The Standard

How States Can Move From Fragmented Programs to Shared, Scalable Infrastructure Using FAST

The CMS Aligned Networks Pledge marks a clear inflection point in federal health IT policy. For the first time, Centers for Medicare & Medicaid Services (CMS) is not simply setting compliance requirements for individual programs—it is asking the healthcare ecosystem to operate as connected networks, capable of secure, real-time, standards-based data exchange across payers, providers, public health and patients.

For states, this shift is significant.

States are no longer just one participant among many. They are increasingly the anchor for trust, identity, consent and directory infrastructure that enable CMS-aligned networks to function at scale. Medicaid programs, state CIO offices and HIEs sit at the intersection of policy, operations and technology. The CMS Aligned Networks Pledge makes that role explicit.

This blog explains:

1. What the CMS Aligned Networks Pledge really changes for states
2. Why traditional, program-by-program approaches will not scale
3. How the  HL7® FHIR® at Scale Taskforce (FAST)  provides the infrastructure states can reuse across initiatives
4. How states can leverage existing systems and vendors without starting over

The CMS Aligned Networks Pledge: A Shift from Programs to Infrastructure

Historically, CMS initiatives have been implemented as discrete programs:

• A new reporting requirement
• A new API mandate
• A new exchange use case
• Trusted digital identity and patient matching
• Scalable security and partner onboarding
• Computable, portable consent
• Authoritative directories for endpoint discovery

The CMS Aligned Networks Pledge represents a different expectation.

CMS is signaling that future interoperability depends on shared infrastructure capabilities, including:

• Trusted digital identity and patient matching
• Scalable security and partner onboarding
• Computable, portable consent
• Authoritative directories for endpoint discovery

These are not features of a single application. They are ecosystem functions.

For states, this means success is no longer measured by whether a single system goes live, but by whether multiple programs can reuse the same trust and exchange foundations.

Why States Feel the Pressure First

States are where CMS expectations converge:

• Medicaid modernization
• TEFCA and Facilitated FHIR
• Prior authorization and payer-to-payer exchange
• Provider directory modernization

Without shared infrastructure, states experience:

• Repeated vendor integrations
• Fragmented identity and consent models
• Inconsistent security onboarding
• Duplicative directory maintenance

The result is higher cost, higher risk and slower progress.

The CMS Aligned Networks Pledge raises the bar by implicitly asking:  Can your state support trusted exchange across programs, partners, and networks—without rebuilding each time?

FAST: The Infrastructure Layer for CMS-Aligned Networks

The HL7 FHIR at Scale Taskforce (FAST) exists specifically to address this challenge. FAST does not create policy. It provides implementation-ready guidance on how networks actually operate together, using FHIR-based, vendor-neutral standards that scale.

FAST focuses on four foundational pillars that directly map to CMS Aligned Network expectations:

Identity

FAST Identity provides standardized approaches for:

• Digital identity assurance
• Patient and entity matching across organizations

This enables states to improve matching accuracy while aligning with federal digital identity direction without dictating a single identity provider.

Security

FAST Security establishes:

• Certificate-based, OAuth-driven trust
• Automated onboarding of external partners and applications
• A shift from point-to-point security to federated trust models

For states and HIEs, this reduces the need for bespoke integrations and strengthens auditability.

Consent

FAST Consent enables:

• Computable consent capture and enforcement
• Consent portability across systems and networks
• Revocation and disclosure tracking

This is essential for Medicaid, public health and sensitive data domains where consent must follow the data and not remain trapped in one system.

Directory

FAST National Directory provides:

• Authoritative provider, organization, endpoint and network data models
• Consistent routing and discovery across participants
• A foundation for CMS provider directory modernization

Directories move from static lists to operational infrastructure.  Together, these pillars form a reusable trust stack rather than four separate projects.

The Opportunity for States: Reuse, Not Reinvention

A key misconception about the CMS Aligned Networks Pledge is that it requires states to replace existing systems.

The opportunity lies in how states use what they already have.

How States Can Leverage Existing Investments

• Medicaid systems continue to manage eligibility, enrollment and claims, but rely on FAST Identity and Security patterns for external exchange
• HIEs continue to operate exchange services, but align onboarding, consent and directory functions to FAST guidance
• Vendors retain their platforms, but implement consistent, standards-based interfaces instead of custom state-by-state logic

Key Points to Help State Leaders Step into This Shift

For State CIOs, Medicaid Directors and HIE executives, three mindset shifts are essential:

1. Think in “trust capabilities,” not programs

Identity, security, consent and directories are long-lived infrastructure. Invest once; reuse everywhere.

2. Use standards to reduce—not increase—vendor dependency

FAST provides vendor-neutral guardrails that allow competition without fragmentation.

3. Start with one high-impact use case

States do not need a big-bang approach. One or two priority workflows (e.g., Medicaid eligibility exchange, prior authorization, public health reporting) can anchor the stack.

A Practical Starting Point for States

Over the next 12–18 months, states can:

• Assess current maturity across Identity, Security, Consent and Directory
• Identify where fragmentation is creating cost or risk
• Participate in FAST testing and implementation activities to validate progress 
•  Align HIEs and vendors on FAST-based expectations 
  

Closing Thought

The CMS Aligned Networks Pledge is not simply a commitment—it is an invitation.

An invitation for states to move from fragmented, program-specific solutions to shared, scalable infrastructure that supports a truly connected healthcare ecosystem.

FAST provides the technical foundation to make that transition achievable using the systems, partners and investments states already have.

The question for state leaders is no longer whether this shift is coming, but how deliberately and sustainably they choose to lead it.

Follow the FAST Community

For those looking to stay informed or contribute, the FAST team welcomes you to join our listserv,  engage through public calls, participate in testing at Connectathons or join FAST as a member to help shape our work. These collaborative efforts are key to building solutions that benefit the entire health IT ecosystem, ensuring that consent management is not only feasible but scalable across varied healthcare settings. 

Be sure to follow the FAST LinkedIn page to stay up- to-date on where FAST is presenting and other timely news.