DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
SMD# 16-003 
RE: Availability of HITECH Administrative 
Matching Funds to Help Professionals and 
Hospitals Eligible for Medicaid EHR 
Incentive Payments Connect to Other 
Medicaid Providers  
February 29, 2016 
Dear State Medicaid Director: 
This letter updates guidance issued by the Centers for Medicare & Medicaid Services (CMS) 
about the availability of federal funding at the 90 percent matching rate for state expenditures on 
activities to promote health information exchange (HIE) and encourage the adoption of certified 
Electronic Health Record (EHR) technology by certain Medicaid providers. CMS previously 
issued guidance on this topic in State Medicaid Director (SMD) Letter #10-016 (August 17, 
2010)1, SMD Letter #11-004 (May 18, 2011)2, and a 2013 guidance document, CMS Answers 
to Frequently Asked Questions (9/10/2013) (2013 guidance).  
This updated guidance expands the scope of State expenditures eligible for the 90 percent 
matching rate, and supports the goals of, Connecting Health and Care for the Nation: A Shared 
Nationwide Interoperability Roadmap Version 1.0,3 published by the Department of Health and 
Human Services, Office of the National Coordinator (ONC) for Health Information Technology, 
on October 6, 2015. In this letter, we are expanding our interpretation of the scope of State 
expenditures eligible for the 90 percent HITECH match, given the greater importance of 
coordination of care across providers and transitions of care in Meaningful Use modified Stage 2 
and Stage 3. This letter supersedes the 2013 guidance but many of the principles of that 
guidance, as indicated in this letter, remain valid.  We intend to issue updated, detailed guidance 
that integrates those principles with the interpretive changes set forth in this letter.    
The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted 
as part of the American Recovery and Reinvestment Act of 2009, Pub. L. 111-5, added sections 
1903(a)(3)(F) and 1903(t) to the Social Security Act. These provisions make available to States 
100 percent Federal matching funding for incentive payments to eligible Medicaid providers to 
encourage the adoption and use of certified EHR technology through 2021, and 90 percent 
Federal matching funding (the 90 percent HITECH match) for State administrative expenses 
related to the program, including State administrative expenses related to pursuing initiatives to 
encourage the adoption of certified EHR technology to promote health care quality and the 
exchange of health care information, subject to CMS approval. CMS has implemented these 
1 Available at http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD10016.pdf 
2 Available at https://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD11004.pdf 
3 Available at https://www.healthit.gov/sites/default/files/hie-interoperability/nationwide-interoperability-roadmap-
final-version-1.0.pdf   Page 2  State Medicaid Director 
provisions in regulations at 42 CFR Part 495. When attesting to Meaningful Use modified Stage 
2 or Stage 3, professionals and hospitals that are eligible for Medicaid EHR Incentive Payments 
(collectively referred to in this document as Eligible Providers) must demonstrate the ability to 
electronically coordinate with other providers across care settings under the CMS regulations at 
42 CFR Part 495. In order to meet these Meaningful Use objectives, Eligible Providers will often 
need to electronically coordinate care with other Medicaid providers that are not eligible for 
Medicaid EHR incentive payments.  
SMD Letters #10-016 and #11-004 explained that state costs related to HIE promotion may be 
matched at the 90 percent HITECH matching rate only if they can be directly correlated to the 
Medicaid EHR Incentive Program. In the 2013 guidance, we therefore explained that States 
costs of facilitating connections for providers to an HIE may be matched at the 90 percent 
HITECH matching rate only if the providers are Eligible Providers. We now explain that State 
costs of facilitating connections between Eligible Providers and other Medicaid providers (for 
example, through an HIE or other interoperable systems), or costs of other activities that promote 
other Medicaid providers use of EHR and HIE, can also be matched at the 90 percent HITECH 
matching rate, but only if State expenditures on these activities help Eligible Providers meet the 
Meaningful Use objectives. Subject to CMS prior approval, States may thus be able to claim 90 
percent HITECH match for expenditures related to connecting Eligible Providers to other 
Medicaid providers, including behavioral health providers, substance abuse treatment providers, 
long-term care providers (including nursing facilities), home health providers, pharmacies, 
laboratories, correctional health providers, emergency medical service providers, public health 
providers, and other Medicaid providers, including community-based Medicaid providers. 
For example, an Eligible Provider might be a physician needing to meet the modified Stage 2 or 
Stage 3 Meaningful Use objective for health information exchange (see 42 CFR 495.22(e)(5)(i) 
or 495.24(d)(7)(i)(A)) when transitioning patients to another Medicaid provider such as a nursing 
facility, or a home health care provider. Or an eligible hospital might need to meet the objective 
for Medication Reconciliation and compare records with other providers to confirm that the 
information it has on patients medication is accurate when it admits patients into its care (see 42 
CFR 495.22(e)(7)(i) or 495.24(d)(7)(ii)(B)(3)(i)). Subject to CMS approval, States can claim 90 
percent HITECH match in the costs of developing connectivity between Eligible Providers 
(whether eligible professionals or eligible hospitals) and other Medicaid providers if this will 
help the Eligible Providers demonstrate Meaningful Use.  
CMS explicitly encourages and welcomes multistate collaboratives partnering on shared 
solutions for HIE and interoperability, including for the activities discussed in this letter 
(facilitation of EHR Meaningful Use and related communications through the HIE system). CMS 
will aggressively support such collaboratives as potentially cost-saving opportunities to increase 
adoption of interoperability standards and help Eligible Providers demonstrate Meaningful Use. 
Such collaboratives should promote Medicaid Information Technology Architecture (MITA) 
principles on scalability, reusability, modularity, and interoperability. We note that ONC is a 
willing partner in helping States develop open source and open architecture tools for HIE that are 
consistent with MITA principles.   Page 3  State Medicaid Director 
 
