US HR1 Medicaid Work Requirements IG (proposed, not supported by CMS)
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US HR1 Medicaid Work Requirements IG (proposed, not supported by CMS) - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Orchestrator

Medicaid Re-enrollment Orchestrator

This page summarizes the proposed state-level Orchestrator that uses FHIR-based interop to automatically verify community engagement or exemption status for Medicaid re-enrollment under HB1.

The design balances automation with strict privacy and statutory controls (Consent, DS4P/Part 2), and relies on a Trusted Source Registry to accept data from authoritative partners.

Components and Responsibilities

  • Front end / Portal
    • Collects re-enrollment inputs and minimal proof; starts orchestration.
  • Medicaid Re-enrollment Orchestrator (core)
    • Coordinates flows, enforces rules, aggregates evidence, and produces decisions.
  • Identity & Matching Service (MPI / PPRL)
    • Deterministic and probabilistic matching; PPRL for privacy-preserving linkage.
  • Consent & Authorization Service
    • Manages Consent resources and access tokens; enforces DS4P/Part 2.
  • Departmental FHIR Façades / Gateways (Labor, SSA, Corrections, Education, TANF/SNAP, VA, HIE, etc.)
    • Translate native data to FHIR; expose minimal authenticated APIs; log access.
  • Trusted Sources & Cache / Data Lake
    • Periodic pulls or subscriptions; TTL/freshness and Provenance maintained.
  • Decision Engine & Audit Trail
    • Rule evaluation; emits CoverageEligibilityResponse (or internal decision) with Provenance; logs AuditEvent.
  • Notification & Appeals Workflow
    • Sends required notices; tracks Tasks for review/appeals; stores DocumentReference.

High-Level Architecture

flowchart LR subgraph Portal[Front end / Portal] Q(Questionnaire/Uploads) end subgraph Orchestrator[Medicaid Re-enrollment Orchestrator] Rules(Decision Engine / Rules) Match(MPI / PPRL) ConsentSvc(Consent & AuthZ) Cache(Cache / Data Lake) Audit(Audit / Provenance) end Portal -->|Start re-enrollment| Orchestrator Orchestrator --> Match Orchestrator --> ConsentSvc Orchestrator --> Rules Orchestrator <--> Cache Orchestrator --> Audit subgraph Facades[Departmental FHIR Façades] Labor[Labor / Unemployment] SSA[SSA / SSDI] Corrections[Corrections] Education[Education] TANF[TANF / SNAP] VA[Veterans Affairs] HIE[HIE / Claims / Hospital] end Rules -->|FHIR queries| Labor Rules --> SSA Rules --> Corrections Rules --> Education Rules --> TANF Rules --> VA Rules --> HIE Facades -->|FHIR R4| Cache Cache --> Rules

Orchestration Sequence (Typical Re-enrollment)

sequenceDiagram autonumber participant P as Portal participant O as Orchestrator participant M as Identity & Matching participant C as Consent/Authorization participant L as Labor Façade participant S as SSA Façade participant X as Corrections Façade participant D as Decision Engine P->>O: Submit re-enrollment (QuestionnaireResponse/Task) O->>C: Validate Consent (purpose: re-enrollment verification) O->>M: Resolve identity (deterministic + probabilistic/PPRL) O->>L: GET Observation?code=employment-hours&date=... O->>S: GET Condition?code=ssdi-entitlement O->>X: GET DocumentReference?type=corrections-release O->>D: Evaluate rules with Provenance & freshness D-->>O: Decision (meets hours OR exemption) O-->>P: Notify outcome (Communication/DocumentReference) O-->>O: Record AuditEvent + Provenance

FHIR Resources Used (Highlights)

  • Patient, Questionnaire/QuestionnaireResponse, Task
  • Observation (employment-hours, income, county unemployment), Condition (pregnancy, disability), Encounter (hospitalization)
  • CoverageEligibilityRequest/Response (optional for decision packaging), Coverage (enrollment context)
  • Consent (purpose-limited), Provenance (source/agent/timestamp), AuditEvent (access logging)
  • DocumentReference (uploaded or agency documents), Bundle (decision package), Endpoint (partner connectivity)
  • Subscription/Bulk Data for periodic refreshes

Mapping Law Checks to Data

  • Worked ≥ 80 hours in lookback month
    • Labor façade → Observation employment-hours; accept if value ≥ 80 and source is trusted.
  • Income threshold (monthly or 6-month avg)
    • Wage/IRS feeds → Observation monthly-income; compute average across period.
  • Education enrollment (half-time)
    • Education façade → Condition student-status or Observation enrollment-status.
  • Treatment program participation (exemption)
    • Behavioral health façade → DS4P-labeled data; enforce Consent/Part 2.
  • Recent incarceration (≤ 3 months)
    • Corrections façade → incarceration period (Observation/DocumentReference).
  • Short-term hardship (hospitalization)
    • HIE/hospital → Encounter with inpatient class overlapping lookback.

Privacy, Trust, and Appeals

  • Consent governs cross-agency queries unless statutory exception applies.
  • DS4P/Part 2 labels applied; store minimal conclusions when possible to minimize redisclosure.
  • Trusted Source Registry defines acceptable evidence (source, type, freshness, signature).
  • Every access is logged via AuditEvent; decisions carry Provenance.
  • Notices delivered via mail + one other channel; appeals tracked with Tasks.

Phased Rollout (Roadmap)

  • Phase 0: Governance & Trusted Source Registry; MOUs and policy.
  • Phase 1: Pilot core façades (Labor, SSA, Corrections, claims) + identity & consent.
  • Phase 2: Expand connectors (Education, TANF/SNAP, VA, HIE) + bulk ingest/cache.
  • Phase 3: Scale & audit; publish acceptance rules; monitoring & appeals.