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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. 


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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. 





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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:
_________________________________________________________________


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