Cost controls, cost allocations, and other payers 
 
States must ensure that any 90 percent HITECH match claimed under the guidance in this letter 
supports Eligible Providers demonstration of Meaningful Use modified Stage 2 and Stage 3, and 
must therefore report on the extent to which the activities they are funding help Eligible 
Providers demonstrate Meaningful Use. CMS will require States to describe in advance which 
specific Meaningful Use measures they intend to support in the Implementation Advance 
Planning Document (IAPD) as well as to confirm such measures are indeed supported post-
implementation. Under no circumstances may States claim 90 percent HITECH match in the 
costs of actually providing EHR technology to providers or supplementing the functionality of 
provider EHR systems. This funding is available, subject to CMS approval, as of the date of this 
letter, and will not be available retroactively. 
 
Additionally, States should claim the 90 percent HITECH match for HIE-related costs relating to 
Medicaid providers that are not eligible for Medicaid EHR incentive payments only if those HIE-
related costs help Eligible Providers demonstrate Meaningful Use. For example, it would not be 
appropriate for States to claim the 90 percent HITECH match for costs related to an HIE system 
that did not connect to or include Eligible Providers and therefore would not help Eligible 
Providers demonstrate Meaningful Use. 
 
States should continue to adhere to the guidance in SMD Letter #11-004 detailing how Medicaid 
funding should be part of an overall financial plan that leverages multiple public and private 
funding sources to develop HIEs. Similarly, States are reminded that per SMD Letter #11-004, 
the 90 percent HITECH match cannot be used for ongoing operations and maintenance costs. 
This updated guidance makes no changes to the general cost allocation principles and fair share 
principles States should follow in proposing funding models to CMS for HIEs or interoperable 
systems, although under this updated guidance, the Medicaid portion of such cost allocations 
may increase to include costs associated with connecting Eligible Providers to other Medicaid 
providers. CMS has approved several different cost allocation methodologies for States and 
those various methodologies will be affected differently by this guidance. CMS will provide 
technical assistance on the impact of this guidance on specific States. Similarly, States should 
continue to complete and update the Health Information Technology Implementation Advance 
Planning Document (HIT IAPD) Template4, developed by CMS and the Office of Management 
and Budget, in which States detail cost allocation models and other financial considerations.  
States should meet with CMS to review cost allocation models that carefully consider the extent 
to which the HIE or other interoperable system benefits Eligible Providers, other Medicaid 
providers, non-Medicaid providers, and other payers. 
 
