CMS-10877 Application User Interface Toolkit

Application UI Toolkit
OMB Control #: 0938-NEW
Expiration Date: XX/XX/20XX
Overview of FFE UI Application Principles
Purpose of FFE UI Application Principles
This document can be used by DE entities to develop their EDE user interfaces (UIs). This document outlines the UI requirements
that must be met in order to successfully integrate the application with the SES application programming interface (API) suite. The
DE Entity User Guide provides a description of tabs and columns in this document relevant to UI development. Any tabs and
columns specific to the audit are included in the Auditor User Guide tab.
Note on Draft
It is important to note that this document is in draft form. All questions and requirements are subject to change.
Navigating Updates to the Companion Guide
In each tab 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 as of 12/5/2022
Purple font: Updated as of 2/8/2023
Red font: Updated as of 3/1/2023
Change Log

User Guide - Tabs
The change log documents all changes made in the current iteration of the
UI Question Companion Guide and any corresponding CMS-initiated Change
Request. This log will be refreshed with each iteration.

Phase 1 Screening Questions

This tab should only be used if planning to implement a Phase 1 application.
This question set must be asked prior to a Phase 1 application and will
screen out any consumer circumstances unsupported by Phase 1
applications.

Phase 2 Screening Questions

This tab should only be used if planning to implement a Phase 2 application.
This question set must be asked prior to a Phase 2 application and will
screen out any consumer circumstances unsupported by Phase 2
applications. This screening question set is shorter than the Phase 1
screening question set.

Screening Question Mapping SES

This tab can be used by Phase 1 and 2 partners to map screening question
answers to SES.

UI Questions

This section includes all of the questions and their individual requirements
that must be included on the application. Questions for all application
phases are included.

Document Type Enums

This tab contains the enumerated response for different
citizenship/immigration document types.
The passport issuing countries tab may be used as a guide for populating
country codes when the passport country code is collected as a follow-up
for certain citizenship/immigration questions.

Passport Issuing Countries

Backend Responses for UI

This tab includes business rules to prompt UI questions in response to
backend interaction with SES services (Update App) and reference data (Get
Reference Data API).

Eligibility Results

Requirements for displaying information on the eligibility results page after
an application is submitted.
Requirements for displaying user-friendly error messaging in the UI.
The requirements tab includes all high-level application requirements.

Error Handling
Requirements

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 56,290 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].

Phase (If applicable)
Tab
Item # (If applicable)
Column (If applicable)
Old
New
CMS-Initiated Change Request?

Question
Question Help

Change Log
Lists the Phase to which the change applies.
Lists the tab where the change was made.
Lists the Item # within the tab to which the change applies.
Lists the Column within the tab to which the change applies.
Displays the old text within the cell.
Displays the new text within the cell.
Details whether the change is associated with a CMS-initiated Change
Request.
Screening Questions
The question as it appears in the FFE.
Question assistance is information related to the question intended to help
the consumer provide an answer. Additional question assistance is more
information related to a specific word in the question.

Learn More Text

Provides additional text to link to the "Question Help" text, when applicable.

Answer Options and Format

The answer options that display with the FFE wording of the question. The
format of the answer pertains to the UI feature such as toggle buttons, radio
buttons, single-selection drop-down menus, etc.

Applies to which members on the application

Screening questions may be asked of all household members or a subset of
household members such as applicants or dependents.
Specific circumstances under which some of the screening questions display
to consumers.
SES data element for integration with the UI.
Some SES data elements will only be set under specific circumstances. This
field elaborates on what SES responses should be sent for specific answers
to screening questions.

Conditional Display Logic
Data Element(s) Name
Conditional SES Response

Question Flow Requirements
Question Wording & Question Help Requirements
Answer Options and Format Requirements

Application Section
Applicable EDE Phase

CMS requirements and flexibilities for the order of the questions displayed
to the consumer.
CMS requirements and flexibilities for wording the question and the
question help.
CMS requirements and flexibilities for answer options and format for each
question.
UI Questions
Section of the application in which the question appears.
The application phase the question must display on.
Phase 1: Simplified application
Phase 2: Expanded simplified application
Phase 3: Complete application

Question
Answers to Previous Questions

The question as it appears in the FFE.
This field is used to show answer fields or questions that are triggered by
answering a question a specific way. In this field, the answer to the
triggering question is bolded.

Informational Text

Informational text may accompany a question or be triggered by answering
a question a specific way.

Answer Options and Format

UI Questions
The answer options that display with the FFE wording of the question. The
format of the answer pertains to the UI feature such as toggle buttons, radio
buttons, single-selection drop-down menus, etc.

Required/Optional to Display Question or
This field indicates if a question is required to display to the consumer in the
Corresponding Answer Fields to Collect Information in UI. If the flexibility requirements allow it, questions and/or answer fields
may be combined.
Application UI
Required/Optional for Consumer to Provide Answer
to Send to SES
Conditional Display Logic in the UI

This field indicates if a question is optional for a consumer to provide an
answer to send to SES.
Conditional circumstances under which the question displays in the UI. N/A
indicates the question is not triggered by a specific consumer circumstance,
and should display on all applications.

Data Element(s) Name
Attestation Level
Data Element Format

SES data element for integration with the UI.
Attestation level can be application, member, or household.
Data element formats include enumerated (enum), boolean, and open text
field.
Policy
Policy and additional information for the user to understand the
requirements for each individual questions.
General Requirements
High-level requirements for each question.
Question Flow Requirements
CMS requirements and flexibilities for the order of the questions displayed
to the consumer.
Question/Informational Text Wording Requirements CMS requirements and flexibilities for wording the question and the
informational text.
Answer Options and Format Requirements
CMS requirements and flexibilities for answer options and format for each
question.
Notes
Notes to assist with application development.

Country Code
Country Description

Item #
Scenario
Legacy UI Question
Legacy Rules to Reveal
Conditional Display Logic based on API Response
Notes
Section of Classic Application
Card in Classic Application
Item # in Input Matrix

Applicable EDE Phase
Eligibility Results Section
Information Included in the Section
Required/Optional to Display to the Consumer
Wording

Passport Issuing Countries
The 3-digit country code that must be sent to the API.
The corresponding country name for each country code.
Backend Responses for UI
Item number for reference on other tabs.
Scenario/purpose of question.
The question as it applies in the legacy UI.
Business rules for revealing the question in the legacy UI.
Business rules to prompt UI questions in response to backend interaction
with APIs.
Notes on rules and purpose of questions.
Section of the classic application that contains the question.
Card in the classic application that contains the question.
Item number for reference in the Input Matrix spreadsheet.
Eligibility Results
Describes the application phase for whom the eligibility result is relevant.
Section of eligibility results.
Overview of information found in the eligibility results section.
Describes whether DE entities are required to display that section of the
eligibility results or if it is optional to display.
Displays the wording of the eligibility results section as it appears on
HealthCare.gov.

Eligibility Results
Requirements
Notes

Details requirements for displaying the eligibility section, and additional
information on required wording.
Notes to assist with providing eligibility results.

Error Handling
Item number for reference.
Scenario/purpose of error message.
Detailed description of the scenario.
Error messaging or questions that should display in the UI
Conditional display logic for displaying error messages in the UI based on API
responses.
Conditional Display Logic Based on Attestations in UI Conditional display logic for displaying error-messaging related content in
the UI based on the consumers selection in the UI.
Requirements
Requirements for displaying the error messaging and wording of the error
message.
Notes
Notes for implementing the error messaging.
Item #
Scenario
Description
Messaging in UI
Conditional Display Logic Based on API Response

High-Level Requirement

Requirement Grouping
Requirement
Question(s) Reference
Question content or display rules vary by state
Applicable EDE Phases

High-Level Requirements
Details the high-level application requirements applicable to the entire
application.
Requirements
Grouping of being collected or displayed in the application.
Details the information that must be collected and displayed in the
application.
Question that directly meets the requirement.
Whether the question content or display rules are dependent on application
state.
The application phase the question must display on.
Phase 1: Simplified application
Phase 2: Expanded simplified application
Phase 3: Complete application

Auditor User Guide
Overview of Application UI Toolkit
Purpose of This Toolkit
This document is used by the Auditors to verify compliance with business operational readiness review (ORR) requirements. The tables below provide the tabs the Auditors must review and the columns that
must be reviewed within each tab. Every column that is colored blue or marked with "**" in the tabs for Auditor review is essential to the Auditor's review. The Auditor must complete the last six columns in each
tab that are highlighted in yellow. Please review this user guide thoroughly. This toolkit should be submitted with the Business Requirements Audit Report Template.
Note: Certain questions in this toolkit should only display when a DE Entity calls an API and receives a particular response from the FFE specific to that consumer. For a few of these questions, there is no
corresponding test case in the Eligibility Results Toolkits or API Functional Integration Toolkit, which means Auditors will not see these questions display while using those toolkits. Auditors should be able to
identify these questions as they are working through the toolkits using the Conditional Display Logic in the UI column of the “UI Questions” tab in Application UI Toolkit. This column will say “See Item #__ on the
‘Backend Responses for UI’ tab” when Auditors can refer to the “Backend Responses for UI” tab for more information. In such cases, Auditors should work with partners to verify the preceding logic that triggers
these questions (i.e., when the questions would appear if the test data had been entered into the application and the appropriate information received from the FFE API), and that they are compliant with the
requirements set forth in the "UI Questions" tab.
Note: If an Auditor is reviewing an EDE Entity’s Spanish-language version of the application UI, the Auditor can document its audit findings for the Spanish-language version of the application UI by adding
columns for the auditor compliance findings fields (yellow-shaded columns) to the Application UI Toolkit required tabs (please refer to the Auditor User Guide information below for detailed instructions on the
required tabs) or by completing a second copy of the Application UI Toolkit. On June 20, 2018, CMS released an FAQ on this topic, available here: https://www.cms.gov/CCIIO/Programs-and-Initiatives/HealthInsurance-Marketplaces/Downloads/FAQ-EDE-Spanish-Translation-and-Audit-Requirements.PDF.
Note on Version
It is important to note that this document is subject to change.
Tab
Change Log

Phase 1 Screening Questions

Phase 2 Screening Questions

Screening Question Mapping SES
UI Questions

Tabs for Auditor Review
Description
How to Review
The change log documents all changes made in the current iteration of The Auditor does not need to review this tab.
the UI Question Companion Guide and any corresponding CMS-initiated
Change Request. This log will be refreshed with each iteration.
DE Entities that are implementing EDE Phase 1 must use the Phase 1
Screening Questions. This question set must be asked prior to a Phase 1
application and will screen out any consumer circumstances
unsupported by Phase 1 applications. These applications must be
redirected to another enrollment pathway.

For a DE Entity that is implementing EDE Phase 1, the Auditor must verify that
each of the screening questions is appropriately implemented based on the
requirements defined in this tab.

DE Entities that are implementing EDE Phase 2 must use the Phase 2
Screening Questions. This question set must be asked prior to a Phase 2
application and will screen out any consumer circumstances
unsupported by Phase 2 applications. These applications must be
redirected to another enrollment pathway. This screening question set
is shorter than the Phase 1 screening question set.

For a DE Entity that is implementing EDE Phase 2, the Auditor must verify that
each of the screening questions is appropriately implemented based on the
requirements defined in this tab.

This tab can be used by Phase 1 and 2 partners to map screening
question answers to SES.
This section includes all of the questions and their individual
requirements that must be included on the application. Questions for
all application phases are included.

The Auditor does not need to review this tab.

Tip: The Auditor may be able to review the compliance of some of the Phasespecific Screening Questions in this tab while completing the Eligibility Results
Toolkit testing scenarios.

Tip: The Auditor may be able to review the compliance of some of the Phasespecific Screening Questions in this tab while completing the Eligibility Results
Toolkit testing scenarios.

The Auditor must audit each question within the DE Entity's EDE application for
compliance with the applicable requirements defined in this tab. The Auditor can
filter the tab to display only the applicable questions for the DE Entity's EDE Phase.
Tip: The Auditor may be able to review the compliance of some of the UI
Questions in this tab while completing the Eligibility Results Toolkit testing
scenarios.

Document Type Enums

This tab contains the enumerated response for different
citizenship/immigration document types.

The Auditor does not need to review this tab.

Passport Issuing Countries

The passport issuing countries tab may be used by DE Entities as a guide
for populating country codes and country names when the passport
country code is collected as a follow-up for certain
citizenship/immigration questions. This tab may be used to confirm the
answer options for the corresponding questions in the UI Questions tab
to which this tab is relevant.

The Passport Issuing Countries tab may be used to review the answer options if
the DE Entity implements an answer option format that displays countries and/or
country codes. If the application displays the countries and/or country codes, the
Auditor must verify all countries and/or country codes are present. If not all
countries and/or country codes are present, an answer option for "other" must be
present that allows a user to input a country not listed. The Auditor must review
this for each corresponding question in the UI Questions tab that has the passport
issuing country as a field. If the application uses an open text field for the passport
issuing country, the Auditor does not need to review this tab.

Backend Responses for UI

This tab includes business rules to prompt UI questions in response to The Auditor does not need to review this tab.
backend interaction with SES services (Update App) and reference data
(Get Reference Data API).

Error Handling

This tab includes requirements for displaying user-friendly error
messaging in the UI.
This tab displays information on the eligibility results page after an
application is submitted to the SES and the DE Entity receives an
eligibility determination.

Eligibility Results

The Auditor does not need to review this tab.
The Auditor must verify that the DE Entity's eligibility results page is compliant
with the requirements in this tab.
Tip: The Auditor may be able to review the Eligibility Results page while
completing the Eligibility Results Toolkit testing scenarios.

High-level Requirements

These requirements are not specific to eligibility questions, but instead The Auditor should understand the high-level requirements while auditing the
reflect broader requirements applicable to parts of the application or
eligibility application. These high-level requirements are based on requirements
the application as a whole.
from the Application UI Principles parent document and are applicable throughout
the application. The Auditor must document the DE Entity's compliance with the
high-level requirements in this tab.

Requirements

This tab lists all high-level application requirements.

The Auditor does not need to review this tab.

Audit Requirements by Tab
The Auditor must review the standards contained in the columns whose column headings are shaded in blue in each tab. In the identified tabs, the Auditor must scroll to the right to complete the last six columns
whose column headings are shaded in yellow.
Tab: Screening Questions (Phase 1 and Phase 2)
Columns
Question**

Description
The question as it appears in the FFE.

Question Help**

Question assistance is information related to the question intended to If a question has Question Help/Assistance text, the Auditor should review the
help the consumer provide an answer. Additional question assistance is Question Help on the DE Entity's application UI for compliance with the standards
more information related to a specific word in the question.
detailed in the "Question Wording & Question Help Requirements" column.

Learn More Text**

Provides additional text to link to the "Question Help" text, when
applicable.

If a question has additional "Learn More" text, the Auditor should review the
"Learn More" text on the DE Entity's application UI for compliance with the
standards detailed in the "Question Wording & Question Help Requirements"
column.

Answer Options and Format**

The answer options that display with the FFE wording of the question.
The format of the answer pertains to the UI feature such as toggle
buttons, radio buttons, single-selection drop-down menus, etc.

The Auditor must verify that the format and content of the Answer Options
provided for each question are compliant with the standards defined in the
"Answer Options and Format Requirements" column.

Applies to which members on the application**

Screening questions may be asked of all household members or a subset The Auditor must verify that the text of the question and answer options covers
of household members such as applicants or dependents. This column the required group as defined in this column.
indicates for which members each question must be asked.

Conditional Display Logic in the UI**

Specific circumstances under which some of the screening questions
display to consumers.

The Auditor will use this field to review that the DE Entity has implemented each
screening question to display when specific circumstances have been met, if
applicable, as defined in this column.

Data Element(s) Name
Conditional SES Response

SES data element for integration with the UI.
Some SES data elements will only be set under specific circumstances.
This field elaborates on what SES responses should be sent for specific
answers to screening questions.

N/A--This is informational for DE Entities.
N/A--This is informational for DE Entities.

Question Flow Requirements**

CMS requirements and flexibilities for the order of the questions
displayed to the consumer.

This column displays the required question flow for each question. This includes
details on where the DE Entity should ask each application question.

Question Wording & Question Help Requirements**

CMS requirements and flexibilities for wording the question and the
question help.

This column details the flexibility and requirements for the question and question
help text for the DE Entity's eligibility application as compared to the FFE eligibility
application question and question help text in the "Question" column and
"Question Help" column.

Answer Options and Format Requirements**

CMS requirements and flexibilities for answer options and format for
each question.

This column details the flexibility and requirements for the answer options and
format requirements for the DE Entity's eligibility application as compared to the
FFE eligibility application answer options and format in the "Answer Options and
Format" column.

Auditor Compliance Conclusion**

The Auditor must provide a conclusion as to whether the scenario or
requirement defined in each row is compliant with the CMS
requirements. A compliance conclusion should be indicated as "Yes" or
"No."

The Auditor will review each row in the spreadsheet for compliance with the
columns highlighted in blue in each tab. If the row is compliant with each
requirement for that row, the Auditor must indicate that compliance with a "Yes"
in this column. If the row is not compliant, the Auditor must indicate the
noncompliance with a "No" in this column.

Risks Identified**

The Auditor must detail any compliance risks identified during the audit As the Auditor reviews each row in the spreadsheet for compliance, the Auditor
in this column for each applicable row. Use this column if the
must indicate any compliance risks identified in this column. This includes any
Compliance Conclusion was “No” or if the entity resolved a risk prior to compliance risks that the DE Entity has since resolved and come into compliance.
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.

Risk Level**

Auditors must assign a risk level to each risk it identifies.
CMS will take the risk level assigned by the Auditor into consideration
when reviewing the audit, but may adjust it if necessary.

How to Review
This column displays the eligibility application questions as displayed in the FFE.
The Auditor must use this column to identify the comparable question on the DE
Entity's eligibility application and the associated requirements for that question.
The Auditor should review the question text for compliance with the standards
detailed in the "Question Wording & Question Help Requirements" column.

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 DE 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**

The Auditor must explain how a risk(s) was mitigated. For example, if
the entity had non-compliant question text, the Auditor must identify
the risk in the "Risks Identified" column and list how the risk was
mitigated or resolved in this column. This field is required for high-risk
findings. The Auditor can work with the DE Entity to decide on whether
or not to include this for low-risk findings.

As the Auditor identifies compliance risks, the Auditor and DE 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 DE Entity has resolved.

Estimated Resolution Date**

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

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

Auditor Comments

The Auditor can use this column to provide any additional notes or
comments pertaining to each item.

The Auditor can add any comments necessary during the review, but is not
required to do so. 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.

Columns
Application Section
Applicable EDE Phase**

Tab: UI Questions
Description
Section of the application in which the question appears.
The application phase the question must display on.
Phase 1: Simplified application
Phase 2: Expanded simplified application
Phase 3: Complete application

How to Review
N/A--This is informational
This tab can be filtered by the Phase that the DE entity is implementing.

Question**

The question as it appears in the FFE.

This column displays the eligibility application questions as displayed in the FFE.
The Auditor must use this column to identify the comparable question on the DE
Entity's eligibility application and the associated requirements for that question.
The Auditor should review the question text for compliance with the standards
detailed in the "Question Wording & Informational Text Requirements" column.

Answers to Previous Questions**

This field is used to show answer fields or questions that are triggered
by answering a question a specific way. In this field, the answer to the
triggering question is bolded.

The Auditor must use this column to confirm that the DE Entity has implemented
each question and answer in compliance with the appropriate display logic. A
requirement in this field will indicate a condition precedent to the question or
answer being displayed in the DE Entity's eligibility application UI.

Informational Text**

Informational text may accompany a question or be triggered by
answering a question a specific way.

If a question has Informational Text, the Auditor should review the Question Help
on the DE Entity's application UI for compliance with the standards detailed in the
"Question Wording & Informational Text Requirements" column.

Answer Options and Format**

The answer options that display with the FFE wording of the question.
The format of the answer pertains to the UI feature such as toggle
buttons, radio buttons, single-selection drop-down menus, etc.

The Auditor must verify that the format and content of the Answer Options
provided for each question are compliant with the standards defined in the
"Answer Options and Format Requirements" column.

Required/Optional to Display Question or
This field indicates if a question is required to display to the consumer
Corresponding Answer Fields to Collect Information in in the UI. If the flexibility requirements allow it, questions and/or
answer fields may be combined.
Application UI**

Required/Optional for Consumer to Provide Answer
to Send to SES**

The Auditor must use this column to confirm that the DE Entity displays all
questions and answers indicated as "required" in this column. Some answer
options within a particular question may be optional where others are required.
The Auditor must carefully review this column against the displayed questions and
answers on the DE Entity's application.

This field indicates if a question is optional for a consumer to provide an The Auditor must use this column to confirm that the DE Entity displays all
answer to send to SES.
answers as required as defined in this column. If an answer option is defined as
required, the DE Entity must include it as a required field in applicable eligibility
applications.
Note: An answer field will never be optional to display ("Required/Optional to
Display Question or Corresponding Answer Fields to Collect Information in
Application UI") and required to provide (this column).

Conditional Display Logic in the UI**

Conditional circumstances under which the question displays in the UI.
N/A indicates the question is not triggered by a specific consumer
circumstance, and should display on all applications.

The Auditor must use this column to confirm that the DE Entity has implemented
each question in compliance with the appropriate conditional display logic. A
requirement in this field will indicate a condition precedent to the question being
displayed in the DE Entity's eligibility application UI.

Data Element(s) Name
Attestation Level
Data Element Format

SES data element for integration with the UI.
Attestation level can be application, member, or household.
Data element formats include enumerated (enum), boolean, and open
text field.
Policy and additional information for the user to understand the
requirements for each individual questions.
High-level requirements for each question.

N/A--This is informational for DE Entities
N/A--This is informational for DE Entities
N/A--This is informational for DE Entities

Question Flow Requirements**

CMS requirements and flexibilities for the order of the questions
displayed to the consumer.

This column displays the required question flow for each question. This includes
details on where the DE Entity should ask each application question. The Auditor
must confirm that each question complies with the flow requirement within the
context of the full application.

Question & Informational Text Wording
Requirements**

CMS requirements and flexibilities for wording the question and the
question help.

This column details the flexibility and requirements for the question and question
help text for the DE Entity's eligibility application as compared to the FFE eligibility
application question and question help text in the "Question" column.

Answer Options and Format Requirements**

CMS requirements and flexibilities for answer options and format for
each question.

This column details the flexibility and requirements for the answer options and
format requirements for the DE Entity's eligibility application as compared to the
FFE eligibility application answer options and format in the "Answer Options and
Format" column.

Notes
Auditor Compliance Conclusion**

Notes to assist with application development.
The Auditor must provide a conclusion as to whether the scenario or
requirement defined in each row is compliant with the CMS
requirements. A compliance conclusion should be indicated as "Yes" or
"No."

The Auditor does not need to review this field.
The Auditor will review each row in the spreadsheet for compliance with the
columns highlighted in blue in each tab. If the row is compliant with each
requirement for that row, the Auditor must indicate that compliance with a "Yes"
in this column. If the row is not compliant, the Auditor must indicate the
noncompliance with a "No" in this column.

Risks Identified**

The Auditor must detail any compliance risks identified during the audit As the Auditor reviews each row in the spreadsheet for compliance, the Auditor
in this column for each applicable row. Use this column if the
must indicate any compliance risks identified in this column. This includes any
Compliance Conclusion was “No” or if the entity resolved a risk prior to compliance risks that the DE Entity has since resolved and come into compliance.
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.

Policy**
General Requirements**

This column contains general policy information and requirements for the Auditor
to verify for each question.
The Auditor will use this column to verify high-level requirements for each
question and answer set, including requirements defined in the Policy column.

Columns

Description

How to Review

Risk Level**

Auditors must assign a risk level to each risk it identifies.

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 DE 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.

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

Risk Mitigation Strategy**

The Auditor must explain how a risk(s) was mitigated. For example, if
the entity had non-compliant question text, the Auditor must identify
the risk in the "Risks Identified" column and list how the risk was
mitigated or resolved in this column. This field is required for high-risk
findings. The Auditor can work with the DE Entity to decide on whether
or not to include this for low-risk findings.

As the Auditor identifies compliance risks, the Auditor and DE 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 DE Entity has resolved.

Estimated Resolution Date**

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

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

Auditor Comments

The Auditor can use this column to provide any additional notes or
comments pertaining to each item.

The Auditor can add any comments necessary during the review, but is not
required to do so. 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.

Columns
Country Code**

Tab: Passport Issuing Countries
Description
This column displays country codes (i.e., three letter abbreviations for
country names).

Country Description**

This column displays country descriptions (i.e., country names)

Columns
High-Level Requirement**

Tab: High-level Requirements
Description
This column displays high-level requirements based on the
requirements in the FFE Application UI Principles document.

How to Review
If the application uses an answer format that displays the country codes, the
Auditor must verify all countries are listed. If all countries are not listed, an answer
option for "other" must be present that allows a user to input a country not listed.
If the application uses an open text field for the passport issuing country, the
Auditor does not need to review this tab.
If the application uses an answer format that displays the country names, the
Auditor must verify all countries are listed. If all countries are not listed, an answer
option for "other" must be present that allows a user to input a country not listed.
If the application uses an open text field for the passport issuing country, the
Auditor does not need to review this tab.

How to Review
The Auditor must review for each of these requirements throughout the DE
Entity's application UI implementation. These are broad requirements that apply
to the entire application UI as opposed to a specific question or set of questions in
the application.

Auditor Compliance Conclusion**

The Auditor must provide a conclusion as to whether the scenario or
requirement defined in each row is compliant with the CMS
requirements. A compliance conclusion should be indicated as "Yes" or
"No."

Risks Identified**

The Auditor must detail any compliance risks identified during the audit As the Auditor reviews each row in the spreadsheet for compliance, the Auditor
in this column for each applicable row. Use this column if the
must indicate any compliance risks identified in this column. This includes any
Compliance Conclusion was “No” or if the entity resolved a risk prior to compliance risks that the DE Entity has since resolved and come into compliance.
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.

Risk Level**

Auditors must assign a risk level to each risk it identifies.
CMS will take the risk level assigned by the Auditor into consideration
when reviewing the audit, but may adjust it if necessary.

The Auditor will review each row in the spreadsheet for compliance with the
columns highlighted in blue in each tab. If the row is compliant with each
requirement for that row, the Auditor must indicate that compliance with a "Yes"
in this column. If the row is not compliant, the Auditor must indicate the
noncompliance with a "No" in this column.

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 DE 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**

The Auditor must explain how a risk(s) was mitigated. For example, if
the entity had non-compliant question text, the Auditor must identify
the risk in the "Risks Identified" column and list how the risk was
mitigated or resolved in this column. This field is required for high-risk
findings. The Auditor can work with the DE Entity to decide on whether
or not to include this for low-risk findings.

As the Auditor identifies compliance risks, the Auditor and DE 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 DE Entity has resolved.

Estimated Resolution Date**

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

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

Auditor Comments

The Auditor can use this column to provide any additional notes or
comments pertaining to each item.

The Auditor can add any comments necessary during the review, but is not
required to do so. 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.

Columns
Item #
Scenario
Legacy UI Question
Legacy Rules to Reveal
Conditional Display Logic based on API Response
Notes
Section of Classic Application
Card in Classic Application
Item # in Input Matrix

Tab: Backend Responses for UI
Description
Item number for reference on other tabs.
Scenario/purpose of question.
The question as it applies in the legacy UI.
Business rules for revealing the question in the legacy UI.
Business rules to prompt UI questions in response to backend
interaction with APIs.
Notes on rules and purpose of questions.
Section of the classic application that contains the question.
Card in the classic application that contains the question.
Item number for reference in the Input Matrix spreadsheet.

How to Review
N/A--This is informational for DE Entities.
N/A--This is informational for DE Entities.
N/A--This is informational for DE Entities.
N/A--This is informational for DE Entities.
N/A--This is informational for DE Entities.
N/A--This is informational for DE Entities.
N/A--This is informational for DE Entities.
N/A--This is informational for DE Entities.
N/A--This is informational for DE Entities.

Eligibility Results Section**

Tab: Eligibility Results
Description
Describes the application phase for whom the eligibility result is
relevant.
Section of eligibility results.

Information Included in the Section**

Overview of information found in the eligibility results section.

Required/Optional to Display to the Consumer**

Describes whether DE entities are required to display that section of the The Auditor must use this column to confirm that the DE Entity displays the
eligibility results or if it is optional to display.
appropriate information and eligibility results sections indicated as "required" in
this column.

Wording**

Displays the wording of the eligibility results section as it appears on
HealthCare.gov.

Requirements**

Details requirements for displaying the eligibility section, and additional The Auditor must use this column to verify that the DE Entity's wording for the
information on required wording.
eligibility results section is compliant with the CMS-defined requirements.

Notes
Auditor Compliance Conclusion**

Notes to assist with providing eligibility results.
The Auditor must provide a conclusion as to whether the scenario or
requirement defined in each row is compliant with the CMS
requirements. A compliance conclusion should be indicated as "Yes" or
"No."

Risks Identified**

The Auditor must detail any compliance risks identified during the audit As the Auditor reviews each row in the spreadsheet for compliance, the Auditor
in this column for each applicable row. Use this column if the
must indicate any compliance risks identified in this column. This includes any
Compliance Conclusion was “No” or if the entity resolved a risk prior to compliance risks that the DE Entity has since resolved and come into compliance.
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.

Risk Level**

Auditors must assign a risk level to each risk it identifies.

Columns
Applicable EDE Phase**

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

How to Review
This tab can be filtered by the Phase that the DE Entity is implementing.
This is informational for the Auditor as the Auditor reviews these requirements.
This is informational for the Auditor as the Auditor reviews these requirements.

The Auditor must review the information in this column to compare the DE
Entity's wording in the application UI with CMS-defined wording consistent with
the "Requirements" column.

N/A--This is informational for DE Entities.
The Auditor will review each row in the spreadsheet for compliance with the
columns highlighted in blue in each tab. If the row is compliant with each
requirement for that row, the Auditor must indicate that compliance with a "Yes"
in this column. If the row is not compliant, the Auditor must indicate the
noncompliance with a "No" in this column.

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 DE 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**

The Auditor must explain how a risk(s) was mitigated. For example, if
the entity had non-compliant question text, the Auditor must identify
the risk in the "Risks Identified" column and list how the risk was
mitigated or resolved in this column. This field is required for high-risk
findings. The Auditor can work with the DE Entity to decide on whether
or not to include this for low-risk findings.

As the Auditor identifies compliance risks, the Auditor and DE 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 DE Entity has resolved.

Estimated Resolution Date**

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

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

Auditor Comments

The Auditor can use this column to provide any additional notes or
comments pertaining to each item.

The Auditor can add any comments necessary during the review, but is not
required to do so.

Tab: Requirements
Description
Grouping of being collected or displayed in the application.

How to Review
N/A--This is informational

Columns
Requirement Grouping
Requirement
Question(s) Reference
Question content or display rules vary by state
Applicable EDE Phases

Detail on the information that must be collected and displayed in the
application.
Question that directly meets the requirement.
Whether the question content or display rules are dependent on
application state.
The application phase the question must display on.
Phase 1: Simplified application
Phase 2: Expanded simplified application
Phase 3: Complete application

N/A--This is informational
N/A--This is informational
N/A--This is informational
N/A--This is informational

Columns
Phase (If applicable)
Tab
Item # (If applicable)
Column (If applicable)
Old
New
CMS-Initiated Change Request?

Tab: Change Log
Description
Lists the Phase to which the change applies.
Lists the tab where the change was made.
Lists the Item # within the tab to which the change applies.
Lists the Column within the tab to which the change applies.
Displays the old text within the cell.
Displays the new text within the cell.
Details whether the change is associated with a CMS-initiated Change
Request.

How to Review
N/A--This is informational
N/A--This is informational
N/A--This is informational
N/A--This is informational
N/A--This is informational
N/A--This is informational
N/A--This is informational

Change Log
CMS-Initiated
Change Request?

Change
Request #

Yes

CR #65

UI Questions
Item # Application Section
* indicates features of this
question may be updated in
future documentation
32

Applicant and non-applicant
information

Applicable EDE Phase**

Question**

Answers to Previous
Questions**

Informational Text**

Answer Options and Format**

Phase 1, Phase 2, Phase 3

What is [FNLNS]'s Social Security
Number (SSN)?

N/A

Help Text: Enter [FNLNS]'s 9-digit SSN. We verify the SSN with Social
Security based on the consent you gave at the start of the application.
Help Drawer: Learn more about entering SSNs
Don’t enter Individual Taxpayer Identification Numbers (ITINS) or any
other numbers here.
Some lawfully present people may not have or be eligible for an SSN.
They can still apply for health coverage without an SSN. For more
information on how to get an SSN, visit socialsecurity.gov [Link to:
https://www.socialsecurity.gov]
If you get an error after you enter an SSN, review the name, date of
birth, and SSN, and make changes as needed. If the information you
entered is correct, you can leave it as is. But, we may ask you to
confirm the information at the end of the application.

[Open text field]: XXX-XX-XXXX
Phases 2 and 3 only:
[checkbox next to statement]: [FNLNS] doesn't have an SSN.
You may only check this box if [FNLNS] attests that they
have never been issued an SSN by the Social Security
Administration.

Required/Optional to Display Question Required/Optional for Consumer to Conditional Display Logic in the UI**
Provide Answer to Send to SES**
or Corresponding Answer Fields to
Collect Information in Application UI** *if optional, consumer must be able
to continue without providing
response in UI
Required- both question and
Required
Display for all applicants
accompanying notice about use of SSN

Data Element(s) Name

Attestation Level

Data Element
Format

Policy**

General Requirements**

ssn

Member

string

Applicants must provide their SSNs if they
have one to use for verifications as well as for
tracking of APTC payments for tax filers who
are eligible. Because SSN is such a sensitive
and private piece of personal information, the
UI must adhere to security protocols for
protection of SSN information (including
masking SSN characters) and must provide
notice to the applicant about how SSN will be
used.

Phases 1: Any request for an SSN must be accompanied by a notice The flow of collecting applicant and nonto the consumer about how the SSN will be used and how a
applicant information is flexible and may be
consumer can get an SSN if he or she does not have one. The UI
done throughout the application.
must clearly tell consumers that the SSN will be used to confirm
information entered on their application, such as income
information. For non-applicants, SSN must be clearly optional but
encouraged.

DE entities must emphasize to agent and broker users the
importance of collecting SSNs from all their applicant clients who
have them by prominently displaying this question as a warning,
alert, or pop-up to encourage applicant SSNs to be entered.

Enter [FNLNS]'s 9-digit SSN. We verify the SSN with Social Security
based on the consent you gave at the start of the application.

Yes

CR #65

No

N/A

Question/Informational Text Wording
Requirements**

Answer Options and Format Requirements**

Wording must be exact.

SSN must be an open text field.
The answer format for the statement related to not
having a SSN must be a checkbox and must be included
on phase 2 and 3 applications. The required text after
"[FNLNS] doesn't have an SSN" is only required for the
agent/broker pathway application, and must be added
to the answer option or otherwise prominently
displayed in close proximity to the answer option (e.g.,
below or beside the answer option to ensure the agent
or broker can clearly see it without further action).

This question must be displayed to agent or
broker users as a warning, alert, or pop-up
after they opt to not provide an SSN for an
applicant client.

Wording must be exact.

Answer format is flexible as long as the agent or broker
has options to enter SSN or indicate their client doesn't
have an SSN.

This question should be displayed to the
consumer after they opt to not provide an
SSN.

Flexible. The wording of the encouragement
Answer format is flexible. Answer options may be
must clearly explain providing an SSN will speed altered for compatibility with question wording.
up the application process, but may not be
necessary to continue.

Phase 2 and 3: Any request for an SSN must be accompanied by a
notice to the consumer about how the SSN will be used and how a
consumer can get an SSN if he or she does not have one. The UI
must clearly tell consumers that the SSN will be used to confirm
information entered on their application, such as income
information. While applicants are required to provide SSNs if they
have them, there are some consumers who are eligible for
coverage who do not have SSNs. Therefore, the UI must have a
pathway that allows consumers to continue with the application and
submission without providing a SSN. For non-applicants, SSN must
be clearly optional but encouraged.

305

Applicant and non-applicant
information

Phase 2, Phase 3

Are you sure? You must provide your
client's SSN, if they have one. CMS
may take enforcement action against
agents or brokers for failing to provide
correct information to the
Marketplace.

Continued in application
without entering an SSN in
Item 32

N/A

[Toggle Buttons]
Enter SSN now (go back to Item 32 and enter SSN)
[FNLNS] doesn't have an SSN, because they have never
been issued an SSN by the Social Security Administration.

Required

Optional

Display for all applicants who continue None. This is not sent to SES.
without providing an SSN, but only
required for the agent/broker
pathway application.

Member

N/A

Agents and brokers must enter SSNs for all
applicant clients who have them. Agents or
brokers who deliberately fail to collect SSNs
from their clients who have them may be
subject to compliance actions for failing to
provide accurate information to the
Marketplace.

35

Applicant and non-applicant
information

Phase 2, Phase 3

Are you sure? It's important to enter
the SSN for everyone on your
application, if they have them…..

Continued in application
without entering an SSN in
Item 34

Help Text: It's important to provide SSNs to determine eligibility for
cost savings. Entering this information helps speed the application
process, ensure your eligibility is correct, and make it less likely you'll
need to provide more information later.

[Toggle Buttons]
Continue without SSN
Back (go back to Item 34 and provide SSN change response
to 'yes')

Optional

Optional

Display for all non-applicants who
continue without providing a SSN.

Member

N/A

DE entities should encourage all applicants and DE entities must encourage non-applicants to provide an SSN;
non-applicants who have SSNs to provide
however, it must be optional for a non-applicant to provide an SSN.
them. When consumers do not provide SSNs,
they often need to provide paper documents
to verify eligibility, which adds burden for the
consumer and costs for the FFE.

None. This is not sent to SES.

Question Flow Requirements**

Notes

Phase 1 Screening Questions
Item # Question**
* indicates features of this question may be updated in future documentation

Question Help**

Learn More Text**

Answer Options and Format**
Bolded Answer = EDE Eligible

Applies to which members on the
application**

Conditional Display Logic in the UI**

Data Element(s) Name

Conditional Data Element Integration

1

Are you single or married?

Question Assistance: If you're separated but not divorced, select "Married." If
you're legally married, select "Married." If you live with your partner, but aren't
legally married, select "Single."

N/A

[Toggle buttons]
Single
Married

Application filer

N/A

maritalStatus
familyRelationships

If married, set maritalStatus to married for the application filer and their
spouse. Later in the application, after collecting the name and DOB of the
spouse, set familyRelationships = spouse.
If single, set maritalStatus to unmarried for the application filer.

2

How many tax dependents, like your children, will you claim on your [coverage
year] tax return? Include all of your dependents on your [coverage year] tax
return, even those not applying for coverage. Don't include yourself [or your
spouse if married].

Question Assistance: If you haven't filed taxes in the past, it's okay to estimate
Learn more about tax returns:
[Drop-down, single-selection]
how many dependents you might have if you plan to file a return next year. If you Your [coverage year] tax return
Display 0-20
don't plan to file taxes next year, don't answer this question — click here to
If you haven't filed taxes in the past, it's okay to estimate how many dependents
continue your application (link redirects to classic application UI). Learn more
you might have if you plan to file a return next year.
about tax returns.
If you don't file taxes and aren't claimed as a dependent on someone else's taxes,
you won't be eligible for a tax credit to help pay for health coverage. You or your
Additional Application Assistance:
family members may still be eligible for Medicaid or the Children's Health
Tax Dependents: Your child, stepchild, foster child, or sibling (if younger) is likely
to be your dependent if he or she lives with you, doesn't provide more than half Insurance Program (CHIP).
of his or her own financial support for the year, and is younger than 19 or a fullLearn more about dependents.
time student younger than 24. Learn more about dependents.
Dependents
[Coverage year] tax return: Which tax return? The tax return for [coverage year] Your child, stepchild, foster child, or sibling (if younger) is likely to be your
dependent if he or she lives with you, doesn't provide more than half of his or her
means the tax return on which you report your income in [coverage year]. Most
own financial support for the year, and is younger than 19 or a full-time student
people file this return during [year after coverage year].
younger than 24.

Application filer

N/A

familyRelationships
taxDependentIndicator
claimsDependentIndicator
taxRelationships
caretakerRelativeIndicator

If seeking financial assistance set the following:
If the application filer is single and claims dependents, set the
claimsDependentIndicator = true for the application filer. If it is identified
that the dependent lives with the tax filer, caretakerRelativeIndicator = true
may be set for the application filer. SES will also identify the
caretakerRelativeIndicator when a dependent lives with their tax filer.
If the application filer is married, files jointly with their spouse, and claims
dependents, set the claimsDependentIndicator = true for the application filer
and their spouse. If it is identified that the dependent lives with the tax filer,
caretakerRelativeIndicator = true may be set for the application filer and
their spouse. SES will also identify the caretakerRelativeIndicator when a
dependent lives with their tax filer.

Question Flow Requirements**
Question Wording & Question Help Requirements**
*All screening questions must occur prior to the application
question
Application filer questions must be asked first in the screening
Question wording must be similar. Question assistance must be
questions. Order of application filer screening questions is flexible; included and wording must be similar.
however, the financial assistance screening questions should be last
in this section. On the application, fields for the name and DOB must
display for non-applicants and applicants. The screening questions
about marital status and the number of dependents claimed on a
tax return may be used to determine how many consumers there
are on the application, and how many times these fields must
display.

Answer Options and Format Requirements**

Application filer questions must be asked first in the screening
Question wording must be similar. Question assistance must be
questions. Order of application filer screening questions is flexible; included and wording must be similar.
however, the financial assistance screening questions should be last
in this section. On the application, fields for the name and DOB must
display for non-applicants and applicants. The screening questions
about marital status and the number of dependents claimed on a
tax return may be used to determine how many consumers there
are on the application, and how many times these fields must
display.

Answer format is flexible. Answer options may be altered
for compatibility with question wording.

Answer format is flexible. Answer options may be altered
for compatibility with question wording. Single and
married must be the only marital status options.

Once names and DOBs are collected for the dependents, set the
taxDependentIndicator = true and taxRelationships = tax dependent for all tax
dependents.
If the application filer is single and does not claim dependents, set
claimsDependentIndicator = false for the application filer.
If the application filer is married, files a joint tax return, and does not claim
dependents, set claimsDependentIndicator = false for the application filer and
their spouse.

You might also claim as a dependent someone else who lives with you if you
provide their support, and they earn little or no income.
For more information on dependents, visit the IRS publication 501 [link:
https://www.irs.gov/publications/p501#en_US_2013_publink1000220868].

3

Of the [total number of household members] people above, who are you
applying for coverage for? Select all that apply.

Question Assistance: If you're applying for someone other than yourself, your
N/A
spouse, or your dependents, click here to continue your application (link redirects
to DE classic or the HealthCare.gov application UI).

[Toggle buttons, multi-selection]
Application filer
• Me
• My Spouse
• My dependent
• Select from the dropdown menu or toggle
buttons:
o Neither of my dependents
o Both of my dependents
o None of my dependents
o # of my dependents
o All [total number of dependents] of my
dependents
*Answers are dependent upon marital status
and number of dependents

N/A

requestingCoverageIndicator

Once the names and DOBs of all applicants have been collected, set the
requestingCoverageIndicator = true, for the application filer's dependents
who are non-applicants, set the requestingCoverageIndicator = false

Application filer questions must be asked first in the screening
Question wording is flexible. Question assistance must be included
questions. Order of application filer screening questions is flexible; and wording must be similar.
however, the financial assistance screening questions should be last
in this section. This question may be used to determine how many
applicants will appear on the application. This can be used to
determine whether or not the question about whether the person
on the application is seeking coverage must display when collecting
name and DOB of the consumer.

Answer format is flexible, as long as it enables consumers
to select up to everyone in the household. Answer
options may be altered for compatibility with question
wording.

4

How much income will your household make this year? (optional)

Question Assistance: Your income on your [coverage year] tax return will be used
to decide how much help you can get paying for coverage. If you don't know how
much you'll make this year, select your best guess. If you get Social Security
income, include it, even if it's not all taxable.

N/A

[Toggle buttons]
• [state income level for advance premium
tax credit eligibility based on number of
household members] or less
• More than [state income level for advance
premium tax credit eligibility based on
number of household members]

Application filer

N/A

N/A

N/A

Application filer questions must be asked first in the screening
Question wording is flexible. Question assistance must be included
questions. Order of application filer screening questions is flexible; and wording must be similar.
however, the financial assistance screening questions should be last
in this section. This question is optional to include in the screening
questions.

Answer format is flexible. Answer options may be altered
for compatibility with question wording. The household
composition from previous screening questions must be
used to determine the income amounts to display to the
consumer as answer options. This tool must use the
federal poverty levels for the number of household
members and the state. The value displayed to the
consumer must be 420% of the FPL amount rounded to
the nearest $1000 for their household size and their
state. The 2022 application must use the 2021 FPLs. The
2023 application must use the 2022 FPLs.

5

Do you want to see if you can get help paying for coverage?

Question Assistance: If you select "Yes," you'll answer questions about your
income and household to see how much financial help you might qualify for.

N/A

[Toggle buttons]
Yes
No

Application filer

This question displays if an answer for "How much income will
your household make this year?" is not selected.

requestingFinancialAssistanceIndicator

This attestation is at the application level, so if yes is selected set the
requestingFinancialAssistanceIndicator = true for the application and if no is
selected set the requestingFinancialAssistanceIndicator = false for the
application.

Application filer questions must be asked first in the screening
questions. Order of application filer screening questions is flexible;
however, the financial assistance screening questions should be last
in this section. This question does not need to be asked again later
in the application and must be used to determine if the consumer
must answer additional screener and application questions related
to financial assistance.

Wording on this question is flexible, but the best practice is to use
Answer format is flexible. Answer options may be altered
generic terminology such as "help paying for coverage" since
for compatibility with question wording.
consumers might not understand the names of the specific programs.
In addition, consumers must choose between all financial assistance
programs or none; they cannot have the option to choose to apply
for APTC but not Medicaid, for example. Question assistance must
be included and wording must be similar.

6

Do you want to see if you can get help paying for coverage?

Hint Text: You'll probably be eligible to get help paying for coverage, based on
your income. If you select "Yes," we'll ask you questions to see if you qualify.

N/A

[Toggle buttons]
Yes
No

Application filer

This question displays if "[state income level for advance
premium tax credit eligibility based on number of household
members] or less" is selected for "How much income will your
household make this year?"

requestingFinancialAssistanceIndicator

This attestation is at the application level, so if yes is selected set the
requestingFinancialAssistanceIndicator = true for the application and if no is
selected set the requestingFinancialAssistanceIndicator = false for the
application.

Application filer questions must be asked first in the screening
questions. Order of application filer screening questions is flexible;
however, the financial assistance screening questions should be last
in this section. This variation of the screening question may be
include if the optional question is included in the UI. This question
does not need to be asked again later in the application and may
be used to determine if the consumer must answer additional
application questions related to financial assistance.

Wording on this question is flexible, but the best practice is to use
Answer format is flexible. Answer options may be altered
generic terminology such as "help paying for coverage" since
for compatibility with question wording.
consumers might not understand the names of the specific programs.
In addition, consumers must choose between all financial assistance
programs or none; they cannot have the option to choose to apply
for APTC but not Medicaid, for example. Question assistance must be
included and wording must be similar.

N/A

[Toggle buttons]
Yes
No

Application filer

This question displays if “More than [state income level for
requestingFinancialAssistanceIndicator
advance premium tax credit eligibility based on number of
household members]” is selected for “How much income will your
household make this year?”

This attestation is at the application level, so if yes is selected set the
requestingFinancialAssistanceIndicator = true for the application and if no is
selected set the requestingFinancialAssistanceIndicator = false for the
application.

Application filer questions must be asked first in the screening
questions. Order of application filer screening questions is flexible;
however, the financial assistance screening questions should be last
in this section. This variation of the screening question may be
include if the optional question is included in the UI. This question
does not need to be asked again later in the application and may
be used to determine if the consumer must answer additional
application questions related to financial assistance.

Wording on this question is flexible, but the best practice is to use
Answer format is flexible. Answer options may be altered
generic terminology such as "help paying for coverage" since
for compatibility with question wording.
consumers might not understand the names of the specific programs.
In addition, consumers must choose between all financial assistance
programs or none; they cannot have the option to choose to apply
for APTC but not Medicaid, for example. Question assistance must be
included and wording must be similar.

N/A

[Toggle buttons]
Yes
No

Household members (everyone)

N/A

https://aspe.hhs.gov/topics/poverty-economicmobility/poverty-guidelines

Question Assistance: If you select "Yes," you'll answer questions about your
income and household to see how much financial help you can get paying for
coverage.

7

Do you want to see if you can save money on your premiums?

Hint Text: More people than ever are eligible to get help paying for health
coverage, even those who weren’t eligible in the past.
You may be eligible to save money on your household's monthly insurance
premiums, based on your income. If you select "Yes," we'll ask you questions to
see if you qualify.

