CMS-10398.GenIC#11 CMS-10398.GenIC#11. MAGI-Based Eligibility Verification

Medicaid and CHIP Disaster Relief MAGI-Based Verification Plan Addendum

The State Medicaid and CHIP agencies will implement the following changes to its policies and procedures described in this MAGI-based verification plan addendum, which are different from the policies and procedures otherwise applied under the state’s current MAGI-based verification plan, during the following period: _______________. These changes are consistent with applicable Medicaid and CHIP eligibility verification statutory and regulatory authorities, including but not limited to section 1137 of the Social Security Act, 42 CFR 435.940 through 435.960 and 457.380.

Check off each item and fill in the requested information if the state is electing the flexibility. Only indicate areas that are changes to your current verification plan elections. Do not check off the item if you currently use the indicated flexibility. For example, if the state currently accepts attestation of residency, that item does not need to be checked off in this addendum. For additional information regarding disaster-related verification flexibilities, refer to the CMS Disaster Preparedness Toolkits.

STATE: _____________________

Effective Date: _______________

Section A – Verification Procedures for Factors of Eligibility

Income-related Verification Processes - Reasonable Compatibility and Documentation:

_____ The agency will utilize a reasonable compatibility standard threshold as follows (percent and/or dollar threshold): __________________

_____ The agency will accept self-attestation without additional verification of income under the circumstances specified here (note: changes in use of data sources are included in Section B below): ______________

______ The agency will conduct post-enrollment verification of income at application. Specify when, post-enrollment, the agency will conduct the post-enrollment verification: ___________

Non-Income-related Verification Processes:

_____ The agency will accept attestation for the following non-income related factors of eligibility:

__ Residency

__ Age/Date of Birth

__ Household composition

__ Receipt of other coverage (such as Medicare)

__ Other (as permissible under applicable statute and regulations): ______________

_____ The agency will conduct post-enrollment verification of the following non-income related factors of eligibility at application as specified here (include when, post-enrollment, the agency will conduct the post-enrollment verification):

__ Residency (Time Period: ___________)

__ Age/Date of Birth (Time Period: ___________)

__ Household composition (Time Period: ___________)

__ Receipt of other coverage (such as Medicare) (Time Period: ___________)

__ Other (as permissible under applicable statute and regulations): ______________

Section B – Use of Electronic Data Sources

_____ The agency has determined that the following income-related data sources will not be checked periodically between initial application and regular renewals:

__ Internal Revenue Service

__ Social Security Service (SSI, Title II

__ State Wage Income Collection Agency

__ State Unemployment Compensation

__ Supplemental Nutrition Assistance Program (SNAP)

__ Temporary Assistance for Needy Families (TANF)

__ The Work Number/TALX

__ PARIS

__ Other: _______________

____ Additional Information/Changes: _____________________________________________________

Other – Indicate Any Additional Changes to Verification Processes That Have Not Been Addressed

____ Other: ___________________________________________________________________________

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 voluntary information collection is 0938-1148 (Expires 03/31/2021).  The time required to complete this information collection is estimated to average 0.75 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to update CMS of changes to your verification plan. All responses are public and will be made available on the CMS web site.  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. ***CMS Disclosure***  Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office.  Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Jessica Stephens at 410-786-3341.         

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