CMS-10877 Eligibility Results Toolkit - Phase 2

OMB Control #: 0938-NEW
Expiration Date: XX/XX/20XX
Eligibility Results Toolkit - Phase 2
Purpose of This Toolkit
This document is designed to help Enhanced Direct Enrollment (EDE) Auditors ensure that the application returns accurate eligibility results for specific consumer scenarios. Each test case is
phase-specific, and describes a consumer scenario that must be supported by an EDE application. Auditors should complete each test case by using the information provided to complete an
application through the EDE Entity's user interface (UI). Some information collected by the UI (e.g., phone numbers, contact method preferences, language preferences) is not specified in
the test data. In these cases, Auditors may enter any value or skip optional inputs unless otherwise noted in the test case. The application must display all appropriate application questions
to the Auditor and provide the opportunity to enter the test case information into the application. After all of the information from the test case is entered into the application and the
application is submitted, the Auditor must verify that the eligibility results returned match the expected eligibility results provided in the test case, which is reflected in the Marketplace
Eligibility Determination Notice (EDN) and should be correctly conveyed in the entity's Eligibility Results Page (ERP).
Documentation Requirements
Phase 2 Entities must submit complete eligibility application UI screenshots only for the Phase 2 Eligibility Results Toolkit (ERT). Phase 2 entities must submit EDNs and unparsed JSONs for
all test cases it completes in the Phase 1 and 2 ERTs. In test cases for which an EDN is not generated, but is expected, Auditors must repeat the test case. If the test case ends after the
screening questions (i.e., if the consumer is not eligible to use a Phase 1 or Phase 2 EDE pathway, the consumer must be guided to an alternate pathway), the Auditor will not provide a
screenshot of the EDN, but must still provide screenshots showing the application questions asked from the start of the application through the end of the test case (i.e., the redirect to the
alternate pathway). Please review row 15 of this tab for more information about naming files.
Required Completion Rate
Auditors must conduct all possible test cases. However, depending on the Entity's intended service areas, Auditors may not be able to conduct a test case because the Entity does not intend
to operate in the specific state(s) provided in the test case. Auditors must conduct a minimum number of test cases from each toolkit it completes. Auditors conducting Phase 1 audits must
submit at least 11 of 14 Phase 1 test cases. Auditors conducting Phase 2 audits must submit at least 8 of 14 Phase 1 test cases AND 6 of 9 Phase 2 test cases. Auditors conducting Phase 3
audits must submit at least 8 of 14 phase 1 test cases AND 5 of 9 Phase 2 test cases AND 7 of 9 Phase 3 test cases. If an Auditor is not able to conduct the minimum number of test cases for
each toolkit because of the Entity's planned service areas, it must email DE Support to request instructions to modify test cases so that the Auditor is able to conduct and submit the
minimum number of test cases.
Note:
Each phase-specific set of eligibility results test scenarios are contained within separate toolkits (e.g., there is a Eligibility Results Toolkit specific to Phase 1).
Note on Version
It is important to note that this document is subject to change.
Navigating Updates to the Toolkit
Different font colors are used to indicate when the content of a cell was last updated. Use the key below to navigate updates to the content of these tabs.
Black font: Original value
Tab
Phase 1 (different toolkit)

Tabs for Auditor Review
Description
How to Review
This tab displays an overview of the test scenarios for The Auditor will use this tab to track compliance with each eligibility result test
scenario defined in the subsequent tabs. The Auditor must carefully examine the
the Phase 1 eligibility application.
"Eligibility Results" section of each "Test Case" input tab prior to confirming the
EDE Entity's compliance with each test case.
Note: Auditors for Phase 1 EDE applications must complete all Phase 1 test case
scenarios, if possible. If an entity does not intend to operate in the specific
state(s) provided in the test case, Auditors must submit at least 11 of 14 Phase 1
test cases.

Phase 2

This tab displays an overview of the test scenarios for The Auditor will use this tab to track compliance with each eligibility result test
scenario defined in the subsequent tabs. The Auditor must carefully examine the
the Phase 2 eligibility application.
"Eligibility Results" section of each "Test Case" input tab prior to confirming the
EDE Entity's compliance with each test case.
Note: Auditors for Phase 2 EDE applications must complete all Phase 2 test case
scenarios, as well as the following test cases from Phase 1: 1.A, 1.B, 1.C, 1.D, 1.E,
1.F, 1.K, 1.L, 1.M, 1.N, 1.O (not 1.D.2, 1.H, 1.J which are Phase 1 only test cases),
if possible. If an entity does not intend to operate in the specific state(s)
provided in the test case, Auditors must submit at least 8 of 14 Phase 1 test
cases AND 6 of 9 Phase 2 test cases. Note that because Phase 2 supports more
consumer scenarios than Phase 1, some information that is gathered via
screening question for a Phase 1 application is asked as an application question
for a Phase 2 application. For instance, pregnancy status is included in Phase 1
screening questions, but will be included as an application question in Phase 2
applications.

PRA DISCLOSURE: 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-NEW, expiration date is XX/XX/20XX. The time required to complete this information
collection is estimated to take up to 144,652 hours annually for all direct enrollment entities. 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 Brittany Cain at [email protected].

Tab
Phase 3 (different toolkit)

Description
How to Review
This tab displays an overview of the test scenarios for The Auditor will use this tab to track compliance with each eligibility result test
scenario defined in the subsequent tabs. The Auditor must carefully examine the
the Phase 3 eligibility application.
"Eligibility Results" section of each "Test Case" input tab prior to confirming the
EDE Entity's compliance with each test case.
Note: Auditors for Phase 3 EDE applications must complete all Phase 3 test case
scenarios, as well as the following test cases from Phase 1 and Phase 2: 1.A, 1.B,
1.C, 1.D, 1.E, 1.F, 1.K, 1.L, 1.M, 1.N, 1.O (not 1.D.2, 1.H, 1.J which are Phase 1 only
test cases) and 2.A, 2.B, 2.B.2, 2.D, 2.E, 2.E.2, 2.F and 2.G (not 2.H which is a
Phase 2 only test case), if possible. If an entity does not intend to operate in the
specific state(s) provided in the test case, Auditors must submit at least 8 of 14
Phase 1 test cases AND 5 of 9 Phase 2 test cases AND 7 of 9 Phase 3 test cases.
Note that because Phase 3 supports all consumer scenarios, Phase 3 does not
have screening questions. Therefore, information that is gathered via screening
question for a Phase 1 or Phase 2 application is asked as an application question
for a Phase 3 application. For instance, American Indian or Alaska Native status is
included in Phase 1 and 2 screening questions, but will be included as an
application question in Phase 3 applications.

Test Case Input Tabs (e.g., Test Case 2.A input, Test
Case 2.B input)

Each test case input tab details the eligibility
application answers to test the eligibility
determination through the EDE pathway.

Auditors should use each tab to complete an eligibility application with the
answers detailed in the tab. Upon receiving an eligibility determination through
the EDE Pathway, the Auditor should confirm that the eligibility results from the
EDE Pathway are identical to the "Eligibility Result" included at the end of each
test case. The Auditor must take screenshots of the eligibility application process
while progressing through the test case, including a screenshot of the ERP, and
also store the EDN and provide the EDN to CMS (if applicable). The Auditor must
also submit the Get App API response (JSON) from each test case. The Auditor
should name the screenshot files sequentially and clearly identify them as
belonging to a specific test case (e.g., TestCase2A-1, TestCase2A-2). Similarly,
the Auditor should name the JSON files to clearly identify them as belonging to a
specific test case (e.g., TestCase2A-JSON). CMS strongly recommends that
Auditors sequentially aggregate the screenshots in a single document for each
test case (e.g., a Microsoft Word, PowerPoint, or PDF document with each
image labelled “TestCase2-A”) instead of submitting each screenshot as an
individually saved image (e.g., TestCase2A-1.jpg, TestCase2A-2.jpg). This may
help expedite CMS’s audit review.

Audit Requirements by Tab
Tab: Phase 2
In this tab, the Auditor must scroll to the right to complete the last six columns whose column headings are shaded in yellow or marked with "**."
Columns
Test Case ID

Description
Test Case ID that corresponds to each input tab.

State

List of state(s) for testing that corresponds to each
input tab.

Summary/Criteria
Expected Results/What's Tested

Summary of test data for each test case.
Summary of tested functionalities and expected
results for each test case.

Test Scenario Description
Auditor Compliance Conclusion**

How to Review
The Auditor must match the Test Case ID in the "Phase 2" tab to the
corresponding Test Case ID input tab, and use information from both tabs to
complete the audit.
The Auditor must use an approved state (i.e., the state or one of the states
provided for each test case) to complete each test case.

The Auditor may use this summary information to inform the audit.
As stated above, the Auditor must carefully examine the "Eligibility Results"
section of each "Test Case" input tab prior to confirming the EDE Entity's
compliance with each test case.
Summary description of the test case.
The Auditor may use this summary information to inform the audit.
The Auditor must provide a conclusion as to whether The Auditor will use the test case eligibility details from the Test Case input tabs
the scenario or requirement defined in each row is to complete the EDE Entity's eligibility application. Upon completing the
compliant with the CMS requirements. A
eligibility application, the Auditor will verify that the eligibility results on the EDE
compliance conclusion should be indicated as "Yes" Entity's website match the eligibility results defined at the end of each Test Case
or "No."
input tab. The Auditor will document each screen within the eligibility
application with screenshots and store the EDN and provide the EDN to CMS,
unless the test case ends after the screener questions, which is clearly marked in
each input tab. For each test case, the Auditor must provide the raw JSON from
the Get App API response for the application version used to complete the
scenario.
There are several required fields in each cell within this column:
- The first required field in each cell is, "Eligibility results compliance conclusion:
_____." If the test case is compliant, and matches the eligibility results expected
for the test case, the Auditor must indicate "Yes" in this column. If the row is not
compliant, the Auditor must indicate the noncompliance with a "No" in this
column.
-The subsequent required fields in each cell refer to the "Auditor Checklist"
column and include the item number from the Application UI Toolkit, and the
row number from the test case. For example, the first item in row 31 of the 2.A
Check List is "Check Item 42: Verify that the alien number is optional." After the
Auditor verifies this checklist item, the Auditor must document its compliance
determination in the corresponding field in the "Auditor Compliance Conclusion"
column in the "Phase 2" tab, "Auditor checklist Item 42/row 31 compliance
conclusion:_____"

Columns

Description

How to Review

Risks Identified**

The Auditor must detail any compliance risks
identified during the audit in this column for each
applicable row. Use this column if the Compliance
Conclusion was “No” or if the entity resolved a risk
prior to audit submission. There are two types of
risks: resolved and unresolved. Please document
them both here. Do not document a risk if the
requirement is compliant and there was no
mitigation required
Auditors must assign a risk level to each risk it
identifies.

