Form CMS-10398 #11 CMS-10398 #11 Verification Plan Template

(Insert Medicaid or CHIP or both) MAGI-BASED ELIGIBILITY VERIFICATION PLAN

State:

Date Submitted: ______

In addition to the electronic data sources, the state uses the following procedures to complete the verification process:

A. Verification Procedures for Factors of Eligibility

Eligibility Factor	Self-Attestation Accepted without Additional Verification (Y/N)	Self-attestation accepted with post-enrollment verification (Y/N)	Electronic Data Source Used (Y/N)	Reasonable Compatibility Standard Used			Ask for a Reasonable Explanation from the Individual (Y/N)	Paper Documentation Required from the Individual (Y/N)	Comments
Income*				●	Both are below or at/above the applicable income standard
				О	Percentage Threshold (Specific Threshold Percentage) %
				О	Dollar Threshold (Specific Dollar Threshold) $
				О	Other (Specify)
Residency
Age (Date of Birth)
Social Security Number **
Citizenship **
Immigration Status **
Household Composition
Pregnancy	Y ***
Caretaker Relative
Medicare
Application for Other Benefits
Other

* States must check electronic data sources determined useful to verify income in accordance with 42 CFR 435.948 but can be done post-enrollment.

** States must follow statute, regulations, and guidance for verification of SSN, citizenship and immigration status including obtaining such information through the federal data services hub if available.

^{***States must accept self-attestation of pregnancy unless they have information that is not reasonably compatible with such attestation.}

(Insert Medicaid or CHIP or both) MAGI-BASED ELIGIBILITY VERIFICATION PLAN

State:

In accordance with 42 CFR 435.940-965, the state sets forth the following policies and procedures for verification:

B-1. Use of Electronic Data Sources

Financial:

Criteria Used to Determine Useful or not Useful (check all that apply for Y or N)

Data Source Usage

Comments

Electronic Data Source

Determined Useful (Y/N)

Accuracy

Timeliness

Ability to Access

Age of Data

Comprehensive

Other (Pleas Describe)

Used at Application (Y/N)

Used at Renewal (Y/N)

Used Post- Enrollment (Y/N)

If Used for Post- Enrollment, Frequency Used (e.g. monthly, quarterly)

1. Internal Revenue Service (IRS)

2. Social Security Administration (SSA) (SSI, Title II)

3. State Wage Information Collection Agency (SWICA)

4. State Unemployment Compensation

5. State Administered Supplementary Payment Program

6. State General Assistance Programs

7. Supplemental Nutrition Assistance Program (SNAP)

8. Temporary Assistance for Needy Families (TANF)

9. Office of Child Support Enforcement (OCSE)

10. State Income Tax

11. Commercial database: (please describe)

12. Other: (please describe)

Non-Financial:

Electronic Data Source

To Be Used (Y/N)

Factor of Eligibility

Other Factors

Data Source Usage

Comments

Social Security Number

Citizenship

Immigration Status

Residency

Age/DOB

Pregnancy

Household Composition

Caretaker Relative

Medicare

Application for other Benefits

Other: (describe)

Used at Application (Y/N)

Used at Renewal (Y/N)

Used for Post- Enrollment (Y/N)

If Used for Post- Enrollment, Frequency Used (i.e. monthly, quarterly)

1. Social Security Administration (SSA)

Y

X

X

X

2. Department of Homeland Security (DHS) - SAVE

Y

X

3. Vital Statistics

4. Department of Motor Vehicles (DMV)

5. Temporary Assistance for Needy Families (TANF)

6. Supplemental Nutrition Assistance Program (SNAP)

7. Office of Child Support Enforcement (OCSE)

8. State General Assistance Programs

9. Women, Infants and Children Program (WIC)

10. State Income Tax

11. Commercial database: (please describe)

12. PARIS

Y*

Y

13. Other: (please describe)

B-2. Use of Electronic Data Sources

*Under 42 CFR 435.945(d), all State Medicaid eligibility systems must conduct a match with PARIS for Interstate benefit information. If used for other purposes, please indicate in Section C.

(Insert Medicaid or CHIP or both) MAGI-BASED ELIGIBILITY VERIFICATION PLAN

State:

C. Additional Factors of Eligibility for Separate CHIP

Eligibility Criteria	Self-Attestation Accepted without Additional Verification (Y/N)	Self-Attestation Accepted with Post-Enrollment Verification (Y/N)	Electronic Data Source Used (Y/N) If Yes, please describe	Paper Documentation Required from the Individual (Y/N)	Non-Applicable (N/A)
Applicant does not have other coverage
Applicant does not have access to affordable ESI
When child last had coverage (as applicable to states' waiting period) perperiod)
Waiting period exception #1 (describe):
Waiting period exception # 2 (describe):
Waiting period exception #3 (describe):
Waiting period exception #4 (describe):
Waiting period exception #5 (describe):
Waiting period exception #6 (describe):
Waiting period exception #7 (describe)
Waiting period exception #8 (describe):
Waiting period exception #9 (describe):
Waiting period exception #10 (describe):
Access to public employee coverage
Other Eligibility criteria or exceptions to eligibility criteria (please describe):

(Insert Medicaid or CHIP or both) _______________ MAGI-BASED ELIGIBILTIY VERIFICATION PLAN

State:

D. Additional Verification Questions

1. If paper documentation is required when a data source is not available or the information obtained from a data source is not reasonably compatible with the information provided by or on behalf of the individual, briefly describe how the state determined that establishing and using an electronic data source was not effective, considering such factors as cost and program integrity in accordance with 42 CFR 435.952(c):

2. Please describe how the state uses PARIS?

3. Please indicate if the state is requesting Secretarial approval to solely use alternative data sources for financial verification other than those listed in

42 CFR 435.948 (Numbers 1-8 in Section B-1), and if so, what sources:

Please describe how the State in using such alternative:

a. Reduces administrative costs and burdens on both individuals and the state:

b. Maximizes accuracy and minimizes delay:

c. Meets the requirements related to confidentiality, disclosure, maintenance and use of information:

d. Promotes coordination with other insurance affordability programs:

4. Please indicate if the state is requesting Secretarial approval to use a mechanism other than the federal data services hub, and if so what mechanism:

Please describe how the State in using such alternative:

a. Reduces administrative costs and burdens on both individuals and the state:

b. Maximizes accuracy and minimizes delay:

c. Meets the requirements related to confidentiality, disclosure, maintenance and use of information:

d. Promotes coordination with other insurance affordability programs:

5. Describe any additional MAGI-based eligibility verification policies and procedures that have not been covered in this verification plan (optional):

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 40 hours 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.