8

Does everyone have the same permanent home address AND currently live in
[application state]?
If single without dependents: Do you currently live in [insert application state?

Question Assistance: If you select "Yes," you'll answer questions about your
income and household to see if you qualify to save money on your household's
thl i
i
Question Assistance: If you don't have a fixed address or you're currently
homeless, select "No." You may still be eligible to get Marketplace health
coverage. You'll need to give an address for a place where someone knows how
to reach you, even if it's not your own home.

homeAddress
noHomeAddressIndicator
resideWithBothParentIndicator
resideTogetherIndicator

If yes, for each household member, set the homeAddress to the home address This question must be asked anytime after the application filer
collected for the application filer. Set noHomeAddressIndicator = false for all screening questions.
household members. Set resideTogetherIndicator = true for family
relationships.

Question wording is flexible. It must be clear to the consumer that
this question applies to all household members. Question assistance
must be included and wording must be similar.

Answer format is flexible. Answer options may be altered
for compatibility with question wording.

This question must be asked anytime after the application filer
screening questions.

Question wording is flexible. It must be clear to the consumer that
this question applies to all household members. Question assistance
must be included and wording must be similar.

Answer format is flexible. Answer options may be altered
for compatibility with question wording.

If seeking financial assistance, set the following:
If the application has two married adult tax filers who claim dependents,
resideWithBothParentIndicator = true may be set for all dependents and
resideTogetherIndicator = true for the spouse and all other relationships.
resideWithBothParentIndicator must be set when a child is added to an
application with no identified parents after screening questions (phase 2 and
phase 3). resideWithBothParentIndicator = true may be set here but is not
required.
If the application has two married adult tax filers without dependents, set
resideTogetherIndicator = true for the spouse.
If the application has a single tax filer who claims dependents, set
resideTogetherIndicator = true for all dependents and relationships.

9

If married: Do you plan to file a joint federal income tax return with your spouse Question Assistance: Select "Yes" if you'll file a tax return in [insert coverage
year], and no one else claims you as a tax dependent. If you select "Yes" and
for [insert coverage year]? You don’t have to file taxes to apply for coverage,
but you’ll need to file next year if you want to get a premium tax credit to help qualify for help paying your costs, you’ll need to file a [insert coverage year]
federal income tax return to compare (“reconcile”) any advance payments of the
pay for coverage now.
premium tax credit (APTC) you took with what you were eligible for based on
your actual income for [insert coverage year]. Learn more about filing taxes.
If single: Do you plan to file a federal income tax return for [insert coverage
year]? You don’t have to file taxes to apply for coverage, but you’ll need to file
next year if you want to get a premium tax credit to help pay for coverage now.

Learn more about filing taxes.
[Toggle buttons]
Applying for coverage and claiming tax dependents on your federal tax return
Yes
Select “Yes” if you’ll file a tax return for 2019 [coverage year], and no one else will No
claim you as a tax dependent on their tax return. You may be able to get help
paying for health coverage through a tax credit. Tell us if you plan to file a tax
return, so we can tell you what you’re eligible for.

Household members (everyone)

Seeking Financial Assistance

taxFilerIndicator
taxReturnFilingStatusType
taxRelationships

If married: If yes, for both the application filer and their spouse, set the
taxFilerIndicator = true set the taxReturnFilingStatusType = married filing
jointly and set taxRelationships to spouse.
If single: If yes, set taxReturnFilingStatusType = single filer for the application
filer and set the taxFilerIndicator = true.

Most people file a federal income tax return each year, even if they have a
limited income. If you’re not sure if you need to file a tax return, visit the IRS
website to learn more [link: https://www.irs.gov/help/ita/do-i-need-to-file-a-taxreturn].
If you don’t file a tax return, you or your family may be eligible for other types of
free or low-cost health benefits.
If you’re married and you plan to file separate federal income tax returns for the
year you want coverage, you won’t be eligible to get premium tax credits or
other savings, unless you meet the specific exceptions described below. You can
still get help paying for health coverage if you qualify for Medicaid or CHIP. You
can enroll in a Marketplace plan together but you won't be eligible for a premium
tax credit or other savings, and you may have to complete a separate application.
If you're married and you plan to file your federal income tax return as head of
household for the year you want coverage, you can select "Single" when asked if
you're single or married. You won't be asked if you plan to file a joint tax return,
and you'll be eligible for a premium tax credit and other savings if you qualify
based on your income and other factors. See IRS rules for filing as head of
household [link:
https://www.irs.gov/publications/p501#en_US_2014_publink1000220780].
If you’re married and a victim of domestic abuse or spousal abandonment, you can
select “Single” when asked if you’re married or single. See these instructions for
more information [link: https://www.healthcare.gov/income-and-householdinformation/household-size/].
Which tax return? The tax return for [current coverage year] means the tax return
on which you report your income in [current coverage year]. Most people file this
return during [upcoming calendar year following coverage year].

10

If married: Are you and your spouse responsible for a child 18 or younger who
lives with you, but isn't on your tax return?
If single: Are you responsible for a child 18 or younger who lives with you, but
isn’t on your tax return?

Question Assistance: Some parents and other adults can get more help paying for
health coverage if they take care of a child under a certain age. You may still be
able to get help paying for health coverage even if you don't take care of
children. Learn more.

Learn more.
Being responsible for a child 18 or younger
Some parents and other adults can get more help paying for health coverage if
they take care of a child under a certain age. You may still be able to get help
paying for health coverage even if you don't take care of children.

[Toggle buttons]
Yes
No

Household members (everyone)

Seeking Financial Assistance

parentCaretakerIndicator

If no, set the parentCaretakerIndicator = false for all applicants age 19 and
older.

This question must be asked anytime after the application filer
screening questions.

Question wording is flexible. It must be clear to the consumer that
this question applies to all household members. Question assistance
must be included and wording must be similar.

Answer format is flexible. Answer options may be altered
for compatibility with question wording.

[Toggle buttons]
Yes
No

Household members (everyone)

Seeking Financial Assistance

fullTimeSatusIndicator

If no, for any household members age 18-22 on the application, set
fullTimeStatusIndicator to false.

This question must be asked anytime after the application filer
screening questions.

Question wording is flexible. It must be clear to the consumer that
this question applies to all household members.

Answer format is flexible. Answer options may be altered
for compatibility with question wording.

[Toggle buttons]
Yes
No

Household members (everyone)

pregnancyIndicator

If no, set the pregnancyIndicator = false for all female applicants.

This question must be asked anytime after the application filer
screening questions.

Question wording is flexible. It must be clear to the consumer that
this question applies to all household members.

Answer format is flexible. Answer options may be altered
for compatibility with question wording.

To be the main person taking care of a child, you must live with the child, pay for
necessary items (like the child's food and clothing), and help the child with daily
activities (like school and transportation).
Only one person can be the main person taking care of a child, except if 2 spouses
or domestic partners take care of a child together. In that case, both adults in
that relationship are considered the "main person."

11

If more than one household member: Is anyone a full-time student aged 18-22?

N/A

N/A

If single without dependents: Are you a full-time student aged 18-22?

12

If more than one household member: Is anyone pregnant?
If single without dependents: Is anyone pregnant?

N/A

N/A

If single without dependents, this question doesn’t need to be
asked. If age is collected for each household member in the preeligibility process, that information may be used to determine
whether or not this question must display. If there are
household members age 18-22, this question must display.
Seeking Financial Assistance
If sex is collected for each household member in the preeligibility process, that information may be used to determine
whether or not this question must display. If there are female
household members this question must display. If age is also
collected in pre-eligibility processes, this question only needs to
display if there are female household members age 9-66.

Auditor Compliance Conclusion**

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor Comments**

Item # Question**
* indicates features of this question may be updated in future documentation
19

If more than one household member: Are any of you an American Indian or
Alaska Native?
If single without dependents: Are you an American Indian or Alaska Native?

Question Help**

Learn More Text**

Answer Options and Format**
Bolded Answer = EDE Eligible

Applies to which members on the
application**

Conditional Display Logic in the UI**

Data Element(s) Name

Conditional Data Element Integration

Question Assistance: American Indian and Alaska Natives who get coverage
through the Marketplace, Medicaid, or the Children's Health Insurance Program
(CHIP) can still get services from the Indian Health Services, tribal health
programs, or urban Indian health programs. The results of your application won't
change that. Learn more.

Learn more.
Health coverage for Native Americans / Alaska Natives
If you are a Native American or an Alaskan native, you may have new benefits
and medical service protections in the Insurance Marketplace.
-Some benefits are available to members of federally recognized tribes or
shareholders of the Alaska Native Claims Settlement Act (ANCSA). See the list of
federally recognized tribes (links to: http://www.ncsl.org/research/state-tribalinstitute/list-of-federal-and-state-recognized-tribes.aspx)
-Others are available to people of indigenous origin or who are eligible for
services of the Indigenous Health Service (also known as indigenous hospital or
Public Health Service (PHS)), a tribal program, or an urban health program for
indigenous people.

[Toggle buttons]
Yes
No

Household members (everyone)

N/A

americanIndianAlaskanNativeIndicator

If no, set
attestationsRequestBody.member.americanIndianAlaskanNativeIndicator =
false for all household members.

Question Flow Requirements**
*All screening questions must occur prior to the application
question
This question must be asked anytime after the application filer
screening questions.

Question Wording & Question Help Requirements**

Answer Options and Format Requirements**

Question wording is flexible. Question assistance must be included
and wording must be similar.

Answer format is flexible. Answer options may be altered
for compatibility with question wording.

[Toggle buttons]
Yes
No

Applicants

N/A

citizenshipIndicator

If yes, set the citizenshipIndicator = true for all applicants.

This question must be asked anytime after the application filer
screening questions.

Question wording is flexible. It must be clear to the consumer that
Answer format is flexible. Answer options may be altered
this question only applies to applicants. Question assistance must be for compatibility with question wording.
included and wording must be similar.

Learn more about entering in SSNs.
[Toggle buttons]
Applying for coverage with or without a Social Security Number (SSN)
Yes
You'll enter each person's SSN. We'll verify the SSNs with Social Security, based No
on the consent you gave at the start of the application. Select "No" if you don't
want to enter or don't have an SSN. You can still apply for health coverage if you
don't enter this information.

Applicants

N/A

N/A

N/A

This question must be asked anytime after the application filer
screening questions.

Question wording is flexible. It must be clear to the consumer that
Answer format is flexible. Answer options may be altered
this question only applies to applicants. Question assistance must be for compatibility with question wording.
included and wording must be similar.

[Toggle buttons]
Yes
No

Applicants

N/A

N/A

N/A

This question must be asked anytime after the application filer
screening questions.

Question wording is flexible. It must be clear to the consumer that
Answer format is flexible. Answer options may be altered
this question only applies to applicants. Question assistance must be for compatibility with question wording.
included and wording must be similar.

Question Assistance: A naturalized citizen is a person who wasn’t born in the U.S. Learn more about naturalized and derived citizens.
[Toggle buttons]
and didn’t acquire U.S. citizenship automatically through his or her relationship to Naturalized and derivative citizens
Yes
a U.S. citizen. Should have a "Certificate of Naturalization." Learn more about
A naturalized citizen:
No
naturalized and derived citizens.
-He is a person who was not born in the USA. and has not acquired U.S. citizenship
automatically through your relationship with a U.S. citizen Naturalization is the
process by which U.S. citizenship is conferred. to a citizen or foreign national after
satisfying the requirements established by law.
-You must have a "Certificate of Naturalization" (Form N-550 or N-570).

Applicants

N/A

naturalizedCitizenIndicator

If no, set naturalizedCitizenIndicator = false for all applicants

This question must be asked anytime after the application filer
screening questions.

Question wording is flexible. It must be clear to the consumer that
Answer format is flexible. Answer options may be altered
this question only applies to applicants. Question assistance must be for compatibility with question wording.
included and wording must be similar.

For your information
Members of the tribes recognized by the federal government and the
shareholders of the ANCSA corporation can enroll in market health insurance at
any time of the year. You can change the plans up to once a month.
Special health coverage protections and benefits for American Indians and Alaska
Natives
The Health Insurance Marketplace benefits American Indians and Alaska Natives
(AI/ANs) by providing opportunities for affordable health coverage through
Marketplace health insurance plans, Medicaid, and the Children’s Health
Insurance Program (CHIP).
Marketplace health insurance plans
While you’re not exempt from paying monthly premiums for an insurance plan you
buy through the Marketplace, like all Americans you may qualify for tax credits
that lower your premiums based on your income.
-If you buy a Marketplace plan and your income is between 100% and 300% of the
federal poverty level, you can enroll in a “zero cost sharing” plan. This means you
won’t have to pay any out-of-pocket costs -- like deductibles, copayments, and
coinsurance -- when you get care.
14

More than two applicants: Are all of you U.S. citizens?
Two applicants: Are both of you U.S. citizens?

Question Assistance: Select "Yes" if everyone applying for coverage is a U.S.
citizen or U.S. national. If you're not a U.S. citizen or U.S. national, you may still
be eligible to get Marketplace health coverage if you have eligible immigration
status. Learn more.

Single applicant: Are you a U.S. citizen?

Learn more.
US citizens
A US citizen is a person who was born in the United States (including US
territories, except American Samoa) or who was born outside the US and that:
-It has become naturalized as a citizen of the USA.
-It has derived citizenship through adoption by parents who are US citizens, if
certain conditions are met.
-He has acquired citizenship at birth because he was born to parents who are US
citizens.
-She is a U.S. citizen by law - a legal term that describes how a person obtains a
right or a liability under an existing law.
Also select "Yes" if you are a US national. A US national is a person who is a U.S.
citizen or who is not a U.S. citizen but owes loyalty to the US With extremely
limited exceptions for which they are entitled to protection, all US nationals. Noncitizens are people born in American Samoa or abroad with a father or mother of
American Samoa under certain conditions.
If you select "No," you may still be eligible for medical coverage if you have an
eligible immigration status. If someone has to check the eligible immigration
status, you will have to give additional information.

15

Multiple applicants: Can you enter Social Security Numbers (SSNs) for each of
you?
Two applicants: Can you enter Social Security Numbers (SSNs) for both of you?

Question Assistance: This information will be used only for eligibility for health
coverage. It won't be used for immigration enforcement purposes. Select "No" if
you don't want to enter or don't have an SSN. You can still apply for health
coverage if you don't enter this info. Learn more about entering in SSNs.

Single applicant: Can you enter your Social Security Number (SSN)?

This information will be used only for eligibility for health coverage. It won't be
used for immigration enforcement purposes. Some lawfully present applicants
may not have or be eligible for an SSN.

16

17

If you or someone on your application doesn't have an SSN, but wants more
i f
ti
h t
t
i it
i l
it
More than two applicants: Are any of you applying under a name different than Question Assistance: If someone has a different name on their Social Security card Learn more about entering in SSNs.
the one on your Social Security card?
than the name they're applying for coverage with, select "Yes." We'll ask you for Applying for coverage with a different name
it later. You can still apply with a name different than the one on your Social
Later, we’ll ask you what the name is on this person’s Social Security card. You
should enter the name exactly as it appears on the Social Security card, even if
Two applicants: Are either of you applying under a name different than the one Security card. Learn more about entering in SSNs.
there’s a mistake on the card. We’ll verify this information with Social Security,
on your Social Security card?
based on the consent you gave at the start of the application.
Single applicant: Are you applying under a name different than the one on your
To change the name and get a new card, visit [link: socialsecurity.gov], or call
Social Security card?
Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

More than two applicants: Were any of you born outside the U.S. and became
naturalized or derived U.S. citizens?
Two applicants: Were either of you born outside the U.S. and became
naturalized or derived U.S. citizens?
Single applicant: Were you born outside the U.S. and became a naturalized or
derived U.S. citizen?

A derivative citizen:
-He is a person who derives U.S. citizenship. through his relationship with a U.S.
citizen by law - a legal term that describes how someone obtains a right or
responsibility under an existing law.
-This state may be transmitted through the naturalization of their parents, the
enactment of certain laws, or the adoption by parents who are US citizens. (if you
are a foreign minor). A person who acquires U.S. citizenship You can have a
"Certificate of Citizenship" (Form N-560 or N-561).

18

More than two applicants: Are any of you currently incarcerated (detained or
jailed)?

N/A

N/A

[Toggle buttons]
Yes
No

Applicants

N/A

incarcerationType

If no, set attestationsRequestBody.member.other.incarcerationType = not
incarcerated for all applicants.

This question must be asked anytime after the application filer
screening questions.

Question wording is flexible. It must be clear to the consumer that
this question only applies to applicants.

Answer format is flexible. Answer options may be altered
for compatibility with question wording.

More than two applicants: Are any of you offered an individual coverage Health Question Assistance: An HRA is type of group health plan that lets an employer
N/A
Reimbursement Arrangement (HRA) or a qualified small employer Health
reimburse a person for qualifying medical expenses, including their monthly health
Reimbursement Arrangement (QSEHRA) through your job, or through the job of plan premium, in some cases. If you're unsure whether you're offered an
another person, like a spouse or parent?
individual coverage HRA or a QSEHRA, you should contact your employer.

[Toggle buttons]
Yes
No

Applicants

N/A

enrolledInIchraIndicator
offeredIchraIndicator

If no, set enrolledInIchraIndicator and offeredIchraIndicator = false.

This question must be asked anytime after the application filer
screening questions.

Question wording is flexible. It must be clear to the consumer that
this question applies to everyone applying for coverage.

Answer format is flexible. Answer options may be altered
for compatibility with question wording.

[Toggle buttons]
Yes
No

Applicants

Seeking Financial Assistance

offeredEmployeeCoverage
stateHealthBenefitIndicator

If no, set offeredEmployeeCoverage = false and stateHealthBenefitIndicator = This question must be asked anytime after the application filer
false for all applicants, if needed by state regulation.
screening questions.

Question wording is flexible. It must be clear to the consumer that
Answer format is flexible. Answer options may be altered
this question only applies to applicants. Question assistance must be for compatibility with question wording.
included and wording must be similar.

[Toggle buttons]
Yes
No

Applicants

Seeking Financial Assistance

fosterCareIndicator

If no, set attestationsRequestBody.member.family.fosterCareindicator = false
for all applicants age 18-25.

This question must be asked anytime after the application filer
screening questions.

Question wording is flexible. It must be clear to the consumer that
this question only applies to applicants.

Answer format is flexible. Answer options may be altered
for compatibility with question wording.

N/A

N/A

This question must be asked anytime after the application filer
screening questions.

Question wording is flexible. It must be clear to the consumer that
this question only applies to dependents.

Answer format is flexible. Answer options may be altered
for compatibility with question wording.

maritalStatus
familyRelationships

Once names and DOBs are collected for the dependents, set
familyRelationships to son/daughter and maritalStatus = unmarried for each
dependent.

This question must be asked anytime after the application filer
screening questions.

Question wording is flexible. It must be clear to the consumer that
this question only applies to dependents. If age is collected for each
dependent in the pre-eligibility process and it is known all
dependents are 25 or younger, that information may be used to
alter the wording to only ask about the relationship of the
dependents to the application filer
Question wording is flexible. It must be clear to the consumer that
this question only applies to dependents. This question could be
combined with the question "Are all of them your children who are
single (not married) and 25 or younger?"

Answer format is flexible. Answer options may be altered
for compatibility with question wording.

Question wording is flexible. It must be clear to the consumer that
this question only applies to dependents.

Answer format is flexible. Answer options may be altered
for compatibility with question wording.

Two applicants: Are either of you currently incarcerated (detained or jailed)?
Single applicant: Are you currently incarcerated (detained or jailed)?

27

Two applicants: Are either of you offered an individual coverage Health
Reimbursement Arrangement (HRA) or a qualified small employer Health
Reimbursement Arrangement (QSEHRA) through your job, or through the job of
another person, like a spouse or parent?

20

Single applicant: Are you offered an individual coverage Health Reimbursement
Arrangement (HRA) or a qualified small employer Health Reimbursement
Arrangement (QSEHRA) through your job, or through the job of another person,
lik
?
More than two applicants: Are any of you offered health coverage through your Question Assistance: If you're eligible (even if it's from another person's job, like a
job, someone else's job, or COBRA? (Select "Yes" even if any of you didn’t enroll, parent or spouse), select "Yes," even if you're not currently enrolled. Select "No" if
or the enrollment period is over.)
you won't be offered coverage in the next 3 months through your job or another
person's job. Learn more.
Two applicants: Are either of you offered health coverage through your job,
someone else's job, or COBRA?
Additional Application Assistance:
(Select "Yes" even if either of you didn’t enroll, or the enrollment period is over.) COBRA: A federal law that may allow you to temporarily keep employer or union
health coverage after the employment ends or after you lose coverage as a
Single applicant: Are you offered health coverage through your job, someone
dependent of the covered employee. This is called "continuation coverage."
else's job, or COBRA? (Select "Yes" even you didn’t enroll, or the enrollment
period is over.)

Learn more.
Applying for coverage while eligible for health coverage through their job,
someone else's job, or COBRA
Select "Yes" if you:
-Have or can get health coverage now or in the next 3 months through your own
job or another person's job
-Are currently enrolled in a COBRA or retiree health plan
-Are currently in a waiting period for health coverage to start
-Could've enrolled in employer coverage this year, even if the enrollment period
for the employer coverage is over
Select "No" if you won't be offered coverage in the next 3 months through your
job or another person's job.

21

More than two applicants: Were any of you in foster care at 18 AND are
currently 25 or younger?

N/A

N/A

If single without dependents, this question only needs to be
asked if the consumer is age 18-25. If age is collected for each
applicant in the pre-eligibility process, that information may be
used to determine whether or not this question must display.
This question only needs to display for applicants age 18-25.

Two applicants: Were either of you in foster care at 18 AND are currently 25 or
younger?
Single applicant: Were you in foster care at 18 AND are currently 25 or
younger?
22

More than one dependent: Will you claim all of them as dependents on your
federal income tax return for [coverage year]?

N/A

N/A

[Toggle buttons]
Yes
No

Dependents

N/A

N/A

[Toggle buttons]
Yes
No

Dependents

Added dependents to household

More than one dependent: Are any of them your stepchildren or grandchildren? N/A

N/A

[Toggle buttons]
Yes
No

Dependents

Added dependents to household

N/A

N/A

This question must be asked anytime after the application filer
screening questions.

N/A

[Toggle buttons]
Yes
No

Dependents

Added dependents to household

resideWithBothParentIndicator

If no and the application filer is single and claims at least one dependent,
resideWithBothParentIndicator = false may be set for all dependents.
resideWithBothParentIndicator must be set when a child is added to an
application with no identified parents (phase 2 and phase 3).
resideWithBothParentIndicator = false may be set here but is not required.

This question must be asked anytime after the application filer
screening questions.

Seeking financial assistance

One dependent: Will you claim your dependent on your federal income tax
return for [coverage year]?
23

More than one dependent: Are all of them your children who are single (not
married) and 25 or younger?

Added dependents to household

One dependent: Is this your child who is single (not married) and 25 or younger?

25

One dependent: Is this your stepchild or grandchild?

26

More than one dependent: Do any of them live with a parent who’s not on your N/A
tax return?
One dependent: Do they live with a parent who's not on your tax return?

Seeking financial assistance

Answer format is flexible. Answer options may be altered
for compatibility with question wording.

Auditor Compliance Conclusion**

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor Comments**

Phase 2 Screening Questions
Item #

Question**
* indicates features of this question may be updated in future
documentation

Question Help**

1

Are you single or married?

Question Assistance: If you're separated but not divorced, select "Married." If N/A
you're legally married, select "Married." If you live with your partner, but
aren't legally married, select "Single."

Learn More Text**

Answer Options and Format**
Bolded Answer = EDE Eligible

Applies to which members on the
application**

Conditional Display Logic in the UI**

Data Element(s) Name

Conditional Data Element Integration

Question Flow Requirements**
*All screening questions must occur prior to the application question

[Toggle buttons]
Single
Married

Household members (everyone)

N/A

maritalStatus
familyRelationships

If married, set maritalStatus to married for the application filer and their
spouse. Later in the application, after collecting the name and DOB of the
spouse, set familyRelationships = spouse.
If single, set maritalStatus to unmarried for the application filer.

Application filer questions must be asked first in the screening questions. Question wording must be similar. Question assistance must be included
Order of application filer screening questions is flexible; however, the
and wording must be similar.
financial assistance screening questions should be last in this section. On
the application, fields for the name and DOB must display for nonapplicants and applicants. The screening questions about marital status
and the number of dependents claimed on a tax return may be used to
determine how many consumers there are on the application, and how
many times these fields must display.

2

How many tax dependents, like your children, will you claim on your
[coverage year] tax return? Include all of your dependents on your
[coverage year] tax return, even those not applying for coverage.
Don't include yourself [or your spouse if married].

Question Assistance: If you haven't filed taxes in the past, it's okay to
Learn more about tax returns:
[Drop-down, single-selection]
estimate how many dependents you might have if you plan to file a return
Your [coverage year] tax return
Display 0-20
next year. If you don't plan to file taxes next year, don't answer this question If you haven't filed taxes in the past, it's okay to estimate how many
— click here to continue your application (link redirects to classic application dependents you might have if you plan to file a return next year.
UI). Learn more about tax returns.
If you don't file taxes and aren't claimed as a dependent on someone else's
Additional Application Assistance:
taxes, you won't be eligible for a tax credit to help pay for health coverage.
Dependents: Your child, stepchild, foster child, or sibling (if younger) is likely You or your family members may still be eligible for Medicaid or the
to be your dependent if he or she lives with you, doesn't provide more than Children's Health Insurance Program (CHIP).
half of his or her own financial support for the year, and is younger than 19 or
a full-time student younger than 24. Learn more about dependents.
Learn more about dependents.
Dependents
Coverage year tax return: Which tax return? The tax return for [coverage
Your child, stepchild, foster child, or sibling (if younger) is likely to be your
year] means the tax return on which you report your income in [coverage
dependent if he or she lives with you, doesn't provide more than half of his or
year]. Most people file this return during [year after coverage year].
her own financial support for the year, and is younger than 19 or a full-time
student younger than 24.

3

Of the [total number of household members] people above, who are
you applying for coverage for? Select all that apply.

Question Assistance: If you're applying for someone other than yourself, your N/A
spouse, or your dependents, click here to continue your application (link
redirects to DE classic or the HealthCare.gov application UI).

[Toggle buttons, multi-selection]
• Me
• My Spouse
• My dependent
• Select from the dropdown menu or
toggle buttons:
o Neither of my dependents
o Both of my dependents
o None of my dependents
o # of my dependents
o All [total number of dependents] of my
dependents
*Answers are dependent upon marital
status and number of dependents

4

How much income will your household make this year? (optional)

Question Assistance: Your income on your [coverage year] tax return will be
used to decide how much help you can get paying for coverage. If you don't
know how much you'll make this year, select your best guess. If you get
Social Security income, include it, even if it's not all taxable.

5

Do you want to see if you can get help paying for coverage?

6

Do you want to see if you can get help paying for coverage?

7

Do you want to see if you can save money on your premiums?

Question Wording & Question Help Requirements**

Answer Options and Format Requirements**

Answer format is flexible. Answer options may be altered for
compatibility with question wording. Single and married must be the
only marital status options.

Application filer

N/A

familyRelationships
taxDependentIndicator
claimsDependentIndicator
taxRelationships
caretakerRelativeIndicator

If seeking financial assistance set the following:
If the application filer is single and claims dependents, set the
claimsDependentIndicator = true for the application filer. If it is identified
that the dependent lives with the tax filer, caretakerRelativeIndicator = true
may be set for the application filer. SES also will identify the
caretakerRelativeIndicator when a dependent lives with their tax filer.
If the application filer is married, files jointly with their spouse, and claims
dependents, set the claimsDependentIndicator = true for the application filer
and their spouse.
Once names and DOBs are collected for the dependents, set the
taxDependentIndicator = true and taxRelationships = tax dependent for all tax
dependents. If it is identified that the dependent lives with the tax filer,
caretakerRelativeIndicator = true may be set for the application filer and
their spouse. SES also will identify the caretakerRelativeIndicator when a
dependent lives with their tax filer.

Application filer questions must be asked first in the screening questions. Question wording is flexible. Question assistance must be included and
Order of application filer screening questions is flexible; however, the
wording must be similar.
financial assistance screening questions should be last in this section. On
the application, fields for the name and DOB must display for nonapplicants and applicants. The screening questions about marital status
and the number of dependents claimed on a tax return may be used to
determine how many consumers there are on the application, and how
many times these fields must display.

Answer format is flexible. Answer options may be altered for
compatibility with question wording.

Application filer

N/A

requestingCoverageIndicator

Once the names and DOBs of all applicants have been collected, set the
requestingCoverageIndicator = true, for the application filer's dependents
who are non-applicants, set the requestingCoverageIndicator = false

Application filer questions must be asked first in the screening questions. Question wording is flexible. Question assistance must be included and
Order of application filer screening questions is flexible; however, the
wording must be similar.
financial assistance screening questions should be last in this section. This
question may be used to determine how many applicants will appear on
the application. This can be used to determine whether or not the
question about whether the person on the application is seeking
coverage must display when collecting name and DOB of the consumer.

Answer format is flexible, as long as it enables consumers to select
up to everyone in the household. Answer options may be altered for
compatibility with question wording.

N/A

[Toggle buttons]
Application filer
• [state income level for advance premium
tax credit eligibility based on number of
household members] or less
• More than [state income level for
advance premium tax credit eligibility
based on number of household members]

N/A

N/A

N/A

Application filer questions must be asked first in the screening questions. Wording on this question is flexible, but the best practice is to use generic
Order of application filer screening questions is flexible; however, the
terminology such as "help paying for coverage" since consumers might not
financial assistance screening questions should be last in this section.
understand the names of the specific programs. In addition, consumers
must choose between all financial assistance programs or none; they
cannot have the option to choose to apply for APTC but not Medicaid, for
example. Question assistance must be included and wording must be
similar.

Answer format is flexible. Answer options may be altered for
compatibility with question wording. The household composition
from previous screening questions must be used to determine the
income amounts to display to the consumer as answer options. This
tool must use the federal poverty levels for the number of household
members and the state. The value displayed to the consumer must
be 420% of the FPL amount rounded to the nearest $1000 for their
household size and their state. The 2022 application must use the
2021 FPLs. The 2023 application must use the 2022 FPLs.

Question Assistance: If you select "Yes," you'll answer questions about your
income and household to see how much financial help you might qualify for.

N/A

[Toggle buttons]
Yes
No

Application filer

This question displays if an answer for "How much requestingFinancialAssistanceIndicator
income will your household make this year?" is not
selected.

This attestation is at the application level, so if yes is selected set the
requestingFinancialAssistanceIndicator = true for the application and if no is
selected set the requestingFinancialAssistanceIndicator = false for the
application

Application filer questions must be asked first in the screening questions. Wording on this question is flexible, but the best practice is to use generic
Order of application filer screening questions is flexible; however, the
terminology such as "help paying for coverage" since consumers might not
financial assistance screening questions should be last in this section. This understand the names of the specific programs. In addition, consumers
question does not need to be asked again later in the application and
must choose between all financial assistance programs or none; they
must be used to determine if the consumer must answer additional
cannot have the option to choose to apply for APTC but not Medicaid, for
screener and application questions related to financial assistance.
example. Question assistance must be included and wording must be
similar.

Answer format is flexible. Answer options may be altered for
compatibility with question wording.

Hint Text: You'll probably be eligible to get help paying for coverage, based
on your income. If you select "Yes," we'll ask you questions to see if you
qualify.

N/A

[Toggle buttons]
Yes
No

Application filer

This question displays if "[state income level for
advance premium tax credit eligibility based on
number of household members] or less" is selected
for "How much income will your household make
this year?"

requestingFinancialAssistanceIndicator

This attestation is at the application level, so if yes is selected set the
requestingFinancialAssistanceIndicator = true for the application and if no is
selected set the requestingFinancialAssistanceIndicator = false for the
application

Application filer questions must be asked first in the screening questions. Wording on this question is flexible, but the best practice is to use generic
Order of application filer screening questions is flexible; however, the
terminology such as "help paying for coverage" since consumers might not
financial assistance screening questions should be last in this section. This understand the names of the specific programs. In addition, consumers
question does not need to be asked again later in the application and
must choose between all financial assistance programs or none; they
may be used to determine if the consumer must answer additional
cannot have the option to choose to apply for APTC but not Medicaid, for
application questions related to financial assistance.
example. Question assistance must be included and wording must be
similar.

Answer format is flexible. Answer options may be altered for
compatibility with question wording.

N/A

[Toggle buttons]
Yes
No

Application filer

This question displays if “More than [state income requestingFinancialAssistanceIndicator
level for advance premium tax credit eligibility
based on number of household members]” is
selected for “How much income will your household
make this year?”

This attestation is at the application level, so if yes is selected set the
requestingFinancialAssistanceIndicator = true for the application and if no is
selected set the requestingFinancialAssistanceIndicator = false for the
application

Application filer questions must be asked first in the screening questions.
Order of application filer screening questions is flexible; however, the
financial assistance screening questions should be last in this section. This
question does not need to be asked again later in the application and
may be used to determine if the consumer must answer additional
application questions related to financial assistance.

Answer format is flexible. Answer options may be altered for
compatibility with question wording.

N/A

[Toggle buttons]
Yes
No

Household members (everyone)

N/A

If yes, for each household member, set the homeAddress to the home address This question must be asked anytime after the application filer screening Question wording is flexible. It must be clear to the consumer that this
collected for the application filer. Set noHomeAddressIndicator = false for all questions.
question applies to all household members. Question assistance must be
household members. Set resideTogetherIndicator = true for family
included and wording must be similar.
relationships.

If the application filer is single and does not claim dependents, set
claimsDependentsIndicator = false for the application filer.
If the application filer is married, files a joint tax return, and does not claim
dependents, set claimsDependentsIndicator = false for the application filer
and their spouse.

You might also claim as a dependent someone else who lives with you if you
provide their support, and they earn little or no income.
For more information on dependents, visit the IRS publication 501 [link:
https://www.irs.gov/publications/p501#en_US_2013_publink1000220868].

https://aspe.hhs.gov/topics/poverty-economic-mobility/povertyguidelines

Question Assistance: If you select "Yes," you'll answer questions about your
income and household to see how much financial help you can get paying for
coverage.
Hint Text: More people than ever are eligible to get help paying for health
coverage, even those who weren’t eligible in the past.
You may be eligible to save money on your household's monthly insurance
premiums, based on your income. If you select "Yes," we'll ask you questions
to see if you qualify.
Question Assistance: If you select "Yes," you'll answer questions about your
income and household to see if you qualify to save money on your
household's monthly insurance premiums.
8

Does everyone have the same permanent home address AND
currently live in [application state]?
If single without dependents: Do you currently live in [insert
application state?

Question Assistance: If you don't have a fixed address or you're currently
homeless, select "No." You may still be eligible to get Marketplace health
coverage. You'll need to give an address for a place where someone knows
how to reach you, even if it's not your own home.

homeAddress
noHomeAddressIndicator
resideWithBothParentIndicator
resideTogetherIndicator

Wording on this question is flexible, but the best practice is to use generic
terminology such as "help paying for coverage" since consumers might not
understand the names of the specific programs. In addition, consumers
must choose between all financial assistance programs or none; they
cannot have the option to choose to apply for APTC but not Medicaid, for
example. Question assistance must be included and wording must be
similar.

Answer format is flexible. Answer options may be altered for
compatibility with question wording.

If seeking financial assistance, set the following:
If the application has two married adult tax filers who claim dependents,
resideWithBothParentIndicator = true may be set for all dependents and
resideTogetherIndicator = true for the spouse and all other relationships.
resideWithBothParentIndicator must be set when a child is added to an
application with no identified parents after screening questions (phase 2 and
phase 3). resideWithBothParentIndicator = true may be set here but is not
required.
If the application has two married adult tax filers without dependents, set
resideTogetherIndicator = true for the spouse.
If the application has a single tax filer who claims dependents, set
resideTogetherIndicator = true for all dependents and relationships.

9

If married: Do you plan to file a joint federal income tax return with
Question Assistance: Select "Yes" if you'll file a tax return in [insert coverage
your spouse for [insert coverage year]? You don’t have to file taxes to year], and no one else claims you as a tax dependent. If you select "Yes" and
apply for coverage, but you’ll need to file next year if you want to get qualify for help paying your costs, you’ll need to file a [insert coverage year]
federal income tax return to compare (“reconcile”) any advance payments of
a premium tax credit to help pay for coverage now.
the premium tax credit (APTC) you took with what you were eligible for
based on your actual income for [insert coverage year]. Learn more about
If single: Do you plan to file a federal income tax return for [insert
coverage year]? You don’t have to file taxes to apply for coverage, but filing taxes.
you’ll need to file next year if you want to get a premium tax credit to
help pay for coverage now.

Learn more about filing taxes.
[Toggle buttons]
Applying for coverage and claiming tax dependents on your federal tax
Yes
return
No
Select “Yes” if you’ll file a tax return for 2019 [coverage year], and no one
else will claim you as a tax dependent on their tax return. You may be able to
get help paying for health coverage through a tax credit. Tell us if you plan to
file a tax return, so we can tell you what you’re eligible for.

Household members (everyone)

Seeking Financial Assistance

taxFilerIndicator
taxReturnFilingStatusType
taxRelationships

If married: If yes, for both the application filer and their spouse, set the
taxFilerIndicator = true set the taxReturnFilingStatusType = married filing
jointly and set taxRelationships to spouse.

This question must be asked anytime after the application filer screening Question wording is flexible. It must be clear to the consumer that this
questions.
question applies to all household members. Question assistance must be
included and wording must be similar.

Answer format is flexible. Answer options may be altered for
compatibility with question wording.

If single: If yes, set taxReturnFilingStatusType = single filer for the application
filer and set the taxFilerIndicator = true.

Most people file a federal income tax return each year, even if they have a
limited income. If you’re not sure if you need to file a tax return, visit the IRS
website to learn more [link: https://www.irs.gov/help/ita/do-i-need-to-file-atax-return].
If you don’t file a tax return, you or your family may be eligible for other
types of free or low-cost health benefits.
If you’re married and you plan to file separate federal income tax returns for
the year you want coverage, you won’t be eligible to get premium tax
credits or other savings, unless you meet the specific exceptions described
below. You can still get help paying for health coverage if you qualify for
Medicaid or CHIP. You can enroll in a Marketplace plan together but you
won't be eligible for a premium tax credit or other savings, and you may
have to complete a separate application.
If you're married and you plan to file your federal income tax return as head
of household for the year you want coverage, you can select "Single" when
asked if you're single or married. You won't be asked if you plan to file a joint
tax return, and you'll be eligible for a premium tax credit and other savings if
you qualify based on your income and other factors. See IRS rules for filing as
head of household [link:
https://www.irs.gov/publications/p501#en_US_2014_publink1000220780].
If you’re married and a victim of domestic abuse or spousal abandonment,
you can select “Single” when asked if you’re married or single. See these
instructions for more information [link: https://www.healthcare.gov/incomeand-household-information/household-size/].
Which tax return? The tax return for [current coverage year] means the tax
return on which you report your income in [current coverage year]. Most
people file this return during [upcoming calendar year following coverage
year].

10

If married: Are you and your spouse responsible for a child 18 or
younger who lives with you, but isn't on your tax return?
If single: Are you responsible for a child 18 or younger who lives with
you, but isn’t on your tax return?

Question Assistance: Some parents and other adults can get more help
Learn more.
[Toggle buttons]
paying for health coverage if they take care of a child under a certain age.
Being responsible for a child 18 or younger
Yes
You may still be able to get help paying for health coverage even if you don't Some parents and other adults can get more help paying for health coverage No
take care of children. Learn more.
if they take care of a child under a certain age. You may still be able to get
help paying for health coverage even if you don't take care of children.

Household members (everyone)

Seeking Financial Assistance

parentCaretakerIndicator

If no, set the parentCaretakerIndicator = false for all applicants age 19 and
older.

This question must be asked anytime after the application filer screening Question wording is flexible. It must be clear to the consumer that this
questions.
question applies to all household members. Question assistance must be
included and wording must be similar.

Answer format is flexible. Answer options may be altered for
compatibility with question wording.

Household members (everyone)

N/A

americanIndianAlaskanNativeIndicator

If no, set
attestationsRequestBody.member.americanIndianAlaskanNativeIndicator =
false for all household members.

This question must be asked anytime after the application filer screening Question wording is flexible. Question assistance must be included and
questions.
wording must be similar.

Answer format is flexible. Answer options may be altered for
compatibility with question wording.

Applicants

N/A

enrolledInIchraIndicator
offeredIchraIndicator

If no, set enrolledInIchraIndicator and offeredIchraIndicator = false.

This question must be asked anytime after the application filer screening Question wording is flexible. It must be clear to the consumer that this
questions.
question applies to everyone applying for coverage.

Answer format is flexible. Answer options may be altered for
compatibility with question wording.

[Toggle buttons]
Yes
No

Applicants

Seeking Financial Assistance

offeredEmployeeCoverage
stateHealthBenefitIndicator

If no, set offeredEmployeeCoverage = false and stateHealthBenefitIndicator = This question must be asked anytime after the application filer screening Question wording is flexible. It must be clear to the consumer that this
false for all applicants, if needed by state regulation.
questions.
question only applies to applicants. Question assistance must be included
and wording must be similar.

Answer format is flexible. Answer options may be altered for
compatibility with question wording.

[Toggle buttons]
Yes
No

Dependents

Added dependents to household

N/A

N/A

Answer format is flexible. Answer options may be altered for
compatibility with question wording.

To be the main person taking care of a child, you must live with the child, pay
for necessary items (like the child's food and clothing), and help the child with
daily activities (like school and transportation).
Only one person can be the main person taking care of a child, except if 2
spouses or domestic partners take care of a child together. In that case, both
adults in that relationship are considered the "main person."

11

If more than one household member: Are any of you an American
Indian or Alaska Native?
If single without dependents: Are you an American Indian or Alaska
Native?

Question Assistance: American Indian and Alaska Natives who get coverage
through the Marketplace, Medicaid, or the Children's Health Insurance
Program (CHIP) can still get services from the Indian Health Services, tribal
health programs, or urban Indian health programs. The results of your
application won't change that. Learn more.

Learn more.
[Toggle buttons]
Health coverage for Native Americans / Alaska Natives
Yes
If you are a Native American or an Alaskan native, you may have new
No
benefits and medical service protections in the Insurance Marketplace.
-Some benefits are available to members of federally recognized tribes or
shareholders of the Alaska Native Claims Settlement Act (ANCSA). See the
list of federally recognized tribes (links to:
http://www.ncsl.org/research/state-tribal-institute/list-of-federal-and-staterecognized-tribes.aspx)
-Others are available to people of indigenous origin or who are eligible for
services of the Indigenous Health Service (also known as indigenous hospital
or Public Health Service (PHS)), a tribal program, or an urban health program
for indigenous people.
For your information
Members of the tribes recognized by the federal government and the
shareholders of the ANCSA corporation can enroll in market health insurance
at any time of the year. You can change the plans up to once a month.
Special health coverage protections and benefits for American Indians and
Alaska Natives
The Health Insurance Marketplace benefits American Indians and Alaska
Natives (AI/ANs) by providing opportunities for affordable health coverage
through Marketplace health insurance plans, Medicaid, and the Children’s
Health Insurance Program (CHIP).

17

More than two applicants: Are any of you offered an individual
coverage Health Reimbursement Arrangement (HRA) or a qualified
small employer Health Reimbursement Arrangement (QSEHRA)
through your job, or through the job of another person, like a spouse
or parent?

Marketplace health insurance plans
While you’re not exempt from paying monthly premiums for an insurance
plan you buy through the Marketplace, like all Americans you may qualify for
tax credits that lower your premiums based on your income.
-If you buy a Marketplace plan and your income is between 100% and 300%
of the federal poverty level, you can enroll in a “zero cost sharing” plan. This
means you won’t have to pay any out-of-pocket costs -- like deductibles,
copayments, and coinsurance -- when you get care.
If you get services from an Indian Health Care Provider you won’t have any
Question Assistance: An HRA is type of group health plan that lets an
N/A
[Toggle buttons]
employer reimburse a person for qualifying medical expenses, including their
Yes
monthly health plan premium, in some cases. If you're unsure whether you're
No
offered an individual coverage HRA or a QSEHRA, you should contact your
employer.

Two applicants: Are either of you offered an individual coverage
Health Reimbursement Arrangement (HRA) or a qualified small
employer Health Reimbursement Arrangement (QSEHRA) through
your job, or through the job of another person, like a spouse or
parent?
Single applicant: Are you offered an individual coverage Health
Reimbursement Arrangement (HRA) or a qualified small employer
Health Reimbursement Arrangement (QSEHRA) through your job, or
through the job of another person, like a spouse or parent?
12

More than two applicants: Are any of you offered health coverage
through your job, someone else's job, or COBRA? (Select "Yes" even if
any of you didn’t enroll, or the enrollment period is over.)
Two applicants: Are either of you offered health coverage through
your job, someone else's job, or COBRA?
(Select "Yes" even if either of you didn’t enroll, or the enrollment
period is over.)
Single applicant: Are you offered health coverage through your job,
someone else's job, or COBRA? (Select "Yes" even you didn’t enroll, or
the enrollment period is over.)

13

More than one dependent: Will you claim all of them as dependents
on your federal income tax return for [coverage year]?
One dependent: Will you claim your dependent on your federal income
tax return for [coverage year]?

Question Assistance: If you're eligible (even if it's from another person's job,
like a parent or spouse), select "Yes," even if you're not currently enrolled.
Select "No" if you won't be offered coverage in the next 3 months through
your job or another person's job. Learn more.

Learn more.
Applying for coverage while eligible for health coverage through their job,
someone else's job, or COBRA
Select "Yes" if you:

Additional Application Assistance:
-Have or can get health coverage now or in the next 3 months through your
COBRA: A federal law that may allow you to temporarily keep employer or
own job or another person's job
union health coverage after the employment ends or after you lose coverage -Are currently enrolled in a COBRA or retiree health plan
as a dependent of the covered employee. This is called "continuation
-Are currently in a waiting period for health coverage to start
coverage."
-Could've enrolled in employer coverage this year, even if the enrollment
period for the employer coverage is over
Select "No" if you won't be offered coverage in the next 3 months through
your job or another person's job.
N/A

N/A

Seeking financial assistance

This question must be asked anytime after the application filer screening Question wording is flexible. It must be clear to the consumer that this
questions.
question only applies to dependents.

Auditor Compliance Conclusion**

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor Comments**

Item #

14

Question**
* indicates features of this question may be updated in future
documentation

Question Help**

Learn More Text**

Answer Options and Format**
Bolded Answer = EDE Eligible

Applies to which members on the
application**

Conditional Display Logic in the UI**

Data Element(s) Name

Conditional Data Element Integration

Question Flow Requirements**
*All screening questions must occur prior to the application question

More than one dependent: Are all of your dependents:
-Your children or stepchildren
-Single (not married)
-25 or younger?

N/A

N/A

[Toggle buttons]
Yes
No

Dependents

Added dependents to household

maritalStatus

Once names and DOBs are collected for the dependents, set maritalStatus =
unmarried for each dependent.

This question must be asked anytime after the application filer screening Question wording is flexible. It must be clear to the consumer that this
Answer format is flexible. Answer options may be altered for
questions.
question only applies to dependents. If age is collected for each dependent compatibility with question wording.
in the pre-eligibility process and it is known all dependents are 25 or
younger, that information may be used to alter the wording to only ask
about the relationship of the dependents to the application filer.

N/A

N/A

[Toggle buttons]
Yes
No

Dependents

Added dependents to household

resideWithBothParentIndicator

If no and the application filer is single and claims at least one dependent, set
resideWithBothParentIndicator = false may be set for all dependents.
resideWithBothParentIndicator must be set when a child is added to an
application with no identified parents (phase 2 and phase 3).
resideWithBothParentIndicator = false may be set here but is not required.

This question must be asked anytime after the application filer screening Question wording is flexible. It must be clear to the consumer that this
questions.
question only applies to dependents.

One dependent: Is your dependent:
-Your child or stepchild
-Single (not married)
-25 or younger?
16

More than one dependent: Do any of them live with a parent who’s
not on your tax return?
One dependent: Do they live with a parent who's not on your tax
return?

Seeking financial assistance

Question Wording & Question Help Requirements**

Answer Options and Format Requirements**

Answer format is flexible. Answer options may be altered for
compatibility with question wording.

Auditor Compliance Conclusion**

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor Comments**

Screening Question Mapping SES

Item #

Screener Question

Create an account
1
Application State
2
First Name
3
Last Name
4
Email address
Verify your identity and contact information
5
First Name
6
Middle Name
7
Last Name
8
Suffix
9
Phone number

10
Street Address
11
Apartment #
12
City
13
State
14
Zip Code
15
Social Security Number
Before you get started
16
Are you single or married?