As the Auditor reviews each test case in its entirety, the Auditor must indicate
any compliance risks identified in this column. This includes any compliance risks
that the EDE Entity has since resolved and come into compliance. One example
finding is the Auditor could not input all of the test data because UI questions
were missing. Another example is if the eligibility result was correct, but the
Auditor found that the Entity's UI did not seem to follow the test data inputs or
display correct questions.

Risk Level**

CMS will take the risk level assigned by the Auditor
into consideration when reviewing the audit, but
may adjust it if necessary.

The Auditor must assign a risk level of "high" or "low" to each risk. High-risk
issues may impact a consumer’s eligibility determination, enrollment disposition
or status, or legal attestation. High-risk issues may also greatly hinder the
consumer experience or impact data collection (e.g., skipping a question that is
required for a EDE Entity to ask, but optional for the consumer to answer).
Low-risk issues are unlikely to affect a consumer’s eligibility determination,
enrollment disposition or status, legal attestation, experience (i.e., in a negative
or confusing way), or data collection. Note: These risk determinations are
applicable for the business audit only and not the privacy and security audit.

Risk Mitigation Strategy**

Auditors must explain how a risk(s) was mitigated.
For example, if the entity had non-compliant
question text, the Auditor must identify that as a risk
and list the specific language used as well as how the
issue was resolved. This field is required for high-risk
findings. The Auditor can work with the EDE Entity to
decide on whether or not to include this for low-risk
findings.

As the Auditor identifies compliance risks, the Auditor and EDE Entity will
identify a mitigation strategy that will mitigate or eliminate the compliance risk.
The Auditor must document that mitigation strategy here. This includes
documenting the mitigation strategy for any identified risk that the EDE Entity
has resolved. One example is, if the initial test did not produce the expected
eligibility results (which would be an identified risk), the EDE Entity made a
system or UI change to correct the issue to produce the correct eligibility result.

Estimated Resolution Date**

Auditors must provide a timeframe for risk
resolution (required for unresolved high-risk
findings).

CMS recommends Auditors work with the EDE Entity to provide a realistic
timeframe of when a risk will be closed or mitigated given other dependencies
and their expertise.

Auditor Comments**

Auditors must use the Auditor comments column for
any additional notes or comments pertaining to each
item. The Auditor must use this column to include
the applicable screenshot file or folder names that
show proof of compliance (or non-compliance) for
this requirement.

For instructions on how to properly document supplemental documentation see
the Enhanced Direct Enrollment (EDE) Business Audit Instructions and Report
Template.
The Auditor can also use this column to provide any additional notes or
comments pertaining to each item. Business requirements audits should not
include comments that describe the Auditor’s process for verifying the
requirement unless there is a specific issue or concern regarding the
requirement that warrants raising a concern.

Tab: Test Case Input
Note: Not all columns are present in all test case tabs.
Columns & Sections
Summary
UI Question Companion Guide Reference

Description
A high-level summary of the test case.
Item numbers from the UI Question Companion
Guide so the Auditor can easily refer back to
requirements.

Application Data

The question, group of questions/application
section, or eligibility result.

Application Input

Test data for the consumer(s) in each test case (i.e.,
test data the EDE Entity and Auditor use to answer
questions in the eligibility application).

Notes to Testers

Additional notes to complete each test case and
provide additional information for the Auditor about
what should or should not appear in the UI.

Auditor Checklist

Each case has 1-7 checklist items for the Auditor to
use when going through the test case to ensure
correct implementation. The Auditor must review
and verify each checklist item.

Testing Notes
The Auditor should note this column does not provide an exhaustive list of item
numbers for each test case and is not intended for audit purposes. It is a tool to
better understand question display requirements by providing an easily
accessible reference to detailed information in the UI Question Companion
Guide.

The Auditor is required to verify all checklist items and include it's compliance
determination for each checklist item in the corresponding field in the "Auditor
Compliance Conclusion" column in the "Phase" tab.

Columns & Sections
Application State & Coverage Year

Description
Testing Notes
This section provides the state and required ZIP Code Some test scenarios require the use of specific application states or ZIP Codes. In
(if any) and coverage year for each test case.
the event an EDE Entity does not support an application state listed in the test
scenario, the Auditor may omit that test case.
Required Completion Rate (Reminder)
Auditors must conduct all possible test cases. However, depending on the
entity's intended service areas, Auditors may not be able to conduct a test case
because the entity does not intend to operate in the specific state(s) provided in
the test case. Auditors must conduct a minimum number of test cases from
each toolkit it completes. Auditors conducting Phase 1 audits must submit at
least 11 of 14 Phase 1 test cases. Auditors conducting Phase 2 audits must
submit at least 8 of 14 Phase 1 test cases AND 6 of 9 Phase 2 test cases. Auditors
conducting Phase 3 audits must submit at least 8 of 14 Phase 1 test cases AND 5
of 9 Phase 2 test cases AND 7 of 9 Phase 3 test cases. If an Auditor is not able to
conduct the minimum number of test cases for each toolkit because of the
entity's planned service areas, it must email DE Support to request instructions
to modify test cases so that the Auditor is able to conduct and submit the
minimum number of test cases.

Screening Questions

This section provides the screener questions and
answers for each test case that determine if
consumer(s) can use a certain phase of EDE.

Screening Pass/Fail

This section describes and explains if the test
consumer(s) may continue the application or if the
test consumer must be guided to an alternate
pathway because the consumer is not eligible for this
phase of EDE.

Household Member Input

Test data for each consumer in the test case.

Household

This section provides the household composition
information such as relationships, whether
household members are applicants/non-applicants,
Social Security Numbers (SSNs), and
citizenship/immigration information.

More About This Household

This section provides information for answering the
Non-MAGI Medicaid eligibility questions (physical
disabilities, assistance with daily living, nursing home
care), pregnancy, foster care, incarceration and fulltime student questions.

Medicaid Block

This section provides information for answering the
questions about Medicaid denial or Medicaid ending
due to a change in eligibility.

Income

This section provides each household member's
current income, deductions, annual income, and
income discrepancies, when applicable.
This section provides additional inputs for each test
case that are specific to APTC, Medicaid, CHIP, SEP,
and QHP eligibility.

Program Questions

Attestations

This section provides information for answering the
legal attestations.

Eligibility Results

This section shows the eligibility results that should
display for each consumer in the ERP. The
information displayed in the UI should accurately
reflect results found in the EDN and use specific
language where noted in the test cases.

All Phase 1 and some Phase 2 scenarios require the use of specific test SSNs
which are provided in the input table. Some Phase 2 and Phase 3 scenarios do
not include SSNs. In these instances, the Auditor should proceed in the
application without entering any values in the SSN field. Entering an invalid SSN
will prevent application submission. Please refer to phase-specific instructions.

Auditors should note that test cases do not include data matching issue (DMI)
status in the Eligibility Result section. If the test case results in a DMI, the ERP
and EDN will provide instruction that the consumer must submit documentation
to confirm information. DMIs can occur for citizenship status; immigration
status; household income; incarceration status; American Indian or Alaska
Native status; eligibility for minimum essential job-based coverage; and eligibility
for coverage through Medicaid or CHIP, TRICARE, Veterans Health Care Program,
Medicare, or Peace Corps.
Auditors should also note that the test cases do include information on Special
Enrollment Verification Issues (SVIs) in the Eligibility Results section, and that
messaging about SVIs is expected on both the ERP and EDN when noted in the
test case. However, SVIs will not be generated for applicants who are current
enrollees or for applications submitted during the annual open enrollment
period. Entities can help ensure they are generating the expected SVIs by always
randomizing demographic data as instructed by the test cases and completing
the toolkit outside of the open enrollment period.

Phase 2
Test Case ID
Test Case 2.A

State
Any state

Summary/Criteria
-Initial application, 1 member household
-Not seeking financial assistance
-Single, no dependents
-U.S. citizen; not born in U.S. (naturalized)

Expected Results/What's Tested
-EDE Entity displays naturalized citizenship
questions properly
-EDE partner allows naturalized citizen to
proceed with the application and is determined
eligible for QHP

Test Scenario Description
This test case demonstrates the functionality for a consumer not applying for
financial assistance. In this scenario, an unmarried 25 year-old in any state with no
dependents completes the screener on the EDE Entity site. Although this consumer is
a U.S. citizen, he was not born in the U.S. and became a naturalized citizen. On the
application, the consumer attests to being a citizen, but citizenship cannot be verified
by SSA. Consumer is able to continue through the application after attesting as a
naturalized citizen and is determined eligible for QHP.
This test case tests the UI and functionality related to pregnant application members
in states with similar Medicaid income limits for pregnant women. The consumers
were married within the last 60 days. The husband is found eligible for QHP and APTC
with a marriage SEP, but the wife is eligible for Medicaid due to her income and
pregnancy status.
This test case should re-access the application from 2.B through a change in
circumstance (CiC). In this scenario, Betty is no longer pregnant and the couple is
adding their child to their application. This demonstrates the EDE partner is able to
support CiCs that result in changes to program eligibility. Because Betty is no longer
pregnant, she is now QHP and APTC with CSRs eligible with an marriage SEP and the
child is eligible for Medicaid.

Auditor Compliance Conclusion**
Eligibility results compliance conclusion:
Auditor checklist Item 42/row 31 compliance conclusion:
Auditor checklist Items 153, 174, 181/rows 41-43 compliance
conclusion:
Auditor checklist item to check Eligibility Results Tab, Item 4/row 49
compliance conclusion:

Any state except -Initial application, 2 member household
AK, HI, LA, SD
-Seeking financial assistance
-Married, no dependents
-Application member is pregnant
-Marriage SEP
Test case 2.B.2 State used in Test -CiC on application from Test Case 2.B, 3
Case 2.B
member household
-Seeking financial assistance
-Married, 1 dependent
-Child less than one year old (but older than 60
days) added to application

-EDE Entity demonstrates UI can support
pregnant application members
-Husband is determined eligible for QHP with
APTC; wife may be eligible for Medicaid

Test case 2.D

AK, AZ, DE, KS, LA, -Initial application, 3 member household
MI, NE, SC, TX,
-Seeking financial assistance
UT, VA
-Single, 2 dependents
-Dependent who is a full-time student
-Dependent stepchild with a disability

-EDE Entity properly displays full-time student
question based on tax dependent child's age
-EDE Entity's UI is able to support stepchildren
and non-MAGI attestation
-Household receives a determination of QHP
eligibility with APTC, and stepchild is referred to
the state Medicaid agency for review

In this scenario, a parent applies for coverage along with their 18 year-old child and a
stepchild, who they will claim on their tax return. Because the tax dependent child is
18 and the parent is applying for coverage, the application asks whether or not the 18
year old is a full-time student. The scenario also includes a dependent stepchild who
attests to a disability, demonstrating a Phase 2 application's ability to support
dependent stepchildren. The household receives a determination of QHP eligibility
with APTC, and the stepchild is referred to the State Medicaid agency based on her
attestations to non-MAGI questions.

