Form CMS-R-74 Attachment 4.32-A: Income and Eligibility Verification S

Revision:

ATTACHMENT 4.32-A
PAGE ______

State/Territory: ____________________________________

Citation
Section 1137
of the Act and
42 CFR 435.940
Through 435.960

4.32 Income and Eligibility Verification System

(a) 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) The State has an eligibility determination system that
provides for data matching through the Public
Assistance Reporting Information System (PARIS),
or any successor system, including matching with
medical assistance programs perated by other
States. The information that is requested will be
exchanged with States and other entities legally
entitled to verify title XIX applicants and individuals
eligible for covered title XIX services consistent with
applicable PARIS agreements.

42 CFR 435.948 (a)(6)

(c) Describe 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
TN No. __________

Approval Date __________

Effective Date ____________

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 0938-0467 (Expires: TBD). The time required to complete this information collection is estimated to
average 2 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.