17

Financial Assistance Screening Questions
User Input to screen into Phase
SES Indicators
1/Phase 2 application
initialrequestBody.application.attestations.coverageState
initialrequestBody.application.attestations.firstName
initialrequestBody.application.attestations.lastName
initialrequestBody.application.attestations.email
initialrequestBody.application.attestations.firstName
initialrequestBody.application.attestations.middleName
initialrequestBody.application.attestations.lastName
initialrequestBody.application.attestations.suffix
initialrequestBody.application.attestations.primaryPhoneNumber.(type, number, ext)
initialrequestBody.application.attestations.secondaryPhoneNumber.(type, number, ext)
initialrequestBody.application.attestations.mobileNotificationPhoneNumber
member.demographic.homeAddress.streetName1
member.demographic.homeAddress.streetName2
member.demographic.homeAddress.cityName
member.demographic.homeAddress.state
member.demographic.homeAddress.zipCode
attestationsRequestBody.member.demographic.ssn
N/A

How many dependents, like your
N/A
children, will you claim on your [current
year] tax return?

18

Of the [x] people below, who are you
N/A
applying for coverage for?
19
Do you want to answer additional
N/A
questions to see if you qualify for help
paying for coverage?
Answer some questions about you, your spouse, and dependent(s).
Does everyone have the same
Yes
20
permanent home address AND currently
live in [application state]?

if married, set attestationsRequestBody.member.demographic.maritalStatus = "MARRIED" and upon collecting
the Name/DOB of the spouse, set
"familiyRelationships": [
"1234",
"SPOUSE",
"5678"
{
"resideTogetherIndicator": true
}
]
if single set maritalStatus = "UNMARRIED" for the hosuehold contact
If the household contact claims any dependents, set claimsDependentIndicator = TRUE for the household contact,
and if the household contact is married and files jointly with their spouse, set the claimsDependentIndicator =
TRUE for their spouse.
Once we've collected their names and DOBs, set the taxDependentIndicator = TRUE, and the
resideWithBothParentIndicator = TRUE only if the application filer is married (and therefore filing jointly with
their spouse due to the screener question below.
"familiyRelationships": [
"1234",
"PARENT",
"5678"
{
"resideTogetherIndicator": true
"caretakerRelativeIndicator": true
}
]
"taxRelationships": [
"1234"
"TAX_DEPENDENT"
"5678"
]
If the household contact does not claim dependents set claimsDependentsIndicator = FALSE
Once we've collected the names and DOBs of all applicants, set the requestingCoverageIndicator=TRUE, for the
filer's dependents who are non-applicants, set the requestingCoverageIndicator=FALSE
This attestation is at the application level, so if yes is selected set the
requestingFinancialAssistanceIndicator=TRUE for the application and if no is selected set the
requestingFinancialAssistanceIndicator=FALSE
If yes, for each applicant, set homeAddress equal to the home address collected for the application filer and set
noHomeAddressIndicator=FALSE for all applicants
If the application filer is married and has tax dependent(s), = TRUE may be set for each dependent
When establishing the family relationships, set the ResidesTogetherIndicator= TRUE

21

If single: Do you plan to file a federal
income tax return for [coverage year]?

Yes

If yes and if single, set taxReturnFilingStatusType = SINGLE_FILER for the filer and set the taxFilerIndicator= TRUE.
If married, see below.

Item #
22

Screener Question
If married: Do you plan to file a joint
federal income tax return with your
spouse for [coverage year]?

User Input to screen into Phase
SES Indicators
1/Phase 2 application
Yes
If yes and if married, for both the filer and their spouse, set the taxFilerIndicator = TRUE, set the
taxReturnFilingStatusType: MARRIED_FILING_JOINTLY and set:
"taxRelationships": [
"1234",
"TAX_FILER",
"1234"
],
[
"4567",
"TAX_FILER",
"4567"
]

23

Are you and your spouse responsible for No
a child 18 or younger who lives with
you, but isn't on your tax return?

If no, set the parentCaretakerIndicator = false for all applicants age 19 and older. If yes screen to healthcare.gov

Is anyone a full-time student aged 18No
If no, set the fullTimeStatusIndicator= FALSE for all applicant with applicantAge < stateStudentAge
22?
Is anyone pregnant?
No
If no, set the pregnancyIndicator=FALSE for all female applicants
25
Answer some questions about the people applying for coverage: you, your spouse, and dependent(s).
Are all of you US citizens?
Yes
If yes, set the citizenshipIndicator=yes for all applicants
26
Can you enter SSNs for each of you?
Yes
N/A, if no screen to healthcare.gov
27
Are any of you applying under a
No
N/A, if yes screen to healthcare.gov
28
different name than the one on your
Social Security Card?
Were any of you born outside of the US No
If no, set naturalizedCitizenIndicator = FALSE for all household members
29
and became naturalized or derived US
citizens?
Are any of you currently incarcerated
No
If no, set attestationsRequestBody.member.other.incarcerationType= NOT_INCARCERATED
30
(detained or jailed)?
Are any of you American Indian or
No
If no, set attestationsRequestBody.member.americanIndianAlaskanNativeIndicator= false
31
Alaska Native?
Are any of you offered health coverage No
If no, set offeredEmployeeCoverage = no and stateHealthBenefitIndicator=FALSE
32
through your job, someone else's job, or
COBRA? (select Yes even if you didn't
enroll, or the enrollment period is over.)
24

Were any of you in foster care at 18
No
AND currently 25 or younger?
Answer some questions about your dependent(s).
Will you claim your dependent on your Yes
34
federal income tax return for 2017?

If no, set attestationsRequestBody.member.family.fosterCareindicator=NO

33

35
36
37

See above for establishing relationships between the tax filer and tax dependents.

Is this your child who is single (not
Yes
married) and 25 or younger?
Is this your stepchild or grandchild?
No
Do they live with a parent who's not on No
your tax return?

Item #
Screener Question
Create an account
Application State
39
First Name
40
Last Name
41
Email address
42
Verify your identity and contact information
First Name
43
Middle Name
44
Last Name
45
Suffix
46
Phone number
47

Street Address
48
Apartment #
49
City
50
State
51
Zip Code
52
Social Security Number
53
Before you get started

set maritialStatus = "UNMARRIED" for all dependents
See above for establishing relationships between the tax filer and tax dependents.
If the application filer is not married but does claim one or more dependents, residesWithBothParentIndicator =
FALSE may be set for all dependent children
Non-Financial Assistance Screening Questions
SES Indicators

User Input to screen into Phase 1/
Phase 2 application

initialrequestBody.application.attestations.coverageState
initialrequestBody.application.attestations.firstName
initialrequestBody.application.attestations.lastName
initialrequestBody.application.attestations.email
initialrequestBody.application.attestations.firstName
initialrequestBody.application.attestations.middleName
initialrequestBody.application.attestations.lastName
initialrequestBody.application.attestations.suffix
initialrequestBody.application.attestations.primaryPhoneNumber.(type, number, ext)
initialrequestBody.application.attestations.secondaryPhoneNumber.(type, number, ext)
initialrequestBody.application.attestations.mobileNotificationPhoneNumber
member.demographic.homeAddress.streetName1
member.demographic.homeAddress.streetName2
member.demographic.homeAddress.cityName
member.demographic.homeAddress.state
member.demographic.homeAddress.zipCode
attestationsRequestBody.member.demographic.ssn

Screener Question

User Input to screen into Phase 1/
Phase 2 application

SES Indicators

54

Are you single or married?

N/A

if married, set attestationsRequestBody.member.demographic.maritalStatus = "MARRIED" and upon collecting
the Name/DOB of the spouse, set
"familiyRelationships": [
"1234",
"SPOUSE",
"5678"
{
"resideTogetherIndicator": true
}
]
if single set maritalStatus = "UNMARRIED" for the hosuehold contact

55

How many dependents, like your
N/A
children, will you claim on your [current
year] tax return?

Item #

If the household contact claims any dependents,
"familiyRelationships": [
"1234",
"PARENT",
"5678"
{
"resideTogetherIndicator": true }
]
"taxRelationships": [
"1234"
"TAX_DEPENDENT"
"5678"
]

Of the [x] people below, who are you
N/A
Once we've collected the names and DOBs of all applicants, set the requestingCoverageIndicator=TRUE
applying for coverage for?
Do you want to answer additional
N/A
This attestation is at the application level, so if yes is selected set the
57
questions to see if you qualify for help
requestingFinancialAssistanceIndicator=TRUE for the application and if no is selected set the
paying for coverage?
requestingFinancialAssistanceIndicator=FALSE
Answer some questions about you, your spouse, and dependent(s).
Does everyone have the same
Yes
If yes, for each applicant, set homeAddress equal to the home address collected for the application filer. Set
58
permanent home address AND currently
noHomeAddressIndicator=FALSE, set the ResideTogetherIndicator = TRUE (see above) when we create the
live in [application state]?
familyRelationships
Answer some questions about the people applying for coverage: you, your spouse, and dependent(s).
Are all of you US citizens?
Yes
If yes, set the citizenshipIndicator=yes for all applicants
59
Can you enter SSNs for each of you?
Yes
N/A, if no screen to healthcare.gov
60
Are any of you applying under a
No
N/A, if yes screen to healthcare.gov
61
different name than the one on your
Social Security Card?
Were any of you born outside of the US No
If no, set naturalizedCitizenIndicator = FALSE for all applicants
62
and became naturalized or derived US
citizens?
Are any of you currently incarcerated
No
If no, set attestationsRequestBody.member.other.incarcerationType= NOT_INCARCERATED
63
(detained or jailed)?
Are any of you American Indian or
No
If no, set attestationsRequestBody.member.americanIndianAlaskanNativeIndicator= false
64
Alaska Native?
56

UI Questions
Item #

Application Section
* indicates features of this question may be
updated in future documentation

Applicable EDE Phase**

Question**

Answers to Previous Questions**

Informational Text**

Answer Options and Format**

Required/Optional to Display Question or
Corresponding Answer Fields to Collect
Information in Application UI**

Required/Optional for Consumer to Provide
Answer to Send to SES**
*if optional, consumer must be able to
ith t
idi
i UI
ti

Conditional Display Logic in the UI**

Data Element(s) Name

Attestation Level

Data Element
Format

Policy**

General Requirements**

Question Flow Requirements**

1

Prior to starting application

Phase 1, Phase 2, Phase 3

Coverage State

N/A

N/A

[Single-selection drop-down menu]
Answer options may be unique to DE entity; however, only states on Federallyfacilitated Marketplace (FFM) should be provided as an option

Required

Required

N/A

coverageState

Application

enum

Coverage state must be a state on the FFM.

Consumer must be able to apply for coverage for a state participating in the
FFM. EDE cannot support applications for State-based Marketplaces.

This question must be asked before the application question flow begins in Flexible. Note that you are asking where the consumer wants to get
all phases, and before screening questions in Phase 1 and 2.
coverage, not the state where the consumer currently resides.

2

Prior to starting application

Phase 1, Phase 2, Phase 3

Coverage Year

N/A

N/A

3

Privacy and use of your information

Phase 1, Phase 2, Phase 3

1. I agree to have my information used and retrieved from
data sources for this application. I have consent for all
people I'll list on the application for their information to be
retrieved and used from data sources.

N/A

Important Marketplace Emails: If the Marketplace has your email address, they’ll automatically send you important
information, updates, and reminders about Marketplace enrollment. You can opt out of these communications at any
time. To do this, click on the "unsubscribe" link in the footer of any Marketplace email.
Privacy and the use of your information: The Marketplace will keep your information private as required by law. Your
answers on this form will only be used to determine eligibility for health coverage or help paying for coverage. The
Marketplace will check your answers using the information in their databases and the databases of other federal
agencies. If the information doesn't match, the Marketplace may ask you to send them proof. The Marketplace won't
ask any questions about your medical history. Household members who don't want coverage won't be asked questions
about citizenship or immigration status.

Question/Informational Text Wording Requirements**

States on FFM: AK, AL, AR, AZ, DE, FL, GA, HI, IA, IL, IN, KS, LA, MI, MO, MS,
MT, NC, ND, NE, NH, OH, OK, OR, SC, SD, TN, TX, UT, VA, WI, WV, WY
During Open Enrollment:
[Drop-down, single-selection]
Current Coverage Year
Next Coverage Year

Required

Required

N/A

coverageYear

Application

number

Consumers must be able to apply for coverage during Open Enrollment Consumer must be able to apply for current year coverage until December
This question must be asked before the application question flow and
31st. Consumer must be able to apply for the next coverage year from the start before screening questions in Phase 1 and 2. The question must be asked
and outside of Open Enrollment. Consumer must be able to apply for
the next coverage year from the start of Open Enrollment to the end of Open Enrollment to the end of the year. Consumer must be able to apply for along the with coverage state to set up the application and can be autopopulated with no consumer choice from January 1st through October
of the year. Consumer must be able to apply for current year
current year coverage using DE entity website through December 15th. For
coverage until December 31st. Consumers who wish to apply between consumers who wish to apply between December 16th and December 31st for 31st.
December 16th and December 31st for current year coverage must current year coverage, the DE entity website must direct them to the
contact the Marketplace Call Center.
Marketplace Call Center.

Flexible.

Answer format is flexible. If a drop-down or [Open text field] is used, the coverage
year must be valid and the consumer should not be able to select invalid coverage
years.

Checkbox next to statements 1 and 2

Required

Required

N/A

privacyPolicyAgreementIndicator

Application

boolean

Privacy agreements with SSA, IRS, and DHS require that this
The application must collect consent from the application filer that all
permission be granted. It is necessary under the ACA to use these data application members agree to have their information used and retrieved from
sources to confirm eligibility information in the application before the
data sources.
system can access data from outside sources. The application filer
must actively affirm that he or she has consent from all the people who
will be on the application before continuing with the application.

Wording must be exact for the questions and informational text. DE
entities may use "they" in place of the Marketplace after the
Marketplace is specified the first time. The application may also use
contractions such as "they'll" in place of "they will."

Must be a checkbox format next to the statements.

Answer Fields
1. First Name: [Open text field]
2. Middle Name: [Open text field]
3. Last Name: [Open text field]
4. Suffix: [drop-down, single selection]: Jr., Sr., III, IV
5. DOB: [Open text field] MM-DD-YYYY
6. Sex: [drop-down, single selection]: Male, Female
7. Do you need coverage for yourself?: [Radio buttons]: Yes, No

Answer Fields
1. Required
2. Required
3. Required
4. Required
5. Required
6. Optional
7. Optional

Answer Fields
1. Required
2. Optional
3. Required
4. Optional
5. Required
6. Required if displayed
7. Required if displayed

N/A

1. firstName
2. middleName
3. lastName
4. suffix
5. birthDate
6. sex
7. requestingCoverageIndicator
If the consumer is requesting coverage, the requestingCoverageIndicator should be set to true.
Otherwise, it should be set to false
8. householdContactIndicator
If the consumer is the household contact, the householdContactIndicator should be set to true. For all
other application members, this must be set to false.

1. member
2. member
3. member
4. member
5. member
6. member
7. member
8. application

1. string
2. string
3. string
4. enum
5. string
6. enum
7. boolean
8. boolean

Names are used for communication, matching with data sources, and The application must collect at least first name, last name, date of birth, mailing This question must be asked with the household contact information and
tracking users in the system.
address, and primary phone number from the application filer in order to create communication preferences questions. Order of these questions is
an application. Additionally, the householdContactIndicator must be set to true flexible; however, these question sets must be included at the beginning
for exactly one person. While first name, last name, and DOB are required, the of the application. The collection of the household contact's sex and
UI must provide the opportunity to provide middle name and suffix. The
needing health care coverage may be collected later in the application
application filer must be 18 years or older to apply for coverage for themselves for all applicants, as displayed in Item 27, 28, 30 or with this question for
and/or on behalf of other consumers.
the household contact.

Flexible. The question wording must include "sex" and may not include
"gender".

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
All of the above must conform with SES character limits
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer
Sex: Answer format is flexible. Female and Male must be used as answer options.
DOB: Flexible in the way the application collects the DOB. May collect DOB
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a DOB.

Answer Fields:
1. Required
2. Optional
3. Required
4. Required
5. Required
6. Optional
7. Required if displayed

County is only requested when the zip code crosses multiple counties (counties are returned by
validating the address through a third party validation service).

1. homeAddress.streetName1
2. homeAddress.streetName2
3. homeAddress.cityName
4. homeAddress.stateCode
5. homeAddress.zipCode
6. homeAddress.plus4Code

Member

1. string
2. string
3. string
4. enum
5. string
6. string
7. string
8. string

The home address is used for determining state residency, which is a
criteria of eligibility for Medicaid, CHIP and QHP, as well as for rating
for QHP premiums.

Outside Open Enrollment:
[Drop-down, single-selection]
Current Coverage Year

2. I understand that I’m required to provide true answers
and that I may be asked to provide additional information,
including proof of my eligibility for a Special Enrollment
Period, if I qualify. If I don’t, I may face penalties, including
the risk of losing my eligibility for coverage.

Answer Options and Format Requirements**

Must be asked prior to collecting any application information from the
application filer. For Phases 1 and 2, this question must be asked prior to
screening questions. All questions related to eligibility (including screening
questions for Phases 1 and 2) must occur after the privacy act
statement.

Notes

The answer format for the state must be a single-selection drop-down menu. The
drop-down menu must only include the 33 FFE states (or the subset of those states
in which the DE partner offers plans). Or if it includes other states, then messaging
must be provided on their selection with directions for accessing the appropriate
external website to apply. The DE entity may provide state abbreviations or the
full state name in the drop-down menu.

As part of the application process, the Marketplace may need to retrieve your information from the Internal Revenue
Service (IRS), Social Security, the Department of Homeland Security (DHS), and/or a consumer reporting agency. They
need this information to check your eligibility for coverage and help paying for coverage if you want it and to give you the
best service possible. The Marketplace may also check your information at a later time to make sure your information is
up to date. The Marketplace will notify you if they find something has changed.
Learn more about your data , or view the Privacy Act Statement .
1

2

Learn more about your data , or view the Privacy Act Statement .
1. This must link to the “How we use your data” page on HealthCare.gov at https://www.healthcare.gov/how-we-useyour-data/
2. This must link to the “Privacy Act Statement” page on HealthCare.gov at https://www.healthcare.gov/individualprivacy-act-statement/
Special Enrollment Period Help Text: A time outside of the Open Enrollment Period when you and your family can sign up
for health coverage. In the Marketplace, you qualify for a Special Enrollment Period 60 days following certain life events
that involve a change in family status (like marriage or the birth of a child) or loss of other health coverage. Job-based
plans must provide a Special Enrollment Period of 30 days.
4

Household contact information

Phase 1, Phase 2, Phase 3

Name

N/A

Warning message that should display if consumer 65 years old or older is added as applicant: If [FNLNS] has Medicare,
they can enroll in a Marketplace plan but aren't eligible for a premium tax credit or extra savings. [FNLNS] would have to
pay full price for a Marketplace plan.
Warning message that should display if consumer 64 years old is added as applicant: It looks like [FNLNS] may be eligible
for Medicare soon. You can continue with the application. As soon as they know their Medicare start date, they should
return to [EDE Entity's website] and "Report a life change" to tell us about their new coverage.
Help Drawer: Learn more about Medicare and the Marketplace.
Important: The Marketplace doesn't offer Medicare Supplement Insurance (Medigap), Medicare Advantage (Part C) or
other Medicare health plans, Medicare prescription drug coverage (Part D), or dental or vision coverage for people with
Medicare. For information, visit Medicare.gov.

If a consumer attests to a date of birth that is 65 years old or older in Item 4, DE
entities must display the warning message outlined in column F.

If you already have Medicare
It's against the law for anyone to sell you a Marketplace plan, and you aren't eligible for a premium tax credit or other
savings.
You can't drop Medicare and enroll in a Marketplace plan without significant penalties (including losing retiree or
disability Social Security/Railroad Retirement benefits, and having to pay back any Social Security/Railroad Retirement
benefits and Medicare claims payments you've received).
If you pay a premium for Medicare Part A (Hospital Insurance): You can drop your Part A coverage (and Part B (Medica
Insurance), if you have it) and enroll in a Marketplace plan instead – and you may be eligible for a premium tax credit and
extra savings, depending on your income.
See below if you have only Part A or only Part B coverage.
If one spouse has Medicare and the other doesn't
Continue your Marketplace application to enroll the spouse without Medicare (and any household members who need
coverage) in a Marketplace plan.
Include in your household both spouses and all dependents, and include both spouses' income. (Marketplace savings are
based on income for the household, not just those who need coverage.)
Be sure to tell us that the spouse with Medicare doesn't need Marketplace coverage.
The spouse with Medicare can't drop it to get a Marketplace plan, except as described above.
5

Household contact information

Phase 1, Phase 2, Phase 3

What's your home address?

N/A

If you're about to be eligible for Medicare and want a Marketplace plan instead
Use your home address in the state where you’re applying for coverage. It can’t be a PO Box.

Answer Fields
Answer Fields:
1. Street Address: [Open text field]
1. Required
2. Street address 2: [Open text field]
2. Optional
3. City: [Open text field]
3. Required
4. State: [Drop-down, single selection] Phases 1 and 2 should provide only the
4. Required
application state for the home address. Phase 3 should allow the consumer to select 5. Required
any of the 50 states or U.S. territories
6. Optional
5. ZIP code: [Open text field]
7. Required if displayed
6. ZIP plus 4 code: [Open text field]

Provided once address is validated through a third party address validation service:
7. homeAddress.countyName
8. homeAddress.countyFipsCode

Provided once address is validated through a third party address validation service
only if zip code crosses multiple counties:
7. County: [Drop-down, single-selection] pre-populated with counties returned
from address validation

Phases 1 and 2: All applicants must live in the same state at the same household
address. The application only needs to collect an address from the household
contact.

In cases where geo API returns a suggested address with a nine-digit zip that is only
linked to one county, and the consumer agrees that the suggested address is
correct, partners should prevent a consumer from attesting to a county that’s
associated with the original five-digit zip but not the nine-digit zip code

Phase 3: The application must request a home address for each applicant and
non-applicant tax filer, but also must allow for a consumer to continue with the
application and indicate their residency without attesting that they live in a
particular home address. If no home address, the UI must collect the applicant's
mailing address which SES will use as their residency address

6

Household contact information

Phase 3

No home address

N/A

N/A

Checkbox next to statement

Required

Optional

N/A

7

Household contact information

Phase 1, Phase 2, Phase 3

Is this also your mailing address? [Display home address]

N/A

Help Drawer: Learn how mailing address affects coverage
This person's mailing address can be a street address or a P.O. box.

[Radio buttons]
Yes
No

Optional

Required

N/A

We may use this address for the health insurance plan rating, so pick a mailing address in the state where this person lives,
if possible.

All Phases: Applications must use a third party address validation service to
This question must be asked with the household contact information and Flexible.
validate the consumer's entered address. Once the home address is validated
communication preferences questions. Order of these questions is
through a third-party validation service, the application should display back both flexible; however, these question sets must be included before the
the manually entered address and the validated address from which the
preliminary eligibility determination so that SES can assess state residency
consumer will select as their address. If more than one county is returned by the eligibility. For Phase 3 applications, if the household contact address will
third-party validation service, the consumer must select their county through a be used as an answer option for applicants, it must be collected prior to
dropdown list of the returned counties. The validation service will also return the asking for the applicant address.
county Fips code which should not be displayed to the consumer, but rather
used by the application to set the homeAdress.countyFipsCode data element in
the API request.

Street Name: Must be an open text field
Street Name 2: Must be an open text field
City: Must be an open text field
State: Phases 1 and 2: State must be preselected as the application state. If the
consumer wishes to change their home address state, they should be directed to
update their answers to the screening questions. There is flexibility for how the DE
entity directs them back to the screening questions. They must explain the
consumer must update their answer to the screening question and they cannot
change the home address state. For phases 1 and 2, one home address should be
collected and should be stored as the home address for each applicant.
Phase 3: Consumer must be able to select any state for their home address. DE
entities must use a single selection drop-down menu with all 50 states and all U.S.
territories. The DE entity may provide state abbreviations or the full state name in
the drop-down menu. For phase 3, each applicant must have the opportunity to
attest to an individual home address if they do not live with the household contact.
ZIP: Must be an open text field
County Name: County must be provided to the consumer if selection of county is
required based on address validation (i.e. zip code crosses more than one county).
The answer format for ZIP code is flexible as long as the counties displayed to the
consumer are counties associated with the provided ZIP code.

noHomeAddressIndicator

Member

boolean

The application must request a home address for each applicant, but also must This question must be asked with the household contact information and
allow for a consumer to continue with the application and indicate their
communication preferences questions. Order of these questions is
residency without attesting that they live in a particular home address in Phase 3 flexible; however, these question sets must be included at the beginning
applications.
of the application.

Flexible, but using the wording "No home address" is recommended.

Answer format is flexible, as long as someone is able to move forward in the
application without providing a home address.

If Yes, copy home address into the mailing address xpath if answered

Member

1. string
2. string
3. string
4. enum
5. string
6. string
7. string
8. string

The application must collect a mailing address for at least the application filer in
order to receive communications by mail. For Phase 3 applications, the mailing
address must be collected when the application filer attests to not having a
home address.

This question must be asked with the household contact information and
communication preferences questions. Order of these questions is
flexible; however, these question sets must be included at the beginning
of the application.

Flexible.

The answer format is flexible. Answer options may be altered for compatibility
with question wording. Consumer should not have any alternative options for
selecting an address and may only indicate if their mailing address is the same or is
different from their home address.

Member

1. string
2. string
3. string
4. enum
5. string
6. string
7. string
8. string

Once the mailing address is validated through a third-party validation service,
the application should display back both the manually entered address and the
validated address from which the consumer will select as their address. The
validated address will also include the county FIPS code provided by the thirdparty validation service and that should be passed in the API request but not
displayed to the consumer. If more than one county is returned by the thirdparty validation service, the consumer must select their county through a
dropdown list of the returned counties.

This question must be asked with the household contact information and
communication preferences questions. Order of these questions is
flexible; however, these question sets must be included at the beginning
of the application.

Flexible.

Street address: Must be an open text field
Street address 2: Must be an open text field
City: Must be an open text field
State: Consumers must be able to select any state for their home address. DE
entities must use a single selection drop-down menu with all 50 states or U.S.
territories. The DE entity may provide state abbreviations or the full state name in
the drop-down menu.
ZIP code: Must be an open text field
County Name: County may be provided to the consumer based on address
validation; however, county validation is not needed for the mailing address
(unless in a Phase 3 application it is being used for residency because the consumer
attested to no home address). The answer format for ZIP code is flexible as long as
the counties displayed to the consumer are counties associated with the provided
ZIP code.

1. email
2. primaryPhoneNumber.number
3. primaryPhoneNumber.ext
4. primaryPhoneNumber.type
5. secondaryPhoneNumber.number
6. secondaryPhoneNumber.ext
7. secondaryPhoneNumber.type

Application

1. string
2. string
3. string
4. enum
5. string
6. string
7. enum

Email address is collected for notifications by email and other
electronic notices. At least one phone number must be collected for
the application. Email is also used as part of backend logic that
determines whether the consumer already exists in Marketplace
records or needs a new unique Person Tracking Number. Therefore
email should be collected whenever possible, though consumers who
do not have email addresses can still apply through a call center for
example.

At least one phone number must be collected for the application. Household
This question must be asked with the household contact information.
contacts must be given an opportunity to provide an email address for
Order of these questions is flexible; however, these question sets must be
electronic communications. DE entities may pre-populate this question if they
included at the beginning of the application.
have a phone number from ID proofing or account creation. If the phone
number is pre-populated, the consumer must be able to edit or delete the phone
number.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording. For example, if instead the DE entity asks the consumer,
"Choose your preferred number?" with the phone number and "Other" listed as
answer options.

The consumer must have the opportunity to attest to their preferred written
and spoken language once per application.

Flexible.

Answer option wording must be exact and all options must be present. Answer
format is flexible.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording. For example, if instead the application asks, "Please select your
communication presences" the answer options may be listed as "Mail" and or "Email" or "Text". Partners can provide all three options together, however,
consumers can't choose both "Mail" and an electronic preference of "Email" or
"Text". Consumers can chose both Email and Text preferences, but neither can
be combined with a paper Mail preference.

1. mailingAddress.streetName1
2. mailingAddress.streetName2
3. mailingAddress.cityName
4. mailingAddress.stateCode
5. mailingAddress.zipCode
6. mailingAddress.plus4Code

Must ensure that people who are homeless are not excluded from the
ability to file an FFE application and get an eligibility determination.
There must be a way for a consumer to continue with the app and
indicate their residency w/out attesting that they live in a particular
home address. Based on SES logic, use mailing address as way to set
residency when someone indicates they're homeless.

The UI may pre-populate the home address from information available from
identity proofing, from a mailing address or from a home address collected for
another application member, as long as the household contact has the
opportunity to provide a unique address.

Provided once address is validated through a third party address validation service:
7. mailingAddress.countyName
8. mailingAddress.countyFipsCode
8

Household contact information

Phase 1, Phase 2, Phase 3

Enter your mailing address

Is this also your mailing address? [Display home address] No
OR Item #7 did not display

Enter a street address or a PO Box. It can't be a foreign address.
Phase 3 ONLY: Alert text if application filer doesn't have a home address and provides a mailing address outside the
application state: Do you have a mailing address in [application state]? We use your address to help find plans near you
that you're eligible for. If you can, enter a home or mailing address in [application state], even if it's a temporary one. Or
you can start a new application in [mailing address state]. (link to beginning of application process).
Help Drawer: Learn how mailing address affects coverage
This person's mailing address can be a street address or a P.O. box.

9

10

Household contact information

Communication Preferences

Phase 1, Phase 2, Phase 3

Phase 1, Phase 2, Phase 3

What's your contact information?

What's your preferred language?

N/A

N/A

Answer Fields
1. Street Address: [Open text field]
2. Street address 2: [Open text field]
3. City: [Open text field]
4. State: [Drop-down, single selection] Phases 1 and 2 should provide only the
application state for the mailing address. Phase 3 should allow the consumer to
select any of the 50 states or U.S. territory.
5. ZIP code: [Open text field]
6. ZIP plus 4 code: [Open text field]

Question: Required (once per application)
Answer Fields:
1. Required
2. Optional
3. Required
4. Required
5. Required
6. Optional
7. Required if displayed

Answer Fields:
1. Required
2. Optional
3. Required
4. Required
5. Required
6. Optional
7. Required if displayed

Display if consumer answered "No" to "Is your mailing address the same as your home address?"

1. mailingAddress.streetName1
2. mailingAddress.streetName2
3. mailingAddress.cityName
4. mailingAddress.stateCode
5. mailingAddress.zipCode
6. mailingAddress.plus4Code
Provided once address is validated through a third party address validation service:
7. mailingAddress.countyName
8. mailingAddress.countyFipsCode

This data element is required once per application, not per applicant.

We may use this address for the health insurance plan rating, so pick a mailing address in the state where this person lives,
if possible.

Provided once address is validated through a third party address validation service:
7. County: [Drop-down, single-selection] pre-populated with counties returned
from address validation

N/A

Answer Fields
1. Email address: [Open text field]
2. Phone number: [Open text field]
3. Extension (optional): [Open text field]
4. Phone type: [radio buttons] Mobile, Home, Work
5. Secondary phone number (optional): [Open text field]
6. Secondary phone number extension (optional): [Open text field]
7. Secondary phone type: [radio buttons] Mobile, Home, Work

1. Required
2. Required
3. Required
4. Required
5. Required
6. Required
7. Required

1. Required [Note that email is required only in N/A
the consumer online channel if they have
indicated their preferred contact method is
electronic, whereas optional for consumers
using a call center, consumer online channel
with mail as their preferred contact method, or
agent/broker channel]
2. Required
3. Optional
4. Required
5. Optional
6. Optional
7. Optional

Answer Fields
1. Preferred written language: [Drop-down, single-selection] English, Spanish,
Arabic, Chinese, French, French Creole, German, Gujarati, Hindi, Korean, Polish,
Portuguese, Russian, Tagalog, Urdu, Vietnamese, Other
2. Preferred spoken language: [Drop-down, single-selection] English, Spanish,
Arabic, Chinese, French, French Creole, German, Gujarati, Hindi, Korean, Polish,
Portuguese, Russian, Tagalog, Urdu, Vietnamese, Other

1. Required (once per application)
2. Required (once per application)

1. Required
2. Required

N/A

1. writtenLanguageType
2. spokenLanguageType
These indicators should be set to the consumer's preference, but are not saved with SES.

Application

1. enum
2. enum

Collected to populate correct language in notice content and
communications.

Required

None. This is not sent to SES. Note that we default to mail if email/text is not selected and there is no
data element for this in Update App.

Consumers must have the option to receive paper notices.

Selecting your preferred language helps the U.S. Department of Health and Human Services improve service to all
people using the Marketplace. Providing this information won't affect your eligibility, options, or costs.
Help Drawer: Learn more about preferred languages. If you select "Spanish" as this person's written language, you'll get a
Spanish eligibility notice when you submit the application. You'll also get most other communication, including some
emails, in Spanish. [Change the application to Spanish] (link to: https://www.cuidadodesalud.gov/es/ or EDE Entity's
Spanish application (if applicable)).

This question may be asked at anytime during the application.

Email address: Must be an open text field
Phone number: Must be an open text field
Extension (optional): Must be an open text field
Phone type: Answer format is flexible. Answer option wording is flexible, such as
using "Cell phone" vs "Mobile"; however, all options must be present. If an
alternate answer option wording is used, the DE entity must correctly map the
answer options to the SES data elements.
Secondary phone number (optional): Must be open text field
Secondary phone extension (optional): Must be open text field
Secondary phone type: Answer format is flexible. Answer option wording is
flexible, such as using "Cell phone" vs "Mobile"; however, all options must be
present. If an alternate answer option wording is used, the DE entity must
correctly map the answer options to the SES data elements.

[Get resources in other languages] (link to: https://www.healthcare.gov/language-resource/).
11

Communication Preferences

Phase 1, Phase 2, Phase 3

How would you like to get notices about your application?

N/A

We need to know the best way to contact you about this application and your health coverage if you're eligible.

[Radio buttons]
Email or text me when there's a new notice in my Marketplace account
Send me paper notices in the mail

Required

N/A

Member

N/A

12

Communication Preferences

Phase 1, Phase 2, Phase 3

How should we let you know when there's a new notice in
your account?

N/A

N/A

[Checkboxes, multi-selection]
Optional Required
Email me at [household contact email address]
Text me (Text STOP to cancel. Text HELP for help. Message frequency varies, but
you may receive 1-3 reminder messages per week during Open Enrollment (Nov. 1
Dec. 15 Jan. 15). Message and data rates may apply. One message per attempt.
Visit Wireless Terms & Conditions or Privacy Policy for more information.)

Optional Required

N/A Consumer selected "Email or text me when there's a new notice in my Marketplace account" contactMethod.email
contactMethod.E_text

Member

array, enum

Flexible. If the question is re-worded, it must at least ask if the consumer Answer format is flexible. Answer options may be altered for compatibility with
would like to receive communications via mail or e-mail/text messages. question wording.; however, the application must provide the opportunity for the
When asking for e-mail, the UI could ask the consumer to re-enter their consumer to select mail or e-mail/text as a contact method. Text messaging
must display disclaimer content on screen without requiring the user to do
email address to ensure they provide the correct address or can display
an already provided email address for consumers to select. This question anything to see it (i.e. not hidden behind a link, accordion, help drawer, tool
tip/hover, etc). Including text messaging as a communication method is optional.
may be combined with the above question to only ask once about the
consumers communication preferences. Text message disclaimer
content is required. If HealthCare.gov is sending the text messages
instead of the EDE partner, all elements of the disclaimer text must be
present, including the links to the Wireless Terms & Conditions as well as
the HealthCare.gov Privacy Policy. If the partner is sending the text
messages, a similar disclaimer needs to be provided anywhere the
consumer can opt into text messages on the partner's site.

13

Communication Preferences

Phase 1, Phase 2, Phase 3

Which mobile number should we use?

Optional Required

Optional Required

Consumer selected "Text" for "How can we contact you?" AND the consumer provided a mobile
number as their "Household contact phone number". OTHERWISE, just display the next Open
Text Field to collect phone number.

contactMethod.E_text

Member

string

Flexible.

Answer format is flexible. Consumers must have an opportunity to provide a
phone number previously listed in the application if that phone number is mobile.

Communication Preferences

Phase 1, Phase 2, Phase 3

Phone number

How should we let you know when there's a new notice in your
N/A
account? Text me (Text STOP to cancel. Text HELP for help.
Message frequency varies, but you may receive 1-3 reminder
messages per week during Open Enrollment (Nov. 1-Dec Jan. 15).
Message and data rates may apply. One message per attempt. Visit
Wireless Terms & Conditions or Privacy Policy for more information )
Which mobile number should we use? A different mobile number
N/A

[Radio buttons]
[Household contact phone number if mobile]
A different mobile number

14

[Open text field]

Optional Required

Optional Required

Consumer selected "Text" for "How can we contact you?" AND selected "A different mobile
contactMethod.E_text
number" for "Which mobile number should we use?"
OR
Consumer selected "Text" for "How can we contact you?" AND no mobile phone number is known
yet (i.e. "Household contact phone number" isn't mobile)

Member

string

Flexible.

Must be an open text field. Must meet phone number validation requirements for
a U.S. phone number.

15

Help Applying for Coverage

Phase 1, Phase 2, Phase 3

Is a professional helping you complete your application?

N/A

[Radio buttons]
Yes
No

Required

Optional

N/A

If no, set applicationAssistorType to NO_ASSISTANCE

N/A

N/A

This question may be asked at anytime during the application

Flexible.

Answer format is flexible; the consumer must be able to add one assistor of each
type. Answer options may be altered for compatibility with question wording.

[Checkboxes, multi-selection]
Navigator
Certified application counselor
Agent or broker
Other Assister
Answer Fields
1. First Name: [Open text field]
2. Middle Initial: [Open text field]
3. Last Name: [Open text field]
4. Suffix: [Drop-down, single selection] Jr., Sr., III, IV
5. Organization Name: [Open text field]
6. ID number: [Open text field]

Required

Required

Consumer selected "Yes" for "Is a professional helping you complete your application?"

applicationAssistorType

Application

enum

This question may be asked at anytime during the application

Flexible.

Answer format is flexible. Answer option wording must be exact and all options
must be present.

Answer Fields
1. Required
2. Optional
3. Required
4. Required
5. Required
6. Required

Answer Fields
1. Required
2. Optional
3. Required
4. Optional
5. Optional
6. Optional

Selected "Navigator" for "Which type of professional is helping you?"

1. assistorFirstName
2. assistorMiddleName
3. assistorLastName
4. assistorSuffix
5. assistorOrganizationName
6. assistorOrganizationId

Application

1. string
2. string
3. string
4. enum
5. string
6. string

This question may be asked at anytime during the application. It is
Flexible.
recommended to display the fields for providing assistor information after
selecting the assistor type.

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer
Organization Name: Must be an open text field
ID Number: Must be an open text field

If a family member or friend is helping you, select “No.”
Help Drawer: Learn more about Professionals who can help with your application
If a professional is currently helping you with your Marketplace application or has helped you in the past, select “Yes.” You
can enter information for more than one professional.

This question must be asked with the household contact information,
language preferences, and communication preferences questions.
Order of these questions is flexible; however, these question sets must be
included at the beginning of the application.

If a family member or friend is helping you, select “No.”
The professional can help you complete this section and enter their ID number or National Producer Number (NPN). If
they aren't helping you right now, you can update this later after you ask for the ID number or NPN.
Several types of professionals are trained to help you complete your application:
Navigator: Can be a person or organization
Certified application counselor: Can be an in-person assister, or a staff member or volunteer of an organization.
Agent or broker: Can make specific recommendations about which plan they think you should enroll in. Agents and
brokers are licensed and regulated by states and usually get commissions from health insurance companies when they
enroll consumers.
These people are trained to help you review your health care coverage options through the Marketplace. You can ask
professionals to see certification showing they’re authorized to help you, or you can look them up at
LocalHelp.HealthCare.gov.
Information for professionals
Please don’t remove another professional’s information without permission from the person you’re helping.

16

Help Applying for Coverage

Phase 1, Phase 2, Phase 3

Which type of professional is helping you?

Is a professional helping you complete your application? Yes

Select all that apply.

17

Help Applying for Coverage

Phase 1, Phase 2, Phase 3

N/A

Which type of professional is helping you? Navigator

N/A

18

Help Applying for Coverage

Phase 1, Phase 2, Phase 3

N/A

Which type of professional is helping you? Certified application
counselor

N/A

Answer Fields
1. First Name: [Open text field]
2. Middle Initial: [Open text field]
3. Last Name: [Open text field]
4. Suffix: [Drop-down, single selection] Jr., Sr., III, IV
5. Organization Name: [Open text field]
6. ID number: [Open text field]

Answer Fields
1. Required
2. Optional
3. Required
4. Required
5. Required
6. Required

Answer Fields
1. Required
2. Optional
3. Required
4. Optional
5. Optional
6. Optional

Selected "Certified application counselor" for "Which type of professional is helping you?"

1. assistorFirstName
2. assistorMiddleName
3. assistorLastName
4. assistorSuffix
5. assistorOrganizationName
6. assistorOrganizationId

Application

1. string
2. string
3. string
4. enum
5. string
6. string

This question may be asked at anytime during the application. It is
Flexible.
recommended to display the fields for providing assistor information after
selecting the assistor type.

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer
Organization Name: Must be an open text field
ID Number: Must be an open text field

19

Help Applying for Coverage

Phase 1, Phase 2, Phase 3

N/A

Which type of professional is helping you? Other Assister

N/A

Answer Fields
1. First Name: [Open text field]
2. Middle Initial: [Open text field]
3. Last Name: [Open text field]
4. Suffix: [Drop-down, single selection] Jr., Sr., III, IV
5. Organization Name: [Open text field]
6. ID number: [Open text field]

Answer Fields
1. Required
2. Optional
3. Required
4. Required
5. Required
6. Required

Answer Fields
1. Required
2. Optional
3. Required
4. Optional
5. Optional
6. Optional

Selected "Other Assister" for "Which type of professional is helping you?"

1. assistorFirstName
2. assistorMiddleName
3. assistorLastName
4. assistorSuffix
5. assistorOrganizationName
6. assistorOrganizationId

Application

1. string
2. string
3. string
4. enum
5. string
6. string

This question may be asked at anytime during the application. It is
Flexible.
recommended to display the fields for providing assistor information after
selecting the assistor type.

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer
Organization Name: Must be an open text field
ID Number: Must be an open text field

20

Help Applying for Coverage

Phase 1, Phase 2, Phase 3

N/A

Which type of professional is helping you? Agent or broker

N/A

Answer Fields
1. First Name: [Open text field]
2. Middle Initial: [Open text field]
3. Last Name: [Open text field]
4. Suffix: [Drop-down, single selection] Jr., Sr., III, IV
5. NPN number: [Open text field]

Answer Fields
1. Required
2. Optional
3. Required
4. Required
5. Required

Answer Fields
1. Required
2. Optional
3. Required
4. Optional
5. Required

Selected "Agent or broker" for "Which type of professional is helping you?"

1. assistorFirstName
2. assistorMiddleName
3. assistorLastName
4. assistorSuffix
5. assistorNationalProducerNumber

Application

1. string
2. string
3. string
4. enum
5. number

This question may be asked at anytime during the application. It is
Flexible.
recommended to display the fields for providing assistor information after
selecting the assistor type.

DE entities are allowed to pre-populate agent/broker information into these fields
of the application; however, if DE entities ask this question in the UI and the
information is pre-populated, it must be displayed back to the consumer for them
to edit.

21

Help Paying for Coverage

Phase 1, Phase 2, Phase 3 (in
screener for Phases 1 and 2)

Do you want to find out if you can get help paying for health N/A
coverage?

If you select "Yes," you'll answer questions about your income and household to see how much financial help you might
qualify for.

[Radio buttons]
Yes
No
I'm not sure

Required to display question in UI.
Optional to display answer option "I'm not
sure"

Required

N/A

requestingFinancialAssistanceIndicator

Application

boolean

22

Help Paying for Coverage

Phase 1, Phase 2, Phase 3 (in
screener for Phases 1 and 2)

How many people are on your federal income tax return
Do you want to find out if you can get help paying for health
this year? (If you aren’t filing taxes, tell us how many people coverage? I'm not sure
live with you, including yourself.) You don’t have to file
taxes to apply for coverage.

N/A

[Drop-down, single selection] 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16,
17, 18, 19, 20

Optional

Optional

Consumer selected "I'm not sure for "Do you want to find out if you can get help paying for health
coverage?" or opts to use the tool to help find out if they should apply for financial assistance

None. This is not sent to SES.

Application

N/A

23

Help Paying for Coverage

Phase 1, Phase 2, Phase 3 (in
screener for Phases 1 and 2)

Based on your best guess, do you expect your total
Do you want to find out if you can get help paying for health
household income to be less than [Equivalent to 400% of the coverage? I'm not sure
federal poverty level in dollars for family size listed plus
buffer] for this year?

N/A

[Radio buttons]
Yes
No
I don’t know

Optional

Optional

Consumer selected "I'm not sure for "Do you want to find out if you can get help paying for health
coverage?" or opts to use the tool to help find out if they should apply for financial assistance

None. This is not sent to SES.

Application

N/A

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer
NPN Number: Must be an open text field
Consumers must have the opportunity to choose between applying for Consumers must have the opportunity to choose between applying for financial
financial assistance (APTC, CSR, Medicaid and CHIP) or applying for
assistance (APTC, CSR, Medicaid and CHIP) or applying just for QHP only. In
QHP only. This is important to ask early on in the application so that
addition, consumers must choose between all financial assistance programs or
consumers seeking full-cost QHP only are not asked questions about
none; they cannot have the option to choose to apply for APTC but not
their household and income which are not relevant for QHP eligibility.
Medicaid, for example. For Phase 3 applications, the UI can provide a screener
tool to help consumers make their decisions on this question, but the screener
tool is not required.

This is important to ask early in the application so that consumers not
seeking financial assistance only are not asked questions about their
household and income which are not relevant for QHP eligibility. It is
recommended to include this question before adding additional
application and/or household members to the application.

Flexible. It is recommended to use generic terminology such as "help
Answer format is flexible. Answer options may be altered for compatibility with
paying for coverage" because consumers may not understand all of the question wording. DE entities do not have to provide an option for "I'm not sure."
program names. Financial assistance must be described accurately to
However, if they include an optional tool to help consumers decided whether or
the consumer if specifics are used in that applying for financial assistance not they would like to see if they qualify for help paying for coverage, they may
means applying for advance tax credits and cost-sharing reductions as
include it as an answer option for this question.
well as for Medicaid and CHIP.

Phase 1 and Phase 2 applications must use answers from screening questions to
determine whether or not the consumer is requesting financial assistance to
avoid re-asking this question
This question is part of an optional tool to assist consumers with decided deciding If included in the UI, this question should be displayed along with or before Flexible.
whether or not they would like to see if they qualify for help paying for
the question regarding applying for financial assistance. The DE entity has
coverage. If included in the UI, Phase 1 and Phase 2 applications must include
flexibility with how this information is shown to the consumer. This
this tool in the screening questions when asking consumers if they would like help information may be shown in conjunction with the financial assistance
question as a pop-up or as a separate follow-up question. The order of the
paying for coverage.
two questions for the optional tool for seeking financial assistance is
flexible.
This question is part of an optional tool to assist consumers with decided deciding
whether or not they would like to see if they qualify for help paying for
coverage. If included in the UI, Phase 1 and Phase 2 applications muse must
include this tool in the screening questions when asking consumers if they would
like help paying for coverage.

If included in the UI, this question should be displayed along with or before Flexible; however, the amount displayed must be 420% of the federal
the question regarding applying for financial assistance. The DE entity has poverty level for the application state and number of members in the
flexibility with how this information is shown to the consumer. This
household.
information may be shown in conjunction with the financial assistance
question as a pop-up or as a separate follow-up question. The order of the
two questions for the optional tool for seeking financial assistance is
flexible.

Answer format is flexible. Answer options should allow the consumer to add
individuals. If an [Open text field] is used, only characters 0-9 should be accepted.

Answer format is flexible. Answer options may be altered for compatibility with
Answer format is flexible. Answer options may be altered for
question wording. If including the federal poverty level dollar amount as an
compatibility with question wording. The household composition
answer option, the application must use the appropriate number for the state and from previous screening questions must be used to determine
the income amounts to display to the consumer as answer
household size.
options. This tool must use the federal poverty levels for the
number of household members and the state. The value
displayed to the consumer must be 420% of the FPL amount
rounded to the nearest $1000 for their household size and their
state. The 2022 appl

Auditor Compliance
Conclusion**

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor
Comments**

Item #

27

Application Section
* indicates features of this question may be
updated in future documentation

Applicable EDE Phase**

Question**

Answers to Previous Questions**

Informational Text**

Answer Options and Format**

Required/Optional to Display Question or
Corresponding Answer Fields to Collect
Information in Application UI**

Household Composition*

Phase 1, Phase 2, Phase 3

Who needs health coverage?