Medicaid Information Technology Architecture (MITA) emphasizes the importance of 
interoperability and industry standards. States should take an aggressive approach to HIE and 
interoperability governance for purposes of supporting interoperability while focusing on 
security and standards to keep interface costs to a minimum. The CMS final rule published on 
December 4, 2015, Mechanized Claims Processing & Information Retrieval Systems (90/10) 
                                                           
4 https://www.cms.gov/regulations-and-
guidance/legislation/ehrincentiveprograms/downloads/medicaid_hit_iapd_template.pdf 
  Page 4  State Medicaid Director 
 
requires in 42 CFR 433.112 a new focus on industry standards in MITA that support more 
efficient, standards-based information exchange as described in 45 CFR Part 170. Specifically, 
45 CFR Part 170 defines the Common Clinical Data Set, transport standards, functional 
standards, content exchange standards and implementation specifications for exchanging 
electronic health information, and vocabulary standards for representing electronic health 
information. In implementing these standards, we encourage States to develop partnerships with 
non-profit collaboratives and other industry participants such as DirectTrust that further support 
Direct Secure Messaging through trust frameworks that reduce the costs and technical 
complexities of electronic health information exchange for providers.   
  
The interoperable systems described in this letter are part of the MITA and interfaces to these 
systems should appropriately follow a Service-Oriented Architecture (SOA) as well as adhere to 
industry standards. States should aggressively pursue HIE and interoperability solutions for 
Medicaid providers that either obviate the need for costly interfaces, or utilize open architecture 
solutions that make such interfaces easily acquired. For example, consistent with the software 
ownership rights held by the state under 45 CFR  95.617, States might require that HIE 
interfaces designed, developed, or installed with Federal financial participation be made 
available at reduced or no cost to other Medicaid providers connecting to the same HIE. 
Furthermore, States could require that such interfaces (or the code for such interfaces) be made 
publicly available. Additionally, CMS and ONC support States in sharing open source tools and 
interfaces with other States to further drive down the costs of HIEs, interfaces, and other 
interoperable systems. 
 
States are also reminded that careful alignment and coordination with other funding sources 
should be thoroughly discussed with CMS and addressed in an Implementation Advance 
Planning Document Update (IAPD-U), specifically Appendix D. States continue to be 
encouraged to consult with CMS in advance of formal State Medicaid HIT Plan (SMHP) and 
IAPD submissions to obtain technical assistance regarding the funding options and boundaries 
outlined in this and the previous SMD Letters, and additional technical assistance will be 
provided when we release an update to the 2013 guidance that reflects the new criteria for the 90 
percent HITECH match described here. States should reach out to their CMS regional offices 
Medicaid HIT staff lead as the initial point of contact.  
 
Below are some examples of the types of state costs for which 90 percent HITECH match might 
be available, subject to CMS approval. 
 
Federal Financial Participation (FFP) for On-boarding Medicaid providers to HIEs or 
interoperable systems 
 
On-boarding is the technical and administrative process by which a provider joins an HIE or 
interoperable system and secure communications are established and all appropriate Business 
Associate Agreements, contracts and consents are put in place. State activities related to on-
boarding might include the HIEs activities involved in connecting a provider to the HIE so that 
the provider is able to successfully exchange data and use the HIEs services. The 90 percent 
HITECH match is available to cover a states reasonable costs (e.g., interfaces and testing) to on-
board providers to an HIE. Subject to the parameters and cost controls described above, States  Page 5  State Medicaid Director 
 
may claim 90 percent HITECH match for state costs of supporting the initial on-boarding of 
Medicaid providers onto an HIE, or onto any interoperable system that connects Eligible 
Providers to other Medicaid providers.  Costs can be claimed both if they are incurred by the 
state to support the initial on-boarding of Eligible Providers and if they are incurred by the state 
to support the on-boarding of other Medicaid providers, provided that connecting the other 
Medicaid providers helps Eligible Providers demonstrate, and meet requirements for, Meaningful 
Use. States should coordinate with CMS on defining benchmarks and targets for on-boarding 
providers. States are reminded that, consistent with the principles described in both SMD Letter 
#10-016 and SMD Letter #11-004, the 90 percent HITECH match is for implementation only, 
and States should work with CMS on establishing an endpoint to onboarding and always ensure 
costs are allocated as appropriate across other payers. Also, the scope of the onboarding should 
be clearly defined and reviewed with CMS prior to IAPD submission to ensure that any costs 
claimed help Eligible Providers meet Meaningful Use and to ensure that HIE-related costs 
benefiting providers that are not eligible for Medicaid EHR incentive payments are claimed only 
if these costs help Eligible Providers demonstrate Meaningful Use. States should generally refer 
to SMD Letters #10-016 and #11-004 for other information about allowable onboarding costs.   
 