Eligibility results compliance conclusion:
Auditor checklist Item 28/row 27 compliance conclusion:
Auditor checklist Item 32/row 29 compliance conclusion:
Auditor checklist Items 144 and 268/row 37 compliance conclusion:
Auditor checklist Item 215/row 46 compliance conclusion:
Auditor checklist item to verify the display of the eligibility results
page/row 50 compliance conclusion:

Test case 2.E

AK, AZ, AR, DE, HI,
IL, IN, IA, LA, MI,
MT, NH, ND, OH,
OR, UT, VA, WV,
WI

An applicant is ineligible for Medicaid due to immigration status and attests to a
recent denial from the state Medicaid/CHIP agency. The consumer is determined
eligible for QHP with APTC and CSRs despite having income below 100% FPL and
eligible for the under 150% FPL SEP.

Eligibility results compliance conclusion:
Auditor checklist Item 4/row 26 compliance conclusion:
Auditor checklist Items 72 and 73/row 32 compliance conclusion:
Auditor checklist item to check Eligibility Results Tab, Item 5/row 51
compliance conclusion:

Test case 2.E.2

State used in 2.E

-EDE Entity is able to support non-citizen
applicants and displays appropriate questions
relating to Medicaid/CHIP denial due to
immigration status
-The consumer is determined eligible for QHP
with APTC and CSR and SEP
-EDE Entity is able to support non-citizen
applicants and displays appropriate questions
relating to veteran status
-The consumer may be Medicaid eligible despite
not meeting the five-year bar
-EDE Entity displays attestation or application
question requiring consumer to attest whether
applicants are incarcerated
-UI then collects information about which
applicants are incarcerated and asks if they are
pending disposition of charges
-Applicant and spouse are QHP ineligible due to
immigration and incarceration status respectively,
and child is QHP and APTC/CSR eligible

This scenario involves the applicant from 2.E reporting a change in circumstance
(CiC). Sarah no longer attests to being denied Medicaid and attests her late spouse is
an honorably discharged veteran. Therefore, Sarah is eligible for Medicaid despite not
meeting the five-year bar.

Eligibility results compliance conclusion:
Auditor checklist item to verify test case is updating the application
submitted in 2.E by reporting a life change/row 4 compliance
conclusion:
Auditor checklist Items 56 and 71/row 31 compliance conclusion:
Eligibility results compliance conclusion:
Auditor checklist Item 44/row 31 compliance conclusion:
Auditor checklist Item 251/row 36 compliance conclusion:
Auditor checklist Item 181/row 43 compliance conclusion:

Test Case 2.B

Test case 2.F

-Initial application, 1 member household
-Seeking financial assistance
-Attests to Medicaid denial due to immigration
status
-Under 150% FLP SEP

-CiC on application from Test Case 2.E, 1
member household
-Seeking financial assistance
-Single, no dependents
-Applicant attests to honorably discharged
Any state except -Initial application, 3 member household
AK and HI
-Seeking financial assistance
-Married, 1 dependent
-2 consumers answer affirmatively to
incarceration question; one consumer is
pending disposition of charges, another
consumer is not pending disposition of charges

Test case 2.G

AR, DE, FL, MI,
MS, NC, ND, NE,
OK, SC, VA

-Initial application, 3 member household
-Seeking financial assistance
-Single, 2 dependents
-One child has aged out of foster care and is
eligible for transitional Medicaid
-Other child applying with name different from
SSN

Test case 2.H

Any state

-Initial application, 3 member household
-Seeking financial assistance
-Married, 1 dependent
-Applicant attests to home address outside of
state where applicant is seeking coverage

-EDE Entity is able to support a CiC, and changes
in program eligibility stemming from life events
-Husband and wife are QHP and APTC/CSR
eligible; child may be eligible for Medicaid/CHIP

-EDE Entity properly displays foster care
questions to dependent child applicant who is
between 18-25 years old
-UI allows applicant to continue with application
when applying under name different from their
SSN card
-Primary applicant and one child eligible for QHP
with APTC; child eligible for Medicaid

This test scenario allows the EDE Entity to demonstrate their UI can support
incarcerated application members as part of Phase 2 requirements. The consumer
attests that application members are incarcerated. The consumer indicates the wife
is incarcerated and answers "No" to the follow-up question of if they are
incarcerated pending disposition of charges. The consumer indicates that the son is
incarcerated pending disposition of charges. The consumer attests to not having
eligible immigration status and is therefore not eligible for a QHP. The wife is not
eligible for a QHP due to her incarceration status (not pending disposition of charges).
The son is eligible for a QHP because his incarceration is pending disposition of

This scenario includes a single parent applying for himself and his two children. It
demonstrates functionality and logic related to former foster care applicants. The
older child answers affirmatively to having been formerly in foster care at age 18 or
older, indicates the age they left foster care was 18 (VA), 19 (MI, NE, SC) or 21 (AR,
DE, FL, MS, NC, ND, OK), and that they were in foster care in the application state.
The younger child is applying with a name different than on their SSN card. The
primary applicant and younger child are found eligible for QHP with APTC based on
income while the older child is determined preliminarily eligible for Medicaid based
on former foster care status. The primary applicant is also referred to his state
Medicaid agency based on age.
-EDE Entity demonstrates UI properly screens out This scenario demonstrates proper UI and functionality of the screener tool for a
scenarios not supported by Phase 2 applications married application filer claiming one dependent who is seeking coverage and
-Applicant is routed to HealthCare.gov or
financial assistance. The application filer also lives in a state different from the
alternate channel after answering screening
application state which requires redirecting the application filer to an alternate
questions
pathway because this scenario is not supported by Phase 2 applications. Therefore,
-Proper disclaimer regarding unsupported
the application filer should answer “No” to the screener question "does everyone
scenarios is displayed on Entity UI
have the same permanent home address and currently live in [application state]?".
Upon doing so, the consumer should be screened out of EDE and directed to
HealthCare.gov or an alternate channel.

Eligibility results compliance conclusion:
Auditor checklist Item 28/row 27 compliance conclusion:
Auditor checklist Item 186 (and Items 185, 187)/row 44 compliance
conclusion:
Auditor checklist items 213, 218, 224/row 48 compliance conclusion:
Eligibility results compliance conclusion:
Auditor checklist item to verify test case is updating the application
submitted in 2.B by reporting a life change/row 4 compliance
conclusion:
Auditor checklist Item 155, Column G/row 41 compliance conclusion:
Auditor checklist Item 186/row 44 compliance conclusion:

Eligibility results compliance conclusion:
Auditor checklist Item 9/row 12 compliance conclusion:
Auditor checklist Item 28/row 26 compliance conclusion:
Auditor checklist Item 37/row 30 compliance conclusion:
Auditor checklist Item 151/row 35 compliance conclusion:
Auditor checklist Item 239/row 46 compliance conclusion:
Auditor checklist item to check Eligibility Results Tab, Item 4/row 51
compliance conclusion:

Eligibility results compliance conclusion:
Auditor checklist Item 9/row 12 compliance conclusion:
Auditor checklist Item 12/row 16 compliance conclusion:
Auditor checklist item to verify the consumer is guided to an alternate
pathway with consumer friendly language/row 21 compliance
conclusion:

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor Comments**

Test Case 2.A input

Summary: This test case demonstrates the functionality for a consumer not applying for financial assistance. In this scenario, an unmarried 25 year-old in any state with no
dependents completes the screener on the EDE entity site. Although this consumer is a U.S. citizen, he was not born in the U.S. and became a naturalized citizen. On the
application, the consumer attests to being a citizen, but citizenship cannot be verified by SSA. Consumer is able to continue through the application after attesting as a
UI Question Companion Guide
Application Data
Reference
Tab: UI Questions
Item 1
State
Item 2
Coverage Year
Tab: Phase 2 Screening
Item 1
Item 2
Item 3
Item 5
Items 4, 6, 7 (depending on
implementation)
Item 8
Item 9
Item 10
Item 11
Item 17

Item 12
Item 13
Item 14
Item 16

Application Input

Notes to Testers

Application State & Coverage Year
Any state
Current year
Screening Questions

Marital Status
Number of tax dependents
Who is applying for coverage?
Seeking financial assistance?

Single
0
Application filer
No

Resides in application state

Yes

Tax filing status
Responsible for a child 18 or younger not
on tax return
American Indian/Alaska Native
Offer of individual coverage HRA (ICHRA)
or a qualified small employer Health
Reimbursement Arrangement (QSEHRA)
Offer of coverage through job or COBRA
Claiming all dependents on tax return
Dependent is child or stepchild, single
(not married), 25 or younger
Dependents live with parent not on tax
return

N/A (should not display)
N/A (should not display)

Pass Screener?