N/A

Warning text when the application filer is not applying for coverage and no applicants are added:
Add at least one person who needs coverage.

[Radio buttons]
[Display known household members]
Add a person who needs health coverage

Required

Required/Optional for Consumer to Provide
Answer to Send to SES**
*if optional, consumer must be able to
ith t
idi
i UI
ti
Required

[Radio Buttons]
Yes
No

Required

Required

Help Drawer: Learn more about who not to include.
Select or add each person in the household who wants to apply for health coverage.

Conditional Display Logic in the UI**

Data Element(s) Name

Attestation Level

Data Element
Format

Policy**

General Requirements**

Question Flow Requirements**

Question/Informational Text Wording Requirements**

Answer Options and Format Requirements**

N/A

requestingCoverageIndicator

Member

boolean

Consumers must have the option to only seek coverage for some,
rather than all, members of their household. The application must ask
this question early on so that non-applicant household members are
not asked questions which are not necessary.

The consumer must have the capability to file an application on behalf of
anyone in their household, as well as other people outside their household for
whom they have responsibility.

The application must ask this question early on so that non-applicant
household members are not asked questions which are not necessary. It
is recommended to ask this question after the household contact
information and communication preferences questions. The application
filer may be asked if they are applying for coverage for themself either
when they add their information in the household contact section of the
application, or here.

Flexible. For Phase 1 and 2 applications, this information may be
collected in the screening questions; however, for FA applications, a
question should be included for each consumer asking whether or not
they are applying for coverage.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

This question only needs to display when a subset of dependents are applying for coverage, as
indicated by answers to the screening question about who is requesting coverage. Otherwise, the
UI may use answers to screening questions to avoid re-asking this information.

requestingCoverageIndicator

Member

boolean

Display all fields for each person applying. Date of Birth is required for
each applicant because it is used to determine Medicaid and CHIP
eligibility, to match with SSA through the Hub for SSN verification, and
for plan rating. Relationships are important for determining whether
QHP eligible consumers can meet issuer business rules to be on a plan
together. In addition, familial relationships can impact Medicaid and
CHIP household composition/size. Sex is collected: 1) as a piece of
demographic data like race and ethnicity; 2) as a mechanism to
determine who should be asked questions about pregnancy as part of a
determination for Medicaid and CHIP; and 3) as an indicator that SES
will use to determine eligibility for post-partum care for new mothers of
newborns.

Each applicant must provide a first name, last name, date of birth, and
relationship to application filer. Middle name and suffix are optional for the
consumer to provide, but must be offered fields. It is recommended to ask for
the relationship to the application filer, but relationship information may be
collected in a different format/section. Sex is not the same as gender and this
question is asking about sex, not gender. This question is asked of applicants and
non-applicants. This question may be combined with item #28 for phase 1 and
phase 2 applications, or item #30 for phase 3 applications, as outlined, or it may
be asked as a standalone question for each applicant and non-applicant.

The flow of adding an applicant is flexible and information collected from
each applicant may be done throughout the application. It is
recommended to ask for relationship to application filer up front, but
relationship information may be collected in a different format/section.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Don't include these people
Roommates
Divorced or legally separated spouse, even if they live in the same house as the tax filer
Spouse, if the tax filer is a victim of domestic abuse, domestic violence, or spousal abandonment
Unborn children
Non-dependent children or other relatives who live with the tax filer (unless they'll be claimed as dependents by the tax
filer)
If any of these people need coverage, but aren't in the household or on a tax return, they should start their own, separate
applications.
People who don't need coverage:
You don't need to tell us about the people in the household who don't need coverage now. We'll ask about them later in this
application.
Help Drawer: Learn more about editing or removing someone.
Edit a person’s information
Select “Edit” next to a person’s name to edit their information. You can review and make any necessary changes,
including whether or not they need health coverage.
Remove a person
Remember, we may need information about all of the people in the household, even those who don’t need health
coverage. It’s a good idea to include all household members on the application, so you don’t have to add them back
later.
Select “Remove” next to a person’s name to completely remove them from the application.
If a person doesn’t have “Remove” next to their name
Contact person: You can’t remove the contact person. If you need to change who you named as the contact person,
start a new application.
Another household member: To remove this person, visit your Marketplace account, select the application you want to
update, and click "Report a life change" on the left-hand menu.

29

28

Household Composition*

Household Composition*

Phase 1, Phase 2

Phase 1, Phase 2

Does [FNLNS] need coverage?

Tell us about your [spouse/child/another child]:
Name
DOB
Sex

N/A

N/A

N/A

Help Text if consumer over 65 added as applicant: If [FNLNS] has Medicare, they can enroll in a Marketplace plan but
aren't eligible for a premium tax credit or extra savings. [FNLNS] would have to pay full price for a Marketplace plan.
Warning message that should display if consumer 64 years old is added as applicant: It looks like [FNLNS] may be eligible
for Medicare soon. You can continue with the application. As soon as they know their Medicare start date, they should
return to [EDE Entity's website] and "Report a life change" to tell us about their new coverage.

Phase 2 Only
How is this person related to [Application filer FNLNS]?
How is this person related to [Application filer's spouse
FNLNS]?

Help Drawer: Learn more about Medicare and the Marketplace.
Important: The Marketplace doesn't offer Medicare Supplement Insurance (Medigap), Medicare Advantage (Part C) or
other Medicare health plans, Medicare prescription drug coverage (Part D), or dental or vision coverage for people with
Medicare. For information, visit Medicare.gov.
If you already have Medicare

Answer Fields
1. First Name: [Open text field]
2. Middle Name: [Open text field]
3. Last Name: [Open text field]
4. Suffix: [drop-down, single selection]: Jr., Sr., III, IV
5. DOB: [Open text field]: YYYY-MM-DD
6. Sex: [drop-down, single selection]: Male, Female
Phase 2 Only:
7. This person is [Application filer FLNLS's]: [Drop-down, single selection] Spouse,
Son/Daughter, Stepson/Stepdaughter
8. This person is [Application filer's spouse FNLNS's]: [Drop-down, single selection]
Son/Daughter, Stepson/Stepdaughter

Answer Fields
1. Required
2. Required
3. Required
4. Required
5. Required
6. Required
7. Required for Phase 2
8. Optional for Phase 2

Answer Fields
1. Required
2. Optional
3. Required
4. Optional
5. Required
6. Required
7. Required
8. Required if displayed

It's against the law for anyone to sell you a Marketplace plan, and you aren't eligible for a premium tax credit or other
savings.
You can't drop Medicare and enroll in a Marketplace plan without significant penalties (including losing retiree or
disability Social Security/Railroad Retirement benefits, and having to pay back any Social Security/Railroad Retirement
benefits and Medicare claims payments you've received).
If you pay a premium for Medicare Part A (Hospital Insurance): You can drop your Part A coverage (and Part B (Medica
Insurance), if you have it) and enroll in a Marketplace plan instead – and you may be eligible for a premium tax credit and
extra savings, depending on your income.
See below if you have only Part A or only Part B coverage.

Fields for the name, sex, and DOB must display for non-applicants and applicants. The screening
1. firstName
questions about marital status and the number of dependents claimed on a tax return may be
2. middleName
used to determine how many consumers there are on the application, and how many times these 3. lastName
fields must display.
4. suffix
5. birthDate
For phase 1 applications, the UI may be used to set the relationship between the applicant/non6. sex
applicant and the application filer. For Phase 1 and 2 applications, EDE entities may automatically 7. familyRelationships
establish the relationship of sibling between dependents. For Phase 2 applications, the UI only
8. householdContactIndicator
needs to collect the relationship for dependents and could automatically establish the relationship If the consumer is the household contact, the householdContactIndicator should be set to true. For all
for the spouse. For Phase 2 applications, the relationship between non-applicants and the
other application members, this must be set to false.
application filer is only required when the dependent is under 19.
9. maritalStatus
If a spouse is added, set maritalStatus to married for both the household contact and the spouse.
10. Set requestingCoverageIndicator = true for each applicant added, if known they are requesting
coverage

1. member
2. member
3. member
4. member
5. member
6. member
7. household
8. application
9. member
10. member

1. string
2. string
3. string
4. enum
5. string
6. enum
7. enum
8. boolean
9. enum
10. boolean

If a consumer attests to a date of birth that is 65 years old or older in Item 28 or
Item 30, DE entities must display the applicable warning message outlined in
column F: (If [FNLNS] has Medicare, they can enroll in a Marketplace plan but
aren't eligible for a premium tax credit or extra savings. [FNLNS] would have to
pay full price for a Marketplace plan.)

Screening question answers may be used for collecting information about
relationship to the application filer and whether or not the consumer is
seeking coverage to avoid re-asking questions. The UI only needs to ask
about whether or not the consumer is requesting coverage if a subset of
consumers are requesting coverage. In this scenario, the UI only needs
Flexible. The question wording must include "sex" and may not include
to collect the relationship to the application filer for the dependents.
"gender".
In this section, the UI could also collect the relationship between the
application filer's spouse and the child to determine if the child is a
stepchild or child. If this information is not collected in this section, it could
be collected later in the application.
For Phase 2 applications, the relationship between non-applicants and the
application filer/spouse is only required when the dependent is under 19.
The UI could display the relationship field to all non-applicants or
selectively display the field to non-applicants under 19. It is required for all
applicants, regardless of age.
Sex can be collected here or later in the application, but before the
pregnancy question.

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer
DOB: Flexible in the way the application collects the DOB. May collect DOB
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a DOB.
Sex: Answer format is flexible. Female and Male must be used as answer options.
Relationship to application filer: Answer options wording may be altered for
compatibility with alternate wording. For example, child or son/daughter may be
used for the relationship. Please reference appropriate answer options for each
phase for this question. In Phase 2, relationship to application filer is only required
for non-applicants if the dependent is under 19
If included on a Phase 1 application, answer options may only include relationship
answer options of Spouse and Son/Daughter. If only collecting relationships for
dependents, only son/daughter must be included.
If included on a Phase 2 application, answer options may only include relationship
answer options of Spouse, Son/Daughter, and Stepson/Stepdaughter. If only
collecting relationships for dependents, only son/daughter and
stepson/stepdaughter must be included.

If one spouse has Medicare and the other doesn't
Continue your Marketplace application to enroll the spouse without Medicare (and any household members who need
coverage) in a Marketplace plan.
Include in your household both spouses and all dependents, and include both spouses' income. (Marketplace savings are
based on income for the household, not just those who need coverage.)
Be sure to tell us that the spouse with Medicare doesn't need Marketplace coverage.
The spouse with Medicare can't drop it to get a Marketplace plan, except as described above.
If you're about to be eligible for Medicare and want a Marketplace plan instead
30

Household Composition*

Phase 3

Add a person applying for coverage:
Name
DOB
Sex
How is this person related to [Application filer FNLNS]?
How is this person related to [other applicant FNLNS]?
How is this person related to [other applicant FNLNS]?
(repeat as needed for each applicant with unknown
relationship to new applicant)

N/A

Answer Fields
1. First Name: [Open text field]
2. Middle Name: [Open text field]
3. Last Name: [Open text field]
4. Suffix: [drop-down, single selection]: Jr., Sr., III, IV
5. DOB: [Open text field]: YYYY-MM-DD
6. Sex: [drop-down, single selection]: Male, Female
7. This person is [Application filer FNLNS's]: [Drop-down, single selection]
Spouse
Domestic Partner
Parent (including adoptive parent)
Stepparent
Warning message that should display if consumer 64 years old is added as applicant: It looks like [FNLNS] may be eligible
Parent's domestic partner
for Medicare soon. You can continue with the application. As soon as they know their Medicare start date, they should
Son/daughter (including adopted child)
return to [EDE Entity's website] and "Report a life change" to tell us about their new coverage.
Stepson/stepdaughter
Child of domestic partner (including adopted & step child)
Help Drawer: Learn more about Medicare and the Marketplace.
Important: The Marketplace doesn't offer Medicare Supplement Insurance (Medigap), Medicare Advantage (Part C) or Brother/sister (including half & step sibling)
other Medicare health plans, Medicare prescription drug coverage (Part D), or dental or vision coverage for people with Uncle/aunt
Medicare. For information, visit Medicare.gov.
Nephew/niece
First cousin
If you already have Medicare
Grandparent
Grandchild
It's against the law for anyone to sell you a Marketplace plan, and you aren't eligible for a premium tax credit or other
Brother-in-law/sister-in-law
savings.
Daughter-in-law/son-in-law
You can't drop Medicare and enroll in a Marketplace plan without significant penalties (including losing retiree or
Mother-in-law/father-in-law
disability Social Security/Railroad Retirement benefits, and having to pay back any Social Security/Railroad Retirement
Other relative
benefits and Medicare claims payments you've received).
Other unrelated
If you pay a premium for Medicare Part A (Hospital Insurance): You can drop your Part A coverage (and Part B (Medical 8. This person is [Spouse of application filer FNLNS's]: [drop-down, single
Insurance), if you have it) and enro
selection]*
Parent (including adoptive parent)
Stepparent
Parent's domestic partner
Son/daughter (including adopted child)
Stepson/stepdaughter
Child of domestic partner (including adopted & step child)
Brother/sister (including half & step sibling)
Uncle/aunt
Nephew/niece
First cousin
Grandparent
Grandchild
Brother-in-law/sister-in-law
Daughter-in-law/son-in-law
Mother-in-law/father-in-law
Other relative
Other unrelated
Warning text if consumer attests a parent is younger than their child: Are you sure [parent FNLNS] is [child FNLNS's]
parent? You told us [parent FNLNS] is [child FNLNS's] parent, even though [parent FNLNS] is younger than [child
FNLNS]. If that's not right, please change their relationship above.

Warning text if consumer attests a child is older than their parent: Are you sure [child FNLNS] is [parent FNLNS's] child?
You told us [child FNLNS] is [parent FNLNS's] child, even though [child FNLNS] is older than [parent FNLNS]. If that's not
right, please change their relationship above.
Help Text if consumer over 65 added as applicant: If [FNLNS] has Medicare, they can enroll in a Marketplace plan but
aren't eligible for a premium tax credit or extra savings. [FNLNS] would have to pay full price for a Marketplace plan.

Answer Fields
1. Required
2. Required
3. Required
4. Required
5. Required
6. Required
7. Required
8. Required (When the application filer adds a
spouse or domestic partner that is applying
for coverage and adds someone else
applying for coverage)
9. Required (When there are additional
applicants)

Answer Fields
1. Required
2. Optional
3. Required
4. Optional
5. Required
6. Required
7. Required
8. Required (When the application filer adds a
spouse or domestic partner that is applying for
coverage and adds someone else applying for
coverage)
9. Required (When there are additional
applicants)

Display answer fields 1-7 for every applicant. Display answer field 8 when the application filer
attests to having a spouse or domestic partner applying for coverage and adds someone else
applying for coverage. Display answer field 9 when more than other person is applying for
coverage.

1. firstName
2. middleName
3. lastName
4. suffix
5. birthDate
There may only be one Spouse or one Domestic Partner relationship to the application filer and to 6. sex
all other household members. If "Spouse" is selected, "Spouse" AND "Domestic Partner" should
7., 8., and 9. familyRelationships
not display as relationship options for additional applicants, if any. If "Domestic Partner" is selected 9. householdContactIndicator
instead of "Spouse", "Spouse" AND "Domestic Partner" should not display as relationship options
If the consumer is the household contact, the householdContactIndicator should be set to true. For all
for additional applicants, if any.
other application members, this must be set to false.
10. maritalStatus

1. member
2. member
3. member
4. member
5. member
6. member
7., 8., and 9.
household
9. application
10. member
11. member

1. string
2. string
3. string
4. enum
5. string
6. enum
7., 8., and 9. enum
9. boolean
10. enum
11. boolean

Required (if QHP eligible)

Optional

Display the corresponding legal relationship options when the selected relationship between
legalRelationships
[applicant FNLNS] and [applicant FNLNS] is grandparent, grandchild, uncle/aunt,
niece/nephew, first cousin, brother/sister, domestic partner, parent's domestic partner, or child's
domestic partner, OR other relative OR is the son/daughter or stepson/stepdaughter of another
applicant and is at least 25 years old OR is the parent or stepparent of another applicant who is at
least 25 years old

Household

array, enum

Legal relationships are required in certain cases for determining
allowable QHP enrollment groupings.

N/A

N/A

N/A

N/A

If a spouse is added, set maritalStatus to married for both the household contact and the spouse.
11. Set requestingCoverageIndicator = true for each applicant added

The flow of adding an applicant is flexible and information collected from
each applicant may be done throughout the application. It is
recommended to ask for relationship to application filer up front, but
relationship information may be collected in a different format/section.

Flexible. The question wording must include "sex" and may not include
"gender".

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer
DOB: Flexible in the way the application collects the DOB. May collect DOB
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a DOB.
Sex: Answer format is flexible. Female and Male must be used as answer options.
Family Relationship: The answer format (i.e., toggle button, drop-down, etc.) for
the family relationship is flexible as long as all answer options are presented to the
consumer. Answer options wording may be altered for compatibility with
alternate wording. For example, child or son/daughter may be used for the
relationship. There can only be one spouse OR one domestic partner relationship
per consumer.

Flexible. Relationships may be collected in either direction.

Answer format is flexible. Answer options must be exact.

The application must give consumers the ability to remove a member or change The option to remove a member should be in the same place where
Applicants can be removed through back navigation prior to
members are added. It can also be an option at the beginning of a
application submission, or on a Change in Circumstance application. If whether the member is requesting coverage.
Change in Circumstance application if the consumer indicates they want
an applicant wants to terminate their coverage but is still a member of
to re-enter the application to remove someone.
the household, it is not necessary to call Remove Member; instead, the
consumer should change to "not requesting coverage". However, if an
applicant is no longer a member of the household, Remove Member
should be called so the rest of the household members receive a new
eligibility determination. The UI must have the option to provide a
reason for the member's removal. The removal reason is collected so
that retroactive termination can be facilitated if appropriate and when
the functionality is available.

Wording is flexible.

Format and wording of answer options is flexible, as long as the consumer has a
pathway to change an applicant to a non-applicant, as well as a pathway to
remove a member from the household completely.

Wording must be similar. The application only needs to collect
information about marriages as legally defined by IRS (can't be grouped
with domestic partnerships, etc.).

Answer format is flexible. Answer options may be altered for compatibility with
question wording. If the answer options are altered, the help text should align with
the answer options (i.e., if a DE entity uses "not married" in place of "single", the
help text should be updated to "not married".)

Sex can be collected here or later in the application, but before the
pregnancy question.
Relationships between all QHP eligible applicants and the subscriber are
required for enrollment grouping, but may be collected at any time
before application submission if not required earlier (such as to determine
Medicaid household composition).

*only displayed when the application filer attests to having a spouse/domestic
partner applying for coverage
9. This person is [Other existing applicant FNLNS's]: [drop-down, single selection]*
Spouse
Domestic Partner
Parent (including adoptive parent)
Stepparent
Parent's domestic partner
Son/daughter (including adopted child)
Stepson/stepdaughter
Child of domestic partner (including adopted & step child)
Brother/sister(including half & step sibling)
Uncle/aunt
Nephew/niece
First cousin
Grandparent
Grandchild
Brother-in-law/sister-in-law
Daughter-in-law/son-in-law
Mother-in-law/father-in-law
Other relative
Other unrelated
*only displayed when there are others added as applicants at this point in the
application

271

272

Household Composition*

Household Composition*

Phase 3

Phase 1, Phase 2, Phase 3

Choose the statement that best describes the legal
relationship between [applicant FNLNS] and [applicant
FNLNS], if any apply.

Remove, or change coverage needs?

How is this person related to [Application filer FNLNS]? How is this
person related to [Application filer's spouse or domestic partner
applying for coverage FNLNS]? OR How is this person related to
[Application filer's other dependent applying for coverage FNLNS]?
Selected a relationship that requires collection of legal relationships
(see item #24 on Backend Responses for UI tab for relationships that
require this)

N/A

Help Drawer: Learn more about legal relationships.
Choose the option that best describes the legal relationship.
Here's some more information about a few of these relationships:
Foster child: A foster child is a person up to age 21 who’s been placed in an institution, group home, or private home of a
state-certified caregiver referred to as a "foster parent" by the state. In some cases, a child living with someone under a
pre-adoption agreement may qualify as a foster child.
Collateral dependent: Select this for a relative by blood or marriage who lives in the home and is dependent on another
person for a major portion of their support.
Sponsored dependent: A person between 19-25 that relies on another adult for support, and isn’t attending school. (Note:
Health plans may define the age range differently.)
Ward: Select this for a person who’s under the care or responsibility of a parent or court-appointed guardian. Wards may
be either minor children or disabled adults.
Guardian: Select this for a person who's responsible for the care and management of a minor child.
Court-appointed guardian: Select this for an adult who's been given legal responsibility by the court to manage the affairs
of another person. Usually this is an adult who's given legal responsibility to care for a child by the court, but the guardian
can also be an adult with legal responsibility to manage the affairs of another adult.
Former spouse: Select this for an ex-wife or ex-husband.
None of these relationships.

Help Drawer: Learn more about removing a person.
Remember, we may need information about all of the people in the household, even those who don’t need health
coverage. It’s a good idea to include all household members on the application, so you don’t have to add them back
later.

If applicant is the grandparent, grandchild, uncle/aunt, niece/nephew, first
cousin, brother/sister, domestic partner, parent's domestic partner, or child's
domestic partner of another applicant display the following answer options:
[Drop-down, single-selection]
Collateral dependent
Sponsored dependent
Court appointed guardian
Guardian
Ward
None of the above
If applicant is the other relative OR is the son/daughter or stepson/stepdaughter of
another applicant and is at least 25 years old OR is the parent or stepparent of
another applicant who is at least 25 years old display the following answer options:
[Drop-down, single-selection]
Collateral dependent
Sponsored dependent
Court appointed guardian
Former spouse
Foster child
Guardian
Ward
None of the above

[Radio buttons]
[Display applicants added in Item #28 for Phase 1 and Phase 2 applications, or Item
#30 for Phase 3 applications]
None of these people listed above

Required

Required

Consumer is requesting coverage AND consumer is not the application filer AND consumer was
added to the application in Item #30 or Item #28

N/A

Required

Required

Consumer is requesting coverage AND consumer is not the application filer AND consumer was
If Remove from application selected:
added to the application in item #30 or Item #28 AND name was selected for wishing to remove or removeMembers:
change coverage needs
memberIdentifier to the identifier of the selected applicant, in a call to the Remove Member API.

Select “Remove” next to a person’s name to completely remove them from the application.

273

Household Composition*

Phase 1, Phase 2, Phase 3

Remove [FNLNS], or keep [him/her] on the application and Remove, or change coverage needs? Applicant name selected
change [his/her] coverage needs?

Relationships may be collected in either direction and may be collected later in
Legal relationships should be populated after the collection of familial
the application, when tax household information is collected. Legal relationships relationships, if needed. Legal relationships may be collected after the
are only required for a subset of applicants as determined by the Update App
preliminary eligibility determination to limit to QHP eligible applicants, if
response.
desired.

See item #24 on the "Backend Responses for UI" tab

If a person doesn’t have “Remove” next to their name
-Contact person: You can’t remove the contact person If you need to change who you named as the contact person
Alert message if removing someone from the application: Some of this person’s information, like their income or whether [Radio buttons]
they claim dependents, may still be needed to determine eligibility for tax credits or other savings.
Remove [FNLNS] from the application
Change [FNLNS]'s status to "Doesn't need coverage" and keep [him/her] on the
If you're seeking help paying for coverage, and [FNLNS] will be included on the tax return of someone on this application, application
keep them on the application by selecting the option above.

If change status selected:
set requestingCoverageIndicator to false for selected applicant

If you think that might be the case, it's a good idea to keep them on the application and change their coverage needs
instead. To do this, select the option above to change their status.
Help Drawer: Learn more about why a person's information may still be needed.
When you apply for help paying for coverage, we ask for information about everyone on the tax return so we can
determine eligibility for tax credits or other savings. In some cases, we may also ask about the household members who
aren't on the tax return. If you're removing a person from this application and they're not on the tax return of anyone on
this application, it's okay to remove them. If their information will be included on the tax return of someone on this
application, you should keep them on this application. If you remove them, you may have to go back and add them
274

Household Composition*

Phase 1, Phase 2, Phase 3

Why are you removing [FNLNS] from the application?

Remove [FNLNS], or keep [him/her] on the application and change
[his/her] coverage needs? Remove [FNLNS] from the application

N/A

[Radio Buttons]
1. Death
1a. if selected: Date of Death: MM/DD/YYYY
2. Divorce
2a. if selected: Date of Divorce: MM/DD/YYYY
3. Other

1. Required
1a. Required
2. Required
2a. Required
3. Required

1. Required
1a. Required
2. Required
2a. Optional
3. Required

Consumer is requesting coverage AND consumer is not the application filer AND consumer was
removalReasonType
added to the application in item #30 or Item #28 AND name was selected for wishing to remove or deathDate
change coverage needs AND "Remove" was selected for item 273
divorceDate

N/A

1. enum
2. string
3. string

76

Household Composition*

Phase 3

What's [FNLNS]'s marital status?

N/A

Help Drawer: Learn more about marital status.
Find this person’s situation to see how to answer this question:

[Radio buttons]
Single
Married

Required

Required

Consumer is requesting financial assistance AND marital status is unknown AND consumer is the
application filer OR consumer is requesting coverage and over age 14

Member

enum

Marital status impacts household size/composition for Medicaid, CHIP,
and APTC.

The application must collect information on if each applicant is married, and if
any non-applicant who is claiming an applicant as a dependent is married. The
application must not restrict consumers from indicating that someone is their
spouse when the person is of the same sex. The application may choose to only
request marital status of consumers who are over the age of 14. If the
application does not request marital status for consumers aged 14 or younger,
SES will assume they are unmarried. (note that this age threshold may be
updated, and will be available through the system configuration data API).

For Medicaid and CHIP eligibility, a married applicant's household size
will always include their spouse if they are living together, even if they
are not filing a joint tax return.

Information about the applicant's spouse must be collected at some point in the This information must be collected within the household composition set. Flexible.
application. The application will need to determine if the applicant is married to The partner can ask this question upfront for applicants, or wait until after
someone on the application or someone else not on the application. If someone the consumer has indicated they will file a joint federal tax return.
else not on the application, the application must collect their name, date of
Household composition questions must be asked prior to the preliminary
birth and whether or not they live together
eligibility determination
Information about the applicant's spouse must be collected at some point in the This information must be collected within the household composition set. Flexible.
application. Information about a non-applicant spouse is required if the spouse is Household composition questions must be asked prior to the preliminary
either part of the applicant's tax or Medicaid household.
eligibility determination.

Is legally married.
Select “Married.”

If yes, set the following:
maritalStatus = married
If no, set the following:
maritalStatus = unmarried

Is separated, but not divorced.
Select “Married.”

This information must be collected within the household composition set.
Within the question set for household composition, there is flexibility for
order of questions, as long as the question is not conditionally triggered
from an answer to a previous question. Household composition questions
must be asked prior to the preliminary eligibility determination.

Is in a common law marriage.
As long as you're living together, and your marriage is recognized in the state where you live, or in the state where the
common law marriage began, select "Married."
Lives with their partner, but isn’t legally married.
Select “Single.”
Is a victim of domestic violence or spousal abandonment. Spousal abandonment means this person can’t locate their
spouse after making a reasonable attempt to find them, also known as desertion.
Select “Single.”
Is widowed.
Select “Single.”
77

Household Composition*

Phase 3

Who is [FNLNS]'s spouse?

What's [FNLNS]'s marital status? Married

78

Household Composition*

Phase 3

Enter [FNLNS]'s spouse's information.

Who is [FNLNS]'s spouse? Someone else who isn't applying for health N/A
coverage

81

Household Composition*

Phase 3

Does [FNLNS] plan to file a joint federal income tax return
with [his/her] spouse for [coverage year]?

What's [FNLNS]'s marital status? Married

N/A

Help Drawer: Learn more about joint tax filing.
Which tax year?
The tax return for 2019 [coverage year] means the federal income tax return on which these people report their income
in 2019 [coverage year]. Most people file this return during 2020 [calendar year following coverage year].

[Drop-down, single-selection]
Unmarried household member names who are over 14 years of age
Someone else who isn't applying for health coverage

Required

Required

Consumer is requesting financial assistance AND marital status is unknown AND consumer is the
application filer OR consumer is requesting coverage and over age 14 AND answered "Yes" for "Is
[FNLNS] married?"

If the name of an applicant is selected, set the familyRelationships to spouse for the relationship
between the two application members.

Member

enum

Answer Fields:
1. First Name: [Open text field]
2. Middle Name: [Open text field]
3. Last Name: [Open text field]
4. Suffix: [drop-down, single selection]: Jr., Sr., III, IV
5. DOB: [Open text field]:YYYY-MM-DD
6. Sex: [drop-down, single selection]: Male, Female

1. Required
2. Required
3. Required
4. Required
5. Required
6. Required

1. Required
2. Optional
3. Required
4. Optional
5. Required
6. Required

Consumer is requesting financial assistance AND answered "Yes" for "Is [FNLNS] married?" AND
selected "Someone else who isn't applying for health coverage" for "Who is [FNLNS]'s spouse?"

1. firstName
2. middleName
3. lastName
4. suffix
5. birthDate
6. householdContactIndicator = false
7. requestingCoverageIndicator = false
8. familyRelationships = spouse
9. sex

1. member
2. member
3. member
4. member
5. member
6. application
7. member
8. member
9. member

1. string
2. string
3. string
4. enum
5. string
6. boolean
7. boolean
8. enum
9. enum

[Radio buttons]
Yes
No

Required

Required

Application is requesting financial assistance AND this consumer is the application filer OR the
household member is an applicant not claimed as a dependent AND the consumer is married*
AND selected "Yes" for "Does [FNLNS] plan to file a federal income tax return for [coverage
year]?"

If yes, set the following:
1. taxReturnFilingStatusType = married filing jointly
2. taxFilerIndicator = true for the household member and their spouse
3. taxRelationships = tax filer for the household member and their spouse

1. member
2. member
3. household

1. enum
2. boolean
3. enum

*If any applicants are 14 years old or younger, the application may assume they are not married

If no, set the following:
1. taxReturnFilingStatusType = married filing separately

Application is requesting financial assistance AND this consumer is the application filer OR the
household member is an applicant not yet identified as being claimed as a dependent AND the
household member is not yet identified as a tax filer (if applicant attested to being married and
answered "No" to filing a joint tax return with spouse)

If single without dependents and consumer answers yes, set the following:
1. taxFilerIndicator = true
2. taxReturnFilingStatusType = SINGLE_FILER

Member

1. member
2. member
3. member

Who’s the “tax filer?”
The tax filer is the person who files a tax return to report their own income and their spouse’s income, and enters their
name(s) at the top of the tax return form.

Answer format is flexible. All names of unmarried applicants must display and
consumers must have an option to add a spouse not seeking coverage.

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer
DOB: Flexible in the way the application collects the DOB. May collect DOB
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a DOB.
Sex: Answer format is flexible. Female and Male must be used as answer options.

If the UI has implemented a flow where it first determines an applicant does not
file taxes with their spouse and does not live with their spouse, then the UI has
flexibility to omit this question.

The UI may collect information on the non-applicant spouse either
before or after collecting the consumer's tax filing and living situation
information.

Filing jointly status impacts household size/composition for Medicaid,
CHIP, and APTC. Consumers who are married and use the Married
Filing Separately status on their federal return are ineligible for APTC.

For married applicants who attest to filing a tax return, as well as married nonapplicant tax filers claiming an applicant as a dependent, the application must
include this question because it is a factor of eligibility for APTC. However, the
application can also include a question about head of household tax filing status
for consumers who attest that they are married and not living with spouse and
claiming dependents. It is important to include a caution though that not
everyone is eligible to use the tax status of "head of household" even if they
consider themselves to be the head of the household as used colloquially.

This information must be collected within the household composition set.
Within the question set for household composition, there is flexibility for
order of questions, as long as the question is not conditionally triggered
from an answer to a previous question. Household composition questions
must be asked prior to the preliminary eligibility determination.

1. boolean
2. enum

If a consumer does not plan to file a tax return, he or she will not be
eligible for APTC. In addition, whether or not a consumer will file a tax
return has an impact on Medicaid/CHIP household composition/size.

Consumers who do not plan to file a tax return must be able to continue with the This question may be asked after the household contact indicated they
Wording must be similar. It is required to ask this question about the tax
application and receive an eligibility determination. It is crucial to determine the are seeking financial assistance. The application could start by asking this return that will be filed for the coverage year; not the last year (and not
tax filing status of applicants. If an applicant has been identified as a tax
question of the household contact, since it is very likely they are also the the current year if applying for future year coverage during open
dependent, you do not need to ask whether he or she also will file their own tax
family's tax filer, or the application could start by asking this type of
enrollment).
return.
question for the first applicant listed, or the oldest applicant, etc., as long
as the tax filing status of every applicant is eventually determined and the
claiming tax filer for any applicant claimed as a dependent is identified.
Household composition questions must be asked prior to the preliminary
eligibility determination.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

1. boolean
2. boolean
3. enum

Tax dependents impact household size/composition for Medicaid,
CHIP, and APTC.

Questions about tax dependents some point in the household composition flow.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Wording must be similar and must conform with IRS terminology.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Why we need this information
If spouses files taxes, we need to know about who they claim as dependents, if anyone. Married spouses who file a joint
tax return will be eligible for a premium tax credit and other savings if they qualify based on their income and other
factors.
Alert text if applicant is not filing jointly: If these spouses plan to file separate tax returns for [coverage year], they won't
be eligible to get premium tax credits or other savings, unless they meet certain exceptions. But, they can still get free or
low-cost health coverage if they qualify for Medicaid or the Children's Health Insurance Program (CHIP).
Help text if applicant is not filing jointly: Learn more about filing taxes separately
If these spouses plan to file separate tax returns for [coverage year], they won't be eligible to get premium tax credits or
other savings, unless they meet certain exceptions. But, they can still get free or low-cost health coverage if they qualify
for Medicaid or the Children's Health Insurance Program (CHIP).

80

Household Composition*

Phase 3

Does [FNLNS] plan to file a federal income tax return for
What's [FNLNS]'s marital status? Single
[coverage year]? You don’t have to file taxes to apply for
OR
coverage, but you'll need to file next year if you want to get Does [FNLNS] plan to file a joint federal income tax return with
a premium tax credit to help pay for coverage now.
[his/her] spouse for coverage]? No

Help Drawer: Learn more about joint tax filing.
Which tax year?
The tax return for 2019 [coverage year] means the federal income tax return on which these people report their income
in 2019 [coverage year]. Most people file this return during 2020 [calendar year following coverage year].

[Radio buttons]
Yes
No

Required

Required

Who’s the “tax filer?”
The tax filer is the person who files a tax return to report their own income and their spouse’s income, and enters their
name(s) at the top of the tax return form.

If single with dependents and consumer answers yes, set the following:
1. taxFilerIndicator = true
2. taxReturnFilingStatusType = SINGLE_FILER
If consumer answers no, set the following:
1. taxFilerIndicator = false

Why we need this information
If spouses files taxes, we need to know about who they claim as dependents, if anyone. Married spouses who file a joint
tax return will be eligible for a premium tax credit and other savings if they qualify based on their income and other
factors.
Alert text if applicant is not filing jointly: If these spouses plan to file separate tax returns for [coverage year], they won't
be eligible to get premium tax credits or other savings, unless they meet certain exceptions. But, they can still get free or
low-cost health coverage if they qualify for Medicaid or the Children's Health Insurance Program (CHIP).
Help text if applicant is not filing jointly: Learn more about filing taxes separately
If these spouses plan to file separate tax returns for [coverage year], they won't be eligible to get premium tax credits or
other savings, unless they meet certain exceptions. But, they can still get free or low-cost health coverage if they qualify
for Medicaid or the Children's Health Insurance Program (CHIP).
82

Household Composition*

Phase 3

Will [FNLNS] [and spouse name (if married and filing jointly)] Does [FNLNS] plan to file a federal income tax return for [coverage
claim any dependents on [his/her/their joint] federal income year]? Yes
tax return for [coverage year]?
OR
Does [FNLNS] plan to file a joint federal income tax return with
[his/her] spouse for [coverage year]? Yes

Help Drawer: Learn more about dependents
If this person claims someone as a dependent on their taxes, select or add their name(s) here. A dependent is someone
who gets most of their financial support from the person filing the tax return. Children, other family members, or other
people who live with the tax filer can be dependents.
Most tax filers claim their own children as their dependents if the children are 19 or younger, full-time students younger
than 25, or are disabled. Tax filers also might claim other people as dependents when they pay for most of their costs, like
housing, food, and clothing.
Be sure to select these people as dependents, if they will be claimed by the tax filer:
A dependent child, stepchild, foster child, or adopted child
A child this person has shared custody of
A dependent parent
A dependent sibling or other relative
An unmarried domestic partner
You don't need to select the name of a child you expect to be born.
[Learn more about who can be claimed as a tax dependent from the IRS](https://www.irs.gov/help/ita/whom-may-iclaim-as-a-dependent).
Sometimes dependents change
Dependents can change from year to year if:
Parents alternate claiming children as dependents.
A child turns 19 or 25 and won't be claimed.
A dependent moves out of the home and won't live with the tax filer.
A dependent has a new job and will support his or herself.
When dependents change
If you're not sure about changes now, like if a person's dependent may be born or become deceased, you can come back
and report the change when it happens.

[Radio buttons]
Yes
No

Required

Required if taxFilerIndicator = true

Consumer is requesting coverage AND requesting financial assistance AND answered "Yes" for
"Does [FNLNS] plan to file a federal income tax return for [coverage year]?"
Display spouse name in the question if the consumer is requesting coverage AND answered "Yes"
for "Does [FNLNS] plan to file a federal income tax return for [coverage year]?" AND answered
"Yes" to "Does [FNLNS] plan to file a joint federal income tax return with [his/her] spouse for
[coverage year]?"

If yes, set the following:
1. claimsDependentIndicator = true for both household member and spouse if married filing jointly
2. taxDependentIndicator = false for both the household member and spouse if married filing jointly
If no, set the following:
1. claimsDependentIndicator = false for both household member and spouse if married filing jointly
If the person is a single filer and they answer yes, set the following:
3. taxReturnFilingStatusType = head of household
If the person is a single filer and they answer no, set the following:
3. taxReturnFilingStatusType = single filer

If a tax dependent is claimed by a tax filer who is not his or her parent,
then different rules apply for determining Medicaid/CHIP household
size/composition.
In some cases, the legal relationship will also be collected between the
tax filer and their claimed dependent-- if they are both applicants, and
it was not collected in item 271.

This information must be collected within the household composition set.
Within the question set for household composition, there is flexibility for
order of questions, as long as the question is not conditionally triggered
from an answer to a previous question. Household composition questions
must be asked prior to the preliminary eligibility determination.

Flexible.

Notes

Auditor Compliance
Conclusion**

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor
Comments**

Item #

83

Application Section
* indicates features of this question may be
updated in future documentation

Applicable EDE Phase**

Question**

Answers to Previous Questions**

Household Composition*

Phase 3

Who are [FNLNS]'s [and spouse name (if married filing
jointly)] dependents?

Will [FNLNS] [and spouse name (if married and filing jointly)] claim
N/A
any dependents on [his/her/their joint] federal income tax return for
[coverage year]? Yes

Informational Text**

Answer Options and Format**

Required/Optional to Display Question or
Corresponding Answer Fields to Collect
Information in Application UI**

[Checkboxes, multi-selection]
Display all other applicant names
Display known non-applicant names
Someone else not applying for coverage

Required

Required/Optional for Consumer to Provide
Answer to Send to SES**
*if optional, consumer must be able to
ith t
idi
i UI
ti
Required

Conditional Display Logic in the UI**

Data Element(s) Name

Consumer is requesting coverage AND requesting financial assistance AND answered "Yes" for
If a name is selected, set the following for each selected dependent name:
"Does [FNLNS] plan to file a federal income tax return for [coverage year]?" AND answered "Yes" 1. taxDependentIndicator = true
for "Will [FNLNS] [and spouse name (if married and filing jointly)] claim any dependents on
2. taxRelationships = tax dependent
[his/her/their joint] federal income tax return for [coverage year]?"
3. taxFilerIndicator = false

Attestation Level

Data Element
Format

General Requirements**

Question Flow Requirements**

Question/Informational Text Wording Requirements**

Answer Options and Format Requirements**

1. member
2. household
3. member

1. boolean
2. enum
3. boolean

Policy**

Questions about tax dependents must be asked at some point in the household
composition flow.

This information must be collected within the household composition set.
Within the question set for household composition, there is flexibility for
order of questions, as long as the question is not conditionally triggered
from an answer to a previous question. Household composition questions
must be asked prior to the preliminary eligibility determination.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Questions about tax dependents must be asked at some point in the household
composition flow.

This information must be collected within the household composition set.
Within the question set for household composition, the order of questions
is flexible, as long as the question is not conditionally triggered from an
answer to a previous question. Household composition questions must be
asked prior to the preliminary eligibility determination.

Flexible. Relationships may be collected in either direction (filer to
dependent or dependent to filer).

Family Relationship: Family Relationship: The answer format (i.e., toggle button,
drop-down, etc.) for the family relationship is flexible as long as all answer options
are presented to the consumer. Answer options wording may be altered for
compatibility with alternate wording. For example, child or son/daughter may be
used for the relationship. There can only be one spouse OR one domestic partner
relationship per consumer.
First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer
DOB: Flexible in the way the application collects the DOB. May collect DOB
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a DOB.
Sex: Answer format is flexible. Female and Male must be used as answer options.

Any applicant who does not claim a tax dependent must be asked whether he or This information must be collected within the household composition set.
she will be claimed as a tax dependent. This question must be asked even when Within the question set for household composition, there is flexibility for
the applicant is filing a tax return themselves, because many tax dependents
order of questions, as long as the question is not conditionally triggered
also file their own tax returns.
from an answer to a previous question. Household composition questions
must be asked prior to the preliminary eligibility determination.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

If a name is selected, and the consumer is single, or married filing separately set the following for the
household contact:
2. taxRelationships = tax filer
If a name is selected and the consumer is married filing jointly set the following for both the spouse and
household contact:
2. taxRelationships = tax filer

84

Household Composition*

Phase 3

Enter dependent information

Who are [FNLNS] [and spouse name (if married filing jointly)]
dependents? Someone else not applying for coverage

N/A

Answer Fields
1. How is this person related to [FNLNS]?
[Drop-down, single-selection]
Spouse
Parent
Son/daughter (including adopted children)
Stepson/stepdaughter
Grandchild
Brother/sister (including half and step siblings)
Domestic partner
Stepparent
Uncle/aunt
Nephew/niece
Grandparent
First cousin
Parent's domestic partner
Child of domestic partner
Brother-in-law/sister-in-law
Daughter-in-law/son-in-law
Mother-in-law/father-in-law
Other relative
Unrelated
2. How is this person related to [Application filer's spouse FNLNS (if married filing
jointly)?
Parent
Son/daughter (including adopted & children)
Stepson/stepdaughter
Grandchild
Brother/sister (including half and step siblings)
Stepbrother/stepsister
Domestic partner
Stepparent
Uncle/aunt
Nephew/niece
Grandparent
First cousin
Parent's domestic partner
Child of domestic partner
Brother-in-law/sister-in-law
Daughter-in-law/son-in-law
Mother-in-law/father-in-law
Other relative
Unrelated
3. How is this person related to [Application filer's other tax dependent FNLNS] (if
Application filer claims more than one tax dependent)?*
Parent
Son/daughter (including adopted & children)
Stepson/stepdaughter
Grandchild
Brother/sister (including half and step siblings)
Stepbrother/stepsister
Domestic partner
Stepparent
Uncle/aunt
Nephew/niece
Grandparent
First cousin
Parent's domestic partner
Child of domestic partner
Brother-in-law/sister-in-law
Daughter-in-law/son-in-law
Mother-in-law/father-in-law
Other relative
Unrelated
4. First Name: [Open text field]
5. Middle Name: [Open text field]
6. Last Name: [Open text field]
7. Suffix: [Drop-down, single-selection] Jr., Sr., III, IV
8. DOB: [Open text field] YYYY-MM-DD
9. Sex: [drop-down, single selection]: Male, Female
9. 10. Add another dependent (Display as button.)

1. Required
2. Required
3. Required
4. Required
5. Required
6. Required
7. Required
8. Required
9. Required
9. 10. Required

1. Required
2. Required
3. Required
4. Required
5. Optional
6. Required
7. Optional
8. Required
9. Required
9. 10. N/A

1., 2., and 3. familyRelationships
Only display answer field 3 when the tax filer adds more than one tax dependent.
4. firstName
Consumer is requesting coverage AND requesting financial assistance AND answered "Yes" for
5. middleName
"Does [FNLNS] plan to file a federal income tax return for [coverage year]?" OR answered "Yes" 6. lastName
for "Does [FNLNS] plan to file a joint federal income tax return with [his/her] spouse for [coverage 7. suffix
year]?" AND answered "Yes" for "Will [FNLNS] [and spouse name (if married and filing jointly)]
8. birthDate
claim any dependents on [his/her/their joint] federal income tax return for [coverage year]?"
9. sex
AND selected "Someone else" for "Who are [FNLNS]'s [and spouse name (if married filing jointly)]
For each dependent added, set the following:
dependents?"
9. 10. taxDependentIndicator = true
There may only be one Spouse or one Domestic Partner relationship to the application filer and to 10. 11. taxRelationships = tax dependent
11. 12. householdContactIndicator = false
all other household members. If "Spouse" is selected, "Spouse" AND "Domestic Partner" should
not display as relationship options for additional applicants, if any. If "Domestic Partner" is selected 12. 13. requestingCoverageIndicator = false
instead of "Spouse", "Spouse" AND "Domestic Partner" should not display as relationship options
for additional applicants, if any.

1., 2., and 3.
household
4. member
5. member
6. member
7. member
8. member
9. member
9. 10. member
10. 11. household
11. 12. application
12. 13. member

1., 2., and 3. array,
enum
4. string
5. string
6. string
7. enum
8. string
9. enum
9. 10. boolean
10. 11. enum
11. 12. boolean
12. 13. boolean

Required

Required

Consumer is requesting coverage AND requesting financial assistance AND consumer is not listed
as a tax filer filing married filing jointly AND consumer is not listed as a tax dependent AND
consumer is not a tax filer who is claiming other tax dependents

Member

boolean

Relationships may be collected in either direction (filer to dependent or
dependent to filer) and may be collected earlier in the application.

Familial relationships between tax filers and tax dependents may be
collected at any point in the application prior to the preliminary eligibility
determination, as long as the application is sequenced such that
subsequent questions about Medicaid household and/or legal relationships
can be populated if needed. Household composition questions must be
asked prior to the preliminary eligibility determination.

*Only display answer field 3 if consumer opts to add another tax dependent.
Display all other answer fields if consumer opts to add another tax dependent.

90

Household Composition*

Phase 3

Will [FNLNS] be claimed as a dependent on someone else's
tax return for [coverage year]?

Does [FNLNS] plan to file a federal income tax return for [coverage
year]? No
OR

Help Drawer: Learn more about dependents
If this person claims someone as a dependent on their taxes, select or add their name(s) here. A dependent is someone
who gets most of their financial support from the person filing the tax return. Children, other family members, or other
people who live with the tax filer can be dependents.

(Does [FNLNS] plan to file a federal income tax return for [coverage Most tax filers claim their own children as their dependents if the children are 19 or younger, full-time students younger
year]? Yes
than 25, or are disabled. Tax filers also might claim other people as dependents when they pay for most of their costs, like
AND
housing, food, and clothing.
Will [FNLNS] claim any dependents on [his/her/their joint] federal
Be sure to select these people as dependents, if they will be claimed by the tax filer:
income tax return for [coverage year]? No)
OR
(Does [FNLNS] plan to file a joint federal income tax return with
[his/her] spouse for coverage]? No
AND
Will [FNLNS] claim any dependents on [his/her/their joint] federal
income tax return for [coverage year]? No)

[Radio buttons]
Yes
No
*If "Yes" selected and household contact is a non-applicant, then he/she is finished
with this section.
If "No" selected and household contact is a tax filer, then he/she is finished with this
section.

taxDependentIndicator
If yes is selected, set taxDependentIndicator = true

Tax dependency impacts household size/composition for Medicaid,
CHIP, and APTC.

If no is selected, set taxDependentIndicator = false

A dependent child, stepchild, foster child, or adopted child
A child this person has shared custody of
A dependent parent
A dependent sibling or other relative
An unmarried domestic partner
You don't need to select the name of a child you expect to be born.
[Learn more about who can be claimed as a tax dependent from the IRS] (Link to: https://www.irs.gov/help/ita/whommay-i-claim-as-a-dependent).
Sometimes dependents change
Dependents can change from year to year if:
Parents alternate claiming children as dependents.
A child turns 19 or 25 and won't be claimed.
A dependent moves out of the home and won't live with the tax filer.
A dependent has a new job and will support his or herself.
When dependents change
If you're not sure about changes now, like if a person's dependent may be born or become deceased, you can come back
and report the change when it happens.

