Exhibits R S T U

Revision:

State/Territory: __________________________

4.31 Disclosure of Information by Providers and Fiscal Agents

Sections 1128 (b)(9) and 1902 (a)(38) of the Act,

P.L. 100-93 (sec. 8(f)) and

42 CFR 455.1033

The Medicaid agency has established procedures for the disclosure of information by providers and fiscal agents as specified in 42 CFR 455.104 through 455. 106 and sections 1128 (b)(9) and 1902 (a)(38) of the Act.

Revision:

Citation(s)
Section 1137 State/Territory:

of the Act and 42 CFR

435.940 through 435.960 4.32 Income and Eligibility Verification System

The Medicaid agency has established a system for income and eligibility verification in accordance with the requirements of 42 CFR 435.940 through 435.960.

(b) ATTACHMENT 4.32-A describes in accordance with 42 CFR 35.948(a)(6) the information that will be requested in order to verify eligibility or the correct payment amount and the agencies and the State(s) from which that information will be requested.

TN No. __________
Supersedes Approval Date ________ Effective Date _______
TN No. _________

79a

Revision
State/Territory: ____________________________________________________________________________

Citation
Section 1902(a)(48) of the Act

4.33 Medicaid Eligibility Cards for Homeless Individuals

The Medicaid agency has a method for making cards evidencing eligibility for medical assistance available to an individual eligible, under the State’s approved plan, who does not reside in a permanent dwelling or does not have a fixed home or mailing address.

(b) ATTACHMENT 4.33-A specifies the method for issuance of Medicaid eligibility cards to homeless individuals.

TN No. _______
Supersedes Approval Date _____________________ Effective Date _________________

_
TN No.

Revision:

State/Territory: ____________ __________________________________________________

Citation(s)

Section 1137 (d)(3) of the Act

4.34 Systematic Alien Verification for Entitlements

__________ The State Medicaid agency has established procedures for the verification of alien status through the Department of Homeland Security’s designated system, System Alien Verification for Entitlements (SAVE).

__________ The State Medicaid agency has received the following type(s) of waiver from participation in SAVE.

__________ Total waiver

__________ Alternative System

__________Partial Implementation

Explain the nature of the waiver and the State Medicaid agency’s established procedures for verification of alien status:

_________________________________________________________________

TN No. ______
Supersedes Approval Date _______ Effective Date _____________
TN No.