No one in household has AI/AN status
Does not have an ICHRA or QSEHRA offer

N/A (should not display)
N/A (should not display)
N/A (should not display)
N/A (should not display)
Screening Pass/Fail
Yes, continue with application

Must provide a valid zip code for the application
state

Auditor Checklist

UI Question Companion Guide
Reference
Tab: UI Questions
Items 4, 28 Name
Item 5 Home address
Items 7, 8 Mailing address
Item 10 Preferred language

Application Data

Household Member Input

Notes to Testers

Auditor Checklist

Household
Household member

John Matthews *
Age: 25
Male

*Do not use Matthews as the last name. Use a
different last name that is unique (it can be a
random string of letters). Do not change the first
name
Must provide a valid county and zip code for the
application state
Use any date of birth that results in the correct
age for each household member

Item 28
Items 27, 29
Item 32
Item 36
Items 38, 40, 41, 42

Items 131, 132

Item 147
Item 268 (depending on
implementation)
Item 149
Item 268 (depending on
implementation)
Item 250
Item 268 (depending on
implementation)

Application Filer/Relationship to
Application Filer
Applicant/Non-Applicant
SSN

Application Filer

Applying with same name as name on
SSN card?
Citizenship/Immigration

Yes

Applicant
421-94-1551

Attests to U.S. citizenship
Attests to being a naturalized U.S. citizen

Select Naturalization Certificate Document:
Alien Number: 660020811
Naturalization Number: 600060020811
More About This Household
Non-MAGI Medicaid Eligibility Questions N/A (should not display)
(physical disabilities, assistance with
daily living, nursing home care)
Pregnancy Questions
N/A (should not display)

Foster Care Questions

N/A (should not display)

Incarceration Questions

Not incarcerated

Other household contact and information fields
(i.e. email, phone, language preference,
race/ethnicity, etc.) may contain any value unless
otherwise noted.
Find additional information in the UI Question
Companion Guide:
- Items 4, 5, 7, 8, 9 Household Contact
Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-applicant
information - Race and Ethnicity

SSN must be entered exactly for test case to
function

Due to unverified SSN, the UI should ask if the
consumer is a naturalized or derived citizen

Check Item 42: Verify that the alien number
and naturalization number are optional

UI Question Companion Guide
Application Data
Reference
Item 144
Full-Time Student Questions
Item 268 (depending on
implementation)

Household Member Input

Medicaid Block
N/A (should not display)
Income
N/A (should not display)
N/A (should not display)
N/A (should not display)
Program Questions
None of these changes
Attestations

Medicaid/CHIP Denial

Item 153
Item 174
Item 181

Current Month Income
Deductions
Annual Income

Items 213, 218, 224

Recent Life Changes (SEPs)

Items 246, 254, 255, 256, 258

Application Review & Legal Attestations Answers affirmatively to all application
attestations

Sample HealthCare.gov Eligibility
Results Messaging

Eligibility Results Page (ERP)

Auditor Checklist

N/A (should not display)

Items 133, 138

Reference Materials
UI Q CG Eligibility Results Tab:
Items 1, 4, 5

Notes to Testers

Eligibility Results
Eligible to buy a Marketplace plan
Not eligible for a Special Enrollment Period*

Check Items 153, 174 and 181: Verify no
income information is collected since this is
a non-financial assistance application

Auditors should review the application review
page (Item 246) to ensure all information
accurately reflects the attestations inputted
during the test case
Auditors should review the Eligibility Results Page Check Eligibility Results Tab, Item 4: Verify UI
displays exact language "What should I do if I
to ensure it accurately reflects the eligibility
results found in the EDN and complies with ERP think my eligibility results are wrong?"
messaging requirements outlined in the
documentation listed in Column A
*Optional to display if consumer is not eligible
for a Special Enrollment Period

Test Case 2.B.1 input

Summary: This test case tests the UI and functionality related to pregnant application members in states with similar Medicaid income limits for pregnant women. The consumers
were married within the last 60 days. The husband is found eligible for QHP and APTC with a marriage SEP, but the wife is eligible for Medicaid due to her income and pregnancy
UI Question Companion
Guide Reference
Tab: UI Questions
Item 1
Item 2
Tab: Phase 2 Screening
Item 1
Item 2
Item 3

Application Data

Application Input

Marital Status

Application State & Coverage Year
Any state except AK, HI, LA, SD
Current year
Screening Questions
Married

Number of tax dependents
Who is applying for coverage?

0
Application filer, spouse

State
Coverage Year

Item 5
Seeking financial assistance?
Items 4, 6, 7 (depending on
implementation)
Item 8
Resides in application state and
lives at same address
Item 9
Tax filing status
Item 10
Responsible for a child 18 or
younger not on tax return
Item 11
American Indian/Alaska Native
Item 17
Offer of individual coverage HRA
(ICHRA)or a qualified small
employer Health Reimbursement
Arrangement (QSEHRA)
Item 12
Offer of coverage through job or
COBRA
Item 13
Claiming all dependents on tax
return
Item 14
Dependent is child or stepchild,
single (not married), 25 or
younger
Item 16
Dependents live with parent not
on tax return
Pass Screener?

Notes to Testers

Yes

Yes, all household members live at same address in application state Must provide a valid zip code for the application
state
Filing jointly
No one in household is responsible for a child 18 or younger who
they live with but isn't on their tax return
No one in household has AI/AN status
No applicants have an ICHRA or QSEHRA offer

No applicants have access to coverage through a job or COBRA
N/A (should not display)
N/A (should not display)

N/A (should not display)

Yes, continue with application

Screening Pass/Fail

Auditor Checklist

UI Question Companion
Guide Reference
Tab: UI Questions

Application Data

Household Member Input

Household Member Input

Notes to Testers

Auditor Checklist

Household

Items 4, 28 Name
Household member
Item 5 Home address
Items 7, 8 Mailing address
Item 10 Preferred language

Betty Curtis*
Age: 21
Female

Dwayne Curtis*
Age: 21
Male

*Do not use Curtis as the last name. Use a
different last name that is unique (it can be a
random string of letters). Do not change the first
name
Must provide a valid county and zip code for the
application state
Use any date of birth that results in the correct
age for each household member
Other household contact and information fields
(i.e. email, phone, language preference,
race/ethnicity, etc.) may contain any value unless
otherwise noted. Find additional information in
the UI Question Companion Guide:
- Items 4, 5, 7, 8, 9 Household Contact Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-applicant
information - Race and Ethnicity

Item 28

Application Filer/Relationship to Application Filer
Application Filer

Spouse

Items 27, 29
Item 32

Applicant/Non-Applicant
SSN

Applicant
317-20-1410

Applicant
317-20-1411

Item 36

Applying with same name as
name on SSN card?
Citizenship/Immigration

Yes

Yes

Item 38
Items 131, 132

Items 147, 148
Item 268 (depending on
implementation)
Item 149
Item 268 (depending on
implementation)
Item 250
Item 268 (depending on
implementation)
Item 144
Item 268 (depending on
implementation)

Non-MAGI Medicaid Eligibility
Questions (physical disabilities,
assistance with daily living,
nursing home care)
Pregnancy Questions

Attests to U.S. citizenship

Attests to U.S. citizenship
More About This Household
Do not answer affirmatively to Do not answer affirmatively to any
any non-MAGI questions
non-MAGI questions

Pregnant
Expecting 1 baby

N/A (should not display for this
household member)

Foster Care Questions

Not former foster care

Not former foster care

Incarceration Questions

Not incarcerated

Not incarcerated

Full-Time Student Questions

Not a full time student

Not a full time student

Medicaid Block

Check Item 28: Verify that the
application collects relationship
between Dwayne and Betty
SSN must be entered exactly for test case to
function

UI Question Companion
Guide Reference
Items 133, 138

Medicaid/CHIP Denial

Does not have Medicaid/CHIP
that recently ended or will end
soon;
Not denied Medicaid/CHIP

Items 153, 154, 155, 209

Current Month Income

Job: $2,087.75 per month

Item 174
Item 181
Item 186

Deductions
Annual Income
Income Discrepancies

No deductions
No deductions
$25,053
$9,999.96
Answer "Other reason" for "Betty's and Dwayne's household income The question will be asked once for the household Verify only Item 186 displays, and
seems like it will be lower than what our records from the past 2
and not for each household member
other income discrepancy
years show. Is there a reason why?"
questions (Items 185, 187) do not

Item 191
Item 239

Current coverage
Help paying for medical bills

None
Do not answer affirmatively

Items 213, 218, 224, 225,
226

Recent Life Changes (SEPs)

Items 246, 247, 252, 254,
255, 256, 258

Application Review & Legal
Attestations

Reference Materials
UI Q CG Eligibility Results
Tab: Items 1, 3, 4, 5

Eligibility Results Page (ERP)

Sample HealthCare.gov
Eligibility Results
Messaging

Application Data

Household Member Input

Household Member Input

Assessment states:
"May be eligible for Medicaid"

Auditor Checklist

Does not have Medicaid/CHIP that
recently ended or will end soon;
Not denied Medicaid/CHIP
Income
Job: $833.33 per month

Program Questions
None
N/A (should not display for this
household member)
N/A (should not display for this Got married
household member)
Provide date in last 60 days
Attest "Yes" to prior coverage
questions
Attestations
Answers affirmatively to all application attestations

Determination states:
"May be eligible for Medicaid"

Notes to Testers

Eligibility Results
Eligible to buy a Marketplace plan
with a premium tax credit of up to
[amount] each month for your tax
household

Employer name (and phone number, where Item
209 is included) fields are required but any value
may be entered (ex: ABC corp; 555-555-5555)

Check Items 213, 218 and 224:
These questions should only display
for Dwayne

Auditors should review the application review
page (Item 246) to ensure all information
accurately reflects the attestations inputted
during the test case
Auditors should review the Eligibility Results Page Check Eligibility Results Tab, Item 3:
to ensure it accurately reflects the eligibility
UI should display Full Medicaid
results found in the EDN and complies with ERP
Determination for Dwayne
messaging requirements outlined in the
documentation listed in Column A

Eligible for lower copayments,
coinsurance, and deductibles (cost- Betty is not eligible for a Special Enrollment
sharing reductions) on Silver plans Period because she qualifies for Medicaid
Eligible for a Special Enrollment
Period

Test Case 2.B.2 input
Summary: This test case should re-access the application from 2.B through a change in circumstance (CiC). In this scenario, Betty is no longer pregnant and the couple is adding their child to their application. This demonstrates the EDE
partner is able to support CiCs that result in changes to program eligibility. Because Betty is no longer pregnant, she is now QHP and APTC with CSRs eligible with a marriage SEP and the child is eligible for Medicaid.
UI Question Companion Guide
Reference
Tab: UI Questions
Item 1

Application Data

Application Input
Application State & Coverage Year

State

State used in Test Case 2.B

Item 2
Tab: Phase 2 Screening Questions
Item 1
Item 2
Item 3

Coverage Year

Current year

Marital Status
Number of tax dependents
Who is applying for coverage?

Married
1
Application filer, spouse, dependent

Item 5
Items 4, 6, 7 (depending on
implementation)

Seeking financial assistance?

Yes

Item 8

Resides in application state and
lives at same address
Tax filing status
Responsible for a child 18 or
younger not on tax return
American Indian/Alaska Native
Offer of individual coverage HRA
(ICHRA) or a qualified small
employer Health Reimbursement
Arrangement (QSEHRA)
Offer of coverage through job or
COBRA
Claiming all dependents on tax
return
Dependent is child or stepchild,
single (not married), 25 or
younger
Dependents live with parent not
on tax return

Yes, all household members live at same address in application state

Pass Screener?