91

Household Composition*

Phase 3

Who is the tax filer that will claim [FNLNS] on their income
tax return?

Will [FNLNS] be claimed as a dependent on someone else's tax
return for [coverage year]? Yes

N/A

[Radio buttons]
Display all household members
Someone else who isn't applying for health coverage

Required

Required

Consumer is requesting coverage AND requesting financial assistance AND consumer is not listed
as a tax filer filing married filing jointly AND consumer is not listed as a tax dependent AND
consumer is not a tax filer who is claiming other tax dependents AND consumer selected "Yes" for
"Will [FNLNS] be claimed as a dependent on someone else's tax return for [coverage year]?"

1. member
2. member
3. household
4. member
5. member

1. boolean
2. boolean
3. enum
4. boolean
5. boolean

This information must be collected within the household composition set.
Within the question set for household composition, there is flexibility for
order of questions, as long as the question is not conditionally triggered
from an answer to a previous question. Household composition questions
must be asked prior to the preliminary eligibility determination.

302

Household Composition*

Phase 3

How is this person related to [Dependent FNLNS]?

Who is the tax filer that will claim [FNLNS] on their income tax
return? Someone else who isn't applying for health coverage (Item
#91)

N/A

Answer Fields
How is this person related to [Dependent FNLNS]?
Spouse
Parent
Son/daughter (including adopted children)
Stepson/stepdaughter
Grandchild
Brother/sister (including half and step siblings)
Domestic partner
Stepparent
Uncle/aunt
Nephew/niece
Grandparent
First cousin
Parent's domestic partner
Child of domestic partner
Brother-in-law/sister-in-law
Daughter-in-law/son-in-law
Mother-in-law/father-in-law
Other relative
Unrelated

Required

Required

Consumer is requesting coverage AND requesting financial assistance AND consumer is not listed familyRelationships
as a tax filer filing married filing jointly AND consumer is not listed as a tax dependent AND
consumer is not a tax filer who is claiming other tax dependents AND consumer selected "Yes" for
"Will [FNLNS] be claimed as a dependent on someone else's tax return for [coverage year]?" AND
selected "Someone else who isn't applying for health coverage" for "Who is the tax filer that will
claim [FNLNS] on their income tax return?"

member

array, enum

This information must be collected within the household composition set. Flexible. (Relationships may be collected in either direction (filer to
Familial relationships between tax filers and tax dependents may be
dependent or dependent to filer).
collected at any point in the application prior to the preliminary eligibility
determination, as long as the application is sequenced such that
subsequent questions about Medicaid household and/or legal relationships
can be populated if needed. Household composition questions must be
asked prior to the preliminary eligibility determination.

Family Relationship: Family Relationship: The answer format (i.e., toggle button,
drop-down, etc.) for the family relationship is flexible as long as all answer options
are presented to the consumer. Answer options wording may be altered for
compatibility with alternate wording. For example, child or son/daughter may be
used for the relationship.

92

Household Composition*

Phase 3

Enter claiming tax filer information

(How is this person related to [Dependent FNLNS]? Selected any
relationship type (Item #302) AND the dependent applicant is over
the state Medicaid age)

N/A

Answer Fields
1. First Name: [Open text field]
2. Middle Name: [Open text field]
3. Last Name: [Open text field]
4. Suffix: [Drop-down, single-selection] Jr., Sr., III, IV
5. DOB: [Open text field] YYYY-MM-DD
6. Sex: [drop-down, single selection]: Male, Female

1. Required
2. Required
3. Required
4. Required
5. Required
6. Required

1. Required
2. Optional
3. Required
4. Optional
5. Required
6. Required

Consumer is requesting coverage AND requesting financial assistance AND consumer selected
1. firstName
"Yes" for "Will [FNLNS] be claimed as a dependent on someone else's tax return for [coverage
2. middleName
year]?" AND selected "Someone else who isn't applying for health coverage" for "Who is the tax
3. lastName
filer that will claim [FNLNS] on their income tax return?" AND consumer is over the state
4. suffix
Medicaid age OR consumer is under the state Medicaid age AND relationship to claiming tax filer is 5. birthDate
parent or stepparent and it is known they live together OR consumer selected "yes" for "Do you
6. householdContactIndicator = false
want to provide more information on the person who claims [dependent FNLNS]" in Item 96
7. requestingCoverageIndicator = false
8. claimsDependentIndicator = true

1. member
2. member
3. member
4. member
5. member
6. application
7. member
8. member
9. member
10. member
11. sex

1. string
2. string
3. string
4. enum
5. string
6. boolean
7. boolean
8. boolean
9. boolean
10. enum
11. sex

This information must be collected within the household composition set. Flexible.
Within the question set for household composition, there is flexibility for
order of questions, as long as the question is not conditionally triggered
from an answer to a previous question. Familial relationships between tax
filers and tax dependents may be collected at any point in the application
prior to the preliminary eligibility determination, as long as the application
is sequenced such that subsequent questions about Medicaid household
and/or legal relationships can be populated if needed. Household
composition questions must be asked prior to the preliminary eligibility
determination.

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer
DOB: Flexible in the way the application collects the DOB. May collect DOB
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a DOB.
Sex: Answer format is flexible. Female and Male must be used as answer options.

OR
How is this person related to [Dependent FNLNS]? Selected Parent
or Stepparent and it is known they live together (Item #302)

1. claimsDependentIndicator = true
2. taxFilerIndicator = true
3. taxRelationships = tax filer between themselves and each tax dependent
4. taxDependentIndicator = false

9. taxFilerIndicator = true
10. taxRelationships = tax filer between themselves and each tax dependent
11. sex

OR
(If displayed) Does [Applicant FNLNS] live with this parent? Yes
(Item #94)
OR
(If displayed) Do you want to provide the claiming tax filer's
information, so the tax filer may apply for a tax credit? Yes (Item
#96)
275

Household Composition*

Phase 3

Is [claiming tax filer FNLNS] married?

Who is the tax filer that will claim [FNLNS] on their income tax
return? Selected existing household member (Item #91)

N/A

[Radio buttons]
Yes
No

Required

Required

Consumer is requesting coverage AND requesting financial assistance AND consumer is not listed maritalStatus
as a tax filer filing married filing jointly AND consumer is not listed as a tax dependent AND
consumer is not a tax filer who is claiming other tax dependents AND consumer selected "Yes" for
"Will [FNLNS] be claimed as a dependent on someone else's tax return for [coverage year]?" AND
selected an existing household member for "Who is the tax filer that will claim [FNLNS] on their
income tax return?" AND the marital status of the existing consumer is unknown

Member

enum

Marital status impacts household size/composition for Medicaid, CHIP,
and APTC.

94

Household Composition*

Phase 3

Does [Applicant FNLNS] live with this parent?

How is this person related to [Dependent FNLNS]? Selected Parent
or Stepparent (Item #302) and it is unknown if they live together

N/A

[Radio buttons]
Yes
No

Required

Required

Consumer is requesting coverage AND requesting financial assistance AND consumer is not a tax
filer AND consumer is a dependent under 21 AND relationship to claiming tax filer is parent or
stepparent and it is unknown if they live together

Member

1. boolean
2. boolean

If a child tax dependent is claimed by a tax filer who is a non-custodial Questions about who lives together may be asked on an as-needed basis as seen This information must be collected within the household composition set.
parent, then different rules apply for determining Medicaid/CHIP
here, or may be inferred based on information provided about who lives at
Within the question set for household composition, there is flexibility for
household size/composition and they may follow the "claimed by a non- which address, as long as information is appropriately translated into required
order of questions, as long as the question is not conditionally triggered
custodial parent" exception to follow non-filer rules.
SES data fields. When an applicant under the child age (determined by state via from an answer to a previous question. Household composition questions
the state reference data API) is claimed as a tax dependent by their parent,
must be asked prior to the preliminary eligibility determination.
In order to determine if a dependent meets an exception, if the
eligibility logic requires information about whether the child lives with the
dependent doesn't live with the parent who claims them, we need to
claiming tax filer.
find out if they live with another parent. If they do live with another
parent, then they meet the "claimed by a non-custodial parent"
These questions must be asked to determine if the consumer meets an
exception and will follow the non-filer rules. If not, they will follow the
exception to follow non-filer rules. Item #94 is asked to determine if the claiming
normal Medicaid tax dependent rules.
tax filer may be a non-custodial parent (does not live with the dependent child).
If the claiming tax filer does not live with the dependent child, Item #95 is asked
to determine if the dependent child lives with another parent and follows the
"claimed by a non-custodial parent" exception to follow non-filer rules. If the
dependent child lives with another parent, that non-applicant parent's
information is collected through Items #301 and 282.

Does [Applicant FNLNS] live with this parent? No (Item #94)

95

Household Composition*

Phase 3

If it is unknown [Dependent FNLNS] has another parent
who is not the claiming tax filer on the application:
Does [Dependent FNLNS] live with any parent or
stepparent?

96

Household Composition*

Phase 3

To determine eligibility for tax credits or free or reduced
(Does [Dependent FNLNS] live with any parent or stepparent?
cost health coverage, we need more information about the or
person who claims [Dependent FNLNS].
Does [Dependent FNLNS] live with [existing parent FNLNS]? Yes
(Item #95))
Do you want to provide more information about the person
who claims [Dependent FNLNS]?
or

If yes, set the following:
1. resideTogetherIndicator = true
If no, set the following:
1. resideTogetherIndicator = false

Help Text if applicant lives with any other parent who is not the claiming tax filer: To determine eligibility for tax credits or
free or reduced cost health coverage, we need more information about the person who claims [Dependent FNLNS].

[Radio buttons]
Yes
No

Required

Required

Consumer is requesting coverage AND requesting financial assistance AND consumer is not a tax
filer AND consumer is a dependent under 21 AND relationship to claiming tax filer is parent or
stepparent AND consumer does not live with the claiming parent or stepparent (and it is unknown
if they live with another parent or stepparent who is not the claiming the tax filer)

If it is known [Dependent FNLNS] has another parent who is not the claiming tax filer on the
application, set resideTogetherIndicator = true

Member

1. boolean
2. boolean

Warning text displayed when applicant selects "No":
Don't have this information? If you don't provide this information, [dependent FNLNS] won't be eligible for extra savings,
like a premium tax credit. But, they can still get free or low-cost health coverage if they qualify for Medicaid or the
Children's Health Insurance Program (CHIP).

[Radio buttons]
Yes
No

Required

Required

Consumer is requesting coverage AND requesting financial assistance AND consumer is not a tax
filer AND consumer is a dependent (under the state Medicaid age) AND claiming tax filer is not an
applicant, not the application filer, and not a parent/stepparent or not a custodial parent who is
living with the child

If "No" is selected and relationship to [Dependent FNLNS] is parent/stepparent, set:
claimingTaxFilerNotOnApplicationIndicator = true

Member

boolean

The application must collect information on if each applicant is married. In most This information must be collected within the household composition set.
cases, the marital status of existing household members is already collected,
Household composition questions must be asked prior to the preliminary
and in that case this question does not need to display. If the marital status of an eligibility determination.
existing household member is unknown, this question should display. The
application must not restrict consumers from indicating that someone is their
spouse when the person is of the same sex.

If it is known [Dependent FNLNS] has another parent who is
not the claiming tax filer on the application:
Does [Dependent FNLNS] live with [existing parent
FNLNS]?

If "No" is selected and relationship to [Dependent FNLNS] is not parent/stepparent, set:
taxFilerNotProvidedIndicator = true

How is this person related to [Dependent FNLNS]? Selected a
relationship other than Parent or Stepparent (Item #302)

The application includes this question so that a parent can get an
Including this question flow for applicants claimed as tax dependents by a noneligibility determination for Medicaid and CHIP for a child that they live parent or a non-custodial parent allows more flexibility for the consumers. The
with even if that child is claimed as a tax dependent by someone else
idea is that if an applicant does not have the income information for their nonwhose income won't be on the application.
parent or non-custodial parent claiming tax filer, they can apply for Medicaid
and CHIP alone without it, since it will not impact the Medicaid/CHIP eligibility
determination, which would be based in that case on only the immediate family
members living with the applicant.

Wording must be similar. The application only needs to collect
information about marriages as legally defined by IRS (can't be grouped
with domestic partnerships, etc.).

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

This information must be collected within the household composition set.
Within the question set for household composition, there is flexibility for
order of questions, as long as the question is not conditionally triggered
from an answer to a previous question. Household composition questions
must be asked prior to the preliminary eligibility determination.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

This information may be collected within the household composition
section or in a different part of the application. Household composition
questions must be asked prior to the preliminary eligibility determination.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

AND
Conditions outlined in column J are met

97

Household Composition*

Phase 3

Is the person who claims [Dependent FNLNS] married?

N/A

[Radio buttons]
Single
Married

Required

Required

Consumer is requesting coverage AND requesting financial assistance AND consumer is not a tax
filer AND consumer is a dependent AND claiming tax filer is not an applicant, not the application
filer, AND if Item 96 was displayed consumer selected "Yes" for "Do you want to provide the
claiming tax filer's information, so the tax filer may apply for a tax credit?" AND marital status of
claiming tax filer is unknown

If yes, set the following:
maritalStatus = married

98

Household Composition*

Phase 3

Does [Tax filer claiming applicant FNLNS] plan to file a joint
federal income tax return with [spouse] for [coverage
year]?

Is the person who claims [Dependent FNLNS] married? Yes
OR
Is [claiming tax filer FNLNS] married? Yes (selected in item #275)

N/A

[Radio buttons]
Yes
No

Required

Required

Consumer is requesting coverage AND requesting financial assistance AND consumer is not a tax
filer AND consumer is a dependent AND claiming tax filer is not an applicant, not the application
filer, AND if Item 96 was displayed consumer selected "Yes" for "Do you want to provide the
claiming tax filer's information, so the tax filer may apply for a tax credit?" AND claiming tax filer
is married

If yes, set the following:
1. taxReturnFilingStatusType = married filing jointly

99

Household Composition*

Phase 3

Who is [Tax filer claiming applicant FNLNS]'s spouse?

Does [Tax filer claiming applicant FNLNS] plan to file a joint federal
income tax return with [spouse] for [coverage year]? Yes

N/A

[Radio buttons]
Display household member names
Someone else

Required

Required

100

Household Composition*

Phase 3

Enter tax filer claiming applicant's spouse information

Who is [Tax filer claiming applicant FNLNS]'s spouse? Someone else

N/A

Answer Fields
1. First Name: [Open text field]
2. Middle Name: [Open text field]
3. Last Name: [Open text field]
4. Suffix: [Drop-down, single-selection] Jr., Sr., III, IV
5. DOB: [Open text field] YYYY-MM-DD
6. Sex: [drop-down, single selection]: Male, Female
6. 7. How is this person related to [Dependent FNLNS]?
[Drop-down, single-selection]
Parent
Son/daughter (including adopted children)
Stepson/stepdaughter
Grandchild
Brother/sister (including half and step siblings)
Stepbrother/stepsister
Stepparent
Uncle/aunt
Nephew/niece
Grandparent
First cousin
Parent's domestic partner
Child of domestic partner
Brother-in-law/sister-in-law
Daughter-in-law/son-in-law
Mother-in-law/father-in-law
Other relative
Unrelated

1. Required
2. Required
3. Required
4. Required
5. Required
6. Required
6. 7. Required

1. Required
2. Optional
3. Required
4. Optional
5. Required
6. Required
6. 7. Required

Who is the tax filer that will claim [FNLNS] on their income tax
return? Name selected (Item #91) or Non-applicant information
added (Item #92)
OR

Member

enum

This information must be collected within the household composition set.
Within the question set for household composition, there is flexibility for
order of questions, as long as the question is not conditionally triggered
from an answer to a previous question. Household composition questions
must be asked prior to the preliminary eligibility determination.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

1. member

1. enum

This information must be collected within the household composition set.
Within the question set for household composition, there is flexibility for
order of questions, as long as the question is not conditionally triggered
from an answer to a previous question. Household composition questions
must be asked prior to the preliminary eligibility determination.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Consumer is requesting coverage AND requesting financial assistance AND consumer is not a tax
If a household member is selected, set the following:
filer AND consumer is a dependent AND claiming tax filer is not an applicant, not the application
1. taxDependentIndicator = false for the household member and their spouse
filer, AND if Item 96 was displayed consumer selected "Yes" for "Do you want to provide the
2. taxFilerIndicator = true for the household member and their spouse
claiming tax filer's information, so the tax filer may apply for a tax credit?" AND claiming tax filer 3. taxRelationships = tax filer for the household member and their spouse
is married AND consumer selected "Yes" for "Does [Tax filer claiming applicant FNLNS] plan to file 4. claimsDependentIndicator = true for the household member and their spouse
a joint federal income tax return with [spouse] for [coverage year]?"
5. taxRelationships = tax filer for household member and their spouse

1. member
2. member
3. member
4. member
5. member

1. boolean
2. boolean
3. enum
4. boolean
5. enum

This information must be collected within the household composition set.
Within the question set for household composition, there is flexibility for
order of questions, as long as the question is not conditionally triggered
from an answer to a previous question. Household composition questions
must be asked prior to the preliminary eligibility determination.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Consumer is requesting coverage AND requesting financial assistance AND consumer is not a tax
1. firstName
filer AND consumer is a dependent AND claiming tax filer is not an applicant, not the application
2. middleName
filer, AND if Item 96 was displayed consumer selected "Yes" for "Do you want to provide the
3. lastName
claiming tax filer's information, so the tax filer may apply for a tax credit?" AND claiming tax filer 4. suffix
is married AND consumer selected "Yes" for "Does [Tax filer claiming applicant FNLNS] plan to file 5. birthDate
a joint federal income tax return with [spouse] for [coverage year]?" AND selected "Someone
6. familyRelationships
else" for "Who is [Tax filer claiming applicant FNLNS]'s spouse?"
7. householdContactIndicator = false
8. requestingCoverageIndicator = false
9. taxDependentIndicator = false
10. taxFilerIndicator = true
11. taxRelationships = tax filer
12. claimsDependentIndicator = true
13. taxRelationships = tax filer
14. sex

1. member
2. member
3. member
4. member
5. member
6. household
7. application
8. member
9. member
10. member
11. member
12. member
13. household
14. member

1. string
2. string
3. string
4. enum
5. string
6. array, enum
7. boolean
8. boolean
9. boolean
10. boolean
11. enum
12. boolean
13. enum
14. enum

This information must be collected within the household composition set.
It is a best practice to ask this question after the consumer has indicated
they will file a joint federal tax return. Household composition questions
must be asked prior to the preliminary eligibility determination.

Flexible.

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer
DOB: Flexible in the way the application collects the DOB. May collect DOB
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a DOB.
Family Relationship: The answer format (i.e., toggle button, drop-down, etc.) for
the family relationship is flexible as long as all answer options are presented to the
consumer. Answer options wording may be altered for compatibility with
alternate wording. For example, child or son/daughter may be used for the
relationship.
Sex: Answer format is flexible. Female and Male must be used as answer options.

If no, set the following:
maritalStatus = unmarried

(If displayed) Do you want to provide the claiming tax filer's
information, so the tax filer may apply for a tax credit? Yes (Item
#96)

If no, set the following:
1. taxReturnFilingStatusType = married filing separately

101

Household Composition*

Phase 3

Will [Tax filer claiming applicant FNLNS] claim any other tax Who is the tax filer that will claim [FNLNS] on their income tax
dependents?
return? Name selected (Item #91) or Non-applicant information
added (Item #92)

N/A

[Radio buttons]
Yes
No

Required

Required

Consumer is requesting coverage AND requesting financial assistance AND consumer is not a tax
filer AND consumer is a dependent AND claiming tax filer is not an applicant, not the application
filer, AND if Item 96 was displayed consumer selected "Yes" for "Do you want to provide the
claiming tax filer's information, so the tax filer may apply for a tax credit?"

102

Household Composition*

Phase 3

Who will [Tax filer claiming applicant FNLNS] claim as tax
dependents?

Will [Tax filer claiming applicant FNLNS] claim any other tax
dependents? Yes

N/A

[Checkboxes, multi-selection]
Display household member names
Someone else not seeking health coverage

Required

Required

Consumer is requesting coverage AND requesting financial assistance AND consumer is not a tax
If a name is selected, set the following for each selected dependent name:
filer AND consumer is a dependent AND claiming tax filer is not an applicant, not the application
1. taxDependentIndicator = true
filer, AND if Item 96 was displayed consumer selected "Yes" for "Do you want to provide the
2. taxRelationships = tax dependent
claiming tax filer's information, so the tax filer may apply for a tax credit?" AND selected "Yes" for 3. taxFilerIndicator = false
"Will [Tax filer claiming applicant FNLNS] claim any other tax dependents?"
If a name is selected, and the consumer is single, or married filing separately set the following for the
household contact:
2. taxRelationships = tax filer

103

Household Composition*

Phase 3

Enter name and DOB of tax dependents

Will [Tax filer claiming applicant FNLNS] claim any other tax
dependents? Someone else not seeking health coverage

N/A

Answer Fields
1. First Name: [Open text field]
2. Middle Name: [Open text field]
3. Last Name: [Open text field]
4. Suffix: [Drop-down, single-selection] Jr., Sr., III, IV
5. DOB: [Open text field] YYYY-MM-DD
6. Sex: [drop-down, single selection]: Male, Female
6. 7. How is this person related to [non-applicant claiming tax filer FNLNS]?
[Drop-down, single-selection]
Spouse
Parent
Son/daughter (including adopted & children)
Stepson/stepdaughter
Grandchild
Brother/sister (including half and step siblings)
Stepbrother/stepsister
Domestic partner
Stepparent
Uncle/aunt
Nephew/niece
Grandparent
First cousin

1. Required
2. Required
3. Required
4. Required
5. Required
6. Required
6. 7. Required
7. 8. Required
8. 9. Required

1. Required
2. Optional
3. Required
4. Optional
5. Required
6. Required
6. 7. Required
7. 8. Required
8. 9. Required

1. firstName
Consumer is requesting coverage AND requesting financial assistance AND consumer is not a tax
2. middleName
filer AND consumer is a dependent AND claiming tax filer is not an applicant, not the application
3. lastName
filer, AND if Item 96 was displayed consumer selected "Yes" for "Do you want to provide the
claiming tax filer's information, so the tax filer may apply for a tax credit?" AND selected "Yes" for 4. suffix
5. birthDate
"Will [Tax filer claiming applicant FNLNS] claim any other tax dependents?" AND selected
6. sex
"Someone else not seeking health coverage" for "Who will [Tax filer claiming applicant FNLNS]
6. 7., 7. 8., and 8. 9. familyRelationships
claim as tax dependents?"
9. 10. householdContactIndicator = false
10. 11. requestingCoverageIndicator = false

OR

N/A

N/A

N/A

This information must be collected within the household composition set.
Within the question set for household composition, there is flexibility for
order of questions, as long as the question is not conditionally triggered
from an answer to a previous question. Household composition questions
must be asked prior to the preliminary eligibility determination.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

1. member
2. household
3. member

1. boolean
2. enum
3. boolean

This information must be collected within the household composition set.
Within the question set for household composition, there is flexibility for
order of questions, as long as the question is not conditionally triggered
from an answer to a previous question. Household composition questions
must be asked prior to the preliminary eligibility determination.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

1. member
2. member
3. member
4. member
5. member
6. member
6. 7., 7. 8., and 8.
9. household
9. 10. application
10. 11. member

1. string
2. string
3. string
4. enum
5. string
6. enum
6. 7., 7. 8., and 8.
9. array, enum
9. 10. boolean
10. 11. boolean

This information must be collected within the household composition set.
It is a best practice to ask this question after the consumer has indicated
they will file a joint federal tax return. Household composition questions
must be asked prior to the preliminary eligibility determination.

Flexible.

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer
DOB: Flexible in the way the application collects the DOB. May collect DOB
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a DOB.
Family Relationship: The answer format (i.e., toggle button, drop-down, etc.) for
the family relationship is flexible as long as all answer options are presented to the
consumer. Answer options wording may be altered for compatibility with
alternate wording. For example, child or son/daughter may be used for the
relationship. There can only be one spouse OR one domestic partner relationship
per consumer.
Sex: Answer format is flexible. Female and Male must be used as answer options.

[(If displayed) Do you want to provide the claiming tax filer's
information, so the tax filer may apply for a tax credit? Yes (Item
#96)
AND
Who is the tax filer that will claim [FNLNS] on their income tax

If a name is selected and the consumer is married filing jointly set the following for both the spouse and
household contact:
2. taxRelationships = tax filer

Notes

Auditor Compliance
Conclusion**

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor
Comments**

Item #

123

Application Section
* indicates features of this question may be
updated in future documentation

Applicable EDE Phase**

Question**

Answers to Previous Questions**

Informational Text**

Answer Options and Format**

Required/Optional to Display Question or
Corresponding Answer Fields to Collect
Information in Application UI**

Required/Optional for Consumer to Provide
Answer to Send to SES**
*if optional, consumer must be able to
ith t
idi
i UI
ti

Conditional Display Logic in the UI**

Data Element(s) Name

Attestation Level

Data Element
Format

Policy**

General Requirements**

Applicant information - other addresses

Phase 3

What's [FNLNS]'s home address?

N/A

Help Drawer: Learn how home address affects coverage
Where a person lives can affect what coverage they're eligible for. Health coverage programs require people in their
programs to be residents in the state where they can get help paying for coverage.

[Toggle buttons]
Address for household contact
Other address
No home address

Required

Required

There is one applicant or one non-applicant who is not the household contact on the application

If "No home address" set, noHomeAddressIndicator = true. If "No home address" is not selected, set
noHomeAddressIndicator = false.

Member

1. string
2. string
3. string
4. enum
5. string
6. string
7. string
8. string

The home address is used for determining state residency, which is a
criteria of eligibility for Medicaid, CHIP, and QHP, as well as for rating
for QHP premiums. Non-applicant tax filer addresses are required so
that the Marketplace can mail tax documents related to their health
coverage. In addition, the resides together indicator must be set
between family members for purposes of household composition and
between applicant tax filers and tax dependents under age 19 on the
application for purposes of parent/caretaker relative eligibility.

Home address

If household contact address is selected, set homeAddress to the selected address, and set
resideTogether = true for the application filer and applicant or non-applicant tax filer.

We’ll use this person's home address to indicate whether or not they're a resident of the state where they're seeking
coverage. Don't use a P.O. box as a home address.

1. homeAddress.streetName1
2. homeAddress.streetName2
3. homeAddress.cityName
4. homeAddress.stateCode
5. homeAddress.zipCode
6. homeAddress.plus4Code

Children who split time
If we’re asking this question about a child who splits time between 2 parents who don’t live together, choose or enter the
address where the child spends most of his or her nights.

276

Applicant information - other addresses

Phase 3

If multiple applicants or any non-applicant tax filers are on
the application:
[display all applicants and any non-applicant tax filers]

N/A

Help Drawer: Learn how home address affects coverage
Where a person lives can affect what coverage they're eligible for. Health coverage programs require people in their
programs to be residents in the state where they can get help paying for coverage.

Provided once address is validated through a third party address validation service:
7. homeAddress.countyName
8. homeAddress.countyFipsCode
[Radio buttons]
Yes
No

Required

Required

N/A

Home address

Do all of these people live together at this address? [Display
application filer's address]

Must ensure that people who are homeless are not excluded from
ability to file a FFE application and get an eligibility determination.
There must be a way for a consumer to continue with the app and
indicate their residency w/out attesting that they live in a particular
home address. Based on SES logic, use mailing address as way to set
residency when someone indicates their homeless.

If yes, set:
resideTogetherIndicator = true (for all applicants and non-applicant tax filers on the application)
noHomeAddressIndicator = false

Question/Informational Text Wording Requirements**

Answer Options and Format Requirements**

The application must ask for home address of each individual applicantThe flow of collecting applicant information is flexible and may be done
collection of mailing address alone is not sufficient (collecting the mailing address throughout the application. If the application is able to collect sufficient
for non applicant tax filers or someone that first indicates they have no home
information to always set the resideTogetherIndicator appropriately
address is sufficient). The application does not need to collect mailing addresses without asking for the home address of non-applicants in this address
for anyone other than the household contact unless another applicant or tax
collection question flow, then it is not required to include most nonfiler attests to not having a home address.
applicants in this question flow. However, non-applicant tax filer
addresses must always be collected.
It is recommended to ask all non-applicants whether they live at the same
address as the household contact so that the resideTogetherIndicator can be
appropriately set within each family relationship between applicants and nonapplicants. This is important for purposes of household composition for
applicants claimed by parents and applicants following non-filer rules, and
important for parent/caretaker relative eligibility for applicants who claim or
take care of children. However, if the application is able to collect sufficient
information to always set the resideTogetherIndicator appropriately without
asking for the home address of non-applicants in this address collection question
flow, then it is not required to include non-applicants in this question flow.

Flexible.

The UI may pre-populate the home address from information available from
identity proofing, from a mailing address or from a home address collected for
another application member, as long as the consumer has the opportunity to
provide a unique address and is able to move forward in the application without
providing a home address. Answer format is flexible.

The flow of collecting applicant information is flexible and may be done
throughout the application. If the application is able to collect sufficient
information to always set the resideTogetherIndicator appropriately
without asking for the home address of non-applicants in this address
collection question flow, then it is not required to include most nonapplicants in this question flow. However, non-applicant tax filer
addresses must always be collected.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Member

1. boolean
2. boolean

Member

1. string
2. string
3. string
4. enum
5. string
6. string
7. string
8. string

The flow of collecting applicant information is flexible and may be done
throughout the application. If the application is able to collect sufficient
information to always set the resideTogetherIndicator appropriately
without asking for the home address of non-applicants in this address
collection question flow, then it is not required to include most nonapplicants in this question flow. However, non-applicant tax filer
addresses must always be collected.

Flexible.

Flexible. Multi-selection must be enabled.

Member

1. string
2. string
3. string
4. enum
5. string
6. string
7. string
8. string

The flow of collecting applicant information is flexible and may be done
throughout the application. If the application is able to collect sufficient
information to always set the resideTogetherIndicator appropriately
without asking for the home address of non-applicants in this address
collection question flow, then it is not required to include most nonapplicants in this question flow. However, non-applicant tax filer
addresses must always be collected.

Flexible.

The UI may pre-populate the home address from information available from
identity proofing, from a mailing address or from a home address collected for
another application member, as long as the consumer has the opportunity to
provide a unique address Answer format is flexible, as long as someone is able to
move forward in the application without providing a home address.

Member

1. string
2. string
3. string
4. enum
5. string
6. string
7. string
8. string

The flow of collecting applicant information is flexible and may be done
throughout the application. If the application is able to collect sufficient
information to always set the resideTogetherIndicator appropriately
without asking for the home address of non-applicants in this address
collection question flow, then it is not required to include most nonapplicants in this question flow. However, non-applicant tax filer
addresses must always be collected.

Flexible.

The UI may pre-populate the home address from information available from
identity proofing, from a mailing address or from a home address collected for
another application member, as long as the consumer has the opportunity to
provide a unique address.

The only time that a mailing address is collected for a household member who is The flow of collecting applicant information is flexible and may be done
not the household contact is when that member is seeking coverage and attests throughout the application.
to having no home address. Once the mailing address is validated through a third
party validation service, the application should display back both the manually
entered address and the validated address from which the consumer will select
as their address. The validation service will also return the county Fips code
which should not be displayed to the consumer. If more than one county is
returned by the third-party validation service, the consumer must select their
county through a dropdown list of the returned counties.

Flexible.

Applications must use a third party address validation service to validate the
consumer's

Also set all home address fields to the application filer's home address for each applicant and nonapplicant tax filer

We’ll use this person's home address to indicate whether or not they're a resident of the state where they're seeking
coverage. Don't use a P.O. box as a home address.

Question Flow Requirements**

Children who split time
If we’re asking this question about a child who splits time between 2 parents who don’t live together, choose or enter the
address where the child spends most of his or her nights.
277

Applicant information - other addresses

Phase 3

Select everyone who lives at this address with [Household
contact].

Do all of these people live together at this address? [Display
application filer's address] No

N/A

[Toggle buttons]
Display all applicant and non-applicant tax filer names [except the application filer]
None of these people live at this address

Required

Required

Consumers are requesting coverage OR filing a tax return AND applicants attested to not all living
together at the household contact's home address

For each applicant and non-applicant tax filer selected, set:
resideTogetherIndicator = true (for all selected applicants and non-applicant tax filers)
noHomeAddressIndicator = false
Also set all home address fields for each applicant and non-applicant tax filer:
1. homeAddress.streetName1
2. homeAddress.streetName2
3. homeAddress.cityName
4. homeAddress.stateCode
5. homeAddress.zipCode
6. homeAddress.plus4Code
Provided once address is validated through a third party address validation service:
7. homeAddress.countyName
8. homeAddress.countyFipsCode

278

Applicant information - other addresses

Phase 3

What's [FNLNS]'s home address?

Select everyone who lives at this address with [Household contact].
Applicant or non-applicant tax filer's name was not selected OR
"None of these people live at this address" was selected

N/A

[Toggle buttons]
Any other address entered for another applicant or non-applicant tax filer
Other address
No home address

Required

Required

Consumers are requesting coverage OR filing a tax return AND applicants attested to not all living If "No home address" set, noHomeAddressIndicator = true
at household contact's home address AND some or none live at the same address as the household
contact
If any other address for another applicant is selected, set homeAddress to the selected address and set
resideTogetherIndicator = true for each applicant and non-applicant tax filer attesting to the same
home address.
1. homeAddress.streetName1
2. homeAddress.streetName2
3. homeAddress.cityName
4. homeAddress.stateCode
5. homeAddress.zipCode
6. homeAddress.plus4Code
Provided once address is validated through a third party address validation service:
7. homeAddress.countyName
8. homeAddress.countyFipsCode

124

Applicant information - other addresses

Phase 3

Enter [FNLNS]'s home address

What's [FNLNS]'s home address? Other address

Answer Fields:
1. Required
2. Optional
3. Required
4. Required
5. Required
6. Optional
7. Required if displayed

Answer Fields:
1. Required
2. Optional
3. Required
4. Required
5. Required
6. Optional
7. Required if displayed

Consumers are requesting coverage OR filing a tax return AND applicants attested to not all living 1. homeAddress.streetName1
at household contact's home address AND some or none live at the same address as the household 2. homeAddress.streetName2
contact AND consumer selected "Other address"
3. homeAddress.cityName
4. homeAddress.stateCode
5. homeAddress.zipCode
6. homeAddress.plus4Code

Answer Fields
1. Street Address: [Open text field]
2. Street address 2: [Open text field]
Alert text if application filer doesn't have a home address and provides a mailing address outside the application state: Do 3. City: [Open text field]
you have a mailing address in [application state]? We use your address to help find plans near you that you're eligible for. If 4. State: [Drop-down, single selection] Phase 3 should allow the consumer to select
you can, enter a home or mailing address in [application state], even if it's a temporary one. Or you can start a new
any of the 50 states or U.S. territories.
application in [application state] (link to beginning of application process).
5. ZIP code: [Open text field]
6. ZIP plus 4 code: [Open text field]
We may use this address for the health insurance plan rating, so pick a mailing address in the state where this person lives,
if possible.
Provided once address is validated through a third party address validation service:
7. County: [Drop-down, single-selection] pre-populated with counties returned
from address validation

Answer Fields:
1. Required
2. Optional
3. Required
4. Required
5. Required
6. Optional
7. Required if displayed

Answer Fields:
1. Required
2. Optional
3. Required
4. Required
5. Required
6. Optional
7. Required if displayed

Consumers are requesting coverage OR filing a tax return AND applicants attested to not all living 1. mailingAddress.streetName1
at household contact's home address AND some or none live at the same address as the household 2. mailingAddress.streetName2
contact AND consumer selected "No home address"
3. mailingAddress.cityName
4. mailingAddress.stateCode
5. mailingAddress.zipCode
6. mailingAddress.plus4Code

Alert text if applicant is living outside of application state permanently:
If [FNLNS] is no longer living in [Application state], they won't be eligible for Marketplace coverage there. They'll need to
apply for coverage on a new, separate application.

[Radio buttons]
Yes
No

Required

Required

Consumer provided a home address in a state different from the application state.

liveOutsideStateTemporarilyIndicator

Member

boolean

Applicants with home addresses in another state must be asked whether or not
they are living outside of the state temporarily.

[Toggle buttons]
Address for household contact
Any other address entered for another applicant
Other address

Required

Required

Consumer provided a home address in a state different from the application state AND answered
"Yes" for "Is [FNLNS] living outside [state of application] temporarily?"

If household contact address or address selected for another applicant is selected, set transientAddress
to the selected address.

Member

1. string
2. string
3. string
4. enum
5. string
6. string
7. string
8. string

If an applicant is temporarily living out of state, then it is required to collect
The flow of collecting applicant information is flexible and may be done
Flexible.
information about where the applicant will live in the state if they plan to return-- throughout the application. For example, if the application filer attests to
the UI can provide the option to provide a full address, but only a city and zip
a home address outside the application state in the household contact
code will be stored by SES.
information section of the application, this question may be asked in the
household contact information section.

The UI may pre-populate the home address from information available from
identity proofing, from a mailing address or from a home address collected for
another application member, as long as the consumer has the opportunity to
provide a unique address. Answer format is flexible.

Answer Fields
1. Street Address: [Open text field]
2. Street address 2: [Open text field]
3. City: [Open text field]
4. State: Default to application state
5. ZIP code: [Open text field]
6. ZIP plus 4 code: [Open text field]

Answer Fields:
1. Required
2. Optional
3. Required
4. Required
5. Required
6. Optional
7. Required if displayed

Answer Fields:
1. Optional
2. Optional
3. Required
4. Required
5. Required
6. Optional
7. Required if displayed

Consumer provided a home address in a state different from the application state AND answered
"Yes" for "Is [FNLNS] living outside [state of application] temporarily?" AND attested to having an
address different from the household contact

Member

1. string
2. string
3. string
4. enum
5. string
6. string
7. string
8. string

If an applicant is temporarily living out of state, then it is required to collect
The flow of collecting applicant information is flexible and may be done
Flexible.
information about where the applicant will live in the state if they plan to return-- throughout the application. For example, if the application filer attests to
the UI can provide the option to provide a full address, but only a city and zip
a home address outside the application state in the household contact
code will be stored by SES.
information section of the application, this question may be asked in the
household contact information section.

Street Address: Must be an open text field
Street address 2: Must be an open text field
City: Must be an open text field
ZIP: Must be an open text field
State: Must be the application state
County Name: County must be provided to the consumer if selection of county is
required based on address validation (i.e. zip code crosses more than one county).
The answer format for ZIP code is flexible as long as the counties displayed to the
consumer are counties associated with the provided ZIP code.

Required to display back all attested home
addresses to applicants.

N/A

Consumers are requesting coverage OR filing a tax return AND attested to not all living at the
household contact's home address AND provided a home address OR provided a mailing address
after attesting to no home address

Member

1. boolean
2. boolean
3. boolean

The resideTogetherIndicator must be set for all applicants that live together.
This may set on the summary page, once all home address information is
collected by each applicant.

N/A

member

boolean

Question wording is flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

member

boolean

Question wording is flexible. The warning message wording must be
similar.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

N/A

Answer Fields
1. Street Address: [Open text field]
2. Street address 2: [Open text field]
3. City: [Open text field]
4. State: [Drop-down, single selection] Phase 3 should allow the consumer to select
any of the 50 states or U.S. territories.
5. ZIP code: [Open text field]
6. ZIP plus 4 code: [Open text field]

Provided once address is validated through a third party address validation service:
7. homeAddress.countyName
8. homeAddress.countyFipsCode

Provided once address is validated through a third party address validation service:
7. County: [Drop-down, single-selection] pre-populated with counties returned
from address validation

125

126

Applicant information - other addresses

Applicant information - other addresses

Phase 3

Phase 3

Enter [FNLNS]'s mailing address

Is [FNLNS] living outside [state of application] temporarily?

What's [FNLNS]'s home address? No home address

What's [FNLNS]'s home address? Consumer selected or entered an
address in a state different from the application state

Help Drawer: Learn how mailing address affects coverage
This person's mailing address can be a street address or a P.O. box.

Member

Provided once address is validated through a third party address validation service:
7. mailingAddress.countyName
8. mailingAddress.countyFipsCode

1. string
2. string
3. string
4. enum
5. string
6. string
7. string
8. string

The only time that a mailing address is collected for a household
member who is not the household contact is when that member is
seeking coverage and attests to having no home address

Help Drawer: Learn more about living outside the state
Sometimes people leave their homes for a period of time, like to go to school, for a short-term job, or for a short-term
military deployment. Children may sometimes live in a different state for a period of time if they’re staying with a family
member during a summer break or attending boarding school.

Street Address: Must be an open text field
Street address 2: Must be an open text field
City: Must be an open text field
State: Consumer must be able to select any state for their home address. DE
entities must use a single selection drop-down menu with all 50 states and U.S.
territories. The DE entity may provide state abbreviations or the full state name in
the drop-down menu.
ZIP: Must be an open text field
County Name: County must be provided to the consumer if selection of county is
required based on address validation (i.e. zip code crosses more than one county).
The answer format for ZIP code is flexible as long as the counties displayed to the
consumer are counties associated with the provided ZIP code.
Answer format is flexible. Answer options may be altered for compatibility with
question wording.
Street Address: Must be an open text field
Street address 2: Must be an open text field
City: Must be an open text field
State: Consumer must be able to select any state for their home address. DE
entities must use a single selection drop-down menu with all 50 states and U.S.
territories. The DE entity may provide state abbreviations or the full state name in
the drop-down menu.
ZIP: Must be an open text field
County Name: County must be provided to the consumer if selection of county is
required based on address validation (i.e. zip code crosses more than one county).
The answer format for ZIP code is flexible as long as the counties displayed to the
consumer are counties associated with the provided ZIP code.

The flow of collecting applicant information is flexible and may be done
Flexible. Use of the word "temporarily" or "temporary" is required here, Answer format is flexible. Answer options may be altered for compatibility with
throughout the application. For example, if the application filer attests to rather than a specific time frame, because different state Medicaid and question wording.
a home address outside the application state in the household contact
CHIP state agencies define temporary in different ways.
information section of the application, this question may be asked in the
household contact information section.

Living out of the state temporarily
If this person is living out of the state temporarily, they can still be considered a resident of the state. Generally, people
must live in the state to be residents in the state where they get savings for coverage. Select "Yes" if there's a plan for this
person to return to the state in the question.
Living out of the state permanently
If this person is no longer living in the state, they won't be eligible for health coverage there. Select "No" if there's no plan
for this person to return to the state in the question.
If he or she wants to apply for Marketplace coverage in their permanent state, start a new, separate application.
127

Applicant information - other addresses

Phase 3

Where will [FNLNS] live in [state of application]?

Is [FNLNS] living outside [state of application] temporarily? Yes

N/A

1. transientAddress.streetName1
2. transientAddress.streetName2
3. transientAddress.cityName
4. transientAddress.stateCode
5. transientAddress.zipCode
6. transientAddress.plus4Code
Provided once address is validated through a third party address validation service:
7. transientAddress.countyName
8. transientAddress.countyFipsCode

279

Applicant information - other addresses

Phase 3

What's [FNLNS]'s new address in [state of application]?

Where will [FNLNS] live in [state of application]? Other address

Help Text: If this person doesn't have a complete new address, enter the city and ZIP code.

Provided once address is validated through a third party address validation service:
7. County: [Drop-down, single-selection] pre-populated with counties returned
from address validation

280

Applicant information - other addresses

Phase 3

[List all applicants and non-applicant tax filers living at each
address]

N/A

N/A

N/A

If applicant or non-applicant tax filer attested to home
address:
[FNLNS]'s home address: [Display attested home address]

1. transientAddress.streetName1
2. transientAddress.streetName2
3. transientAddress.cityName
4. transientAddress.stateCode
5. transientAddress.zipCode
6. transientAddress.plus4Code
Provided once address is validated through a third party address validation service:
7. transientAddress.countyName
8. transientAddress.countyFipsCode

1. Set resideTogetherIndicator in the relationships between each applicant and non-applicant tax filer
that attested to living at the same address
2. Set homeAddress to the input address for each applicant

This page should display after all home address information is collected for Flexible.
each applicant.

3. For each member who has an address, set noHomeAddressIndicator = false

If applicant or non-applicant tax filer attested to mailing
address (no home address):
[FNLNS]'s mailing address: [Display attested mailing
address]
If applicant or non-applicant tax filer attested to transient
address:
[FNLNS]'s home address in [state of application]: [Display
281

Applicant information - other addresses

Phase 3

Does [Spouse FNLNS] live with [Tax filer FNLNS] at this
address?

Does [FNLNS] plan to file a joint federal income tax return with
[his/her] spouse for [coverage year]? No
AND Will [FNLNS] claim any dependents on [his/her/their joint]
federal income tax return for [coverage year]? Yes

If consumer answers "Yes" to this question, display the following warning text: If these spouses live together but file taxes [Radio buttons]
separately, they won't be eligible for extra savings, like a premium tax credit. But, they can still get free or low-cost health Yes
coverage if they qualify for Medicaid or the Children's Health Insurance Program (CHIP).
No

Required

Required

Household member is filing a tax return AND married AND will not file jointly with their spouse AND
will claim a dependent AND it is unknown if they live with their spouse

If yes, set:
resideTogetherIndicator = true
If no, set:
resideTogetherIndicator = false
If no, an optional indicator, liveApartFromSpouseIndicator can also be set to true. This optional
indicator can be used to capture whether a married consumer resides with a non-applicant spouse. This
indicator may be helpful when the spouses are not filing a joint tax return and not living together. The
new field will allow the requestor to record the attestation that the spouses don’t live together without
calling Add Member for the non-applicant spouse, and without setting the resideTogetherIndicator. As
a result, the consumer would not need to provide the name and birthdate of a non-applicant spouse
who is not in the tax or Medicaid household.

89

Applicant information - other addresses

Phase 3

Does [FNLNS] plan to file as Head of Household?

Does [Spouse FNLNS] live with [Tax filer FNLNS] at this address? No
OR
It is known the applicant does not live with their spouse

If consumer answers "No" to this question, display the following warning text: If you aren't filing taxes as Head of
Household, you won't be eligible for extra savings, like a premium tax credit. But, you can still get free or low-cost health
coverage if you qualify for Medicaid or the Children's Health Insurance Program (CHIP).

[Radio buttons]
Yes
No

Required

Required

Household member is filing a tax return AND married AND will not file jointly with their spouse AND
will claim a dependent AND does not live with their spouse

attestedHeadOfHouseHoldIndicator

Help Drawer: Learn who's a Head of Household
Generally, a person may claim "Head of Household" filing status on their tax return if all of these apply:
-They're unmarried or are permanently living separately from their spouse.
-They live in their home with a dependent or other qualifying individual.
-They pay more than 50% of the costs of keeping up that home.
For more information, visit irs.gov.

Applicant information - other addresses

Phase 3

You told us [Dependent FNLNS] lives with [Parent FNLNS].
Does [Dependent FNLNS] also live with another parent at
this address?
[Display [Parent FNLNS's] home address]

N/A

N/A

[Radio buttons]
Yes
No

Required

Required

Consumer is requesting coverage AND requesting financial assistance AND consumer is not a tax
N/A
filer AND consumer is a dependent under the state Medicaid age AND the relationship between
the consumer and claiming tax filer is parent or stepparent AND the claiming tax filer parent is not
married filing jointly AND consumer lives with the claiming tax filer parent AND it is unknown if the
consumer lives with another parent

N/A

N/A

In order to determine if a dependent meets an exception, if the
dependent lives with one claiming tax filer parent who is not married
filing jointly, the application needs to determine if the dependent lives
with another parent to trigger the "live with both parents who don't file
jointly" exception. If the dependent lives with two parents who do not
file jointly, they will follow the non-filer rules.

This question must be asked to determine if the consumer meets an exception
to follow non-filer rules. Item #88 is asked to determine if the consumer meets
the "living with both parents that don't file jointly" exception.

This information must be collected within the household composition set.
Within the question set for household composition, there is flexibility for
order of questions, as long as the question is not conditionally triggered
from an answer to a previous question. Household composition questions
must be asked prior to the preliminary eligibility determination.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

301

88

Household Composition

Phase 3

[Display [Dependent FNLNS's] home address]

Does [Dependent FNLNS] live with any parent or stepparent? Yes
(Item #95)

Help Text: We need more information about [Dependent FNLNS]'s parent to determine eligibility for free or reduced cost [Radio buttons]
health coverage through Medicaid or the Children's Health Insurance Program (CHIP).
Yes
No

Required

Required

Consumer is requesting coverage AND requesting financial assistance AND consumer is not a tax
filer AND consumer is a dependent under the state Medicaid age AND the relationship between
the consumer and claiming tax filer is parent or stepparent AND consumer does not live with
claiming tax filer parent or stepparent AND consumer attested to living with another parent or
stepparent in Item #95 and did not opt out of providing information on claiming tax filer parent or
stepparent in Item #96

Member

boolean

In order to determine if a dependent meets an exception, if the
dependent doesn't live with the parent who claims them, but lives with
another parent, we need to find out if they can provide the
information for the parent they live with.

