Form CMS-10398 (#36) CMS-10398 (#36) DOMA Medicaid Eligibility SPA Template

Medicaid Eligibility

State: _____________ OMB Control Number: 0938-1148

Transmittal Number: _____________ OMB Expiration Date: xx/xx/xxxx

Same-Sex Marriage Policy SXX

1902(e)(14)(G)

1902(a)(17)

• With respect to individuals for whom the state must complete a determination of income either based on MAGI or for MAGI-excepted groups utilizing AFDC-related or SSI-related methodologies, the state:

• Recognizes same-sex couples as spouses, if they are legally married under the laws of the state, territory, or foreign jurisdiction in which the marriage was celebrated.

• Does not recognize same-sex couples as spouses, even if they were legally married in a state, territory, or foreign jurisdiction that recognizes same-sex marriages.

• With respect to individuals whose eligibility for Medicaid is based on eligibility for another benefit program, and for whom the state does not complete a determination of income for Medicaid eligibility, the state will not make any determination concerning marital status. Medicaid eligibility will continue to be based on the determination of eligibility for the applicable benefits.

• The option elected above, with respect to income determinations, also governs the state’s definition for post-eligibility issues, including spousal impoverishment, asset transfers and estate recovery rules, to the degree permitted by state law.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850.