Yes, continue with application

Item 9
Item 10
Item 11
Item 17

Item 12
Item 13
Item 14

Item 16

Notes to Testers

The tester should update the application submitted in
Test Case 2.B through a change in circumstance (CiC),
which will use the same application state

Screening Questions

Filing jointly
No one in household is responsible for a child 18 or younger who they live with but isn't on their tax return
No one in household has AI/AN status
No applicants have an ICHRA or QSEHRA offer

No applicants have access to coverage through a job or COBRA
Yes
Yes

No
Screening Pass/Fail

Must provide a valid zip code for the application state

Auditor Checklist

Verify entity is updating the
application submitted in 2.B by
reporting a life change in order to
complete test case 2.B.2

UI Question Companion Guide
Reference

Application Data

Household Member Input

Household Member Input

Tab: UI Questions
Items 4, 28 Name
Item 5 Home address
Items 7, 8 Mailing address
Item 10 Preferred language

Household Member Input

Notes to Testers

Auditor Checklist

Household
Household member

Betty Curtis *
Age: 21
Female

Dwayne Curtis *
Age: 21
Male

Baby Curtis*
Age: more than 60 days old, but
less than 1 year old
Male

*Do not use Curtis as the last name. Use a different last
name that is unique (it can be a random string of letters).
Do not change the first name
Must provide a valid county and zip code for the
application state
Use any date of birth that results in the correct age for
each household member

Item 28
Items 27, 29
Item 32
Item 36
Items 38, 40

Items 131, 132

Item 147
Item 268 (depending on
implementation)
Item 149
Item 268 (depending on
implementation)
Item 250
Item 268 (depending on
implementation)
Item 144
Item 268 (depending on
implementation)

Application Filer/Relationship to Application Filer
Application Filer
Applicant/Non-Applicant
Applicant
SSN
317-20-1410

Spouse

Son/Daughter

Applicant
317-20-1411

Applicant
Does not have SSN, continue
SSN must be entered exactly for test case to function
without providing SSN
Yes
N/A (should not display for this
household member)
Attests to U.S. citizenship
Attests to U.S. citizenship, not
naturalized or derived
More About This Household
Do not answer affirmatively to any Do not answer affirmatively to any
non-MAGI questions
non-MAGI questions

Applying with same name as on
name on SSN card?
Citizenship/immigration

Yes

Non-MAGI Medicaid Eligibility
Questions (physical disabilities,
assistance with daily living,
nursing home care)
Pregnancy Questions

Do not answer affirmatively to any
non-MAGI questions

Not pregnant

N/A (should not display for this
household member)

N/A (should not display for this
household member)

Foster Care Questions

Not former foster care

Not former foster care

N/A (should not display for this
household member)

Incarceration Questions

Not incarcerated

Not incarcerated

Not incarcerated

Full-Time Student Questions

Not a full time student

Not a full time student

N/A (should not display for this
household member)

Items 133, 138

Medicaid/CHIP Denial

Items 153, 154, 155, 209

Current Month Income

Item 174
Item 181
Item 186

Deductions
Annual Income
Income Discrepancies

Attests to U.S. citizenship

Other household contact and information fields (i.e.
email, phone, language preference, race/ethnicity, etc.)
may contain any value unless otherwise noted. Find
additional information in the UI Question Companion
Guide:
- Items 4, 5, 7, 8, 9 Household Contact Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-applicant information Race and Ethnicity

Medicaid Block
Does not have Medicaid/CHIP that Does not have Medicaid/CHIP that Does not have Medicaid/CHIP that
recently ended or will end soon; Not recently ended or will end soon; Not recently ended or will end soon;
denied Medicaid/CHIP
denied Medicaid/CHIP
Not denied Medicaid/CHIP
Income
Job: $2,087.75 per month
Job: $833.33 per month
No income
Employer name (and phone number, where Item 209 is
included) fields are required but any value may be
entered (ex: ABC corp; 555-555-5555)
No deductions
No deductions
$25,053
$9,999.96
Answer "Other reason" for "Betty's and Dwayne's household income
seems like it will be lower than what our records from the past 2 years
show. Is there a reason why?"

No deductions
$0
N/A (should not display for this
household member)

Program Questions

The question will be asked once for the household and
not for each household member

Check Item 155, Column G: Verify all
required job income frequencies
display as answer options

Check Item 186: Verify that this is the
only income discrepancy question
that displays. Verify that the question
only displays once for the whole
household

UI Question Companion Guide
Reference

Application Data

Item 191
Item 239

Current coverage
Help paying for medical bills

Items 213, 218, 224, 225, 226

Recent Life Changes (SEPs)

Items 246, 247, 252, 254, 255,
256, 258

Application Review & Legal
Attestations

Reference Materials
UI Q CG Eligibility Results Tab:
Items 1, 3, 4, 5

Eligibility Results Page (ERP)

Sample HealthCare.gov Eligibility
Results Messaging

Household Member Input

Household Member Input

None
N/A (should not display for this
household member)
Got married
Provide date in last 60 days
Attest "Yes" to prior coverage
questions

None
N/A (should not display for this
household member)
Got married
Provide date within last 60 days
Attest "Yes" to prior coverage
questions
Attestations
Answers affirmatively to all application attestations

Household Member Input
None
Do not answer affirmatively
N/A (should not display for this
household member)

Eligible for lower copayments,
coinsurance, and deductibles (costsharing reductions) on Silver plans

Eligibility Results
Eligible to buy a Marketplace plan
Determination states:
with a premium tax credit of up to "May be eligible for Medicaid"
[amount] each month for your tax
household
Assessment states:
"May be eligible for Medicaid"
Eligible for lower copayments,
coinsurance, and deductibles (costsharing reductions) on Silver plans

Eligible for a Special Enrollment
Period

Eligible for a Special Enrollment
Period

Eligible to buy a Marketplace plan
with a premium tax credit of up to
[amount] each month for your tax
household

Notes to Testers

Auditors should review the application review page (Item
246) to ensure all information accurately reflects the
attestations inputted during the test case
Auditors should review the Eligibility Results Page to
ensure it accurately reflects the eligibility results found in
the EDN and complies with ERP messaging requirements
outlined in the documentation listed in Column A

Auditor Checklist

Test Case 2.D input
Summary: In this scenario, a parent applies for coverage along with their 18 year-old child and a stepchild, who they will claim on their tax return. Because the tax dependent child is 18 and the parent is applying for coverage, the
application asks whether or not the 18 year old is a full-time student. The scenario also includes a dependent stepchild who attests to a disability, demonstrating a Phase 2 application's ability to support dependent stepchildren. The
household receives a determination of QHP eligibility with APTC, and the stepchild is referred to the State Medicaid agency based on her attestations to non-MAGI questions.
UI Question Companion Guide
Application Data
Application Input
Notes to Testers
Reference
Tab: UI Questions
Application State & Coverage Year
Item 1
State
AK, AZ, DE, KS, LA, MI, NE, SC, TX, UT, VA
Item 2
Coverage Year
Current year
Tab: Phase 2 Screening
Screening Questions
Item 1
Marital Status
Single
Item 2
Number of tax dependents
2
Item 3
Who is applying for coverage?
Application filer, both dependents
Item 5
Seeking financial assistance?
Yes
Items 4, 6, 7 (depending on
implementation)
Item 8
Item 9
Item 10
Item 11
Item 17

Item 12
Item 13
Item 14
Item 16

Resides in application state and
lives at same address
Tax filing status
Responsible for a child 18 or
younger not on tax return
American Indian/Alaska Native
Offer of individual coverage HRA
(ICHRA) or a qualified small
employer Health Reimbursement
Arrangement (QSEHRA)
Offer of coverage through job or
COBRA

Tab: UI Questions
Items 4, 28 Name
Item 5 Home address
Items 7, 8 Mailing address
Item 10 Preferred language

Application Data

Household member

Must provide a valid zip code for the application
state

Filing taxes
No one in household is responsible for a child 18 or younger who they live with but isn't on their tax return
No one in household has AI/AN status
No applicants have an ICHRA or QSEHRA offer

No applicants have access to coverage through a job or COBRA

Claiming all dependents on tax
Yes
Dependent is children or
Yes
stepchildren, single (not married),
Dependents live with parent not on No
tax return
Pass Screener?

UI Question Companion Guide
Reference

Yes, all household members live at same address in application state

Auditor Checklist

Screening Pass/Fail

Yes, continue with application
Household Member Input

Peter Linnade*
Age: 49
Male

Household Member Input

Nelly Linnade*
Age: 18
Female

Household

Household Member Input

Lisa Linnade*
Age: 15
Female

Notes to Testers

*Do not use Linnade as the last name. Use a
different last name that is unique (it can be a
random string of letters). Do not change the first
name
Must provide a valid county and zip code for the
application state
Use any date of birth that results in the correct
age for each household member
Other household contact and information fields
(i.e. email, phone, language preference,
race/ethnicity, etc.) may contain any value
unless otherwise noted. Find additional
information in the UI Question Companion
Guide:
- Items 4, 5, 7, 8, 9 Household Contact
Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-applicant
information - Race and Ethnicity

Auditor Checklist

UI Question Companion Guide
Reference

Application Data

Household Member Input

Household Member Input

Item 28

Application Filer/Relationship to
Application Filer

Application Filer
Parent of Nelly
Stepparent of Lisa

Items 27, 29
Item 32

Applicant/Non-Applicant
SSN

Applicant
Applicant
Applicant
Does not have SSN, continue without Does not have SSN, continue without Does not have SSN, continue without
providing SSN
providing SSN
providing SSN

Item 36

Applying with same name as on
name on SSN card?
Citizenship/immigration

N/A (should not display for this
household member)
Attests to U.S. citizenship, not a
naturalized or derived citizen

Items 38, 40

Child of Peter

Household Member Input
Stepchild of Peter

Non-MAGI Medicaid Eligibility
Do not answer affirmatively to any
Questions (physical disabilities,
non-MAGI questions
assistance with daily living, nursing
home care)

Item 147
Item 268 (depending on
implementation)
Item 149
Item 268 (depending on
implementation)
Item 250
Item 268 (depending on
implementation)
Item 144
Item 268 (depending on
implementation)

Pregnancy Questions

N/A (should not display for this
household member)

Not pregnant

Not pregnant

Foster Care Questions

N/A (should not display for this
household member)

Not former foster care

N/A (should not display for this
household member)

Incarceration Questions

Not incarcerated

Not incarcerated

Not incarcerated

Full-Time Student Questions

N/A (should not display for this
household member)

Full-time student

N/A (should not display for this
household member)

Items 133, 138

Medicaid/CHIP Denial

Does not have Medicaid/CHIP that
recently ended or will end soon;
Not denied Medicaid/CHIP

Items 153, 154, 155, 209

Current Month Income

Item 174
Item 181

Job: $5,683.75 per month

Medicaid Block
Does not have Medicaid/CHIP that
recently ended or will end soon;
Not denied Medicaid/CHIP
Income
Job: $272.08 per month

No income

Deductions
Annual Income

No deductions
$68,205

No deductions
$3,264.96

No deductions
$0

Item 191
Items 213, 214, 215, 218, 224

Current coverage
Recent Life Changes (SEPs)

None
Recent loss of minimum essential
coverage (MEC)
Provide date within last 60 days; Do
not provide the name of the plan