Including this question for applicants claimed as tax dependents by a nonThis information must be collected within the household composition set.
custodial parent allows more flexibility for the consumers. The idea is that if an
Within the question set for household composition, there is flexibility for
applicant does not have the income information for their non-claiming tax filer order of questions. Household composition questions must be asked prior
custodial parent, they can apply for a QHP and APTC alone without it, since it will to the preliminary eligibility determination.
not impact the APTC/QHP eligibility determination, which would be based on
only the family members on the same tax return as the applicant.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

282

Applicant information - other addresses

Phase 3

Tell us about [Dependent FNLNS]'s parent.

N/A

Answer Fields
1. First Name: [Open text field]
2. Middle Name: [Open text field]
3. Last Name: [Open text field]
4. Suffix: [Drop-down, single-selection] Jr., Sr., III, IV
5. DOB: [Open text field] YYYY-MM-DD
6. Sex [drop-down, single selection]: Male, Female

Required

Required

Consumer is requesting coverage AND requesting financial assistance AND consumer is not a tax
1. firstName
filer AND consumer is a dependent under the state Medicaid age AND the relationship between
2. middleName
the consumer and claiming tax filer is parent or stepparent AND consumer lives with the claiming 3. lastName
tax filer parent or stepparent and it is known the dependent lives with a non-applicant
4. suffix
parent/stepparent whose information has not yet been collected OR consumer does not live with 5. birthDate
the claiming tax filer parent or stepparent and it is known the dependent lives with a non-applicant 6. sex
parent/stepparent whose information has not yet been collected AND the dependent attests
7. resideTogetherIndicator = true
"Yes" to providing their custodial parent's information in Item #301 or the dependent opted out of
providing information on claiming tax filer parent or stepparent in Item #96

1. member
2. member
3. member
4. member
5. member
6. member
7. member

1. string
2. string
3. string
4. enum
5. string
6. enum
7. boolean

In order to determine if a dependent meets an exception to follow non- DE entities should collect information on any parents living with an applicant
filer rules, the application will need to collect information on parent(s)
under the state Medicaid age, if the applicant did not opt out of providing
living with the dependent.
information on that parent.

Flexible.

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer
DOB: Flexible in the way the application collects the DOB. May collect DOB
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a DOB.
Sex: Answer format is flexible. Female and Male must be used as answer options.

N/A

[Radio buttons]
Yes
No

Required

Required

Consumer is requesting coverage AND not filing taxes AND not claimed as a tax dependent OR
meets an exception

If yes is selected, set:
liveWithParentOrSiblingIndicator = true

member

boolean

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Applicants who meet a tax dependent exception and therefore follow the non-filer rules are:
1. Individuals who are a tax dependent of someone other than a parent/parent's spouse
(biological, step, or adopted)
2. Individuals who are a child under 19 (or FTS) living with both parents but his/her parents don't
file jointly
3. Individuals who are a child under 19 (or FTS) who expect to be claimed as a tax dependent by a
non-custodial parent

If no is selected, set:
liveWithParentOrSiblingIndicator = false

Can you provide more information about [Dependent
FNLNS]'s parent?

AND
conditions in column J are met
You told us [Dependent FNLNS] lives with [Parent FNLNS]. Does
[Dependent FNLNS] also live with another parent at this address?
Yes (Item #88)
OR
(It is known [Dependent FNLNS] lives with a non-applicant parent
and their information has not been collected. (Does [Dependent
FNLNS] live with any parent or stepparent? Yes (Item #95))
AND
Item #301 did not display)

If "No", set livesWithCustodialParentNotOnApplicationIndicator = true
If "No", the applicant's Medicaid household cannot be built and the UI should not ask questions from the
"Non-filer Households" section.

This information must be collected within the household composition set.
Within the question set for household composition, there is flexibility for
order of questions. Household composition questions must be asked prior
to the preliminary eligibility determination.

OR
Can you provide more information about [FNLNS]'s parent? Yes
(Item #301)

104

Household Composition*

Phase 3

Do any other family members live with [FNLNS] at
[FNLNS's address]?

N/A

You don't need to include these people:
[Display household member names who previously attested
to living with the non-filer applicant or has the
resideTogetherIndicator set to true with the non-filer
applicant]

105

Household Composition*

Phase 3

Can you provide more information about the family
members who live with [FNLNS]?

Do any other family members live with [FNLNS] at [FNLNS's
address]? Yes (#104) AND conditions outlined in column J are met

106

Household Composition*

Phase 3

It's known they live with only 1 parent: Does [Applicant
FNLNS] live with another parent and/or stepparent?

Can you provide more information about the family members who
live with [FNLNS]? Yes (If Item # 105 applies to applicant)

It's unknown if the applicant lives with either parent: Does
[Applicant FNLNS] live with either of [his/her] parents
and/or stepparents?

OR

Select [FNLNS]'s parents and stepparent(s) that live with
[FNLNS].

Does [Applicant FNLNS] live with [his/her] parent and/or
stepparent? Yes (Item #106)

107

Household Composition*

Phase 3

Alert message if applicant selects "No": If you don't provide this information, [FNLNS] won't be eligible for Medicaid, but
they may still be eligible for other savings.

[Radio buttons]
Yes
No

Required

Required

[Radio buttons]
Yes
No

Required

Required

N/A

[Checkboxes, multi-selection]
Display all household members older than applicant who did not already attest to a
relationship with the applicant (unless that relationship was "Parent" or
"Stepparent")
Someone else who isn't applying for health coverage

Required

Required

N/A

Answer Fields
1. First Name: [Open text field]
2. Middle Name: [Open text field]
3. Last Name: [Open text field]
4. Suffix: [Drop-down, single-selection] Jr., Sr., III, IV
5. DOB: [Open text field] YYYY-MM-DD
6. Relationship: [Drop-down, single-selection] Parent, Stepparent
7. Sex: [drop-down, single selection]: Male, Female
8. Add a second parent (Display button)

1. Required
2. Required
3. Required
4. Required
5. Required
6. Required
7. Required
8. Required

1. Required
2. Optional
3. Required
4. Optional
5. Required
6. Required
7. Required
8. N/A

Help Text: Include all of these:

[Radio buttons]
Yes
No

Required

Required

Help Text: We need this information to determine eligibility for free or low-cost health care
Help Text: Include all of these:
Parents: Biological, adoptive, or stepparents.

Do any other family members live with [FNLNS] at [FNLNS's
address]? Yes

OR
[Does [Dependent FNLNS] live with any other parent or stepparent?
Yes (item #95)
AND
Can you provide more information about the family members who
live with [FNLNS]? Yes (item #105)]

108

Household Composition*

Phase 3

Name of parent or stepparent:

Select [FNLNS]'s parents and stepparent(s) that live with [FNLNS].
Someone else who isn't applying for health coverage

109

Household Composition*

Phase 3

If it is known they live with siblings: [Display applicant siblings Do you want to provide more information about the family
that live with them.] Does [Applicant FNLNS] live with any
members who live with [FNLNS]? Yes (If Item #105 applies to
other brothers or sisters who are under age [State Medicaid applicant)
Age]? (Include stepbrothers, stepsisters, half-brothers, halfOR
sisters).
Do any other family members live with [FNLNS] at [FNLNS's
If it is unknown if they live with or have siblings: Does
[Applicant FNLNS] live with brothers or sisters who are under address]? Yes
age [State Medicaid Age]? (Include stepbrothers,
stepsisters, half-brothers, half-sisters).

Sisters or brothers: Biological, adopted, foster, half, or stepsiblings.

Consumer is requesting coverage AND not filing taxes AND consumer is a dependent under the
If yes is selected, set:
state Medicaid age AND is claimed by a non-parent tax filer AND did not opt out of providing
medicaidFamilyNotProvidedIndicator = false
information about that tax filer in Item 96 or the claiming tax filer is a non-applicant non-custodial If no is selected, set:
parent application filer
medicaidFamilyNotProvidedIndicator = true
Consumer is requesting coverage AND requesting financial assistance AND under 14 OR age 14-20 If yes is selected:
(and under medicaid state child age) AND follows non-filer rules AND indicated they want to
Proceed to items #107 and 108 to set the resideTogetherIndicator to true
provide information about their family members (if Item 105 was displayed) AND it is unknown if
they live with one or more parents (or stepparents)
If no is selected and there is already a person with a relevant relationship that exists on the application,
set the following:
Note that full time student status may impact whether or not applicants age 19 and 20 are
1. resideTogetherIndicator = false
considered children for medicaid household composition rules. If the UI has collected information
about full time student status at this point in the flow, the UI may limit this question to only display *Reference p. 30 FAQs for further details
to 19 and 20 year olds who are counted as children under state medicaid household composition
rules (as determined by the state via the state reference data API).
Consumer is requesting coverage AND requesting financial assistance AND under 14 OR age 14-20 1. familyRelationships
(and under medicaid state child age) AND follows non-filer rules AND indicated they want to
2. resideTogetherIndicator = true
provide information about their family members (if Item 105 was displayed) AND consumer
indicated they live with a parent and/or stepparent

In the event that DE entities do need to ask the non-filer questions, each
If included in the UI, this information may be collected within the
applicant who meets the conditions above should be looped through and first ask household composition section or asked in another application section.
if anyone else lives with them at their address to determine if we need to ask
additional questions.

member

boolean

For some applicants who meet exceptions, DE entities need to ask if the
application filer can provide more information about who they live with.

If included in the UI, this information may be collected within the
household composition section or asked in another application section.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Member

1. boolean
2. boolean

For child applicants who are not claimed as tax dependents or who are
claimed as tax dependents by non-parents, Medicaid and CHIP
household composition rules require collecting information about any
parents that the child lives with.

Questions about who lives together may be asked on an as-needed basis as seen
here, or may be inferred based on information provided about who lives at
which address. For applicants under the child age (determined by state via the
state reference data API), who are either not claimed as tax dependents, or
who are claimed by non-parents or non-custodial parents, DE entities need to
find out about the parents they live with, if any, to determine Medicaid and
CHIP eligibility.

If included in the UI, this information may be collected within the
household composition section or asked in another application section.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

1. member
2. member

1. enum
2. boolean

For child applicants who are not claimed as tax dependents or who are
claimed as tax dependents by non-parents, Medicaid and CHIP
household composition rules require collecting information about any
parents that the child lives with.

Questions about who lives together may be asked on an as-needed basis as seen
here, or may be inferred based on information provided about who lives at
which address. For applicants under the child age (determined by state via the
state reference data API), who are either not claimed as tax dependents, or
who are claimed by non-parents or non-custodial parents, DE entities need to
find out about the parents they live with, if any, to determine Medicaid and
CHIP eligibility.

If included in the UI, this information may be collected within the
household composition section or asked in another application section.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Consumer is requesting coverage AND requesting financial assistance AND under 14 OR age 14-20 1. firstName
(and under medicaid state child age) AND follows non-filer rules AND indicated they want to
2. middleName
provide information about their family members (if Item 105 was displayed) AND consumer
3. lastName
indicated they live with a parent and/or stepparent AND selected "Someone who isn't applying for 4. suffix
health coverage" for "Select [FNLNS]'s parents and stepparent(s) that live with [FNLNS]."
5. birthDate
6. familyRelationships
7. householdContactIndicator = false
8. requestingCoverageIndicator = false
9. resideTogetherIndicator = true
10. sex

1. member
2. member
3. member
4. member
5. member
6. household
7. application
8. member
9. member
10. sex

1. string
2. string
3. string
4. enum
5. string
6. enum
7. boolean
8. boolean
9. boolean
10. enum

For child applicants who are not claimed as tax dependents or who are
claimed as tax dependents by non-parents, Medicaid and CHIP
household composition rules require collecting information about any
parents that the child lives with.

Questions about who lives together may be asked on an as-needed basis as seen
here, or may be inferred based on information provided about who lives at
which address. For applicants under the child age (determined by state via the
state reference data API), who are either not claimed as tax dependents, or
who are claimed by non-parents or non-custodial parents, DE entities need to
find out about the parents they live with, if any, to determine Medicaid and
CHIP eligibility.

If included in the UI, this information may be collected within the
household composition section or asked in another application section.

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the
suffix is flexible as long as all answer options are presented to the
consumer
DOB: Flexible in the way the application collects the DOB. May collect
DOB through separate field for year, month, and day. May use a
calendar widget to assist the consumer with selecting a DOB.

Consumer is requesting coverage AND requesting financial assistance AND under 14 OR age 14-20 If yes is selected:
(and under medicaid state child age) AND follows non-filer rules AND indicated they want to
Proceed to items #110 and 111 to set the resideTogetherIndicator to true
provide information about their family members (if Item 105 was displayed) AND it is unknown if
they live with any siblings OR unknown if they live with additional siblings not on the application
If no is selected and there is already a person with a relevant relationship that exists on the application,
set the following:
1. resideTogetherIndicator = false

Member

1. boolean
2. boolean

For child applicants who are not claimed as tax dependents or who are
claimed as tax dependents by non-parents, Medicaid and CHIP
household composition rules require collecting information about any
child-age siblings that the child lives with.

Questions about who lives together may be asked on an as-needed basis as seen If included in the UI, this information may be collected within the
here, or may be inferred based on information provided about who lives at
household composition section or asked in another application section.
which address. For applicants under the child age (determined by state via the
state reference data API), who are either not claimed as tax dependents, or
who are claimed by non-parents or non-custodial parents, DE entities need to
find out about the siblings they live with, if any, to determine Medicaid and CHIP
eligibility.

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer
DOB: Flexible in the way the application collects the DOB. May collect DOB
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a DOB.
Relationship: Format is flexible, but options must be for parent or stepparent.
Wording of answer options is flexible (i.e., using Stepmom/Stepdad for
Stepparent)
Sex: Answer format is flexible Female and Male must be used as answer options
Answer format is flexible. Answer options may be altered for compatibility with
question wording.

*Reference p. 30 FAQs for further details

Flexible.

Notes

Auditor Compliance
Conclusion**

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor
Comments**

Item #

Application Section
* indicates features of this question may be
updated in future documentation

Applicable EDE Phase**

Question**

Answers to Previous Questions**

Informational Text**

Answer Options and Format**

Required/Optional to Display Question or
Corresponding Answer Fields to Collect
Information in Application UI**

110

Household Composition*

Phase 3

Who is a brother or sister living with [Applicant FNLNS]?

Does [Applicant FNLNS] live with brothers or sisters who are under
age [state age]? (Include stepbrothers, stepsisters, half-brothers,
half-sisters). Yes

N/A

[Checkboxes, multi-selection]
Display all household members under the state Medicaid age who did not already
attest to a relationship with the applicant (unless that relationship was "Sibling" )
Someone else who isn't applying for health coverage

Required

Required/Optional for Consumer to Provide
Answer to Send to SES**
*if optional, consumer must be able to
ith t
idi
i UI
ti
Required

Conditional Display Logic in the UI**

Data Element(s) Name

111

Household Composition*

Phase 3

Enter brother or sister information.

Who is brother or sister living with [Applicant dependent FNLNS]?
Someone else who isn't applying for coverage

N/A

Answer Fields
1. First Name: [Open text field]
2. Middle Name: [Open text field]
3. Last Name: [Open text field]
4. Suffix: [Drop-down, single-selection] Jr., Sr., III, IV
5. DOB: [Open text field]: YYYY-MM-DD
6. Sex: [drop-down, single selection]: Male, Female
6. 7. Add another child sibling (Display button)

1. Required
2. Required
3. Required
4. Required
5. Required
6. Required
6. 7. Required

1. Required
2. Optional
3. Required
4. Optional
5. Required
6. Required
6. 7. N/A

Consumer is requesting coverage AND requesting financial assistance AND applicant is under 14
OR age 14-20 AND follows non-filer rules AND indicated they want to provide information about
their family members (if Item 105 was displayed) AND consumer indicated they live with siblings
AND consumer selected "Someone else who isn't applying for health coverage" for "Who is
brother or sister living with [Applicant FNLNS]?"

Consumer is requesting coverage AND requesting financial assistance AND applicant is age 14 and If yes, set the following:
older AND follows non-filer rules AND indicated they want to provide information about their
1. resideTogetherIndicator = true
family members (if Item 105 was displayed) AND consumer is married but it is unknown if they live and set their 2. homeAddress to the home address of their spouse
with their spouse
If no, set the following:
1 resideTogetherIndicator = false
Consumer is requesting coverage AND requesting financial assistance AND applicant is age 14 and If yes is selected:
older AND follows non-filer rules AND indicated they want to provide information about their
Proceed to items #114 and 115 to set the resideTogetherIndicator to true
family members (if Item 105 was displayed) AND it is unknown if they live with any
If no is selected and there is already a person with a relevant relationship that exists on the application,
children/stepchildren OR unknown if they live with additional children/stepchildren not on the
set the following:
application
1. resideTogetherIndicator = false

Consumer is requesting coverage AND requesting financial assistance AND under 14 OR age 14-20 1. familyRelationships
(and under medicaid state child age) AND follows non-filer rules AND indicated they want to
2. resideTogetherIndicator = true
provide information about their family members (if Item 105 was displayed) AND consumer
indicated they live with siblings

Attestation Level

Data Element
Format

Policy**

General Requirements**

Question/Informational Text Wording Requirements**

Answer Options and Format Requirements**

1. member
2. member

1. enum
2. boolean

For child applicants who are not claimed as tax dependents or who are
claimed as tax dependents by non-parents, Medicaid and CHIP
household composition rules require collecting information about any
child-age siblings that the child lives with.

Questions about who lives together may be asked on an as-needed basis as seen If included in the UI, this information may be collected within the
here, or may be inferred based on information provided about who lives at
household composition section or asked in another application section.
which address. For applicants under the child age (determined by state via the
state reference data API), who are either not claimed as tax dependents, or
who are claimed by non-parents or non-custodial parents, DE entities need to
find out about the siblings they live with, if any, to determine Medicaid and CHIP
eligibility.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

1. member
2. member
3. member
4. member
5. member
6. application
7. member
8. member
9. member

1. string
2. string
3. string
4. enum
5. string
6. boolean
7. boolean
8. boolean
9. enum

For child applicants who are not claimed as tax dependents or who are
claimed as tax dependents by non-parents, Medicaid and CHIP
household composition rules require collecting information about any
child-age siblings that the child lives with.

Questions about who lives together may be asked on an as-needed basis as seen If included in the UI, this information may be collected within the
here, or may be inferred based on information provided about who lives at
household composition section or asked in another application section.
which address. For applicants under the child age (determined by state via the
Household composition questions must be asked prior to the preliminary
state reference data API), who are either not claimed as tax dependents, or
eligibility determination.
who are claimed by non-parents or non-custodial parents, DE entities need to
find out about the siblings they live with, if any, to determine Medicaid and CHIP
eligibility.

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the
suffix is flexible as long as all answer options are presented to the
consumer
DOB: Flexible in the way the application collects the DOB. May collect
DOB through separate field for year, month, and day. May use a
calendar widget to assist the consumer with selecting a DOB.

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer
DOB: Flexible in the way the application collects the DOB. May collect DOB
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a DOB.
Sex: Answer format is flexible. Female and Male must be used as answer options.

Note that full time student status may impact whether or not applicants age 19 and 20 are
considered children for medicaid household composition rules. If the UI has collected information
about full time student status at this point in the flow, the UI may limit this question to only display
to 19 and 20 year olds who are counted as children under state medicaid household composition
rules (as determined by the state via the state reference data API).

If 6 7 is selected to add another person, display 1-56
112

Household Composition*

Phase 3

Does [FNLNS] live with [FNLNS's spouse]?

Is [FNLNS] married? Yes

N/A

[Radio buttons]
Yes
No

Required

Required

113

Household Composition*

Phase 3

It is unknown if they live with sons/daughters: Does
[FNLNS] live with [his/her] son, daughter, stepson, or
stepdaughter?

Do you want to provide more information about the family
members who live with [FNLNS]? Yes (If Item #105 applies to
applicant)

N/A

[Radio buttons]
Yes
No

Required

Required

It is known they live with sons/daughters: [Display
OR
applicant's children that live with them.] Does [FNLNS] live
with any other sons, daughters, stepsons, or stepdaughters? Do any other family members live with [FNLNS] at [FNLNS's
address]? Yes

1. firstName
2. middleName
3. lastName
4. suffix
5. birthDate
6. householdContactIndicator = false
7. requestingCoverageIndicator = false
8. resideTogetherIndicator = true
9. sex

1. member
2. member

1. boolean
2. string

For adult applicants who do not file a tax return and/or who are
claimed as tax dependents by non-parents, Medicaid and CHIP
household composition rules require collecting information about
whether or not they live with their spouse.

Questions about who lives together may be asked on an as-needed basis as seen
here, or may be inferred based on information provided about who lives at
which address. For applicants who are not claimed as tax dependents and who
do not file their own tax return, DE entities need to find out if they live with their
spouse to determine Medicaid and CHIP eligibility.

If included in the UI, this information may be collected within the
household composition section or asked in another application section.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Member

1. boolean
2. boolean

For adult applicants who do not file a tax return and/or who are
claimed as tax dependents by non-parents, Medicaid and CHIP
household composition rules require collecting information about any
sons, daughters or step-children that the applicant lives with.

Questions about who lives together may be asked on an as-needed basis as seen
here, or may be inferred based on information provided about who lives at
which address. For applicants who are not claimed as tax dependents and who
do not file their own tax return, DE entities need to find out about their
sons/daughters they live with, if any, to determine Medicaid and CHIP eligibility.

If included in the UI, this information may be collected within the
household composition section or asked in another application section.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

For adult applicants who do not file a tax return and/or who are
claimed as tax dependents by non-parents, Medicaid and CHIP
household composition rules require collecting information about any
sons, daughters or step-children that the applicant lives with. In some
states, individuals who are 19 and 20 and are a full-time student are
considered to be children and are therefore sometimes included in the
adult’s Medicaid/CHIP household if they live together
For adult applicants who do not file a tax return and/or who are
claimed as tax dependents by non-parents, Medicaid and CHIP
household composition rules require collecting information about any
sons, daughters or step-children that the applicant lives with.

Questions about who lives together may be asked on an as-needed basis as seen
here, or may be inferred based on information provided about who lives at
which address. For applicants who are not claimed as tax dependents and who
do not file their own tax return, DE entities need to find out about their
sons/daughters they live with, if any, to determine Medicaid and CHIP eligibility.

If included in the UI, this information may be collected within the
household composition section or asked in another application section.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Questions about who lives together may be asked on an as-needed basis as seen
here, or may be inferred based on information provided about who lives at
which address. For applicants who are not claimed as tax dependents and who
do not file their own tax return, DE entities need to find out about their
sons/daughters they live with, if any, to determine Medicaid and CHIP eligibility.

If included in the UI, this information may be collected within the
household composition section or asked in another application section.

Flexible.

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer
DOB: Flexible in the way the application collects the DOB. May collect DOB
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a DOB.
Sex: Answer format is flexible. Female and Male must be used as answer options.

Notes

*Reference p. 30 FAQs for further details

114

Household Composition*

Phase 3

Who is son, daughter, stepson, or stepdaughter living with
[FNLNS]?

Does [FNLNS] live with [his/her] son, daughter, stepson, or
stepdaughter? Yes

N/A

[Checkboxes, multi-selection]
Display any members under age 21 who are not already known to be
children/stepchildren living with the applicant
Someone else who isn't applying for health coverage

Required

Required

Consumer is requesting coverage AND requesting financial assistance AND applicant is age 14 and 1. familyRelationships
older AND follows non-filer rules AND indicated they want to provide information about their
2. resideTogetherIndicator = true
family members (if Item 105 was displayed) AND consumer indicated they live with their
children/stepchildren

1. member
2. member

1. enum
2. boolean

115

Household Composition*

Phase 3

Enter son, daughter, stepson, or stepdaughter information.

Who is son, daughter, stepson, or stepdaughter living with [FNLNS]?
Someone else who isn't applying for health coverage

N/A

Answer Fields
1. First Name: [Open text field]
2. Middle Name: [Open text field]
3. Last Name: [Open text field]
4. Suffix: [Drop-down, single-selection] Jr., Sr., III, IV
5. DOB: [Open text field]: YYYY-MM-DD
6. Sex: [drop-down, single selection]: Male, Female
6. 7. Add another child (Display button)

1. Required
2. Required
3. Required
4. Required
5. Required
6. Required
6. 7. Required

1. Required
2. Optional
3. Required
4. Optional
5. Required
6. Required
6. 7. N/A

Consumer is requesting coverage AND requesting financial assistance AND applicant is age 14 and 1. firstName
older AND follows non-filer rules AND indicated they want to provide information about their
2. middleName
family members (if Item 105 was displayed) AND consumer indicated they live with their
3. lastName
children/stepchildren AND selected "Someone else who isn't applying for health coverage" for
4. suffix
5. birthDate
"Who is son, daughter, stepson, or stepdaughter living with [FNLNS]?"
6. householdContactIndicator = false
7. requestingCoverageIndicator = false
8. resideTogetherIndicator = true
9. sex

1. member
2. member
3. member
4. member
5. member
6. application
7. member
8. member
9. member

1. string
2. string
3. string
4. enum
5. string
6. boolean
7. boolean
8. boolean
9. enum

116

Applicant information - parent/caretaker
relatives*

Phase 3

Your Household
[Display household]

This question would appear only when the
parentCaretakerCategoryStatus does not already equal yes for
applicants over age 18. The parentCaretakerCategoryStatus is
determined by SES through the Update App response after the
household composition section.

Help text: Select "Yes" if both of these apply:
-They live with any children age 18 or younger
-They're the main person taking care of at least one of those children
If two adults both take care of the same child, select only one of their names.

[Checkboxes, multi-selection]
Display names of applicants and non-applicants under 19 they live with
None of these children

Required for a subset of applicants

Required

Consumer is requesting coverage AND requesting financial assistance AND age 19 or older AND
parentCaretakerCategoryStatus is not equal to Y. The parentCaretakerCategoryStatus is
determined by SES through the Update App response after the household composition section.

Member

boolean

If 6 7 is selected to add another person, display 1-56

Is [FNLNS] the main person taking care of any of these
children?

Question Flow Requirements**

parentCaretakerIndicator

This question must be asked for applicants above 19 years of age if not
Flexible.
already confirmed whether or not they are the parent or caretaker of a
child living with them. The flow of collecting this information is flexible and
information collected from each applicant may be done throughout the
application. Questions about parent/caretaker relatives must be asked
prior to the preliminary eligibility determination.

Help Drawer: Learn more about who's considered a parent or caretaker relative
Some adults can get extra savings on coverage if they’re the main person taking care of a child they live with.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

A person is considered to be a child’s main caretaker – even if the child is in child care (or “day care”) most days – if they
are responsible for essential activities such as:
-Paying for necessary items, like the child’s food and clothing
-Helping the child with daily activities, like school and transportation
If 2 people both care for a child
If 2 unmarried people both live with and take care of a child, select only one of their names.
Divorced, legally separated, or single parents
-If a person has primary or shared custody of a child, select their name.
-If the child lives with one parent and one stepparent, select both of their names, which may be listed together. If they're
listed separately, select either person’s name.
Pregnant or adopting
-If a person is pregnant and expecting a baby during the coverage year, don’t select their name. Come back and update
the application after the child is born.
-If a person is planning to adopt a child and the child is already living with them, select their name.
Children age 18 attending college
-If a person has a child who’s 18, in college full-time, and lives at home, select their name.
-If a person has a child who’s 18, in college full-time, and lives at school, don’t select their name.
-If a person has a child who’s 18 and in college part-time, don’t select their name.
Children age 19 or older
-If a person takes care of a child who will turn 19 during the coverage year, select their name.
-If a person has children both under and over age 19, select their name. Then, select or add the names of only the
children who are under age 19
N/A

117

Applicant information - parent/caretaker
relatives*

Phase 3

Does [FNLNS] live with and take care of any other children
age 18 or younger?

Is [FNLNS] the main person taking care of any of these children?
None of these children
OR that question wasn't asked because there were no known
children under 19 on the app (if so, then "other" would not be in the
question in column D)

118

Applicant information - parent/caretaker
relatives*

Phase 3

Is [FNLNS] the main person taking care of this child (or
children)?

Does [FNLNS] live with any other children under age 19? Yes

N/A

131

Applicant information - MAGI Questions

Phase 1, Phase 2, Phase 3

Do any of these people have a physical disability or mental
health condition that limits their ability to work, attend
school, or take care of their daily needs? Optional.

N/A

Help Drawer: Why we ask about disabilities and mental health conditions

[Radio Buttons]
Yes
No

Required

Required

Consumer is requesting coverage AND requesting financial assistance AND age 19 or older AND
(selected "None of these children" for "is [FNLNS] the main person taking care of any of these
children?" OR that question was not displayed)

N/A

N/A

N/A

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

[Radio Buttons]
Yes
No

Required

Required

Consumer is requesting coverage AND requesting financial assistance AND age 19 or older AND
selected "None of these children" for "is [FNLNS] the main person taking care of any of these
children?" AND selected "Yes" for "Does [FNLNS] live with any other children under age 19?"

parentCaretakerIndicator

Member

boolean

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Required

Optional

Consumer is requesting financial assistance AND requesting coverage

blindOrDisabledIndicator

Member

boolean

The flow of collecting applicant information is flexible and may be done
throughout the application.

Wording must be exact.

All applicant names must display as answer options. Answer format is flexible;
however, multi-selection must be enabled.

[Checkboxes, multi-selection]
Display each applicant name
None of these people

Required

Optional

Consumer is requesting financial assistance AND requesting coverage

longTermCareIndicator

Member

boolean

The flow of collecting applicant information is flexible and may be done
throughout the application.

Wording must be exact.

[Checkboxes, multi-selection]
Is pregnant
Is 18-25 years old and was ever in foster care
Is currently incarcerated (detained or jailed)
Is 18-22 years old and is a full-time student
None of these apply to anyone in my household

Required

Required

Display pregnancy attestation when consumer is seeking financial assistance AND an applicant or
non-applicant:
1) consumer is female
2) consumer is 9-66 years old

If "None of these apply to anyone in my household" is selected, set:
1. pregnancyIndicator = false
2. fosterCareIndicator = false
3. incarcerationType = NOT_INCARCERATED AND nonIncarcerationAgreementIndicator = true
4. fullTimeStatusIndicator = false

1. Member
2. Member
3. Member
4. Member

1. boolean
2. boolean
3. boolean
4. boolean

[Checkboxes, multi-selection]
Display each applicant name
Select a person’s name if one or more of these applies (even if you’re not sure these conditions will qualify them for health None of these people
coverage based on their disability):
- They’re blind, deaf, or hard of hearing.
- They get Social Security Disability Insurance (SSDI) or Supplemental Security Insurance (SSI).
- They have a physical, cognitive, intellectual, or mental health condition, which may include one of more of these:
o Difficulty doing errands, like visiting a doctor’s office or shopping
o Serious difficulty concentrating, remembering, or making decisions
o Difficulty climbing or walking stairs
If a person needs help only because they’re too young to do these things for themselves, don’t select their name. Select a
child’s name only if one or more of these applies:
- They have limited ability to do things most children of the same age can do
- They need or use more health care than most children of the same age
- They get special education services or services under a Section 504 plan
If you select at least one person’s name, we’ll send your Marketplace application to your state Medicaid office. Your
state office will determine if a person qualifies for Medicaid based on the disability. Your state Medicaid office will contact
you for more information.

132

Applicant information - MAGI Questions

Phase 1, Phase 2, Phase 3

Do any of these people need help with daily activities like
N/A
dressing or using the bathroom, or live in a medical facility or
nursing home? Optional.

268

Applicant Information - More About this
Household

Phase 2

Do any of these situations apply to any of the people in your
household?

Help Drawer: Why we ask about needing help with daily activities
Select a person’s name if they need help with daily activities, including seeing, hearing, walking, eating, sleeping,
standing, lifting, bending, breathing, learning, reading, communicating, thinking, and working. Select a person’s name if
they have a cognitive or mental health condition, and need help with these activities through coaching or instruction.

All applicant names must display as answer options. Answer format is flexible;
however, multi-selection must be enabled.

If a person needs help only because they’re too young to do these things for themselves, don’t select their name.

N/A

N/A

Display foster care attestation when consumer is requesting financial assistance AND applying for
coverage and:
1) consumer is 18-25 years old

Applicant Information - More About this
Household

Phase 3

Do any of these situations apply to any of the people in your
household?

N/A

N/A

[Checkboxes, multi-selection]
Is pregnant
Is American Indian or Alaska Native
Is 18-25 years old and was ever in foster care
Is currently incarcerated (detained or jailed)
Is 18-22 years old and is a full-time student
None of these apply to anyone in my household

Required

Required

Display pregnancy attestation when consumer is seeking financial assistance AND an applicant or
non-applicant and:
1) consumer is female
2) consumer is 9-66 years old
Display American Indian or Alaskan Native attestation when consumer is an applicant or nonapplicant

If "None of these apply to anyone in my household" is selected, set:
1. pregnancyIndicator = false
2. AmericanIndianAlaskanNativeIndicator = false
3. fosterCareIndicator = false
4. incarcerationType = NOT_INCARCERATED AND nonIncarcerationAgreementIndicator = true
5. fullTimeStatusIndicator = false

1. Member
2. Member
3. Member
4. Member
5. Member

1. boolean
2. boolean
3. boolean
4. boolean
5. boolean

Display incarceration attestation when consumer is applying for coverage

Phase 3

If more than one applicant or non-applicant:
Which of these people are American Indians or Alaska
Natives?

Do any of these situations apply to any of the people in your
household? Is American Indian or Alaska Native

If one applicant or non-applicant:
Is [FNLNS] American Indian or Alaska Native?

Help Drawer: Learn more about the benefits that American Indians and Alaska Natives can get through the Marketplace
If a person is American Indian or an Alaska Native, they may have health coverage benefits and protections through the
Marketplace.
American Indians and Alaska Natives may get extra savings. For example, if they’re a member of a federally recognized
tribe and enroll in a Marketplace plan, they may not have to pay cost sharing and may get monthly Special Enrollment
Periods (SEPs).
American Indians and Alaska Natives who enroll in Medicaid, the Children's Health Insurance Program (CHIP), or the
Marketplace can still get services from the Indian Health Services, tribal health programs, or urban Indian health
programs. The results of this application won’t change that.

147

Applicant and non-applicant information pregnancy status

Phase 2, Phase 3

If more than one applicant or non-applicant:
Which of these people are pregnant?

Do any of these situations apply to any of the people in your
household? Is pregnant

If one applicant or non-applicant:
Is [FNLNS] pregnant?

If more than one applicant or non-applicant name is selected:
[Checkboxes, multi-selection]
Display all applicants and non-applicants (UI can pre-populate with checkmarks
those who have already selected AI/AN on the race and ethnicity questions)
None of these people listed above

Required

Consumer is an applicant or non-applicant AND consumer name was selected for "Is American
Indian or Alaska Native"

If consumer name or "Yes" is selected, set:
americanIndianAlaskanNativeIndicator = true

If more than one applicant or non-applicant name is selected:
[Checkboxes, multi-selection]
Display names of each applicant and non-applicant female
None of these people listed above

Help Drawer: Learn more about coverage options for pregnant women and the baby when it's born.

If one applicant or non-applicant name is selected:
[Radio buttons]
Yes
No

Required

Optional

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Consumer is requesting financial assistance AND consumer is an applicant or non-applicant AND
consumer is female AND consumer is 9-66 years old AND consumer name was selected for "Is
pregnant"

If consumer name or "Yes" is selected, set:
pregnancyIndicator = true

babyDueQuantity

The application must ask females (both applicants and relevant non-applicants)
for pregnancy status because pregnancy/number of babies due affects
household size and income limits for Medicaid and CHIP. The application is
permitted to omit this question for children under the age of nine and assume
Former foster care status can help someone aged 18-25 become
they are not pregnant.
Medicaid eligible with no income test. However, there are rules around
state and Medicaid receipt and age the consumer left foster care.
The application must ask for former foster care status because it can help
someone aged 18-25 become Medicaid eligible with no income. However,
Incarceration is a factor of eligibility for QHP and Medicaid/CHIP.
there are rules around state and Medicaid receipt and age the consumer left
Consumers who are currently incarcerated are not QHP-eligible.
foster care. The application is permitted to omit this question for consumers who
Consumers who are incarcerated pending disposition may be QHPare not 18-25 years old.
eligible.
The application must ask for incarceration status because it impacts a
Full time student status impacts whether or not an 18 year-old can be consumer's QHP eligibility. Incarceration status is only required for applicants.
considered a dependent child for purposes of Medicaid
parent/caretaker relative rules, whether 19-20 year old's can be
In some situations, information on full time student status is required for 18-22
counted as children for Medicaid and CHIP household composition
year-olds. The application may use the state reference data available through
rules in some states, and in some states help the Exchange to apply
the SES API to limit the situations further in which to ask this question. If so, the
special residency rules that aim to prevent a student from Medicaid in application would ask if applicants aged 18-22 are full time students in states with
a state when only residing their temporarily for schooling, while their
special residency rules in Medicaid/CHIP for full-time students, and if 18 year old
parents live elsewhere.
household members are students if their parent or caretaker is applying for
coverage and if 19-20 year old household members are students if the state
American Indians and Alaska natives (AI/AN) may qualify for special
The application must ask questions related to American Indian or Alaska Native
benefits (SEP, CSR, Medicaid/CHIP cost-sharing rules). The broad
status because American Indians and Alaska natives may qualify for special
AI/AN term is used here because Medicaid and CHIP have different
benefits (SEP, CSR, Medicaid/CHIP cost-sharing rules). Medicaid and CHIP have
rules for who gets benefits related to AI/AN status than the Exchange. different rules for who gets benefits related to AI/AN status than the Exchange.
If someone attests to this question then the Exchange knows to show
On financial assistance applications, it is important that AI/AN household
them tribal income questions and appropriate follow-up questions
members, including non-applicants, have the opportunity to flag whether any
about tribal membership and ITU membership.
of their attested income falls into the tribal income categories. In addition, for
applicants who are potentially Medicaid/CHIP eligible, the application must ask
about eligibility and receipt of Indian Health Services using the FFE language.
For applicants who are potentially QHP eligible, the application must ask
whether the consumer is a member of a federally recognized tribe, and if so, for
the name of the tribe. It is optional to ask all application members whether they
identify as American Indian or Alaska Native, but if the application does not ask,
then the specific questions just described would need to be asked for everyone.

Member

boolean

Member

boolean

Pregnancy affects household size and income limits for Medicaid and
CHIP. This question may be limited to female consumers age 9 and
older.

Number of babies due impacts household size for Medicaid and CHIP.

If consumer name is not selected OR "None of these people listed above" or "No" is selected, set:
americanIndianAlaskanNativeIndicator = false

If one applicant or non-applicant name is selected:
[Radio buttons]
Yes
No

Help Text: Optional. Select all that apply. Pregnant women and their household members may be eligible for free or lowcost coverage through Medicaid or CHIP. If she enrolls in Medicaid, the baby will automatically be enrolled in Medicaid
when they’re born, and they’ll remain eligible for at least a year. If a pregnant woman is already enrolled in Marketplace
coverage and wants to keep her current coverage, don't select her name here.

Information for pregnant women who are currently enrolled in Marketplace coverage
Telling us about a pregnancy is optional. Read below for tips to help you decide if you should select her name or skip this
question.

Required

Consumers must have the opportunity to attest to being an American The application must ask questions related to American Indian or Alaska Native The flow of collecting applicant and non-applicant information is flexible Flexible.
Indian or Alaskan Native (AI/AN), being pregnant, formerly being in
status because American Indians and Alaska natives may qualify for special
and may be done throughout the application. This information impacts
foster care, and/or currently incarcerated. These attestations affect a benefits (SEP, CSR, Medicaid/CHIP cost-sharing rules). Medicaid and CHIP have household composition and eligibility so must be asked before the income
consumer's eligibility for QHP, APTC, CSR, and Medicaid/CHIP.
different rules for who gets benefits related to AI/AN status than the Exchange. section. This variation is specific to Phase 3 applications. Including this
On financial assistance applications, it is important that AI/AN household
comprehensive question is optional. The application could use this
AI/AN may qualify for special benefits (SEP, CSR, Medicaid/CHIP cost- members, including non-applicants, have the opportunity to flag whether any
question to determine which follow up questions to display to the
sharing rules). The broad AI/AN term is used here because Medicaid
of their attested income falls into the tribal income categories. In addition, for
consumer. If this question is not used, the application must ask about
and CHIP have different rules for who gets benefits related to AI/AN
applicants who are potentially Medicaid/CHIP eligible, the application must ask
each attestation individually.
status than the Exchange. If someone attests to this question then the about eligibility and receipt of Indian Health Services using the FFE language. It
Exchange knows to show them tribal income questions and
is optional to ask all application members whether they identify as American
appropriate follow-up questions about tribal membership and ITU
Indian or Alaska Native, but if the application does not ask, then the specific
membership.
questions just described would need to be asked for everyone.
Pregnancy affects household size and income limits for Medicaid and
CHIP. This question may be limited to female consumers age 9 and
older.

Display full-time student question when consumer is seeking financial assistance and:
1) Whenever there is an 18 year old applicant or non-applicant that has a parent caretaker (a.
parent that lives with the child, b. claiming tax filer that lives with the child, or c. attested parent
caretaker of the child)
2) Applicant 18-22 in a state that has the student residency option (optionStudentResidency = Y)
3) Applicant or non-applicant age is 19 or 20 AND the coverage state's Under21AndFTSOption = Y
(Under21AndFTSOption is included in the reference data API)

Applicant information - American
Indian/Alaska Native status

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

The application must ask for former foster care status because it can help
someone aged 18-25 become Medicaid eligible with no income. However,
there are rules around state and Medicaid receipt and age the consumer left
Former foster care status can help someone aged 18-25 become
foster care. The application is permitted to omit this question for consumers who
Medicaid eligible with no income test. However, there are rules around are not 18-25 years old.
state and Medicaid receipt and age the consumer left foster care.
The application must ask for incarceration status because it impacts a
Incarceration is a factor of eligibility for QHP and Medicaid/CHIP.
consumer's QHP eligibility. Incarceration status is only required for applicants.
Consumers who are currently incarcerated are not QHP-eligible.
Consumers who are incarcerated pending disposition may be QHPIn some situations, information on full time student status is required for 18-22
eligible.
year-olds. The application may use the state reference data available through
the SES API to limit the situations further in which to ask this question. If so, the
Full time student status impacts whether or not an 18 year-old can be application would ask if applicants aged 18-22 are full time students in states with
considered a dependent child for purposes of Medicaid
special residency rules in Medicaid/CHIP for full-time students, and if 18 year old
parent/caretaker relative rules, whether 19-20 year old's can be
household members are students if their parent or caretaker is applying for
counted as children for Medicaid and CHIP household composition
coverage and if 19-20 year old household members are students if the state
rules in some states, and in some states help the Exchange to apply
counts 19-20 year old students as children for Medicaid and CHIP household
special residency rules that aim to prevent a student from Medicaid in composition rules. If the DE partner does not want to build in these complex
a state when only residing their temporarily for schooling, while their
rules, instead the application could ask all 18-20 year old applicants and nonparents live elsewhere.
applicants, and all 21-22 year old applicants, if they are full-time students.

Display foster care attestation when consumer is requesting financial assistance AND applying for
coverage and:
1) consumer is 18-25 years old

146

The application must ask females (both applicants and relevant non-applicants)
for pregnancy status because pregnancy/number of babies due affects
household size and income limits for Medicaid and CHIP. The application is
permitted to omit this question for children under the age of nine and assume
they are not pregnant.

The flow of collecting applicant and non-applicant information is flexible Flexible.
and may be done throughout the application. This information impacts
household composition and eligibility so must be asked before the income
section. This variation is specific to Phase 2 applications. Including this
comprehensive question is optional. The application could use this
question to determine which follow up questions to display to the
consumer. If this question is not used, the application must ask about
each attestation individually.

Pregnancy affects household size and income limits for Medicaid and
CHIP. This question may be limited to female consumers age 9 and
older.

Display incarceration attestation when consumer is applying for coverage
Display full-time student question when consumer is seeking financial assistance and:
1) Whenever there is an 18 year old applicant or non-applicant that has a parent caretaker (a.
parent that lives with the child, b. claiming tax filer that lives with the child, or c. attested parent
caretaker of the child)
2) Applicant 18-22 in a state that has the student residency option (optionStudentResidency = Y)
3) Applicant or non-applicant age is 19 or 20 AND the coverage state's Under21AndFTSOption = Y
19-20 applicant or non-applicant Under21FTS (Under21AndFTSOption is included in the
reference data API)

269

Consumers must have the opportunity to attest to being pregnant,
formerly being in foster care, and/or currently incarcerated. These
attestations affect a consumer's eligibility for QHP, APTC, CSR, and
Medicaid/CHIP.

If consumer name is not selected OR "None of these people listed above" or "No" is selected, set:
pregnancyIndicator = false

The application must ask females (both applicants and relevant non-applicants)
for pregnancy status because pregnancy/number of babies due affects
household size and income limits for Medicaid and CHIP. The application is
permitted to omit this question for children under the age of nine and assume
they are not pregnant.

This question could be a stand-alone question that is separate from the
Flexible. It is a best practice that this question should welcome AI/AN
optional race and ethnicity question about American Indian and Alaska
applicants and explain how the information will be used. However, if
Native status. The goal of the general AI/AN question is to be able to
desired, the UI could have a different format that directly requests
narrowly tailor the more specific AI/AN questions to the right people so it information about tribal membership and eligibility/receipt of I/T/U
should be asked after all applicants and relevant non-applicants are
services without the general AI/AN question.
identified, and before the income section. If this question is asked, this
question must be a stand-alone question. Including it as a standalone
question prior to the preliminary eligibility determination would enable the
application to ask follow-up questions of relevant applicants, rather than
all applicants. If not asked, then AI/AN income and tribe/ITU questions
must be asked of all relevant applicants.

All applicant and non-applicant names must display as answer options. Answer
format is flexible; however, multi-selection must be enabled.

This information impacts household composition and eligibility so must be
asked before the income section. This question will be used in the
preliminary eligibility determination.

All relevant applicant and non-applicant names must display as answer options.
Answer format is flexible; however, multi-selection must be enabled.

Wording must be exact.

If she wants to keep her Marketplace coverage, don’t select her name.
-This will help her keep her current Marketplace coverage and savings throughout the pregnancy and after birth.
-If she keeps her Marketplace coverage, be sure to update the application after she gives birth to add the baby to the
plan or enroll them in coverage through Medicaid or the Children’s Health Insurance Program (CHIP), if they qualify.
If she wants to see if she qualifies for other free or low-cost coverage, select her name.
-Telling us about the pregnancy makes it more likely that she’ll be found eligible for coverage through Medicaid or CHIP.
If she’s found eligible for Medicaid or CHIP, she won’t be able to keep her current Marketplace coverage or be eligible for
savings on Marketplace coverage.
-Medicaid and CHIP are free or very low cost, and are likely to be the most affordable coverage option.
-If she enrolls in Medicaid, the baby will automatically be enrolled in Medicaid when they’re born, and they’ll remain
eligible for at least a year.
-If she’s eligible for Medicaid or CHIP due to the pregnancy, she may lose that coverage about 2 months after she has the
baby. If this happens, be sure to come back to HealthCare.gov to enroll in other coverage.
Information for pregnant women who aren’t currently enrolled in Marketplace coverage
Answer this question, so we can help make sure pregnant women and their family members get the most affordable
coverage.

148

Applicant and non-applicant information pregnancy status

Phase 2, Phase 3

How many babies is [Name selected in item #147]
expecting during this pregnancy?

If more than one applicant:
Which of these people are pregnant? Name selected

149

Applicant information - foster care status

Phase 2, Phase 3

If more than one applicant:
Which of these people were in foster care?

Do any of these situations apply to any of the people in your
household? Is 18-25 years old and was ever in foster care

N/A

[Drop-down, single selection]
1, 2, 3, 4, 5, 6, 7, 8

Required

Required

Consumer is requesting financial assistance AND consumer is an applicant or non-applicant AND
consumer is female AND consumer is between 9 and 66 years old AND consumer name was
selected for "Which of these people are pregnant? (If more than one applicant) OR consumer
attested to being pregnant (If one applicant)"

Member

number

The application must ask females for pregnancy status because
pregnancy/number of babies due affects household size and income limits for
Medicaid and CHIP. If the consumer does not know, we can assume there is 1
baby expected for eligibility purposes.

The flow of collecting applicant and non-applicant information is flexible Flexible.
and may be done throughout the application. This information impacts
household composition and eligibility so must be asked before the income
section. All pregnant women should be asked this question.