Pharmacies: Similarly, subject to the parameters and cost controls described above, States may 
claim the 90 percent HITECH match for the costs of supporting the initial on-boarding of 
pharmacies to HIEs or other interoperable systems, if on-boarding the pharmacies helps Eligible 
Providers meet Meaningful Use objectives, such as the objectives around sending electronic 
prescriptions or the objectives around conducting medication reconciliations, both described in 
42 CFR 495.22 and 495.24. 
 
Clinical Laboratories: Subject to the parameters and cost controls described above, States may 
also claim 90 percent HITECH match for the costs of supporting the initial on-boarding of 
clinical laboratories to HIEs or interoperable systems, if on-boarding these laboratories helps 
Eligible Providers meet Meaningful Use objectives, such as the objectives for Electronic 
Reportable Lab Results or laboratory orders in Computerized Provider Order Entry (CPOE) 
described in 42 CFR 495.22 and 495.24. 
 
Public Health Providers: Similarly, subject to the parameters and cost controls described above, 
States may also claim 90 percent HITECH match for the costs of on-boarding Medicaid public 
health providers to interoperable systems and HIEs connected to Eligible Providers so that 
Eligible Providers are able to meet Meaningful Use measures focused on public health reporting 
and the exchange of public health data, including activities such as validation and testing for 
reporting of public health measures described in 42 CFR 495.22 and 495.24. 
 
FFP for interoperability and HIE architecture 
 
As with expenses for on-boarding, States may claim 90 percent HITECH match for their costs of 
connecting Eligible Providers to other Medicaid providers via HIEs or other interoperable 
systems, if doing so helps Eligible Providers demonstrate Meaningful Use and the cost controls 
described above are met.   
  Page 6  State Medicaid Director 
 
Specifically, 90 percent HITECH match would be available for States costs related to the 
design, development, and implementation of infrastructure for several HIE components and 
interoperable systems that most directly support Eligible Providers in coordinating care with 
other Medicaid providers in order to demonstrate Meaningful Use. As described in SMD Letter 
#11-004, the 90 percent HITECH match cannot be used for ongoing operations and maintenance 
costs after this technology is established and functional. These components and systems include: 
 
Provider Directories: States may claim the 90 percent HITECH match for costs related to the 
design, development, and implementation of provider directories that allow for the exchange of 
secure messages and structured data to coordinate care or calculate clinical quality measures 
between Eligible Providers and other Medicaid providers, so long as these costs help Eligible 
Providers meet Meaningful Use and the cost controls described above are met. The 90 percent 
HITECH match would not be appropriate for costs of developing a separate subdirectory for a 
class of providers that are not eligible for Medicaid EHR incentive payments and that are 
unlikely ever to exchange records with an Eligible Provider. CMS emphasizes the importance of 
dynamic provider directories with, as appropriate, bidirectional communications to public health 
agencies and public health registries. CMS particularly supports approaches to provider 
directories that provide solutions for Eligible Providers to connect to other Medicaid providers 
with lower EHR adoption rates, if doing so helps the Eligible Providers demonstrate Meaningful 
Use. Secure, web-based provider directories, for example, might help Eligible Providers 
coordinate care more effectively with long term care providers, behavioral health providers, 
substance abuse providers, etc. CMS expects that States will consider provider directories as a 
Medicaid enterprise asset that can also support Medicaid Management Information System 
(MMIS) functionality, with the reminder that, per SMD Letter #10-016, States should not claim 
90 percent HITECH match for costs that could otherwise be matched with MMIS matching 
funds.  
 