Program Questions
None
None of these changes

None
None of these changes

Items 246, 252, 254, 255, 256,
258

Application Review & Legal
Attestations

Answers affirmatively to all application attestations

Reference Materials
UI Q CG Eligibility Results Tab:
Items 1, 3, 4, 5

Eligibility Results Page (ERP)

Eligible to buy a Marketplace plan
with a premium tax credit of up to
[amount] each month for your tax
household

Eligibility Results
Eligible to buy a Marketplace plan
with a premium tax credit of up to
[amount] each month for your tax
household

Eligible for a Special Enrollment
Period

Eligible for a Special Enrollment
Period

Auditor Checklist
Check Item 28: Verify that the UI collects
both dependents' relationship with the
filer and that child and stepchild are
distinct answer options
Check Item 32: Verify that applicants can
proceed without entering an SSN and that
wording and answer option format
conform to UI Q CG requirements

N/A (should not display for this
N/A (should not display for this
household member)
household member)
Attests to U.S. citizenship, not a
Attests to U.S. citizenship, not a
naturalized or derived citizen
naturalized or derived citizen
More About This Household
Do not answer affirmatively to any
Physical disability, Needs help with
non-MAGI questions
activities of daily living

Items 131, 132

Sample HealthCare.gov
Eligibility Results Messaging

Notes to Testers

Check Items 144 and 268: Verify full time
student question displays for Nelly

Does not have Medicaid/CHIP that
recently ended or will end soon;
Not denied Medicaid/CHIP

Attestations

Employer name (and phone number, where Item
209 is included) fields are required but any value
may be entered (ex: ABC corp; 555-555-5555)

Check Item 215: Verify that plan name is
marked as "optional" and that the
consumer can proceed to the next screen
without providing a response in the UI
Auditors should review the application review
page (Item 246) to ensure all information
accurately reflects the attestations inputted
during the test case

Eligible to buy a Marketplace plan with
a premium tax credit of up to
[amount] each month for your tax
household
Eligible for a Special Enrollment Period
May be eligible for Medicaid*

Auditors should review the Eligibility Results
Page to ensure it accurately reflects the
eligibility results found in the EDN and complies
with ERP messaging requirements outlined in
the documentation listed in Column A
*Optional to display for QHP applicant who is
also being referred to the state Medicaid agency
based on age/disability (non-MAGI)

Verify eligibility results page displays that
Peter, Nelly, and Lisa are "eligible to buy a
Marketplace plan with a premium tax
credit of up to [amount]," and "eligible for
a Special Enrollment Period"

Test Case 2.E.1 input

Summary: An applicant is ineligible for Medicaid due to immigration status and attests to a recent denial from the state Medicaid/CHIP agency. The consumer is determined eligible for
QHP with APTC and CSRs despite having income below 100% FPL and eligible for the under 150% FPL SEP.
UI Question Companion Guide
Reference

Application Data

Tab: UI Questions

Application Input

Marital Status
Number of tax dependents
Who is applying for coverage?
Seeking financial assistance?

Application State & Coverage Year
AK, AZ, AR, DE, HI, IL, IN, IA, LA, MI, MT, ND, NH, OH,
OR, UT, VA, WV, WI
Current Year
Screening Questions
Single
0
Application filer
Yes

Resides in application state

Yes

Item 1

State

Item 2
Tab: Phase 2 Screening
Item 1
Item 2
Item 3
Item 5
Items 4, 6, 7 (depending on
implementation)
Item 8

Coverage Year

Item 9
Item 10

Tax filing status
Filing taxes
Responsible for a child 18 or younger not on No one in household is responsible for a child 18 or
tax return
younger who they live with but isn't on their tax
return
American Indian/Alaska Native
No one in household has AI/AN status
Offer of individual coverage HRA (ICHRA)or Does not have an ICHRA or QSEHRA offer
a qualified small employer Health
Reimbursement Arrangement (QSEHRA)
Offer of coverage through job or COBRA
Does not have access to coverage through a job or
COBRA

Item 11
Item 17

Item 12
Item 13
Item 14

Claiming all dependents on tax return
Dependent is children or stepchildren,
single (not married), 25 or younger

N/A (should not display)
N/A (should not display)

Item 16

Dependents live with parent not on tax
return

N/A (should not display)

Pass screener?

Screening Pass/Fail
Yes, continue with application

Notes to Testers

Must provide a valid zip code for the application
state

Auditor Checklist

UI Question Companion Guide
Reference
Tab: UI Questions
Items 4, 28 Name
Item 5 Home address
Items 7, 8 Mailing address
Item 10 Preferred language

Application Data

Household Member Input

Notes to Testers

Auditor Checklist

Household
Household member

Sarah Noelfl*
Age: 20
Female

*Do not use Noelfl as the last name. Use a different Check Item 4: Verify Answer fields for Middle
last name that is unique (it can be a random string Name and Suffix are optional
of letters). Do not change the first name
Must provide a valid county and zip code for the
application state
Use any date of birth that results in the correct age
for each household member
Other household contact and information fields
(i.e. email, phone, language preference,
race/ethnicity, etc.) may contain any value unless
otherwise noted. Find additional information in the
UI Question Companion Guide:
- Items 4, 5, 7, 8, 9 Household Contact Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-applicant
information - Race and Ethnicity

Item 28
Items 27, 29
Item 32
Item 36
Items 38, 39, 44, 46, 48, 56, 71

Application Filer/Relationship to Application
Filer
Applicant/Non-Applicant
SSN
Applying with same name as name on SSN
card?
Citizenship/Immigration

Application Filer
Applicant
717-07-6993
Yes
Not a U.S. citizen/national
Attest to eligible immigration status
Document Type:
I-327 Reentry permit
Alien Number:
660031769

Items 72, 73

Five-Year Bar/Veteran Status Questions

Items 131, 132

Non-MAGI Medicaid Eligibility Questions
(physical disabilities, assistance with daily
living, nursing home care)

Do not enter expiration date
Do not answer affirmatively to honorably discharged
Veteran or active-duty member of the U.S. military
questions (including for deceased spouse)

More About This Household
Do not answer affirmatively to any non-MAGI
questions

Check Items 72 and 73: Verify that Item 72 does
not display (applicant's birthday is after 1996).
Verify that both Sarah and Sarah's deceased
spouse are listed as answer options for Item
73's question "Are any of these people an
honorable discharged veteran or active duty
member of the military?"

UI Question Companion Guide
Reference

Application Data

Household Member Input

Item 147
Item 268 (depending on
implementation)
Item 149
Item 268 (depending on
implementation)
Item 250
Item 268(depending on
implementation)
Item 144
Item 268 (depending on
implementation)

Pregnancy Questions

Not pregnant

Foster Care Questions

Not former foster care

Incarceration Questions

Not incarcerated

Full-Time Student Questions

Not a full-time student

Items 133, 138, 141, 142, 143

Medicaid/CHIP Denial

Medicaid Block
Does not have Medicaid/CHIP that recently ended or
will end soon

Notes to Testers

Not denied Medicaid/CHIP in the last 90 days
Denied Medicaid/CHIP due to immigration status in
the last five years
Answer "No" to question: "Has Sarah had their
current immigration status since [current year minus
5 years]?"

Items 153, 154, 155, 209

Current Month Income

Answer "No" to question: "Has Sarah had a change
in their immigration status since they were found
not eligible for [state Medicaid program name] or
[state CHIP program name]?"
Income
Job: $750 per month

Item 174
Item 181

Deductions
Annual Income

No deductions
$9,000

Item 191
Items 213, 218, 224

Current coverage
Recent Life Changes (SEPs)

Program Questions
None
None of these changes

Items 246, 252, 254, 255, 256,
258

Application Review & Legal Attestations

Attestations
Answers affirmatively to all application attestations

Reference Materials

Eligibility Results

Employer name (and phone number, where Item
209 is included) fields are required but any value
may be entered (ex: ABC corp; 555-555-5555)

Auditors should review the application review
page (Item 246) to ensure all information
accurately reflects the attestations inputted during
the test case

Auditor Checklist

UI Question Companion Guide
Reference
UI Q CG Eligibility Results Tab:
Items 1, 3, 4, 5
Sample HealthCare.gov Eligibility
Results Messaging

Application Data
Eligibility Results Page (ERP)

Household Member Input

Notes to Testers

Auditor Checklist

Eligible to buy a Marketplace plan with a premium Auditors should review the Eligibility Results Page Check Eligibility Results Tab, Item 5: UI should
tax credit of up to [amount] each month for your tax to ensure it accurately reflects the eligibility results display link to voter registration
household
found in the EDN and complies with ERP messaging
requirements outlined in the documentation listed
in Column A
Eligible for lower copayments, coinsurance, and
deductibles (cost-sharing reductions) on Silver plans
Eligible for a Special Enrollment Period

Test Case 2.E.2 input

Summary: This scenario involves the applicant from 2.E reporting a change in circumstance (CiC). Sarah no longer attests to being denied Medicaid and attests her late spouse is an honorably
discharged veteran. Therefore, Sarah is eligible for Medicaid despite not meeting the five-year bar.
UI Question Companion Guide
Reference
Tab: UI Questions
Item 1
State

Application Data

Application Input
Application State & Coverage Year
State used in 2.E

Item 2
Tab: Phase 2 Screening
Item 1
Item 2
Item 3
Item 5
Items 4, 6, 7 (depending on
implementation)
Item 8

Coverage Year

Current Year

Marital Status
Number of tax dependents
Who is applying for coverage?
Seeking financial assistance?