Answer format is flexible. Answer options may be altered for compatibility with the
question wording (i.e., may use the term twins instead of the number two).

N/A

If more than one applicant name is selected:
[Checkboxes, multi-selection]
Display names of applicants aged 18-25
None of these people listed above

Required

Required

Consumer is requesting financial assistance AND consumer is requesting coverage AND consumer If consumer name or "Yes" is selected, set:
is 18-25 years old AND consumer name was selected for "Is 18-25 years old and was ever in foster fosterCareIndicator = true
care"
If consumer name is not selected OR "None of these people listed above" or "No" is selected, set:
fosterCareIndicator = false

Member

boolean

The application must ask for former foster care status because it can help
someone aged 18-25 become Medicaid eligible with no income. However,
there are rules around state and Medicaid receipt and age the consumer left
foster care.

The flow of collecting applicant information is flexible and may be done
throughout the application. The former foster care questions must be
asked before the preliminary eligibility determination.

Flexible.

All relevant applicant names must display as answer options. Answer format is
flexible, as long as the consumer may select multiple names.

If one applicant:
Is [FNLNS] pregnant? Yes

If one applicant:
Was [FNLNS] in foster care?

150

Applicant information - foster care status

Phase 2, Phase 3

In what state was [Name selected in item #149] in the foster If more than one applicant:
care system?
Which of these people were in foster care? Name selected

N/A

If one applicant name is selected:
[Radio buttons]
Yes
No
[Drop-down, single-selection]
Display dropdown menu of all 50 states (Default to State of application.)

Required

Required

Consumer is requesting financial assistance AND consumer is requesting coverage AND consumer fosterCareState
is 18-25 years old AND consumer name was selected for "Which of these people were in foster
care?" (If more than one applicant) OR consumer attested to being in foster care (If one
applicant)

Member

enum

The application must ask for former foster care status because it can help
someone aged 18-25 become Medicaid eligible with no income. However,
there are rules around state and Medicaid receipt and age the consumer left
foster care.

The flow of collecting applicant information is flexible and may be done
throughout the application.
The former foster care questions must be asked before the preliminary
eligibility determination.

Flexible.

Must be a drop-down menu. All 50 states must display on the drop down menu.
The application may use state abbreviations or full state names.

[Radio buttons]
Yes
No

Required

Required

Consumer is requesting financial assistance AND consumer is requesting coverage AND consumer medicaidDuringFosterCareIndicator
is 18-25 years old AND consumer name was selected for "Which of these people were in foster
care?" (If more than one applicant) OR consumer attested to being in foster care (If one
applicant)

Member

boolean

The application must ask for former foster care status because it can help
someone aged 18-25 become Medicaid eligible with no income. However,
there are rules around state and Medicaid receipt and age the consumer left
foster care.

The flow of collecting applicant information is flexible and may be done
throughout the application. The former foster care questions must be
asked before the preliminary eligibility determination.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with the State Medicaid and CHIP program names can now be found
question wording.
through using the State Reference Data API, and do not have to
be hard-coded. CMS advises the UI include (Medicaid) or (CHIP)
when a state Medicaid or CHIP program does not include it or the
state uses the same name for their Medicaid and CHIP
programs.

[Open text field]*

Required

Required

Consumer is requesting financial assistance AND consumer is requesting coverage AND consumer
is 18-25 years old AND consumer name was selected for "Which of these people were in foster
care? (If more than one a

If one applicant:
Was [FNLNS] in foster care? Yes
151

Applicant information - foster care status

Phase 2, Phase 3

Was [Name selected in item #150] getting health care
through [Name of state Medicaid program](Medicaid)?

152

Applicant information - foster care status

Phase 2, Phase 3

How old was [Name selected in item #151] when [he/she]
left the foster care system?

If more than one applicant:
Which of these people were in foster care? Name selected
If one applicant:
Was [FNLNS] in foster care? Yes

Help Drawer: Learn why having Medicaid matters.
Sometimes young adults who were in foster care can get extra savings paying for health coverage, but only if they were
enrolled in Medicaid while they were in foster care.

In what state was [Applicant name] in the foster care system? State
selected
If more than one applicant:
Which of these people were in foster care? Name selected
If one applicant:
Was [FNLNS] in foster care? Yes
In what state was [Applicant name] in the foster care system? State
selected
Was [Applicant name] getting health care through [Name of state
Medicaid program](Medicaid)? Yes

N/A

*Age must be between 1-25

Auditor Compliance
Conclusion**

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor
Comments**

Item #

144

Application Section
* indicates features of this question may be
updated in future documentation

Applicable EDE Phase**

Question**

Answers to Previous Questions**

Informational Text**

Answer Options and Format**

Applicant information - full-time student
status

Phase 2, Phase 3

If more than one applicant:
Which of these people are full-time students?

Do any of these situations apply to any of the people in your
household? Is 18-22 years old and is a full-time student

Help Text: If you're not sure if someone is considered a full-time student, check with their school.

If more than one applicant name is selected:
Required
[Checkboxes, multi-selection]
Display each applicant aged 18-22 (If state has adopted a restriction on residency
for students going to school in their state)
Display each potential parent/caretaker relative child (any child whose parents or
caretaker are applying for coverage) who is age 18, even if non-applicant or not in
household
Display each non-applicant aged 19 or 20 if the state has elected to include such full
time students as children for purposes of household composition
None of these people listed above

If one applicant:
Is [FNLNS] a full-time student?

Required/Optional to Display Question or
Corresponding Answer Fields to Collect
Information in Application UI**

Required/Optional for Consumer to Provide
Answer to Send to SES**
*if optional, consumer must be able to
ith t
idi
i UI
ti
Required

Conditional Display Logic in the UI**

Data Element(s) Name

Attestation Level

Data Element
Format

Policy**

Display full-time student question when consumer is seeking financial assistance and:
1) Whenever there is an 18 year old applicant or non-applicant that has a parent caretaker (a.
parent that lives with the child, b. claiming tax filer that lives with the child, or c. attested parent
caretaker of the child)
2) Applicant 18-22 in a state that has the student residency option (optionStudentResidency = Y)
3) Applicant or non-applicant age is 19 or 20 AND the coverage state's Under21AndFTSOption = Y
(Under21AndFTSOption is included in the reference data API)

If "Yes", or a name is selected, set:
fullTimeStatusIndicator = true

Member

boolean

There are 3 policy reasons for this question. Full time student status
In some situations, information on full time student status is required for 18-22
This information may be needed to determine which consumers are
impacts whether or not an 18 year-old can be considered a dependent year-olds. The application may use the state reference data available through
relevant non-applicants, so this should be asked before the income
child for purposes of Medicaid parent/caretaker relative rules,
the SES API to limit the situations further in which to ask this question. If so, the
section. Full-time student status questions must be asked prior to the
whether 19-20 year old's can be counted as children for Medicaid and application would ask if applicants aged 18-22 are full time students in states with preliminary eligibility determination.
CHIP household composition rules in some states, and in some states
special residency rules in Medicaid/CHIP for full-time students, and if 18 year old
help the Exchange to apply special residency rules that aim to prevent household members are students if their parent or caretaker is applying for
a student from Medicaid in a state when only residing their temporarily coverage and if 19-20 year old household members are students if the state
for schooling, while their parents live elsewhere.
counts 19-20 year old students as children for Medicaid and CHIP household
composition rules. If the DE partner does not want to build in these complex
rules, instead the application could ask all 18-20 year old applicants and nonapplicants, and all 21-22 year old applicants, if they are full-time students.

Member

boolean

The flow of collecting applicant information is flexible and may be done
throughout the application. The application should only ask this question
for applicants aged 18-22 who attested to full time student status, and
could choose to ask this only for applicants in that group.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

If a consumer name is not selected OR "No", or "None of these people listed above" is selected, set:
fullTimeStatusIndicator = false

If one applicant name is selected:
[Radio buttons]
Yes
No
259

Applicant information - full-time student
status

Phase 3

Does one or more of [Applicant name selected above]'s
parents or guardians live in [State of application]?

If more than one applicant:
Which of these people are full-time students? Name selected
If one applicant:
Is [FNLNS] a full-time student? Yes

Help Drawer: Learn how a parent's address affects coverage
Select "Yes" if this person's parents or guardians live in the state in the question. A parent can be a birth, adoptive, step, or
foster parent.

[Radio buttons]
Yes
No

Required

Required

Applicant is 18-22 years old AND lives in a state with student residency (optionStudentResidency = If "Yes", set:
Y) AND is prelimMedicaid=Y (if asked after the preliminary eligibility determination) AND applicant parentLivesInStudentStateIndicator = true
is a tax dependent AND answered "Yes" to "Are any of these people full time students?"

General Requirements**

Going to school in a different state than parents

Question Flow Requirements**

Question/Informational Text Wording Requirements**

Answer Options and Format Requirements**

Flexible; however, the question must use the term "full time student," as All relevant applicant names must display as answer options. Answer format is
this is the term used in Medicaid regulations.
flexible; however, multi-selection must be enabled if more than one applicant.

If a child goes to college in a different state, they can apply for coverage in the state that's their parents' primary place of
living or in the state where they live and go to college.
Full-time students may be eligible for a Special Enrollment Period when they move to or from the place where they live
and go to college.
Why we're asking this
We want to make sure people get health coverage in the right state. Sometimes full-time students get coverage in the
state where their parents live instead of the state where they go to school.
283

Applicant information - full-time student
status

Phase 3

Does [Applicant name selected in Item #144] go to school in Does [Applicant name selected above] have a parent or guardian
[Application state]?
living in [State of application]? No

N/A

[Radio buttons]
Yes
No

Required

Required

Applicant is 18-22 years old AND lives in a state with student residency (optionStudentResidency = If "Yes", set:
Y) AND is prelimMedicaid=Y (if asked after the preliminary eligibility determination) AND applicant parentLivesInStudentStateIndicator = false AND studentsParentLivingInExchangeStateIndicator =
is a tax dependent AND answered "Yes" to "Are any of these people full time students?" AND
true
answered "No" to "Does one or more of [Applicant name selected above]'s parents or guardians
live in [State of application]?"
If "No", set:
parentLivesInStudentStateIndicator = true AND
studentsParentLivingInExchangeStateIndicator = false

Member

boolean

The flow of collecting applicant information is flexible and may be done
throughout the application. The application should only ask this question
for applicants aged 18-22 who attested to full time student status, and
could choose to ask this only for applicants in that group.

Flexible.

128

Applicant and non-applicant information race and ethnicity

Phase 1, Phase 2, Phase 3

Is [FNLNS] of Hispanic, Latino, or Spanish origin? (optional)

Selecting this person's race and ethnicity helps the U.S. Department of Health and Human Services improve service to all [Radio buttons]
people using the Marketplace. We use this information to make sure everyone gets fair access to coverage. Providing this Yes
information won't impact eligibility, plan options, or costs.
No

Required

Optional

N/A

Member

boolean

The flow of collecting applicant information is flexible and may be done
throughout the application.

Flexible. This question must be clearly labeled as optional. Notice must
Answer format is flexible. Answer options may be altered for compatibility with
be given to applicants that their answer will not impact their eligibility and question wording.
will be used only on an aggregate basis as part of HHS efforts to eliminate
health disparities.

N/A

Set "hispanicOriginIndicator" to true if consumer provides answer to Item 129

129

Applicant and non-applicant information race and ethnicity

Phase 1, Phase 2, Phase 3

What's [FNLNS]'s specific origin?

Is [FNLNS] of Hispanic, Latino, or Spanish origin? (optional) Yes

N/A

[Checkboxes, multi-selection]
Cuban
Mexican, Mexican American, or Chicano/a
Puerto Rican
Other: [Open text field]

Required

Optional

Consumer selected "Yes" for "Is [FNLNS] of Hispanic, Latino, or Spanish origin? (optional)"

Member

array, enum

The flow of collecting applicant information is flexible and may be done
throughout the application.

Flexible. This question must be clearly labeled as optional. Notice should Answer option wording must be exact and all options must be present. Answer
be given to applicants that their answer will not impact their eligibility and format is flexible. An option for "Other" must be provided with an open text field.
will be used only on an aggregate basis as part of HHS efforts to eliminate
health disparities.

130

Applicant and non-applicant information race and ethnicity

Phase 1, Phase 2, Phase 3

What's [FNLNS]'s race?

N/A

Optional. Select all that apply.

[Checkboxes, multi-selection]
American Indian or Alaska Native
Asian Indian
Black or African American
Chinese
Filipino
Guamanian or Chamorro
Japanese
Korean
Native Hawaiian
Samoan
Vietnamese
White
An Asian race not listed above
A Pacific Islander race not listed above
Another race not listed above: [Open text field]

Required

Optional

Display an open text field if "Other" is selected

otherEthnicityText = [answer to open text field] when ethnicity = “OTHER”
1. race
2. If "Other" is selected: otherRaceText

Member

1. array, enum
2. string

The flow of collecting applicant information is flexible and may be done
throughout the application.

Flexible. This question must be clearly labeled as optional. Notice should Answer option wording must be exact and all options must be present. Answer
be given to applicants that their answer will not impact their eligibility and format is flexible. An option for "Other" must be provided with an open text field.
will be used only on an aggregate basis as part of HHS efforts to eliminate
health disparities.

32

Applicant and non-applicant information

Phase 1, Phase 2, Phase 3

What is [FNLNS]'s Social Security Number (SSN)?

N/A

Help Text: Enter [FNLNS]'s 9-digit SSN. We verify the SSN with Social Security based on the consent you gave at the start [Open text field]: XXX-XX-XXXX
of the application.
Phases 2 and 3 only:
Help Drawer: Learn more about entering SSNs
Don’t enter Individual Taxpayer Identification Numbers (ITINS) or any other numbers here.
[checkbox next to statement]: [FNLNS] doesn't have an SSN. You may only
Some lawfully present people may not have or be eligible for an SSN. They can still apply for health coverage without an
check this box if [FNLNS] attests that they have never been issued an SSN by the
SSN. For more information on how to get an SSN, visit socialsecurity.gov [Link to: https://www.socialsecurity.gov]
Social Security Administration.
If you get an error after you enter an SSN, review the name, date of birth, and SSN, and make changes as needed. If the
information you entered is correct, you can leave it as is. But, we may ask you to confirm the information at the end of
the application.

Required- both question and accompanying
notice about use of SSN

Required

Display for all applicants

ssn

Member

string

Display an open text field if "Other" is selected

ethnicity = “CUBAN”, and/or
“MEXICAN”, and/or
“PUERTO_RICAN”, and/or
“OTHER”

Enter [FNLNS]'s 9-digit SSN. We verify the SSN with Social Security based on the consent you gave at the start of the
application.

Applicants must provide their SSNs if they have one to use for
Phases 1: Any request for an SSN must be accompanied by a notice to the
The flow of collecting applicant and non-applicant information is flexible
verifications as well as for tracking of APTC payments for tax filers who consumer about how the SSN will be used and how a consumer can get an SSN if and may be done throughout the application.
are eligible. Because SSN is such a sensitive and private piece of
he or she does not have one. The UI must clearly tell consumers that the SSN wil
personal information, the UI must adhere to security protocols for
be used to confirm information entered on their application, such as income
protection of SSN information (including masking SSN characters) and information. For non-applicants, SSN must be clearly optional but encouraged.
must provide notice to the applicant about how SSN will be used.
Phase 2 and 3: Any request for an SSN must be accompanied by a notice to the
consumer about how the SSN will be used and how a consumer can get an SSN if
he or she does not have one. The UI must clearly tell consumers that the SSN wil
be used to confirm information entered on their application, such as income
information. While applicants are required to provide SSNs if they have them,
there are some consumers who are eligible for coverage who do not have SSNs.
Therefore, the UI must have a pathway that allows consumers to continue with
the application and submission without providing a SSN. For non-applicants, SSN
must be clearly optional but encouraged.

Wording must be exact.

SSN must be an open text field.
The answer format for the statement related to not having a SSN must be a
checkbox and must be included on phase 2 and 3 applications. The required text
after "[FNLNS] doesn't have an SSN" is only required for the agent/broker
pathway application, and must be added to the answer option or otherwise
prominently displayed in close proximity to the answer option (e.g., below or
beside the answer option to ensure the agent or broker can clearly see it without
further action).

305

Applicant and non-applicant information

Phase 2, Phase 3

Are you sure? You must provide your client's SSN, if they
have one. CMS may take enforcement action against
agents or brokers for failing to provide correct information
to the Marketplace.

Continued in application without entering an SSN in Item 32

N/A

[Toggle Buttons]
Required
Enter SSN now (go back to Item 32 and enter SSN)
[FNLNS] doesn't have an SSN, because they have never been issued an SSN by the
Social Security Administration.

Optional

Display for all applicants who continue without providing an SSN, but only required for the
agent/broker pathway application.

None. This is not sent to SES.

Member

N/A

Agents and brokers must enter SSNs for all applicant clients who have DE entities must emphasize to agent and broker users the importance of
them. Agents or brokers who deliberately fail to collect SSNs from their collecting SSNs from all their applicant clients who have them by prominently
clients who have them may be subject to compliance actions for failing displaying this question as a warning, alert, or pop-up to encourage applicant
to provide accurate information to the Marketplace.
SSNs to be entered.

This question must be displayed to agent or broker users as a warning,
alert, or pop-up after they opt to not provide an SSN for an applicant
client.

Wording must be exact.

Answer format is flexible as long as the agent or broker has options to enter SSN or
indicate their client doesn't have an SSN.

34

Applicant and non-applicant information

Phase 1, Phase 2, Phase 3

What is [FNLNS]'s Social Security Number (SSN)?
(Optional)

N/A

Help text: Optional. Enter [FNLNS]'s 9-digit SSN. We verify the SSN with Social Security based on the consent you gave
at the start of the application.

[Open text field]: XXX-XX-XXXX

Optional

Display for all non-applicants

ssn

Member

string

This question is a way to make clear that providing an SSN for nonapplicants is optional. People in the household who are not themselves
seeking coverage are not required to provide SSNs even if they have
them, but doing so will help usually help their household members
reduce the amount of paper documentation they need to provide

The flow of collecting applicant and non-applicant information is flexible
and may be done throughout the application.

Flexible. This question must be clearly labeled as optional for the nonapplicant to provide an SSN.

The SSN field must be an open text field.

N/A

DE entities should encourage all applicants and non-applicants who
DE entities must encourage non-applicants to provide an SSN; however, it must This question should be displayed to the consumer after they opt to not
have SSNs to provide them. When consumers do not provide SSNs,
be optional for a non-applicant to provide an SSN.
provide an SSN.
they often need to provide paper documents to verify eligibility, which
adds burden for the consumer and costs for the FFE
In phase 2 and 3 applications, if providing an SSN, consumers must indicate
The flow of collecting applicant and non-applicant information is flexible
whether or not they are applying for coverage using the same name as on their and may be done throughout the application. Questions about SSN must
SSN card. In Phase 1 applications, the screener question covers this.
be asked prior to the preliminary eligibility determination.

35

Applicant and non-applicant information

Phase 2, Phase 3

Providing your Social Security number (SSN) can be helpful if you don' t want health coverage because it can speed up
the application process. We use SSNs to check income and other information to see who is eligible for help paying for
health coverage. If [FNLNS] needs help getting an SSN, visit socialsecurity.gov, or call Social Security at 1-800-7721213 TTY users should call 1 800 325 0778
Help Text: It's important to provide SSNs to determine eligibility for cost savings. Entering this information helps speed the [Toggle Buttons]
application process, ensure your eligibility is correct, and make it less likely you'll need to provide more information later.
Continue without SSN
Back (go back to Item 34 and provide SSN change response to 'yes')

Required

Any request for an SSN must be accompanied by a notice to the consumer
about how the SSN will be used and how a consumer can get an SSN if he or she
does not have one. The UI must clearly tell consumers that the SSN will be used
to confirm information entered on their application, such as income
information. For non-applicants, SSN must be clearly optional but encouraged.

Are you sure? It's important to enter the SSN for everyone
on your application, if they have them…..

Continued in application without entering an SSN in Item 34

36

Applicant and non-applicant information

Phase 2, Phase 3

Is [FNLNS] the same name that appears on [his/her] Social
Security card?

N/A

N/A

[Radio buttons]
Yes
No

Required

Required

Display for all applicants and non-applicants that provide a SSN.

None. This is not sent to SES.

Member

N/A

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

37

Applicant and non-applicant information

Phase 2, Phase 3

Enter the same name as shown on [FNLNS]'s Social Security Is [FNLNS] the same name that appears on [his/her] Social Security
card
card? No

N/A

Answer Fields
1. First Name: [Open text field]
2. Middle Name: [Open text field]
3. Last Name: [Open text field]
4. Suffix: [Drop-down, single-selection] Jr., Sr., III, IV

Answer Fields:
1. Required
2. Required
3. Required
4. Required

If the consumer indicates their
application name does not match the name
that appears on their Social Security card:
1. Required
2. Optional
3. Required
4. Optional

Display these fields if the consumer answers "No" to "Is [FNLNS] the same name that appears on
[his/her] Social Security card?"

1. ssnAlternateName.firstName
2. ssnAlternateName.middleName
3. ssnAlternateName.lastName
4. ssnAlternateName.suffix

Member

1. string
2. string
3. string
4. enum

In phase 2 and 3 applications, if providing an SSN, consumers must indicate
whether or not they are applying for coverage using the same name as on their
SSN card. In Phase 1 applications, the screener question covers this.

In Phase 2 and 3 applications, if the consumer is applying using a name
different than the one on their SSN card, this question should be asked
after the question "Is [FNLNS] the same name that appears on [his/her]
Social Security card?" Questions about SSN must be asked prior to the
preliminary eligibility determination.

Flexible.

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer

38

Applicant information citizenship/immigration status

Phase 2, Phase 3

If more than one applicant: Is every person applying for
coverage a U.S. citizen or U.S. national?

Help Drawer: Learn more about being a U.S. citizen or U.S. national
A U.S. citizen is someone who was born in the United States (including U.S. territories, except for American Samoa), or
who was born outside the U.S., including those who:
-Are naturalized as U.S. citizens.
-Have derived citizenship through the naturalization of parent(s).
-Have derived citizenship through adoption by U.S. citizen parents, provided certain conditions are met.
-Have acquired citizenship at birth because they were born to U.S. citizen parent(s).

[Radio buttons]
Yes
No

Required

Required

Consumer is requesting coverage.

If yes, set citizenshipIndicator = true for all applicants

Member

boolean

Non-applicants cannot be listed in the list of consumers that display. In Phase 1,
this is covered in the screener.

The flow of collecting applicant information is flexible. All citizenship and
immigration questions must occur prior to the preliminary eligibility
determination.

Flexible. The UI could ask each applicant individually if they are a U.S.
Citizen or a U.S. National instead of asking about all applicant names at
once.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

This question must be asked of applicants. The UI may not ask citizen or
immigration questions of non-applicants, even if it is clearly optional.

The flow of collecting applicant information is flexible . All citizenship and
immigration questions must occur prior to the preliminary eligibility
determination
Flexible. The UI must display this prior to the preliminary eligibility
determination.

Flexible. The UI could instead ask about US citizenship separately from
US national status.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

N/A

If one applicant: Is [FNLNS] a U.S. citizen or U.S. national?

Optional

Optional

Display for all non-applicants who continue without providing a SSN.

None. This is not sent to SES.

Member

Flexible. The wording of the encouragement must clearly explain
providing an SSN will speed up the application process, but may not be
necessary to continue.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

A U.S. national is someone who's either a U.S. citizen or non-citizen who owes permanent allegiance to the U.S. In nearly
all cases, non-citizen U.S. nationals are people born in American Samoa or abroad with one or more American Samoan
parent under certain conditions.
If someone isn't a U.S. citizen or U.S. national, select "No."
We'll ask about immigration status later in the application.
39

Applicant information citizenship/immigration status

Phase 2, Phase 3

Which of these people aren't U.S citizens or U.S. nationals?

Is every person applying for coverage a U.S. citizen or U.S.
national? No

Select all that apply. People who aren't U.S. citizens or U.S. national can still apply for coverage.

[Checkboxes, multi-selection]
Display list of applicants

Required

Required

Consumer is requesting coverage AND selected "No" for "Is every person applying for coverage a
U.S. citizen or U.S. national?"

For every applicant not selected, set citizenshipIndicator = true
For every applicant selected, set citizenshipIndicator = false

Member

boolean

260

Applicant information citizenship/immigration status

Phase 1, Phase 2, Phase 3

We weren't able to verify [FNLNS]'s information. Please
confirm the information below is correct and try again.

Consumer provided SSN but SSN couldn't be verified by SSA

Help Drawer: Learn what to do if the names don't match.
If the name on this person's Social Security card is different from the name displayed, select "No", and enter the name
exactly as it appears on the Social Security card, even if there's a mistake on the card. We'll verify this information with
Social Security, based on the consent you gave at the start of the application.

[Radio buttons]
Yes
No

Required

Required

See Item #1 on the "Backend Responses for UI" tab

N/A

N/A

N/A

Answer Fields
1. First Name: [Open text field]
2. Middle Name: [Open text field]
3. Last Name: [Open text field]
4. Suffix: [drop-down, single selection]: Jr., Sr., III, IV
5. DOB: [Open text field] MM-DD-YYYY

Answer Fields
1. Required
2. Required
3. Required
4. Required
5. Required

Answer Fields
1. Required
2. Optional
3. Required
4. Optional
5. Required

See Item #1 on the "Backend Responses for UI" tab

1. ssnAlternateName.firstName
2. ssnAlternateName.middleName
3. ssnAlternateName.lastName
4. ssnAlternateName.suffix
5. birthDate

Member

Does this match the name and date of birth on [FNLNS]'s
Social Security card?

To change the name with Social Security and get a new card, visit socialsecurity.gov [link to https://socialsecurity.gov]
or call Social Security at 1-800-772-1213 (TTY: 1-800-325-0778)
N/A

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

1. string
2. string
3. string
4. enum
5. string

Flexible. For name and DOB, the UI could display the name and DOB to
the consumer and only display fields to update it if they indicate it is
different from what they previously provided or it could display all fields
to the consumer.

Name and DOB may be pre-populated for the consumer in each field.

Flexible.

261

Applicant information citizenship/immigration status

Phase 1, Phase 2, Phase 3

[Display applicant name and DOB]
Enter this person's information exactly as it appears on their
Social Security card.

262

Applicant information citizenship/immigration status

Phase 1, Phase 2, Phase 3

Re-enter [FNLNS]'s Social Security Number (SSN).

Consumer provided SSN but SSN couldn't be verified by SSA

N/A

[Open text field]

Required

Optional

See Item #1 on the "Backend Responses for UI" tab

ssn

Member

string

40

Applicant information citizenship/immigration status

Phase 2, Phase 3

Is [FNLNS] a naturalized or derived citizen?

N/A

Help Drawer: Learn more about naturalized or derived citizenship.
A naturalized citizen is a foreign citizen or national who obtained U.S. citizenship by fulfilling certain requirements as
established by law. A naturalized citizen wasn't born in the U.S. and didn't get U.S. citizenship automatically through his or
her relationship to a U.S. citizen.

[Radio buttons]
Yes
No

Required

Required

Consumer is requesting coverage AND attested to U.S. citizenship, but citizenship wasn't verified,
including the scenario where an SSN has not been provided by the applicant

naturalizedCitizenIndicator

Member

boolean

[Radio buttons]
Naturalization Certificate
Certificate of Citizenship
None of these

Required

Optional (Note: if the
Consumer is requesting coverage AND answered "Yes" to "Is [FNLNS] a naturalized or derived
naturalizationCertificateNumber is not
citizen?"
provided for the
lawfulPresenceDocumentation provided in
Column K, then SES will not initiate a Hub call to
DHS for that member)

lawfulPresenceDocumentation.Certificate_Of_Naturalization
lawfulPresenceDocumentation.Certificate_Of_Citizenship

Member

Answer Fields
1. [FNLNS]'s Naturalization Certificate number Optional : [Open text field]
2. [FNLNS]'s alien number Optional : [Open text field] AXXXXXXXXX
3. Checkbox next to "I don't have one"

1. Required
2. Required
3. Optional

1. Optional (Note: if the
Consumer is requesting coverage AND answered "Yes" to "Is [FNLNS] a naturalized or derived
naturalizationCertificateNumber is not
citizen?" AND selected "Naturalization certificate" as the document type
provided for the
lawfulPresenceDocumentation provided in
Column K, then SES will not initiate a Hub call to
DHS for that member)
2. Optional
3. Optional

lawfulPresenceDocumentation.Certificate_Of_Naturalization
1. naturalizationCertificateNumber
2. alienNumber
3. noAlienNumberIndicator

41

Applicant information citizenship/immigration status

Phase 2, Phase 3

Does [FNLNS] have one of these documents? Optional

Consumer provided SSN but SSN couldn't be verified by SSA
Does this match the name and date of birth on [FNLNS]'s Social
Security card? No

Is [FNLNS] a naturalized or derived citizen? Yes

A derived citizen is:
-A person who derives U.S. citizenship through his or her relationship to a U.S. citizen (by operation of law).
-A child who derives citizenship through the naturalization of the child's parents, through passage of certain laws, or
through adoption by U.S. citizen parents.
-A person who acquires U S citizenship may have a "Certificate of Citizenship" (Form N-560 or N-561)
Help Drawer: Learn more about these documents.
If a person is a derived or naturalized citizen, select one of these two documents to show their status:
-Naturalization Certificate. See what this document looks like. [Link to
https://www.healthcare.gov/downloads/certificate-of-naturalization.pdf]
-Certificate of Citizenship. See what this document looks like [Link to
https://www.healthcare.gov/downloads/certificate-of-citizenship.pdf]

Consumer answered "No" for "Does this match the name and date of birth on [FNLNS]'s Social
Security card?"

This question may only be asked of applicants. This question must be asked for
attested citizens not verified by SSA. The UI may not ask citizen or immigration
questions of non-applicants, even if it is clearly optional.

The flow of collecting applicant information is flexible . All citizenship and
immigration questions must occur prior to the preliminary eligibility
determination.

Flexible. The UI could make it more clear what a naturalized citizen is as
long as terminology is accurate and comprehensive.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

enum

This question may only be asked of applicants. It is required to collect
naturalization document information in this same format so that it can be
properly processed by the Hub.

The flow of collecting applicant information is flexible . All citizenship and
immigration questions must occur prior to the preliminary eligibility
determination.

Flexible.

Answer format is flexible. Answer option wording must be exact and all options
must be present.

Member

1. string
2. string
3. boolean

This question may only be asked of applicants. It is required to collect
naturalization document information in this same format so that it can be
properly processed by the Hub.

The flow of collecting applicant information is flexible . All citizenship and
immigration questions must occur prior to the preliminary eligibility
determination.

Flexible.

Alien number: Must be an open text field
Naturalization certificate number: Must be an open text field
DE entities may provide an option for consumers to select "I don't' have one"
through a checkbox format, but this is not a required answer option.

Member

1. string
2. string
3. boolean

This question may only be asked of applicants. It is required to collect
naturalization document information in this same format so that it can be
properly processed by the Hub.

The flow of collecting applicant information is flexible . All citizenship and
immigration questions must occur prior to the preliminary eligibility
determination.

Flexible.

Alien number: Must be an open text field
Citizenship certificate number: Must be an open text field
DE entities may provide an option for consumers to select "I don't' have one"
through a checkbox format, but this is not a required answer option.

If the consumer does not provide an answer to the eligible immigration status
question, then the UI must may encourage the consumer to answer the
immigration status question.

If included in the UI, this question must be displayed after the question,
"Check here if [FNLNS] has eligible immigration status" and should only
show up when someone does not check the box. All citizenship and
immigration questions must occur prior to the preliminary eligibility
determination.

Informational text format may conform to answer option choices.
Wording must be exact.

N/A

See Item #4 on the "Backend Responses for UI" tab

A naturalized/derived citizen may have their citizenship status verified
through DHS rather than SSA. Therefore, this question is asked so the
UI knows whether or not to ask subsequent questions about
naturalization document information that can used by the SAVE DHS
service through the Hub.

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer
DOB: Flexible in the way the application collects the DOB. May collect DOB
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a DOB.
Must be an open text field. The UI must not pre-populate the SSN for the
consumer.

If a person doesn't have one of these documents, select “None of these.”
We can't electronically verify this person's status using a U.S. passport, state-issued driver's license or ID card, or birth
certificate. However, if they're a naturalized or derived citizen and they don't have a "Naturalization Certificate" or
"Certificate of Citizenship," you can still submit a Marketplace application and get a temporary eligibility determination.
Then, you'll be asked to mail or upload a copy of their citizenship documentation later.
42

Applicant information citizenship/immigration status

Phase 2, Phase 3

[FNLNS]'s Document Information

Document Type: Naturalization certificate

Alert text if the optional naturalized or derived citizen questions are skipped: Continue without entering this information?
Enter all of the immigration information you can, even when a field is optional. Providing this information helps make sure
eligibility is correct, helps the application process go smoother and faster, and makes it less likely you'll need to submit
more information later.
Help Drawer: Learn where to find the document number.
Try to find and enter both the alien number and the Naturalization Certificate number. This will speed up the process. If
you don't see both numbers on the document, check the back side. (Some older documents may not list both numbers.)
If this person only has one number, enter it and continue the application anyway.

If consumer selects the checkbox for "I don't have one" next to alien number, set
noAlienNumberIndicator = true.
If consumer provides an alien number, set noAlienNumberIndicator = false.
If the consumer provides an Alien number of less than 9 digits, then the requestor should prepend
zero(s) so that the string submitted in the JSON is 9 digits.

Alien number: This can be found at the top, right-hand corner of the “Naturalization Certificate“ (Form N-560 or N-561).
The alien number is sometimes called the "alien registration number" or "USCIS number." Alien numbers start with an "A"
and end with 7-9 digits.
Naturalization Certificate number: This can be found at the top, right-hand corner of the "Naturalization Certificate"
(Form N-550).
See where to find these numbers. [Link to https://www.healthcare.gov/downloads/certificate-of-naturalization.pdf]
For help, call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).
43

Applicant information citizenship/immigration status

Phase 2, Phase 3

[FNLNS]'s Document Information

Document Type: Certificate of Citizenship

Alert text if the optional naturalized or derived citizen questions are skipped: Continue without entering this information?
Enter all of the immigration information you can, even when a field is optional. Providing this information helps make sure
eligibility is correct, helps the application process go smoother and faster, and makes it less likely you'll need to submit
more information later.

Answer Fields
1. [FNLNS]'s Certificate of Citizenship number Optional : [Open text field]
2. [FNLNS]'s alien number Optional : [Open text field] AXXXXXXXXX
3. Checkbox next to "I don't have one"

1. Required
2. Required
3. Optional

Help Drawer: Learn where to find the document number.
Try to find and enter both the alien number and the Certificate of Citizenship number. This will speed up the process. If you
don't see both numbers on the document, check on the back side. (Some older documents may not list both numbers.) If
this person only has one number, enter it and continue the application anyway.

1. Optional (Note: if the
Consumer is requesting coverage AND answered "Yes" to "Is [FNLNS] a naturalized or derived
naturalizationCertificateNumber is not
citizen?" AND selected "Certificate of citizenship" as the document type
provided for the
lawfulPresenceDocumentation provided in
Column K, then SES will not initiate a Hub call to
DHS for that member)
2. Optional
3. Optional

Alien number: This can be found at the top, right-hand corner of the “Naturalization Certificate“ (Form N-560 or N-561).
The alien number is sometimes called the "alien registration number" or "USCIS number." Alien numbers start with an "A"
and end with 7-9 digits.

lawfulPresenceDocumentation.Certificate_Of_Citizenship
1. citizenshipNumber
2. alienNumber
3. noAlienNumberIndicator
If consumer selects the checkbox for "I don't have one" next to alien number, set
noAlienNumberIndicator = true.
If consumer provides an alien number, set noAlienNumberIndicator = false.
If the consumer provides an Alien number of less than 9 digits, then the requestor should prepend
zero(s) so that the string submitted in the JSON is 9 digits.

Certificate of Citizenship number: This can also be found at the top, right-hand corner of the "Certificate of Citizenship"
(Form N-560 or N-561).
See where to find these numbers. [Link to https://www.healthcare.gov/downloads/certificate-of-citizenship.pdf]
For help, call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).
Help Drawer: Select “Yes” if this person has any of these eligible immigration statuses:
-Lawful permanent resident (LPR/Green Card holder)
-Asylee
-Refugee
-Cuban/Haitian entrant
-Paroled into the U.S.
-Conditional entrant granted before 1980
-Battered spouse, child, or parent
-Victim of trafficking and their spouse, child, sibling, or parent
-Special Immigrant Visa holders from Iraq or Afghanistan
-Granted Withholding of Deportation or Withholding of Removal, under the immigration laws or under the Convention
against Torture (CAT)
-Individual with non-immigrant status (including worker visas, student visas, and citizens of Micronesia, the Marshall
Islands, and Palau)
-Temporary Protected Status (TPS)
-Deferred Enforced Departure (DED)
-Deferred Action Status (Exception: Deferred Action for Childhood Arrivals (DACA) isn't considered an eligible immigration
status for health coverage through the Marketplace)
-Lawful temporary resident
-Granted an administrative stay of removal by the Department of Homeland Security (DHS)
-Member of a federally recognized Indian tribe or American Indian born in Canada
-Resident of American Samoa
-Special Immigrant Juvenile Status

[Radio buttons]

Or, if they're an applicant for one of these:
-Temporary protected status with employment authorization
-Special Immigrant Juvenile Status
-Adjustment to LPR Status with an approved visa petition
-Victim of trafficking visa
-Asylum — See note below.
-Withholding of Deportation or Withholding of Removal, under the immigration laws or under the Convention against
Torture (CAT) — See note below.
-Cancellation of Removal or Suspension of Deportation with approved employment authorization
-Legalization under Immigration Reform and Control Act (IRCA) with approved employment authorization
Note:
-Deferred Action Status (Deferred Action for Childhood Arrivals (DACA)) isn't considered an eligible immigration status for
applying for health coverage.
-Applicants for asylum or for withholding of deportation or removal under the immigration laws or under CAT are eligible
for Marketplace coverage only if employment authorization has been granted, OR the person is under 14 and has had an
application pending for at least 180 days.
Or individuals with approved employment authorization and these:
-Registry applicants
-Order of supervision
-Legalization under the LIFE Act
-Applicant for Temporary Protected Status
-Applicant for Cancellation of Removal or Suspension of Deportation
-Applicant for Legalization under IRCA
How this information will be used
We’ll use this information only to determine if the people applying for coverage are eligible for a Marketplace plan, help
with costs, or coverage through Medicaid or the Children's Health Insurance Program (CHIP). We'll verify this information
with trusted data sources, based on the consent you gave at the start of your application.
Applying won’t impact public charge status
Applying for or receiving Medicaid or CHIP benefits, or getting savings for health insurance costs in the Marketplace,
doesn’t make someone a "public charge. [Link to:https://www.uscis.gov/green-card/green-card-processes-andprocedures/public-charge] " This means it won’t affect their chances of becoming a Lawful Permanent Resident or U.S.
citizen.
There’s one exception for people receiving long-term care in an institution at government expense, like in a nursing
facility. These individuals may face barriers getting a green card.
We won't use the information for immigration enforcement purposes.
You don't need to provide citizenship or immigration status information for people on your application who aren't applying
for health coverage.
Learn more about these statuses. [Link to: https://www.uscis.gov/tools/glossary ]

45

Applicant information citizenship/immigration status

Phase 2, Phase 3

N/A

Does [FNLNS] have eligible immigration status? Checkbox not
checked (if checkbox format used)
Does [FNLNS] have eligible immigration status? I would like to
continue the application without answering this question.

I would like to continue the application without answering this question:

N/A

Important: If [FNLNS] has an immigration status on this list of statuses [link to help drawer for eligible immigration
statuses] , change the answer to “Yes.” If you’re not sure or you need help, call the Marketplace Call Center at 1-800-318
2596 (TTY: 1-855-889-4325).

Required*

N/A

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or None. This is not sent to SES.
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND does not
provide an answer for the immigration status question

Member

N/A

Optional

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or lawfulPresenceDocumentation
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
eligible immigration status

Member

array, enum

Only non-citizen applicants may provide this information.

This question must be asked anytime after the applicant has indicated
they have eligible immigration status. All citizenship and immigration
questions must occur prior to the preliminary eligibility determination.

Flexible.

Answer format for selecting a document type is flexible. Answer options wording
must be exact. However, the UI could group certain answer options together to
offer a more manageable list of choices and then ask a second question if needed
to determine the more specific document type. For example, the initial choices
could be grouped as: Green card; passport or travel document; visa; and notice
of action (I-797).

Required

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or N/A
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
eligible immigration status AND selected "Permanent Resident Card (Green Card) or Reentry
Permit (I-551, temporary I-551 stamp, I-327)" as the document type

Member

N/A

Only non-citizen applicants may provide this information.

After selecting a document group, these documents must display for
Green Card, if the UI does not group documents differently.

Flexible.

Answer format is flexible. Answer option wording must be exact and all options
must be present.

*The required text to display is located in
column F under Informational Text

It is a best practice to ensure that the consumer has not opted not to
provide an answer to the question if they have an eligible immigration
status. Since it is important not to require an answer to the question,
this is an alternate way to improve the response rate and ensure
consumers know that the answer is important.

Checkbox not checked (if checkbox format used) and consumer is requesting financial assistance: Important: If this
question is not answered, [FNLNS] won't be eligible for full Medicaid or Marketplace coverage and will be considered only
for coverage of emergency services, including labor and delivery services. If [FNLNS] has an immigration status on this
list of statuses [link to help drawer for eligible immigration statuses], change the answer to “Yes.” If you’re not sure or you
need help, call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).
Checkbox not checked (if checkbox format used) and consumer is not requesting financial assistance: Important: If this
question is not answered, [FNLNS] won't be eligible for Marketplace coverage. If [FNLNS] has an immigration status on
this list of statuses [link to help drawer for eligible immigration statuses], change the answer to “Yes.” If you’re not sure or
you need help, call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).
46

Applicant information citizenship/immigration status

Phase 2, Phase 3

Select the document type that corresponds with [FNLNS]'s
most current documentation and status. Optional

Does [FNLNS] have eligible immigration status? Yes, [FNLNS] has
eligible immigration status

N/A

48

Applicant information citizenship/immigration status

Phase 2, Phase 3

N/A

Select the document type that corresponds with [FNLNS]'s most
current documentation and status.
Permanent Resident Card (Green Card) or Reentry Permit (I-551,
temporary I-551 stamp, I-327)

N/A

[Radio buttons]
Required
Permanent Resident Card (Green Card) or Reentry Permit (I-551, temporary I-551
stamp, I-327)
Machine Readable Immigrant Visa with temporary I-551 language
Employment Authorization Card (I-766)
Arrival/Departure Record (I-94, I-94A)
Refugee Travel Document (I-571)
Nonimmigrant Student or Exchange Visitor Status (I-20, DS2019)
Notice of Action (I-797)
Another document or [FNLNS]'s alien number/I-94 number
Unexpired foreign passport
None of these
[Drop-down, single selection]
Required
I-551 (Permanent Resident Card, "Green Card")
Temporary I-551 Stamp (on passport or I-94/I-94A)
I-327 (Reentry Permit)

Note, if the consumer does not have one of the listed documents, but does know
their Alien number or I-94 number, they must be allowed to enter it.

47

Applicant information citizenship/immigration status

Phase 2, Phase 3

N/A

Select the document type that corresponds with [FNLNS]'s most
current documentation and status.
Arrival/Departure Record (I-94, I-94A)

N/A

[Drop-down, single selection]
Arrival/Departure Record (I-94/I-94A)
Arrival/Departure Record in unexpired foreign passport (I-94)

Required

Required

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or N/A
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
eligible immigration status AND selected "Arrival/Departure Record (I-94, I-94A)" as the
document type

Member

N/A

Only non-citizen applicants may provide this information.

After selecting a document group, these documents must display for
Arrival/Departure Record, if the UI does not group documents
differently.

Flexible.

Answer format is flexible. Answer option wording must be exact and all options
must be present.

265

Applicant information citizenship/immigration status

Phase 2, Phase 3

N/A

Select the document type that corresponds with [FNLNS]'s most
current documentation and status.
Nonimmigrant Student or Exchange Visitor Status (I-20, DS2019)

N/A

[Drop-down, single selection]
Certificate of Eligibility for Nonimmigrant (F-1) Student Status (I-20)
Certificate of Eligibility for Exchange Visitor (J-1) Status

Required

Required

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or N/A
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
eligible immigration status AND selected "Nonimmigrant Student or Exchange Visitor Status (I-20,
DS2019)" as the document type

Member

N/A

Only non-citizen applicants may provide this information.

After selecting a document group, these documents must display for
Nonimmigrant Student or Exchange Visitor Status, if the UI does not
group documents differently.

Flexible.

Answer format is flexible. Answer option wording must be exact and all options
must be present.

Notes

Auditor Compliance
Conclusion**

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor
Comments**

Item #

49

Application Section
* indicates features of this question may be
updated in future documentation

Applicable EDE Phase**

Question**

Answers to Previous Questions**

Applicant information citizenship/immigration status

Phase 2, Phase 3

[FNLNS]'s Document Information

Immigration status document type: I-551 (Permanent Resident
Card, "Green Card")

Informational Text**

Answer Options and Format**

All questions about immigration status are optional, but answering them will make getting coverage easier.

Answer Fields
Answer Fields
1. [FNLNS]'s alien number Optional : [Open text field] AXXXXXXXXX
1. Required
2. [FNLNS]'s card number Optional : [Open text field] XXXXXXXXXXXXX
2. Required
3. Does the name below match the name on the I-551? Optional. [FNLNS]: [radio 3. Required
buttons] Yes, No
4. Required
4. Document expiration date Optional : [Open text field] YYYY-MM-DD

Help Drawer: Learn more about entering I-551 information.
Permanent Resident Cards are issued to lawful permanent residents. A lawful permanent resident (LPR) or "Green Card"
recipient is a person who isn't a U.S. citizen, but who has permission to live and work permanently in the U.S. If this person
is a lawful permanent resident, they should use their I-551 document information if possible.

Required/Optional to Display Question or
Corresponding Answer Fields to Collect
Information in Application UI**

Required/Optional for Consumer to Provide
Answer to Send to SES**
*if optional, consumer must be able to
ith t
idi
i UI
ti
Answer Fields
1. Optional
2. Optional
3. Optional
4. Optional

You can enter an I-551 card number without entering a Social Security Number (SSN) if this person doesn't have one yet.
(It's not necessary to enter an SSN to get Marketplace coverage.) Learn more about I-551s. [link to
https://www.uscis.gov/greencard]

Conditional Display Logic in the UI**

Data Element(s) Name

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or 1. alienNumber
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
2. cardNumber
eligible immigration status AND selected "Permanent Resident Card ("Green Card", I-551)" as the 3. documentExpirationDate
document type
If the consumer provides an Alien number of less than 9 digits, then the requestor should prepend
zero(s) so that the string submitted in the JSON is 9 digits--See Document Type Enums tab

Attestation Level

Data Element
Format

General Requirements**

Question Flow Requirements**

Member

1. string
2. string
3. string

Policy**

Only non-citizen applicants may provide this information.

This information must be asked any time after an applicant indicates they Flexible.
have eligible immigration status and selects a document type. It is a best
practice to display these answer fields after the consumer selects a
document type. All citizenship and immigration questions must occur
prior to the preliminary eligibility determination.

Question/Informational Text Wording Requirements**

Alien number: Must be an open text field
Card number: Must be an open text field
Confirming name: The UI must allow the consumer to provide an alternate
document name if they indicate that the name on their documentation is
different (see item #70). Answer format is flexible. Answer options may be altered
for compatibility with question wording.
Document expiration date: Answer format is flexible. A calendar widget may be
used to help the consumer select a date. Year, month, and day may be collected
in separate fields.

Member

1. string
2. string
3. string
4. string

Only non-citizen applicants may provide this information.

This information must be asked any time after an applicant indicates they Flexible.
have eligible immigration status and selects a document type. It is a best
practice to display these answer fields after the consumer selects a
document type. All citizenship and immigration questions must occur
prior to the preliminary eligibility determination.

Alien number: Must be an open text field
Reference the Passport Issuing Countries tab for the list of
Document expiration date: Answer format is flexible. A calendar widget may be
countries and the corresponding country codes.
used to help the consumer select a date. Year, month, and day may be collected
in separate fields.
Passport number: Must be an open text field
Country of issuance: Answer format is flexible. We recommend a drop-down, but
because this is a string value, an open text field could also be used. The response
that is passed to SES must contain the country code, however the UI could also
allow the consumer to select from or enter the full name of the country and
translate the response on the backend into a country code. If an open text field is
used, we recommend a field validation to prevent the consumer from proceeding
if they enter an invalid country or country code. If a drop-down is used, and the
full list of countries is not displayed in the drop-down, an option for "Other" must be
available for consumers to enter their country.