Secure Electronic Messaging: States may claim the 90 percent HITECH match for costs related 
to the design, development, and implementation of secure messaging solutions that connect 
Eligible Providers to other Medicaid providers and allow for the exchange of secure messages 
and structured data, so long as these costs help Eligible Providers meet Meaningful Use and the 
cost controls described above are met. States are encouraged to utilize Direct Secure Messaging 
as a transport standard that is secure and scalable. States should refer to the Medicare and 
Medicaid Programs; Electronic Health Record Incentive Program  Stage 3 and Modifications to 
Meaningful Use in 2015 Through 2017 rule for guidance on meeting the Certified Electronic 
Health Record Technology (CEHRT) requirements for purposes of Meaningful Use5. States may 
also refer to ONCs 2016 Interoperability Standards Advisory (ISA), a publication that provides 
the identification, assessment, and determination of the best available interoperability 
standards and implementation specifications for industry use to fulfill specific clinical health IT 
interoperability needs6. States should also be prescriptive in governance requirements to ensure 
maximal interoperability in the most secure and efficient manner possible. ONC is a willing 
partner with CMS in helping States deploy Direct Secure Messaging systems and developing 
                                                           
5 https://www.federalregister.gov/articles/2015/10/16/2015-25595/medicare-and-medicaid-programs-electronic-
health-record-incentive-program-stage-3-and-modifications 
6 https://www.healthit.gov/sites/default/files/2016-interoperability-standards-advisory-final-508.pdf  Page 7  State Medicaid Director 
 
related governance requirements to ensure that Eligible Providers can connect to other Medicaid 
providers. 
 
Query Exchange: States may claim the 90 percent HITECH match for costs related to the design, 
development, and implementation of query-based health information exchange, so long as these 
costs help Eligible Providers meet Meaningful Use, and the cost controls described above are 
met. States may support coordination of care between Eligible Providers and other Medicaid 
providers by linking them into a query-based HIE that allows for secure, standards-based 
information exchange with thorough identity management protocols. A Query Exchange might 
access a states Clinical Data Warehouse and similarly be integrated with analytic and reporting 
functions. These activities may support aggregate queries from providers to support population 
health activities performed by public health or other entities involved in population health 
improvement, provided that doing so helps Eligible Providers meet Meaningful Use. Given the 
unique data and exchange governance challenges of Query Exchange, States are encouraged to 
reach out to ONC to help formulate governance guidance and best practices.  
 
Care Plan Exchange: States may claim the 90 percent HITECH match for costs related to the 
design, development, and implementation of interoperable systems and HIEs that facilitate the 
exchange of electronic care plans between Eligible Providers and other Medicaid providers, so 
long as these costs help Eligible Providers meet Meaningful Use, and the cost controls described 
above are met. Medicaid providers coordinating care across multiple care settings may exchange 
care plans containing treatment plans and goals, as well as problem lists, medication history and 
other clinical and non-clinical content added and updated as appropriate by members of a 
patients care team, including Medicaid social service providers. States are encouraged to 
consider care plan exchange for patients with multiple chronic conditions who might be 
coordinating care between many specialists, hospital(s), long term care facilities, rehabilitation 
centers, home health care providers, or other Medicaid community-based providers. Similarly, 
children in the foster care system might benefit from care plans shared across Medicaid providers 
(including Eligible Providers) to facilitate coordination of the childrens care.  As discussed 
above, costs related to exchanging care plans between Medicaid providers and other programs, 
such as foster care programs, may need to be allocated between benefitting programs. 
 
Encounter Alerting: States may claim the 90 percent HITECH match for costs related to the 
design, development, and implementation of communications within an HIE or interoperable 
system connecting Eligible Providers and other Medicaid providers about the admission, 
discharge or transfer of Medicaid patients, so long as these costs help Eligible Providers meet 
Meaningful Use, and the cost controls described above are met. These communications among 
Medicaid providers may contain structured data regarding treatment plans, medication history, 
drug allergies, or other secure content that aids in the coordination of patient care, including 
coordination of social services as appropriate.  
 
Public Health Systems: States may claim the 90 percent HITECH match for costs related to the 
design, development, and implementation of public health systems and connections to public 
health systems, so long as the cost controls described above are met, and so long as these costs 
help Eligible Providers meet Meaningful Use measures focused on public health reporting and 
the exchange of public health data described in 42 CFR 495.22 and 495.24. It is worth  Page 8  State Medicaid Director 
 
emphasizing that state costs eligible for the 90 percent HITECH match might include costs 
related to developing registry and system architecture for Prescription Drug Monitoring 
Programs (PDMPs), as per FAQ #134137 PDMPs can be considered a specialized registry to 
which Eligible Providers may submit data in order to meet Meaningful Use objectives. States 
should, however, keep in mind that MMIS matching funds might in some circumstances be a 
more appropriate source of federal funding for costs related to developing a PDMP.  Again, 
States should not claim 90 percent HITECH match for costs that could otherwise be matched 
with MMIS matching funds.  
 