Single
0
Application filer
Yes

Resides in application state

Yes

Item 9
Item 10

Tax filing status
Responsible for a child 18 or younger not on
tax return

Filing taxes
No one in household is responsible for a child 18 or
younger who they live with but isn't on their tax return

Item 11
Item 17

American Indian/Alaska Native
Offer of individual coverage HRA (ICHRA)or a
qualified small employer Health
Reimbursement Arrangement (QSEHRA)
Offer of coverage through job or COBRA

No one in household has AI/AN status
Does not have an ICHRA or QSEHRA offer

Item 12
Item 13
Item 14
Item 16

Notes to Testers

The tester should update the application
submitted in Test Case 2.E through a change in
circumstance (CiC), which will use the same
application state

Screening Questions

Does not have access to coverage through a job or
COBRA
N/A (should not display)
N/A (should not display)

Claiming all dependents on tax return
Dependent is children or stepchildren, single
(not married), 25 or younger
Dependents live with parent not on tax return N/A (should not display)
Screening Pass/Fail
Pass screener?
Yes, continue with application

Must provide a valid zip code for the application
state

Auditor Checklist

Verify partner is updating the
application submitted in 2.E by
reporting a life change in order to
complete test case 2.E.2

UI Question Companion Guide
Application Data
Reference
Tab: UI Questions
Items 4, 28 Name
Household member
Item 5 Home address
Items 7, 8 Mailing address
Item 10 Preferred language

Household Member Input

Notes to Testers

Auditor Checklist

Household
Sarah Noelfl*
Age: 20
Female

*Do not use Noelfl as the last name. Use a
different last name that is unique (it can be a
random string of letters). Do not change the first
name
Must provide a valid county and zip code for the
application state
Use any date of birth that results in the correct
age for each household member
Other household contact and information fields
(i.e. email, phone, language preference,
race/ethnicity, etc.) may contain any value
unless otherwise noted. Find additional
information in the UI Question Companion
Guide:
- Items 4, 5, 7, 8, 9 Household Contact
Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-applicant
information - Race and Ethnicity

Item 28
Items 27, 29
Item 32
Item 36
Items 38, 39, 44, 46, 48, 56, 71

Application Filer/Relationship to Application
Filer
Applicant/Non-Applicant
SSN
Applying with same name as name on SSN
card?
Citizenship/Immigration

Application Filer
Applicant
717-07-6993
Yes
Not a U.S. citizen/national
Attest to eligible immigration status
Document Type:
I-327 Reentry permit
Alien Number:
660031769

Item 73

Five-Year Bar/Veteran Status Questions

Items 131, 132

Non-MAGI Medicaid Eligibility Questions
(physical disabilities, assistance with daily
living, nursing home care)
Pregnancy Questions

Item 147
Item 268 (depending on
implementation)

Do not enter expiration date
Answer "Yes" to question: "Are any of these people an
honorable discharged veteran or active duty member
of the military?" and select Sarah's deceased spouse
More About This Household
Do not answer affirmatively to any non-MAGI questions

Not pregnant

Check Item 56: Verify that alien
number, expiration date, and
additional document type text fields
are optional to provide
Check Item 71: Verify that document
type is optional

UI Question Companion Guide
Application Data
Reference
Item 149
Foster Care Questions
Item 268 (depending on
implementation)
Item 250
Incarceration Questions
Item 268 (depending on
implementation)
Item 144
Full-Time Student Questions
Item 268 (depending on
implementation)
Items 133, 138, 142

Medicaid/CHIP Denial

Household Member Input

Notes to Testers

Not former foster care

Not incarcerated

Not a full time student

Medicaid Block
Does not have Medicaid/CHIP that recently ended or
will end soon
Not denied Medicaid/CHIP in the last 90 days

Items 153, 154, 155, 209

Current Month Income

Item 174
Item 181

Deductions
Annual Income

Item 191
Item 239

Current coverage
Help paying for medical bills

Items 246, 247, 252, 254, 256,
258

Application Review & Legal Attestations

Reference Materials
UI Q CG Eligibility Results Tab:
Items 1, 4, 5
Sample HealthCare.gov Eligibility
Results Messaging

Eligibility Results Page (ERP)

Not denied Medicaid/CHIP due to immigration status in
the last five years
Income
Job: $750 per month
Employer name (and phone number, where Item
209 is included) fields are required but any value
may be entered (ex: ABC corp; 555-555-5555)
No deductions
$9,000.00
Program Questions
None
Do not answer affirmatively
Attestations
Answers affirmatively to all application attestations

Eligibility Results
Determination states:
"May be eligible for Medicaid"
Assessment states:
"May be eligible for Medicaid"

Auditors should review the application review
page (Item 246) to ensure all information
accurately reflects the attestations inputted
during the test case
Auditors should review the Eligibility Results
Page to ensure it accurately reflects the eligibility
results found in the EDN and complies with ERP
messaging requirements outlined in the
documentation listed in Column A

Auditor Checklist

Test Case 2.F input
Summary: This test scenario allows the EDE Entity to demonstrate their UI can support incarcerated application members as part of Phase 2 requirements. The consumer attests that application members are incarcerated. The consumer indicates
the wife is incarcerated and answers "No" to the follow-up question of if they are incarcerated pending disposition of charges. The consumer indicates that the son is incarcerated pending disposition of charges. The consumer attests to not
having eligible immigration status and is therefore not eligible for a QHP. The wife is not eligible for a QHP due to her incarceration status (not pending disposition of charges). The son is eligible for a QHP because his incarceration is pending
UI Question Companion Guide
Application Data
Reference
Tab: UI Questions
Item 1
State
Item 2
Coverage Year
Tab: Phase 2 Screening
Item 1
Item 2
Item 3
Item 5
Items 4, 6, 7 (depending on
implementation)
Item 8
Item 9
Item 10
Item 11
Item 17

Item 12
Item 13
Item 14
Item 16

Application Input

Any state Except AK and HI
Current year

Auditor Checklist

Screening Questions

Marital Status
Number of tax dependents
Who is applying for coverage?
Seeking financial assistance?

Married
1
Application filer, spouse, dependent
Yes

Resides in application state and
lives at same address
Tax filing status
Responsible for a child 18 or
younger not on tax return
American Indian/Alaska Native
Offer of individual coverage HRA
(ICHRA)or a qualified small
employer Health Reimbursement
Arrangement (QSEHRA)
Offer of coverage through job or
COBRA
Claiming all dependents on tax
return
Dependent is child or stepchild,
single (not married), 25 or younger
Dependents live with parent not on
tax return

Yes, all household members live at same address in application state

Pass Screener?

Yes, continue with application

UI Question Companion Guide
Application Data
Reference
Tab: UI Questions
Items 4, 28 Name
Household member
Item 5 Home address
Items 7, 8 Mailing address
Item 10 Preferred language

Notes to Testers

Application State & Coverage Year

Must provide a valid zip code for the application
state

Filing jointly
No one in household is responsible for a child 18 or younger who they live with but isn't on their tax return
No one in household has AI/AN status
No applicants have an ICHRA or QSEHRA offer

No applicants have access to coverage through a job or COBRA
Yes
Yes
No

Household Member Input

John Smyth*
Age: 38
Male

Screening Pass/Fail

Household Member Input

Rita Smyth*
Age: 38
Female

Household

Household Member Input

Todd Smyth*
Age: 19
Male

Notes to Testers

Auditor Checklist

*Do not use Smyth as the last name. Use a different
last name that is unique (it can be a random string
of letters). Do not change the first name
Must provide a valid county and zip code for the
application state
Use any date of birth that results in the correct age
for each household member
Other household contact and information fields
(i.e. email, phone, language preference,
race/ethnicity, etc.) may contain any value unless
otherwise noted. Find additional information in the
UI Question Companion Guide:
- Items 4, 5, 7, 8, 9 Household Contact Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-applicant
information - Race and Ethnicity

Item 28

Items 27, 29
Item 32
Item 36
Items 38, 40, 44, 45

Application Filer/Relationship to
Application Filer

Application Filer
Spouse of Rita
Parent of Todd
Applicant/Non-Applicant
Applicant
SSN
Does not have SSN, continue without
providing SSN
Applying with same name as name N/A (should not display for this
on SSN card?
household member)
Citizenship/Immigration
Not a U.S. citizen/national;
Proceed without attesting to eligible
immigration status

Spouse of John
Parent of Todd

Child of John
Child of Rita

Applicant
Does not have SSN, continue without
providing SSN
N/A (should not display for this
household member)
Attests to U.S. citizenship, not
naturalized or derived

Applicant
Does not have SSN, continue without
providing SSN
N/A (should not display for this
household member)
Attests to U.S. citizenship, not
naturalized or derived

Check Item 44: Verify partner's implementation is
compliant with answer options and format outlined
in the UI Q CG (see Item 44, Columns G and R). For
privacy reasons, this question cannot be presented as
a "Yes/No" choice to consumers

UI Question Companion Guide
Reference
Items 131, 132

Item 147
Items 268 (depending on
implementation)
Item 149
Item 268 (depending on
implementation)
Items 250, 251
Item 268 (depending on
implementation)
Item 144
Item 268 (depending on
implementation)

Application Data

Household Member Input

Household Member Input

Household Member Input

Non-MAGI Medicaid Eligibility
Questions (physical disabilities,
assistance with daily living, nursing
home care)
Pregnancy Questions
N/A (should not display for this
household member)

Not pregnant

N/A (should not display for this
household member)
Not former foster care

Foster Care Questions

N/A (should not display for this
household member)

N/A (should not display for this
household member)

Incarceration Questions

Not incarcerated

Incarcerated, not pending disposition of Incarcerated, pending disposition of
charges
charges

Full-Time Student Questions

N/A (should not display for this
household member)

N/A (should not display for this
household member)

Items 133, 138

Medicaid/CHIP Denial

Does not have Medicaid/CHIP that
recently ended or will end soon;
Not denied Medicaid/CHIP

Items 153, 154, 155, 209

Current Month Income

Job: $3,333.33 per month

Items 174, 175, 176
Items 181, 182, 183

Deductions
Annual Income

Alimony: $100 per month
No deductions
Disagree with calculated annual
$0
income;
Income is not hard to predict; Attest to
$42,000 per year

No deductions
$0

Item 191

Current coverage

None

Items 213, 218, 224

Recent Life Changes (SEPs)

N/A (should not display for this
household member)
N/A (should not display for this
household member)

Items 246, 252, 254, 255, 256,
258

Application Review & Legal
Attestations

Reference Materials
UI Q CG Eligibility Results Tab:
Items 1, 3, 4, 5

Eligibility Results Page (ERP)

Sample HealthCare.gov Eligibility
Results Messaging

Notes to Testers

Auditor Checklist

More About This Household
Do not answer affirmatively to any non- Do not answer affirmatively to any non- Do not answer affirmatively to any
MAGI questions
MAGI questions
non-MAGI questions

Medicaid Block
Does not have Medicaid/CHIP that
recently ended or will end soon;
Not denied Medicaid/CHIP
Income
No income

Program Questions
N/A (should not display for this
household member)
N/A (should not display for this
household member)
Attestations
Answers affirmatively to all application attestations

Not eligible for health plans, premium
tax credits, lower copayments,
coinsurance, and deductibles (costsharing reductions), or state health
benefits

Eligibility Results
Not eligible for health plans, premium
tax credits, lower copayments,
coinsurance, and deductibles (costsharing reductions), or state health
benefits

Check Item 251: Verify this question displays
conditionally for Rita and Todd after indicating these
applicants are incarcerated

Not a full-time student

Does not have Medicaid/CHIP that
recently ended or will end soon;
Not denied Medicaid/CHIP
No income

