompass the differences across states, as well as the variety of outcomes that HHS might render with respect to eligibility policy.”

Farzad Mostashari — the deputy national coordinator for programs and policy at the Office of the National Coordinator for Health IT and an Ex Officio/Federal member of the enrollment work group — added, “It’s a big challenge to harmonize and come up with standards for programs in which there’s currently so much variability.” He said, “I think if you had tried to solve every problem and resolve every difference, it would have been an impossible task.”

Instead, Mostashari said the work group decided to focus on “bold instrumentalism.” He described the work group’s strategy as “we know where we want to go, but let’s start with where we are now and work stepwise.”


Mostashari said the Standards and Policy committees accepted the enrollment recommendations “virtually unchanged.” He added, “There were some specific line edits after our brief internal clearance process, making sure that everything is legally correct, but essentially, the heart of the recommendations was adopted.”

The recommendations address:

  • Business rules;
  • Consumer usability;
  • Core data analysis;
  • Privacy and security;
  • Transmission of enrollment information; and
  • Verification interfaces.

Cris Ross, a work group member and CIO of Lab Hub Initiative, said an e-mail that the business rules are in response to the variability among state and federal health and human services programs. He said, “If data models were fully articulated and consistent across all states, if the program rules were consistent across all states, and the deployment architecture were the same, we wouldn’t need business rules, and this could be a relatively straightforward problem. That’s not the case, obviously.”

The work group recommended that federal and state governments “document rules in a technology-neutral way, congruent with a data model that’s also documented in a technology-neutral way,” according to Ross. He added, “This is a principle of good system design generally, but specifically we wanted to foster opportunities for a single [Affordable Care Act] interface across siloed systems. We also wanted to provide a blueprint that could be used equally well for building new systems or retrofitting old ones.”

The group’s second recommendation on business rules was that “the federal government manage an open-source-type process for sharing these rules between states and other programs,” Ross explained, adding, “The opportunity to re-use rules and potentially code and data artifacts that come out of those rules could help reduce systems cost, speed delivery and increase quality.”

Dean said that the consumer usability recommendations are aimed at making consumers “a partner” in the eligibility process and giving consumers control over what benefits they want to pursue and what information they want to be used. She said, “So it really was both a sense of providing empowerment and responsibility and creating systems that consumers can navigate.”

As far as the work group’s verification recommendations, Dean said the goal is to create a system that ensures program integrity by accepting only eligible people, but does not continually require applicants to reverify their information for various programs. She said, “If I’ve demonstrated who I am, what my household circumstances are and what my income is for one program, why not export that over to other programs?” Dean noted that “technology makes that possible” and that she believes implementation of this recommendation “will be transformative.”

Future of Work Group

Dean said, “There’s sort of been some unofficial discussion” about whether the enrollment work group would continue to meet and develop additional recommendations. She added, “I think that most of the members of the work group had a very positive experience and are caught up in the momentum of wanting health care reform to be a success so I’d imagine that if we were called upon, we would be available.”

Mostashari said he views enrollment standards development as “an incremental process,” adding, “I do hope that we can continue to rely on the generosity of the members of the work group.” Mostashari said that the recently accepted recommendations and report “provide a sense of where the next steps would be in filling in the gaps where they exist in the standards.”

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