Health Information Services Provider (HISP) Services: States may claim the 90 percent HITECH 
match for costs related to the design, development, and implementation of HISP Services that 
coordinate the technical and administrative work of connecting Eligible Providers to other 
Medicaid providers, so long as these costs help Eligible Providers meet Meaningful Use, and the 
cost controls described above are met. HISP Services may coordinate encryption standards 
across providers, as well as coordinate contracts, Business Associate Agreements or other 
consents deemed appropriate for the HIEs or interoperable systems. States should be careful to 
distinguish between on-boarding services and HISP Services, as the scope of HISP activities 
overlaps with the scope of on-boarding activities, and the state should confirm that activities are 
only supported with federal funding once.  States should clearly define the scope of HISP 
activities and on-boarding activities as appropriate. 
 
This is not an exhaustive list of the types of state costs for design, development, and 
implementation of HIE components and interoperable systems for which 90 percent HITECH 
match might be claimed. Design, development, and implementation costs associated with other 
HIE components and interoperable systems might be supported by the 90 percent HITECH 
match as long as these costs help Eligible Providers achieve Meaningful Use and meet the cost 
controls described above, and will be considered by CMS accordingly.  
 
Under this updated guidance, States remain able, subject to CMS approval, to claim 90 percent 
HITECH match for design, development, and implementation costs related to personal health 
records (PHRs), as utilizing a PHR through an HIE will often be the best way for many Eligible 
Providers to meet the Meaningful Use modified stage 2 Patient Electronic Access objective (see 
42 CFR 495.22(e)(8)) and/or the Meaningful Use stage 3 Coordination of Care Through Patient 
Engagement objective (see 42 CFR 495.24(d)(6)).  The parameters for HITECH administrative 
funding discussed in SMD Letters #10-016 and #11-004 continue to be relevant to PHR funding 
requests from States. 
 
Conclusion 
 
With more States utilizing or exploring the possibilities of vehicles for delivery system reform 
that benefit from coordination of care, such as health homes, primary care case management, 
managed care, home and community-based service programs, and performance-based incentive 
payment structures, there is an expectation that the Medicaid Enterprise infrastructure will be 
designed to support these efforts. These efforts therefore support the MITA principles of 
                                                           
7 https://questions.cms.gov/faq.php?faqId=13413  Page 9  State Medicaid Director 
 
reusability, interoperability, and care management in providing a foundation for further delivery 
system reform.  
 
As States enter the fifth year of the Medicaid EHR Incentive Program, CMS and ONC expect 
them to leverage available federal funding for tools and guidance to help Eligible Providers 
demonstrate Meaningful Use, which might include strengthening data exchange between Eligible 
Providers and other Medicaid providers. States may have questions about the Health Insurance 
Portability and Accountability Act (HIPAA) considerations applicable to creating more diverse 
HIEs and interoperable systems, so we have included links to guidance from the U.S. 
Department of Health and Human Services Office for Civil Rights and the Office of the National 
Coordinator for Health Information Technology describing uses and disclosures that are 
permitted under HIPAA8. Note that the discussion in the linked guidance only concerns the uses 
and disclosures that are permitted under HIPAA, and does not address when state costs related to 
the discussed activities would be eligible for the 90 percent HITECH match. This next phase of 
infrastructure development and connectivity will best position all Eligible Providers to 
successfully demonstrate Meaningful Use of Certified EHR Technology while solidifying a 
broader network of health information exchange among Medicaid providers, writ large. 
 
 
Sincerely, 
 
   /s/ 
 
Vikki Wachino 
Director 
 
Enclosure 
 
cc: 
 
National Association of Medicaid Directors 
National Academy for State Health Policy 
National Governors Association 
American Public Human Services Association 
Association of State Territorial Health Officials 
Council of State Governments 
National Conference of State Legislatures 
                                                           
8 https://www.healthit.gov/sites/default/files/exchange_health_care_ops.pdf and 
https://www.healthit.gov/sites/default/files/exchange_treatment.pdf