Employer name (and phone number, where Item
209 is included) fields are required but any value
may be entered (ex: ABC corp; 555-555-5555)
Check Item 181: Verify all household members are
asked of their current income and deductions
regardless of age. The UI should display expected
annual income for each household member

None of these changes

Auditors should review the application review page
(Item 246) to ensure all information accurately
reflects the attestations inputted during the test
case
Eligible to buy a Marketplace plan
with a premium tax credit of up to
[amount] each month for your tax
household
Eligible for lower copayments,
coinsurance, and deductibles (costsharing reductions) on Silver plans
Not eligible for a Special Enrollment
Period*

Auditors should review the Eligibility Results Page
to ensure it accurately reflects the eligibility results
found in the EDN and complies with ERP messaging
requirements outlined in the documentation listed
in Column A
*Optional to display if consumer is not eligible for
SEP

Test Case 2.G input
Summary: This scenario includes a single parent applying for himself and his two children. It demonstrates functionality and logic related to former foster care applicants. The older child answers affirmatively to having been formerly in
foster care at age 18 or older, indicates the age they left foster care was 18 (VA), 19 (MI, NE, SC), or 21 (AR, DE, FL, MS, NC, ND, OK), and that they were in foster care in the application state. The younger child is applying with a name
different than on their SSN card. The primary applicant and younger child are found eligible for QHP with APTC based on income while the older child is determined preliminarily eligible for Medicaid based on former foster care status.
The primary applicant is also referred to his state Medicaid agency based on age.
UI Question Companion Guide
Application Data
Application Input
Notes to Testers
Reference
Tab: UI Questions
Application State & Coverage Year
Item 1

State

AR, DE, FL, MI, MS, NC, ND, NE, OK, SC, VA

Item 2

Coverage Year

Current Year

Item 1

Marital Status

Single

Item 2

Number of tax dependents

2

Item 3

Who is applying for coverage?

Application filer, both dependents

Item 5
Items 4, 6, 7 (depending on
implementation)

Seeking financial assistance?

Yes

Item 8

Resides in application state and
lives at same address

Yes, all household members live at same address in application state

Item 9

Tax filing status

Filing taxes

Item 10

Responsible for a child 18 or
younger not on tax return

No one in household is responsible for a child 18 or younger who they live with but isn't on their tax return

Item 11

American Indian/Alaska Native

No one in household has AI/AN status

Item 17

Offer of individual coverage HRA
(ICHRA)or a qualified small
employer Health Reimbursement
Arrangement (QSEHRA)
Offer of coverage through job or
COBRA

No applicants have an ICHRA or QSEHRA offer

Tab: Phase 2 Screening Questions

Item 12
Item 13

Auditor Checklist

Screening Questions

Must provide a valid zip code for the
application state
Check Item 9: Verify the current coverage year
displays in question text

No applicants have access to coverage through a job or COBRA

Claiming all dependents on tax
Yes
return
Dependents are children or
Yes
stepchildren, single (not married),
25 or younger
Dependents live with parent not
No
on tax return

Item 14

Item 16

Screening Pass/Fail
Pass screener?
UI Question Companion Guide

Yes, continue with application

Application Data

Household Member Input

Household Member Input

Tab: UI Questions

Household Member Input

Items 4, 28 Name
Item 5 Home address
Items 7, 8 Mailing address
Item 10 Preferred language
Item 28

Household member

Martin Hartman*
Age: 78
Male

Helen Hartman*
Age: 22
Female

Robert Hartman*
Age: 8
Male

Application Filer/Relationship to
Application Filer

Application Filer

Son/Daughter

Son/Daughter

Items 27, 29

Applicant/Non-Applicant

Applicant

Applicant

Applicant

Item 32

SSN

339-18-0391

339-18-1790

339-18-4454

Items 36, 37

Applying with same name as name Yes
on SSN card?

Yes

No, name on SSN card is William
[last name chosen for scenario]

Item 38

Citizenship/immigration

Attests to U.S. citizenship

Attests to U.S. citizenship

Attests to U.S. citizenship

More About This Household
Items 131, 132

Notes to Testers

Auditor Checklist

Household

Non-MAGI Medicaid Eligibility
Do not answer affirmatively to any
non-MAGI questions
Questions (physical disabilities,
assistance with daily living, nursing
home care)

Do not answer affirmatively to any
non-MAGI questions

Do not answer affirmatively to any
non-MAGI questions

*Do not use Hartman as the last name. Use a
different last name that is unique (it can be a
random string of letters). Do not change the
first name

Check Item 28: Help text appears for Martin
because he is over 65 years old that states if he
has Medicare then he can still get a Marketplace
plan but will not be eligible for tax credits or extra

SSN must be entered exactly for test case to
function
Check Item 37: Verify this open text field only
displays for Robert because he answered "No" to
Item 36

UI Question Companion Guide

Application Data

Household Member Input

Household Member Input

Household Member Input

Item 147
Item 268 (depending on
implementation)

Pregnancy Questions

N/A (should not display for this
household member)

Not pregnant

N/A (should not display for this
household member)

Items 149, 150, 151, 152
Item 268 (depending on
implementation)

Foster Care Questions

N/A (should not display for this
household member)

Former foster care;
State of application state;
Attest "Yes" to receiving Medicaid

N/A (should not display for this
household member)

Item 250
Item 268 (depending on
implementation)

Incarceration Questions

Not incarcerated

Not incarcerated

Not incarcerated

Item 144
Item 268 (depending on
implementation)

Full-Time Student Questions

N/A (should not display for this
household member)

Not a full time student

N/A (should not display for this
household member)

Items 133, 138

Medicaid/CHIP Denial

Does not have Medicaid/CHIP that
recently ended or will end soon;
Not denied Medicaid/CHIP

Medicaid Block
Does not have Medicaid/CHIP that
recently ended or will end soon;
Not denied Medicaid/CHIP
Income

Does not have Medicaid/CHIP that
recently ended or will end soon;
Not denied Medicaid/CHIP

Items 153, 154, 155, 209

Current Month Income

Job: $5,458.33 per month

No income

No income

Item 174

Deductions

No deductions

No deductions

No deductions

Item 181

Annual Income

$65,499.96

$0

Notes to Testers

Auditor Checklist

Check Item 151: Verify the question references
the state Medicaid program that is in the state
where the consumer was in foster care

Employer name (and phone number, where
Item 209 is included) fields are required but
any value may be entered (ex: ABC corp; 555555-5555)

$0
Program Questions

Item 191

Current coverage

None

None

None

Item 239

Help paying for medical bills

N/A (should not display for this
household member)

Do not answer affirmatively

N/A (should not display for this
household member)

Items 213, 218, 224, 231, 232, 233, Recent Life Changes (SEPs)
234

Recently moved;
Provide zip code in a different
county than zip code provided in
home address;

N/A (should not display for this
household member)

None of these changes

Items 246, 247, 252, 254, 255, 256, Application Review & Legal
258
Attestations

Answers affirmatively to all application attestations

Check Item 239: Verify "Would any of these
people like help paying for medical bills from the
last 3 months?" only displays for Helen because
she is prelim Medicaid eligible
If a date outside of the last 60 days is entered,
then an error message will appear

Attestations

Reference Materials
UI Q CG Eligibility Results Tab: Items Eligibility Results Page (ERP)
1, 3, 4, 5
Sample HealthCare.gov Eligibility
Results Messaging

Eligible to buy a Marketplace plan
with a premium tax credit of up to
[amount] each month for your tax
household
Not eligible for a Special Enrollment
Period*
May be eligible for Medicaid**

Eligibility Results
Determination states:
"Eligible for Medicaid"
Assessment states:
"May be eligible for Medicaid"

Auditors should review the application
review page (Item 246) to ensure all
information accurately reflects the
attestations inputted during the test case
Eligible to buy a Marketplace plan
with a premium tax credit of up to
[amount] each month for your tax
household

Auditors should review the Eligibility Results
Check Eligibility Results Tab, Item 4: Verify UI
Page to ensure it accurately reflects the
displays exact language "What should I do if I
eligibility results found in the EDN and
think my eligibility results are wrong?"
complies with ERP messaging requirements
outlined in the documentation listed in Column
Not eligible for a Special Enrollment A
Period*
*Optional to display if consumer is not eligible
for SEP
**Optional to display for QHP applicant who is
also being referred to the state Medicaid

Test Case 2.H input

Summary: This scenario demonstrates proper UI and functionality of the screener tool for a married application filer claiming one dependent who is seeking coverage and financial assistance.
The application filer also lives in a state different from the application state which requires redirecting the application filer to an alternate pathway because this scenario is not supported by
Phase 2 applications. Therefore, the application filer should answer “No” to the screener question "does everyone have the same permanent home address and currently live in [application
UI Question Companion
Guide Reference
Tab: UI Questions
Item 1
Item 2
Tab: Phase 2 Screening
Questions
Item 1
Item 2
Item 3
Item 5
Items 4, 6, 7 (depending on
implementation)
Item 8

Application Data

State
Coverage Year

Application Input

Any state
Current Year

Screening Questions
Married
1
Application filer, spouse, dependent
Yes

Resides in application state and lives at
same address

No, application filer lives in separate state from application state

Item 9

Tax filing status

Filing jointly

Item 10

Responsible for a child 18 or younger not
on tax return
American Indian/Alaska Native
Offer of individual coverage HRA (ICHRA)
or a qualified small employer Health
Reimbursement Arrangement (QSEHRA)
Offer of coverage through job or COBRA

No one in household is responsible for a child 18 or younger who they
live with but isn't on their tax return
No one in household has AI/AN status
Does not have an ICHRA or QSEHRA offer

Item 12

Item 13
Item 14
Item 16

Auditor Checklist

Application State & Coverage Year

Marital Status
Number of tax dependents
Who is applying for coverage?
Seeking financial assistance?

Item 11
Item 17

Notes to Testers

No applicants have access to coverage through a job or COBRA

Claiming all dependents on tax return
Yes
Dependent is child or stepchild, single (not Yes
married), 25 or younger
Dependents live with parent not on tax
No
return
Pass Screener?

Screening Pass/Fail
No, consumer should be guided to alternate pathway and should not
complete application

This scenario is not supported by Phase 2
applications. This answer will result in the
consumer being redirected to an alternate
pathway

Check Item 9: Verify that the question is
worded as or similarly to "Do you plan to
file a joint federal income tax return with
your spouse for [insert coverage year]?"

Check Item 12: The question should be
worded as or similarly to "Are either of
you offered health coverage through your
job, someone else's job, or COBRA?"

When a consumer fails the screening
Verify the consumer is guided to an
questions, the UI should redirect the
alternate pathway with consumer friendly
consumer to HealthCare.gov or a Direct
language
Enrollment pathway and display consumer
friendly language as to why they cannot
continue the application on the entity site