If none of the data elements are provided, then noIdentifiersProvidedIndicator = true should be set in
the object

Answer Options and Format Requirements**

Notes

To verify this person's status, enter both the alien number and the card number:
-Alien number: This number is listed under the heading "A#" or "USCIS#." This number is sometimes called an "alien
registration number" or "USCIS number." Alien numbers start with an "A" and end with 7-9 digits.
-Card number: This is sometimes called a receipt number. It's listed on either the front or back of the card and starts with 3
letters and ends with 10 numbers. If this person has a card number but you don't enter it, it'll take longer to verify their
status.
See where to find these numbers [link to https://www.healthcare.gov/downloads/permanent-resident-green-card.pdf]
If you're having trouble finding or entering this information
If you have trouble finding these numbers, check on the back of the card. Some older cards may not list both numbers.
Try to find and enter as many fields as possible to make the process go smoother and faster.
If you know this person's alien or I-94 number, change the document type in the drop-down menu to "Other documents
or status types." From the next drop-down list, select "Other." Then, enter a description of the document and this person's
alien and/or I-94 number in the text field.
For help, call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).
If you're getting errors
Continue the application without entering the document numbers. You may be asked to provide a copy of the document
after you submit your application.
50

Applicant information citizenship/immigration status

Phase 2, Phase 3

[FNLNS]'s Document Information

Immigration status document type: Temporary I-551 Stamp (on
passport or I-94/I-94A)

All questions about immigration status are optional, but answering them will make getting coverage easier.
Help Drawer: Learn more about entering temporary I-551 stamp information.
Temporary I-551 stamps can be used to attest to permanent resident status. A temporary I-551 stamp will have a
handwritten or stamped issue date and a "valid until" date. This stamp can be found on the front of an I-94 form or in the
foreign passport.
Enter the alien number, which is sometimes called an "alien registration number" or "USCIS number." This number is listed
under the heading "A#" or "USCIS#." Alien numbers start with an "A" and end with 7-9 digits.

Answer Fields
1. [FNLNS]'s alien number Optional: [Open text field] AXXXXXXXXX
2. Document expiration date Optional : [Open text field] YYYY-MM-DD
3. [FNLNS]'s passport number Optional : [Open text field] XXXXXXXXXXXXX
4. Select the country that issued [FNLNS]'s passport Optional [Drop-down, singleselection or open text field] Reference the Passport Issuing Countries tab for the list
of countries and the corresponding country codes

1. Required
2. Required
3. Required
4. Required

Answer Fields
1. [FNLNS]'s alien number Optional : [Open text field] AXXXXXXXXX
2. Document expiration date Optional : [Open text field] YYYY-MM-DD

1. Required
2. Required

1. Optional
2. Optional

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or 1. alienNumber
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
2. documentExpirationDate
eligible immigration status AND selected "Reentry Permit (I-327)" as the document type
If none of the data elements are provided, then noIdentifiersProvidedIndicator = true should be set in
the object

Member

1. string
2. string

Only non-citizen applicants may provide this information.

This information must be asked any time after an applicant indicates they Flexible.
have eligible immigration status and selects a document type. It is a best
practice to display these answer fields after the consumer selects a
document type. All citizenship and immigration questions must occur
prior to the preliminary eligibility determination.

Alien number: Must be an open text field
Document expiration date: Answer format is flexible. A calendar widget may be
used to help the consumer select a date. Year, month, and day may be collected
in separate fields.

Answer Fields
1. [FNLNS]'s alien number Optional : [Open text field] AXXXXXXXXX
2. [FNLNS]'s passport number Optional : [Open text field] XXXXXXXXXXXXX
3. Select the country that issued [FNLNS]'s passport Optional [Drop-down, singleselection or open text field] Reference the Passport Issuing Countries tab for the list
of countries and the corresponding country codes
4. Does the name below match the name on the passport? Optional. [FNLNS]:
[radio buttons] Yes, No
5. Document expiration date Optional : [Open text field] YYYY-MM-DD

Answer Fields
1. Required
2. Required
3. Required
4. Required
5. Required

Answer Fields
1. Optional
2. Optional
3. Optional
4. Optional
5. Optional

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or 1. alienNumber
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
2. passportNumber
eligible immigration status AND selected "Machine Readable Immigrant Visa (with temporary I3. passportIssuingCountry
551 language)" as the document type
4. documentExpirationDate

Member

1. string
2. string
3. string
4. string

Only non-citizen applicants may provide this information.

This information must be asked any time after an applicant indicates they Flexible.
have eligible immigration status and selects a document type. It is a best
practice to display these answer fields after the consumer selects a
document type. All citizenship and immigration questions must occur
prior to the preliminary eligibility determination.

Alien number: Must be an open text field
Reference the Passport Issuing Countries tab for the list of
Passport number: Must be an open text field
countries and the corresponding country codes.
Country of issuance: Answer format is flexible. We recommend a drop-down, but
because this is a string value, an open text field could also be used. The response
that is passed to SES must contain the country code, however the UI could also
allow the consumer to select from or enter the full name of the country and
translate the response on the backend into a country code. If an open text field is
used, we recommend a field validation to prevent the consumer from proceeding
if they enter an invalid country or country code. If a drop-down is used, and the
full list of countries is not displayed in the drop-down, an option for "Other" must be
available for consumers to enter their country.
Confirming name: The UI must allow the consumer to provide an alternate
document name if they indicate that the name on their documentation is
different (see item #70). Answer format is flexible. Answer options may be altered
for compatibility with question wording.
Document expiration date: Answer format is flexible. A calendar widget may be
used to help the consumer select a date. Year, month, and day may be collected
in separate fields.

Answer Fields
1. [FNLNS]'s alien number Optional : [Open text field] AXXXXXXXXX
2. [FNLNS]'s card number Optional : [Open text field] XXXXXXXXXXXXX
3. Document expiration date Optional : [Open text field] YYYY-MM-DD
4. Category code Optional : [Open text field] xxx
5. Does the name below match the name on the card? Optional. [FNLNS]: [radio
buttons] Yes, No

Answer Fields
1. Required
2. Required
3. Required
4. Required
5. Required

Answer Fields
1. Optional
2. Optional
3. Optional
4. Optional
5. Optional

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or 1. alienNumber
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
2. cardNumber
eligible immigration status AND selected "Employment Authorization Card (I-766)" as the
3. documentExpirationDate
document type
4. employmentAuthorizationCategoryIdentifier

Member

1. string
2. string
3. string
4. string

Only non-citizen applicants may provide this information.

This information must be asked any time after an applicant indicates they Flexible.
have eligible immigration status and selects a document type. It is a best
practice to display these answer fields after the consumer selects a
document type. All citizenship and immigration questions must occur
prior to the preliminary eligibility determination.

Alien number: Must be an open text field
Card number: Must be an open text field
Document expiration date: Answer format is flexible. A calendar widget may be
used to help the consumer select a date. Year, month, and day may be collected
in separate fields.
Category code: Must be an open text field
Confirming name: The UI must allow the consumer to provide an alternate
document name if they indicate that the name on their documentation is
different (see item #70). Answer format is flexible. Answer options may be altered
for compatibility with question wording.

Answer Fields
1. [FNLNS]'s I-94 Number Optional : [Open text field] XXXXXXXXXXX
2. Document expiration date Optional : [Open text field] YYYY-MM-DD
3. [FNLNS]'s SEVIS ID number Optional : [Open text field] NXXXXXXXXXX

1. Required
2. Required
3. Required

1. Optional
2. Optional
3. Optional

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or Set lawfulPresenceDocumentation = ARRIVAL_DEPARTURE_RECORD_IN_FOREIGN_PASSPORT_I_94
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
1. i94Number
eligible immigration status AND selected "Arrival/Departure Record (I-94, I-94A)" as the
2. documentExpirationDate
document type
3. sevisId

Member

1. string
2. string
3. string

Only non-citizen applicants may provide this information.

This information must be asked any time after an applicant indicates they Flexible.
have eligible immigration status and selects a document type. It is a best
practice to display these answer fields after the consumer selects a
document type. All citizenship and immigration questions must occur
prior to the preliminary eligibility determination.

I-94 number: Must be an open text field
Document expiration date: Answer format is flexible. A calendar widget may be
used to help the consumer select a date. Year, month, and day may be collected
in separate fields.
SEVIS ID: Must be an open text field

Member

1. string
2. string
3. string
4. string
5. string

Only non-citizen applicants may provide this information.

This information must be asked any time after an applicant indicates they Flexible.
have eligible immigration status and selects a document type. It is a best
practice to display these answer fields after the consumer selects a
document type. All citizenship and immigration questions must occur
prior to the preliminary eligibility determination.

I-94 number: Must be an open text field
Reference the Passport Issuing Countries tab for the list of
Passport number: Must be an open text field
countries and the corresponding country codes.
Document expiration date: answer format is flexible. A calendar widget may be
used to help the consumer select a date. Year, month, and day may be collected
in separate fields.
Country of issuance: Answer format is flexible. We recommend a drop-down, but
because this is a string value, an open text field could also be used. The response
that is passed to SES must contain the country code, however the UI could also
allow the consumer to select from or enter the full name of the country and
translate the response on the backend into a country code. If an open text field is
used, we recommend a field validation to prevent the consumer from proceeding
if they enter an invalid country or country code. If a drop-down is used, and the
full list of countries is not displayed in the drop-down, an option for "Other" must be
available for consumers to enter their country.
Confirming name: The UI must allow the consumer to provide an alternate
document name if they indicate that the name on their documentation is
different (see item #70). Answer format is flexible. Answer options may be altered
for compatibility with question wording.
SEVIS ID: Must be an open text field

1. Optional
2. Optional
3. Optional
4. Optional

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or 1. alienNumber
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
2. documentExpirationDate
eligible immigration status AND selected "Temporary I-551 Stamp (on passport or I-94, I-94A)" as 3. passportNumber
the document type
4. passportIssuingCountry
If none of the data elements are provided, then noIdentifiersProvidedIndicator = true should be set in
the object

See where to find this number. [Link to https://www.healthcare.gov/downloads/temporary-i-551-stamp.pdf]
If you're having trouble finding or entering this information
If you have trouble finding this number, check on the back of the card. Some older cards may not list both numbers. Try
to find and enter as many fields as possible to make the process go smoother and faster.
If you know this person's alien or I-94 number, change the document type in the drop-down menu to "Other documents
or status types." From the next drop-down list, select "Other." Then, enter a description of the document and this person's
alien and/or I-94 number in the text field.
For help, call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).
If you're getting errors
Continue through the application without entering the document numbers. You may be asked to provide a copy of the
document after you submit your application.
56

Applicant information citizenship/immigration status

Phase 2, Phase 3

[FNLNS]'s Document Information

Immigration status document type: I-327 (Reentry Permit)

All questions about immigration status are optional, but answering them will make getting coverage easier.
Help Drawer: Learn more about entering I-327 information.
Reentry permits allow permanent residents to leave and reenter the U.S. These permits are located in booklets called
"U.S. Travel Documents."
Enter the alien number, which is sometimes called an "alien registration number" or "USCIS number." This number is listed
under the heading "A#" or "USCIS#." This number is located on the right-hand side of the document. Alien numbers start
with an "A" and end with 7-9 digits.
See where to find these numbers. [Link to https://www.healthcare.gov/downloads/reentry-permit.pdf]
If you're having trouble finding or entering this information
If you have trouble finding this number, check on the back of the card. Try to find and enter as many fields as possible to
make the process go smoother and faster.
If you know this person's alien or I-94 number, change the document type in the drop-down menu to "Other documents
or status types." From the next drop-down list, select "Other." Then, enter a description of the document and this person's
alien and/or I-94 number in the text field.
For help, call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).
If you're getting errors
Continue through the application without entering the document numbers. You may be asked to provide a copy of the
document after you submit your application.

51

Applicant information citizenship/immigration status

Phase 2, Phase 3

[FNLNS]'s Document Information

Immigration status document type: Machine Readable Immigrant
Visa (with temporary I-551 language)

All questions about immigration status are optional, but answering them will make getting coverage easier.
Help Drawer: Learn more about entering machine readable visa information.
Machine readable immigrant visas (MRIVs) (with temporary I-551 language) are documents indicating permanent
resident status.
Enter this information:
-Alien number: This number is listed under the heading "A#" or "USCIS#." This number is sometimes called an "alien
registration number" or "USCIS number." Alien numbers start with an "A" and end with 7-9 digits.
-Passport number
-Country of issuance of your document
See where to find these numbers. [Link to https://www.healthcare.gov/downloads/machine-readable-immigrantvisa.pdf]

If none of the data elements are provided, then noIdentifiersProvidedIndicator = true should be set in
the object

If you're having trouble finding or entering this information
If you have trouble finding these numbers, check on the back of the card. Try to find and enter as many fields as possible
to make the process go smoother and faster.
If you know this person's alien or I-94 number, change the document type in the drop-down menu to "Other documents
or status types." From the next drop-down list, select "Other." Then, enter a description of the document and this person's
alien and/or I-94 number in the text field.
For help, call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).
If you're getting errors
Continue through the application without entering the document numbers. You may be asked to provide a copy of the
52

Applicant information citizenship/immigration status

Phase 2, Phase 3

[FNLNS]'s Document Information

Immigration status document type: Employment Authorization
Card (I-766)

All questions about immigration status are optional, but answering them will make getting coverage easier.
Help Drawer: Learn more about entering employment authorization card information.
Employment authorization documents are issued to some people who are authorized to work temporarily in the U.S.
Enter this information:
-Alien number: This number is listed under the heading "A#" or "USCIS#." This number is sometimes called an "alien
registration number" or "USCIS number." Alien numbers start with an "A" and end with 7-9 digits.
-Card number: If this person has a card number but don't enter it, it'll take longer to verify your status.
Expiration date
-Category code: The 3-digit code listed on the employment authorization document. This code starts with an A or C.
See where to find this information [Link to https://www.healthcare.gov/downloads/employment-authorizationcard.pdf]

If none of the data elements are provided, then noIdentifiersProvidedIndicator = true should be set in
the object

If the document is expired
If you have trouble finding this information, check on the back of the card. Try to find and enter as many fields as possible
to make the process go smoother and faster.
If this person has an expired copy of their I-766 but they've renewed it, enter all the document information they have,
including information from the expired card.
If you're having trouble finding or entering this information
If you have trouble finding this information, check on the back of the card. Try to find and enter as many fields as possible
to make the process go smoother and faster.
If you know this person's alien or I-94 number, change the document type in the drop-down menu to "Other documents
or status types." From the next drop-down list, select "Other." Then, enter a description of the document and this person's
alien and/or I-94 number in the text field.
For help, call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).

53

Applicant information citizenship/immigration status

Phase 2, Phase 3

[FNLNS]'s Document Information

Immigration status document type: Arrival/Departure Record (I94/I-94A)

If you're getting errors
Continue through the application without entering the document numbers. You may be asked to provide a copy of the
d
t ft
b it
li ti
All questions about immigration status are optional, but answering them will make getting coverage easier.
Help Drawer: Learn more about entering I-94/I-94A information.
I-94 Arrival/Departure Records are issued in either paper or electronic formats to foreign travelers when they enter the
U.S. The bottom portion of the paper I-94 should be stapled to the foreign passport. If a person doesn't have a paper
version of the I-94, they can get a copy at cbp.gov/I94 [link to https://www.cbp.gov/travel/international-visitors/i-94] .

Note validation rules for i94Number in Document Type Enums tab

Enter the I-94 number. This 11-digit number (also called the admission number) is printed on the I-94 or I-94A. It's usually
found at the top, left-hand side of the document. Note: In some cases, Customs and Border Protection may have struck
out the pre-printed I-94 number and hand-written a different number on the form. If so, enter the hand-written number.

If none of the data elements are provided, then noIdentifiersProvidedIndicator = true should be set in
the object

See where to find this information. [Link to https://www.healthcare.gov/downloads/arrival-departure-record.pdf]
If you're having trouble finding or entering this information
If you have trouble finding this information, check on the back of the card. Try to find and enter as many fields as possible
to make the process go smoother and faster.
If you know this person's alien or I-94 number, change the document type in the drop-down menu to "Other documents
or status types." From the next drop-down list, select "Other." Then, enter a description of the document and this person's
alien and/or I-94 number in the text field.
For help, call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).
If you're getting errors
Continue through the application without entering the document numbers. You may be asked to provide a copy of the
document after you submit your application.
54

Applicant information citizenship/immigration status

Phase 2, Phase 3

[FNLNS]'s Document Information

Immigration status document type: Arrival/Departure Record in
foreign passport (I-94)

Answer Fields
Answer Fields
1. [FNLNS]'s I-94 number Optional : [Open text field] XXXXXXXXXXX
1. Required
2. [FNLNS]'s Passport number Optional : [Open text field] XXXXXXXXXXXX
2. Required
3. Document expiration date Optional : [Open text field] MM/DD/YYYY
3. Required
4. Select the country that issued [FNLNS]'s passport. Optional : [Drop-down, single- 4. Required
selection, or open text field] Reference the Passport Issuing Countries tab for the list 5. Required
of countries and the corresponding country codes
6. Required
5. Does the name below match the name on the passport? Optional. [FNLNS]:
[radio buttons] Yes, No
6. [FNLNS]'s SEVIS ID number Optional : [Open text field] NXXXXXXXXXX

Answer Fields
1. Optional
2. Optional
3. Optional
4. Optional
5. Optional
6. Optional

Answer Fields
1. [FNLNS]'s alien number Optional : [Open text field] AXXXXXXXXX
2. Document expiration date Optional : [Open text field] YYYY-MM-DD

Answer Fields
1. Optional
2. Optional

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or 1. alienNumber
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
2. documentExpirationDate
eligible immigration status AND selected "Refugee Travel Document (I-571)" as the document
If none of the data elements are provided, then noIdentifiersProvidedIndicator = true should be set in
type
the object

Member

string

Only non-citizen applicants may provide this information.

This information must be asked any time after an applicant indicates they Flexible.
have eligible immigration status and selects a document type. It is a best
practice to display these answer fields after the consumer selects a
document type. All citizenship and immigration questions must occur
prior to the preliminary eligibility determination.

Alien number: Must be an open text field
Document expiration date: answer format is flexible. A calendar widget may be
used to help the consumer select a date. Year, month, and day may be collected
in separate fields.

Answer Fields
1. Required
1. [FNLNS]'s SEVIS ID number Optional : [Open text field] NXXXXXXXXXX
2. Required
2. [FNLNS]'s Passport number Optional : [Open text field] XXXXXXXXXXXX
3. Required
3. Document expiration date Optional : [Open text field] MM/DD/YYYY
4. Required
4. Select the country that issued [FNLNS]'s passport. Optional : [Drop-down, single- 5. Required
selection, or open text field] Reference the Passport Issuing Countries tab for the list
of countries and the corresponding country codes
5. [FNLNS]'s I-94 number Optional : [Open text field] XXXXXXXXXXX

1. Optional
2. Optional
3. Optional
4. Optional
5. Optional

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or 1. sevisId
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
2. passportNumber
eligible immigration status AND selected "Certificate of Eligibility for Nonimmigrant (F-1) Student 3. documentExpirationDate
Status (I-20)" as the document type
4. passportIssuingCountry
5. i94Number

Member

1. string
2. string
3. string
4. string
5. string

Only non-citizen applicants may provide this information.

This information must be asked any time after an applicant indicates they Flexible.
have eligible immigration status and selects a document type. It is a best
practice to display these answer fields after the consumer selects a
document type. All citizenship and immigration questions must occur
prior to the preliminary eligibility determination.

SEVIS ID: Must be an open text field
Passport number: Must be an open text field
Document expiration date: answer format is flexible. A calendar widget may be
used to help the consumer select a date. Year, month, and day may be collected
in separate fields.
Country of issuance: Answer format is flexible. We recommend a drop-down, but
because this is a string value, an open text field could also be used. The response
that is passed to SES must contain the country code, however the UI could also
allow the consumer to select from or enter the full name of the country and
translate the response on the backend into a country code. If an open text field is
used, we recommend a field validation to prevent the consumer from proceeding
if they enter an invalid country or country code. If a drop-down is used, and the
full list of countries is not displayed in the drop-down, an option for "Other" must be
available for consumers to enter their country.
I-94 number: Must be an open text field

Answer Fields
1. Required
1. [FNLNS]'s SEVIS ID number Optional : [Open text field] NXXXXXXXXXX
2. Required
2. [FNLNS]'s Passport number Optional : [Open text field] XXXXXXXXXXXX
3. Required
Help Drawer: Learn more about entering DS2019 information.
Certificates of Eligibility for Exchange Visitor Status (DS-2019s) are the documents that support applications for exchange 3. Document expiration date Optional : [Open text field] MM/DD/YYYY
4. Required
visitor visa statuses (J-1s or J-2s).
4. Select the country that issued [FNLNS]'s passport. Optional : [Drop-down, single- 5. Required
selection, or open text field] Reference the Passport Issuing Countries tab for the list
Enter the SEVIS ID number, which is located at the top, right-hand side of the document.
of countries and the corresponding country codes
5. [FNLNS]'s I-94 number Optional : [Open text field] XXXXXXXXXXX
See where to find this number. [Link to https://www.healthcare.gov/downloads/certificate-of-eligibility-for-exchangevisitor-status.pdf]

1. Optional
2. Optional
3. Optional
4. Optional
5. Optional

Member

1. string
2. string
3. string
4. string
5. string

Only non-citizen applicants may provide this information.

This information must be asked any time after an applicant indicates they Flexible.
have eligible immigration status and selects a document type. It is a best
practice to display these answer fields after the consumer selects a
document type. All citizenship and immigration questions must occur
prior to the preliminary eligibility determination.

SEVIS ID: Must be an open text field
Passport number: Must be an open text field
Document expiration date: answer format is flexible. A calendar widget may be
used to help the consumer select a date. Year, month, and day may be collected
in separate fields.
Country of issuance: Answer format is flexible. We recommend a drop-down, but
because this is a string value, an open text field could also be used. The response
that is passed to SES must contain the country code, however the UI could also
allow the consumer to select from or enter the full name of the country and
translate the response on the backend into a country code. If an open text field is
used, we recommend a field validation to prevent the consumer from proceeding
if they enter an invalid country or country code. If a drop-down is used, and the
full list of countries is not displayed in the drop-down, an option for "Other" must be
available for consumers to enter their country.
I-94 number: Must be an open text field

All questions about immigration status are optional, but answering them will make getting coverage easier.
Help Drawer: Learn more about entering I-94/I-94A information.
I-94 Arrival/Departure Records are issued in either paper or electronic formats to foreign travelers when they enter the
U.S. The bottom portion of the paper I-94 should be stapled to the foreign passport. If a person doesn't have a paper
version of the I-94, they can get a copy at cbp.gov/I94 [link to https://www.cbp.gov/travel/international-visitors/i-94] .
Enter this information:
-I-94 number: This 11-digit number (also called the admission number) is printed on the I-94 or I-94A. It's usually found at
the top, left-hand side of the document. Note: In some cases, Customs and Border Protection may have struck out the
pre-printed I-94 number and hand-written a different number on the form. If so, enter the hand-written number.
-Passport number
-Expiration date
-Country of issuance

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or Set lawfulPresenceDocumentation =
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
ARRIVAL_DEPARTURE_RECORD_IN_UNEXPIRED_FOREIGN_PASSPORT_I_94
eligible immigration status AND selected "Arrival/Departure Record in foreign passport (I-94)" as
1. i94Number
the document type
2. passportNumber
3. documentExpirationDate
4. passportIssuingCountry
5. sevisId
If none of the data elements are provided, then noIdentifiersProvidedIndicator = true should be set in
the object

See where to find this information. [Link to https://www.healthcare.gov/downloads/arrival-depature-record-in-foreignpassport.pdf]
If you're having trouble finding or entering this information
If you have trouble finding these numbers, check on the back of the card. Try to find and enter as many fields as possible
to make the process go smoother and faster.
If you know this person's alien or I-94 number, change the document type in the drop-down menu to "Other documents
or status types." From the next drop-down list, select "Other." Then, enter a description of the document and this person's
alien and/or I-94 number in the text field.
For help, call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).
If you're getting errors
Continue through the application without entering the document numbers. You may be asked to provide a copy of the
document after you submit your application.
57

Applicant information citizenship/immigration status

Phase 2, Phase 3

[FNLNS]'s Document Information

Immigration status document type: Refugee Travel Document (I571)

All questions about immigration status are optional, but answering them will make getting coverage easier.
Help Drawer: Learn more about entering I-571 information.
Refugee Travel Documents may be issued to refugees and asylees (and lawful permanent residents who adjusted from
refugee/asylum status) for travel purposes. These permits should be located in booklets called "U.S. Travel Documents."

Answer Fields
1. Required
2. Required

Enter the alien number, which is sometimes called an "alien registration number" or "USCIS number." This number is listed
under the heading "A#" or "USCIS#." This number is located on the right-hand side of the document. Alien numbers start
with an "A" and end with 7-9 digits.
See where to find this number. [Link to https://www.healthcare.gov/downloads/refuge-travel-document.pdf]
If you're having trouble finding or entering this information
If you have trouble finding this number, check on the back of the card. Try to find and enter as many fields as possible to
make the process go smoother and faster.
If you know this person's alien or I-94 number, change the document type in the drop-down menu to "Other documents
or status types." From the next drop-down list, select "Other." Then, enter a description of the document and this person's
alien and/or I-94 number in the text field.
For help, call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).
If you're getting errors
Continue through the application without entering the document numbers. You may be asked to provide a copy of the
document after you submit your application.
58

Applicant information citizenship/immigration status

Phase 2, Phase 3

[FNLNS]'s Document Information

Immigration status document type: Certificate of Eligibility for
Nonimmigrant (F-1) Student Status (I-20)

All questions about immigration status are optional, but answering them will make getting coverage easier.
Help Drawer: Learn more about entering I-20 information.
I-20 Certificates of Eligibility for Nonimmigrant Student Status support applications for student visa statuses (for M visas).
Enter the SEVIS ID number, which is located at the top, right-hand side of the document.
See where to find this number. [Link to https://www.healthcare.gov/downloads/certificate-of-eligibility-fornonimmigrant-student-status.pdf]

If none of the data elements are provided, then noIdentifiersProvidedIndicator = true should be set in
the object

If you're having trouble finding or entering this information
If you have trouble finding this number, check on the back of the card. Try to find and enter as many fields as possible to
make the process go smoother and faster.
If you know this person's alien or I-94 number, change the document type in the drop-down menu to "Other documents
or status types." From the next drop-down list, select "Other." Then, enter a description of the document and this person's
alien and/or I-94 number in the text field.
For help, call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).
If you're getting errors
Continue through the application without entering the document numbers. You may be asked to provide a copy of the
document after you submit your application.
59

Applicant information citizenship/immigration status

Phase 2, Phase 3

[FNLNS]'s Document Information

Immigration status document type: Certificate of Eligibility for
Exchange Visitor (J-1) Status

All questions about immigration status are optional, but answering them will make getting coverage easier.

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or 1. sevisId
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
2. passportNumber
eligible immigration status AND selected "Certificate of Eligibility for Exchange Visitor (J-1) Status 3. documentExpirationDate
(DS2019)" as the document type
4. passportIssuingCountry
5. i94Number
If none of the data elements are provided, then noIdentifiersProvidedIndicator = true should be set in
the object

If you're having trouble finding or entering this information
If you have trouble finding this number, check on the back of the card. Try to find and enter as many fields as possible to
make the process go smoother and faster.
If you know this person's alien or I-94 number, change the document type in the drop-down menu to "Other documents
or status types." From the next drop-down list, select "Other." Then, enter a description of the document and this person's
alien and/or I-94 number in the text field.
For help, call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).
If you're getting errors
Continue through the application without entering the document numbers. You may be asked to provide a copy of the
document after you submit your application.
60

Applicant information citizenship/immigration status

Phase 2, Phase 3

[FNLNS]'s Document Information

Immigration status document type: Notice of Action (I-797)

All questions about immigration status are optional, but answering them will make getting coverage easier. Enter either
the Alien number or I-94 number, not both
Help Drawer: Learn more about entering I-797 information.
Notices of Action are communications from U.S. Citizenship and Immigration Services about immigration benefits. I-797s
can be used for different purposes, like an approval notice, receipt notice, or a replacement for an I-94. Sometimes
these notices have other documents attached to them, like I-360s (petitions for Amerasian, widow(er), or special
immigrant statuses).

Answer Fields
1. [FNLNS]'s alien number Optional: [Open text field] AXXXXXXXXX
2. [FNLNS]'s I-94 number Optional: [Open text field] XXXXXXXXXXX

Answer Fields
1. Required
2. Required

Answer Fields
1. Optional
2. Optional

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or 1. alienNumber
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
2. i94Number
eligible immigration status AND selected "Notice of Action (I-797)" as the document type
If none of the data elements are provided, then noIdentifiersProvidedIndicator = true should be set in
the object

Member

1. string
2. string

Only non-citizen applicants may provide this information.

This information must be asked any time after an applicant indicates they Flexible.
have eligible immigration status and selects a document type. It is a best
practice to display these answer fields after the consumer selects a
document type. All citizenship and immigration questions must occur
prior to the preliminary eligibility determination.

Alien number: Must be an open text field
I-94 number: Must be an open text field

Answer Fields
Answer Fields
1. [FNLNS]'s Passport number Optional : [Open text field] XXXXXXXXXXXX
1. Required
2. [FNLNS]'s Passport expiration date Optional : [Open text field] MM/DD/YYYY
2. Required
3. Select the country that issued [FNLNS]'s passport. Optional : [Drop-down, single- 3. Required
selection, or open text field] Reference the Passport Issuing Countries tab for the list 4. Required
of countries and the corresponding country codes
5. Required
4. Does the name below match the name on the passport? Optional. [FNLNS]:
6. Required
[radio buttons] Yes, No
5. [FNLNS]'s SEVIS ID number Optional : [Open text field] NXXXXXXXXXX
6. [FNLNS]'s I-94 number Optional : [Open text field] XXXXXXXXXXX

Answer Fields
1. Optional
2. Optional
3. Optional
4. Optional
5. Optional
6. Optional

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or Set lawfulPresenceDocumentation = FOREIGN_PASSPORT
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
1. passportNumber
eligible immigration status AND selected "Unexpired foreign passport" as the document type
2. documentExpirationDate
3. passportIssuingCountry
4. sevisId
5. i94Number

Member

1. string
2. string
3. string
4. string
5. string

Only non-citizen applicants may provide this information.

This information must be asked any time after an applicant indicates they Flexible.
have eligible immigration status and selects a document type. It is a best
practice to display these answer fields after the consumer selects a
document type. All citizenship and immigration questions must occur
prior to the preliminary eligibility determination.

Passport number: Must be an open text field
Reference the Passport Issuing Countries tab for the list of
Passport expiration date: answer format is flexible. A calendar widget may be
countries and the corresponding country codes.
used to help the consumer select a date. Year, month, and day may be collected
in separate fields.
Country of issuance: Answer format is flexible. We recommend a drop-down, but
because this is a string value, an open text field could also be used. The response
that is passed to SES must contain the country code, however the UI could also
allow the consumer to select from or enter the full name of the country and
translate the response on the backend into a country code. If an open text field is
used, we recommend a field validation to prevent the consumer from proceeding
if they enter an invalid country or country code. If a drop-down is used, and the
full list of countries is not displayed in the drop-down, an option for "Other" must be
available for consumers to enter their country.
Confirming name: The UI must allow the consumer to provide an alternate
document name if they indicate that the name on their documentation is
different (see item #70). Answer format is flexible. Answer options may be altered
for compatibility with question wording.
SEVIS ID: Must be an open text field
I-94 number: Must be an open text field

Enter this information:
-I-94 number: This number (also called the admission number) is printed on the I-94 or I-94A. This is an 11-digit number
and is usually found at the top, left-hand side of the document. Note: In some cases, Customs and Border Protection may
have struck out the pre-printed I-94 number and hand-written a different number on the form. If this is the case, enter
the hand-written number.
-Alien number: This number is sometimes called an "alien registration number" or "USCIS number." This number is listed
under the heading "A#" or "USCIS#." Alien numbers start with an "A" and end with 7-9 digits.
See where to find this information. [Link to https://www.healthcare.gov/downloads/notice-of-action.pdf]
If the document has been re-issued
If this person has been issued a new immigration benefit or had the duration of their stay in the U.S. extended, they'll be
issued an I-797 with a tear-away I-94 at the bottom. Enter the I-94 number.
If you're having trouble finding or entering this information
If you have trouble finding this number, check on the back of the card. Try to find and enter as many fields as possible to
make the process go smoother and faster.
If you know this person's alien or I-94 number, change the document type in the drop-down menu to "Other documents
or status types." From the next drop-down list, select "Other." Then, enter a description of the document and this person's
alien and/or I-94 number in the text field.
For help, call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).
If you're getting errors
Continue through the application without entering the document numbers. You may be asked to provide a copy of the
document after you submit your application.
55

Applicant information citizenship/immigration status

Phase 2, Phase 3

[FNLNS]'s Document Information

Immigration status document type: Unexpired foreign passport

The passport from a foreign country is used when entering the U.S. Enter the passport number and expiration date.
All questions about immigration status are optional, but answering them will make getting coverage easier.
Help Drawer: Learn more about entering foreign passport information.
Passports from foreign countries are used when entering the U.S.
Enter this information:
-Passport number
-Expiration date
-Country of issuance
See where to find this information [Link to https://www.healthcare.gov/downloads/foreign-passport.pdf]
If you're having trouble finding or entering this information
If you have trouble finding these numbers, check on the back of the card. Try to find and enter as many fields as possible
to make the process go smoother and faster.
If you know this person's alien or I-94 number, change the document type in the drop-down menu to "Other documents
or status types." From the next drop-down list, select "Other." Then, enter a description of the document and this person's
alien and/or I-94 number in the text field.
For help, call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).
If you're getting errors
Continue through the application without entering the document numbers. You may be asked to provide a copy of the
document after you submit your application.

70

Applicant information citizenship/immigration status

Phase 2, Phase 3

Update [FNLNS]'s information so that it matches their
[document type from Items 49, 51, 52, 54, and 55].
Documents types: card or passport

Immigration status document type: I-551 (Permanent Resident
Card, "Green Card"), Machine Readable Immigrant Visa (with
temporary I-551 language), Employment Authorization Card (I766), Arrival/Departure Record in foreign passport (I-94),
Unexpired foreign passport
Does the name below match the name on the [document]? No

N/A

Answer Fields
1. First Name: [Open text field]
2. Middle Name: [Open text field] Optional
3. Last Name: [Open text field]
4. Suffix: [drop-down, single selection]: Jr., Sr.,

If none of the data elements are provided, then noIdentifiersProvidedIndicator = true should be set in
the object

Auditor Compliance
Conclusion**

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor
Comments**

Item #

71

Application Section
* indicates features of this question may be
updated in future documentation

Applicable EDE Phase**

Question**

Answers to Previous Questions**

Applicant information citizenship/immigration status

Phase 2, Phase 3

Does [FNLNS] also have any of these document types or
statuses? Optional.

Does [FNLNS] have eligible immigration status? Yes, [FNLNS] has
eligible immigration status

63

Applicant information citizenship/immigration status

Phase 2, Phase 3

[FNLNS]'s Document Information

Does [FNLNS] also have any of these document types or statuses?
Another document or [FNLNS]'s alien number/I-94 number

72

Applicant information citizenship/immigration status

Phase 2, Phase 3

Has [FNLNS] lived in the U.S. since 1996? Optional

Does [FNLNS] have eligible immigration status? Yes, [FNLNS] has
eligible immigration status

73

Applicant information citizenship/immigration status

Phase 2, Phase 3

Are any of these people an honorable discharged veteran or Has [FNLNS] lived in the U.S. since 1996? No/Null (applicant was
active duty member of the military? Optional
not asked question)

74

75

138

Informational Text**

Answer Options and Format**

All questions about immigration status are optional, but answering them will make getting coverage easier.

[Checkboxes, multi-selection]
Required
Document indicating members Of A Federally Recognized Indian Tribe or American
Indian born in Canada
Certification from U.S. Department of Health and Human Services (HHS) Office
of Refugee Resettlement (ORR)
Office of Refugee Resettlement (ORR) eligibility letter (if under 18)
Cuban/Haitian Entrant
Resident of American Samoa
Battered spouse, child, or parent under the Violence Against Women Act
Another document or [FNLNS]'s alien number/I-94 number (This option may not
be displayed if consumer selected this option in item 46)*
None of these (Select this if this person doesn't have a listed document. You can
continue the application without selecting a document or status type.)

Help Drawer: Learn more about these document types and statuses.
-Document indicating member of a federally recognized Indian tribe or American Indian born in Canada: Several types of
documents show membership in a federally recognized Indian tribe or status as an American Indian born in Canada,
including membership cards, letters, and other tribal documents. For American Indians born in Canada, this could also
include a birth certificate or other evidence of being born in Canada. You'll need to upload or mail this document later on in
the application process.
-Certification from U.S. Department of Health and Human Services (HHS) Office of Refugee Resettlement (ORR): This is
a certification letter issued to a victim of a severe form of trafficking, stating victims are eligible for benefits and services.
You'll need to upload or mail this document later on in the application process.
-Office of Refugee Resettlement (ORR) eligibility letter (if under 18): This letter indicates a child is a victim of a severe form
of trafficking, and states victims are eligible for benefits and services. You'll need to upload this document later on in the
application process.
-Cuban/Haitian entrant: "Cuban or Haitian entrants" must be Cuban or Haitian and:
-Be granted parole into the U.S.
-Have an application for asylum pending with USCIS.
-Be granted special status under the immigration laws for nationals of Cuba or Haiti.
-Be a subject of removal proceedings.
-If this person is Cuban or Haitian or they're not sure, select this, and we'll check our data sources.
-Document indicating withholding of removal (or "withholding of deportation"): There are several documents that might
show withholding of removal or deportation.
-Resident of American Samoa: A document showing this person is a resident of, or lives in, American Samoa. You'll need to
submit this document later on in the application process.
-Violence Against Women Act: Select this if this person is a battered spouse, child, or parent who filed a petition based on
the Violence Against Women Act (VAWA).
-Another document or alien number/I-93 number: If you don't see the document or status type listed, select this option,
then enter this information:
-Description: Describe or enter the name of another type of immigration document issued by U.S. Citizenship and
Immigration Services, Immigration Customs Enforcement, and Customs and Border Protection.
-I-94 number: This number (also called the admission number) is printed on the I-94 or I-94A. This is an 11-digit number
and is usually found at the top, left-hand side of the document. Note: In some cases, Customs and Border Protection may
have struck out the pre-printed I-94 number and hand-written a different number on the form. If this is the case, enter
the hand-written number.
Alien number: This number is sometimes called an "alien registration number" or "USCIS number " This number is listed
Enter either the Alien number or I-94 number, not both

Required/Optional to Display Question or
Corresponding Answer Fields to Collect
Information in Application UI**

Required/Optional for Consumer to Provide
Answer to Send to SES**
*if optional, consumer must be able to
ith t
idi
i UI
ti
Optional

Conditional Display Logic in the UI**

Data Element(s) Name

Attestation Level

Data Element
Format

Policy**

General Requirements**

Question Flow Requirements**

Question/Informational Text Wording Requirements**

Answer Options and Format Requirements**

Member

array, enum

Only non-citizen applicants may provide this information. Consumers
may have additional document types to provide for citizenship and
immigration status verification. Consumers must be given an
opportunity to provide additional documentation.

Consumers may have additional document types to provide for citizenship and
immigration status verification. Consumers must be given an opportunity to
provide additional documentation. Only non-citizen applicants may provide this
information.

While it is important that non-citizen consumers have the opportunity to
attest to these additional documents/statuses, they could be otherwise
presented as long as clear and accurate and as long as consumers can
attest to one of these statuses even when they already have another
status as well. Flexible when this question is asked. All citizenship and
immigration questions must occur prior to the preliminary eligibility
determination.

Flexible.

Answer format is flexible. Answer option wording must be exact and all options
must be present.

1. Optional (Note: if the otherTypeText is not
Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or lawfulPresenceDocumentation.OTHER
provided for the
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
otherTypeText
lawfulPresenceDocumentation provided in
eligible immigration status AND selected "Another document with an Alien Number or I-94
alienNumber
Column K, then SES will not initiate a Hub call to Number" as the other document type
i94Number
DHS for that member)
2 Optional
Optional
Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or livedInUs5yearIndicator
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
eligible immigration status AND consumer was born before 8/22/1996

Member

string

Only non-citizen applicants may provide this information.

This information must be asked any time after an applicant indicates they Flexible.
have eligible immigration status and selects a document type. It is a best
practice to display these answer fields after the consumer selects a
document type. All citizenship and immigration questions must occur
prior to the preliminary eligibility determination.

Document description: Must be an open text field
Alien number: Must be an open text field
I-94 number: Must be an open text field

Member

boolean

Non-citizen applicants who have lived in the US since 1996 are exempt This question must be asked, but only of non-citizen applicants who were born
from the five year bar, which is a restriction on Medicaid and CHIP
before 1996.
eligibility for most non-citizens

This question may be asked anytime after the applicant has indicated
they have eligible immigration status. All citizenship and immigration
questions must occur prior to the preliminary eligibility determination.

Flexible. This question must be clearly labeled as optional.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Member

boolean

Non-citizen applicants who are active duty military or veterans (or the
spouse or dependent child of one) are exempt from the five year bar,
which is a restriction on Medicaid and CHIP eligibility for most noncitizens

Non-citizen applicants must have the opportunity to attest to veteran status.

This question may be asked anytime after the applicant has indicated
they have eligible immigration status. All citizenship and immigration
questions must occur prior to the preliminary eligibility determination.

Flexible as long as the wording references active duty or honorably
discharged veterans and allows married applicants to answer yes based
on their spouse, and children to attest based on their parents.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

It is a best practice to ensure that the consumer has not left the
question blank by mistake. Since it is important not to require an
answer to the question, this is an alternate way to improve the
response rate and ensure consumers know that the answer is
important

It is a best practice to ensure that the consumer has not left the fields for
immigrations documentation blank by mistake. Since it is important not to
require an answer to the question, this is an alternate way to improve the
response rate and ensure consumers know that the answer is important.

This question may be asked anytime after the applicant has indicated
Flexible.
they have eligible immigration status, selected a document type, and did
not complete all fields. All citizenship and immigration questions must
occur prior to the preliminary eligibility determination.

If DHS response is available, this question must be displayed.

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or lawfulPresenceDocumentation
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
If any option is selected other than an alien number/I-94 number, then noIdentifiersProvidedIndicator
eligible immigration status AND selected any document type
= true should be set in the object

*This option should not display if consumer attests to an immigration document and
provides an ID number in item 46. This is because only information for one
document type can be sent to DHS for verification.

Answer Fields
1. Document description Optional: [Open text field]
2. [FNLNS]'s alien number Optional : [Open text field] AXXXXXXXXX
3. [FNLNS]'s I-94 number Optional : [Open text field] XXXXXXXXXXX

1. Required
2. Required
3. Required

Help Drawer: Learn more about how to answer this question.
Select "Yes" if this person came to live in the U.S. before August 22, 1996 and has taken trips outside the U.S. for less than
30 days per trip, or less than 90 days total.

[Toggle buttons]
Yes
No

Required

Help Drawer: Learn more about how to answer this question.
Select a person's name if this person, their current spouse, or their parent (if they're an unmarried, independent child) is
an honorably discharged or active-duty member of the U.S. military, or if they're an unmarried surviving spouse of an
honorably discharged or active-duty member of the U.S. military.

[Checkboxes, multi-selection]
Display list of applicants
None of these people

Required

Optional

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or If a name is selected, set:
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
veteranIndicator = true for the non-citizen applicant
eligible immigration status AND consumer was born after 8/22/1996 OR selected "No" for "Has
Set the veteranIndicator=true for the non-citizen we are asking the question for and repeat the
[FNLNS] lived in the U.S. since 1996?" AND meets one of the following conditions:
question for every non-citizen applicant. It is recommended to pre-fill names if already selected. That
1. Applicant is age 17 or older
way the veteran indicator will be set for the applicant, not necessarily for the veteran (who may be a
2. Applicant is married
non-applicant, etc)
3. Applicant is not married and over age 14
Optional data elements:
3. Applicant is a tax dependent and has relationship of child to their tax filer

N/A

Continue without adding more
Back

Required

Optional

Consumer is requesting coverage AND selected "No" for "Is everyone listed below a U.S. citizen or None. This is not sent to SES.
U.S. national?" AND consumer did not attest to U.S. citizenship or nationality AND attested to
eligible immigration status AND selected a document type AND did not provide all information in
the fields displayed for the document type (even if optional)

Member

N/A

Display the following names:
If Applicant is age 17 or older: FNLNS
If Applicant is married:
If Applicant is not married, and is a tax
dependent of their parent(s):
If Applicant is not married, and is a tax
dependent of 2 parents filing jointly:
If Applicant is not married and over age
14: [FNLNS]'s deceased spouse

If a name is selected, set:
1. veteranSelfIndicator = true for the household member who is selected as a veteran (including a nonapplicant or non-citizen)
2. nonMemberVeteranRelationshipTypes may be set to record who the veteran is, if it is a family
member of the applicant who is not on the application

Applicant information citizenship/immigration status

Phase 2, Phase 3

Are you sure? It's important to enter as many fields from
Consumer did not provide answer to all fields for a selected
your immigration documents as possible, even though some document type
fields may be labeled "optional." Entering all of your
document information makes the application process go
smoother and faster, helps make sure your eligibility results
are correct, and may prevent you from needing to come
back later and provide information.

Applicant information citizenship/immigration status

Phase 2, Phase 3

When did [FNLNS] get [his/her] current immigration status? N/A
Optional

Enter the date [FNLNS] was granter granted their most current immigration status.

Answer Fields
[Open text field] MM/DD/YYYY

Required

Optional

See Item #5 on the "Backend Responses for UI" tab

lawfulPresenceGrantDate

Member

string

This question is asked for certain non-citizens (based on DHS Hub
response) in order to determine whether or not they likely meet the 5year bar and therefore could be eligible for Medicaid based on
immigration status

Phase 1, Phase 2, Phase 3

Did [FNLNS] have [state Medicaid program name] or [state N/A
CHIP program name] that will end soon or that recently
ended because of a change in eligibility?

N/A
Starting on June 30, 2023 and continuing through July 31, 2024:
Select a person’s name if one applies:
• Their coverage ended between March 31, 2023 and today
• Their coverage is going to end between today and [60 days in future]

[Radio buttons]
Yes
No

Required

Required

Consumer is requesting financial assistance AND requesting coverage

Legacy Indicators:
If user selected "Yes", set:
medicaidDeniedIndicator = true

Member

boolean

This question is asked primarily so that the FFE can prevent a consumer The application must ask whether any applicants have Medicaid or CHIP
coverage that will end soon.
who has recently been found ineligible for Medicaid and CHIP by the
state from being again found eligible for Medicaid or CHIP by the FFE
and sent back to the state. When a consumer attests yes to this
question, they will be considered ineligible for Medicaid and CHIP by
the system, so they can receive an accurate QHP, APTC and CSR
determination. Information about a recent or future loss of Medicaid
or CHIP is also used to grant a Special Enrollment Period based on loss of
Minimum Essential Coverage and to pre-fill the Loss of MEC SEP
questions. However, starting on May 31, 2023 and continuing through
July 31, 2024, the application should not display the past loss of MEC
SEP question (item 213/214) for consumers who attest to past loss of
Medicaid or CHIP.

Medicaid Block
Applicant information - Medicaid & CHIP
Denial

If user selected "No", leave medicaidDeniedIndicator null
New Indicators:
If user selected "Yes", set:
medicaidEndIndicator = true
If user selected "No", set:
medicaidEndIndicator = false

140

Applicant information - Medicaid & CHIP
Denial

Phase 1, Phase 2, Phase 3

What's the last day of [FNLNS]'s Medicaid or CHIP
coverage?

N/A
Did [FNLNS] have [state Medicaid program name] or [state CHIP
name] that will end soon or that recently ended because of a change If you don't have it, give your best estimate.
in eligibility? Yes

Notes

Answer Fields
Month: [Open text field]
Day: [Open text field]
Year: [Open text field]

Required

Required

Consumer is requesting financial assistance AND requesting coverage AND selected "Yes" for "Did
[FNLNS] have [state Medicaid program name] or [state CHIP program name] that will end soon
or that recently ended because of a change in eligibility?"

Legacy Indicators:
If the date selected is in the future 60 days or the current date, set the changeInCircumstance to
FUTURE_LOSS_OF_MEC
If the date selected is in the past 60 days, set the
changeInCircumstance to LOSS_OF_MEC

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

This question must be asked anytime after the applicant has indicated
Flexible. This question must be clearly labeled as optional.
they have eligible immigration status, selected a document type, and the
DHS response is available. All citizenship and immigration questions must
occur prior to the preliminary eligibility determination

Flexible in the way the application collects the date. May collect date through
separate field for year, month, and day. May use a calendar widget to assist the
consumer with selecting a date.

Medicaid/CHIP recently ending or ending soon questions must be asked
Flexible. Starting on June 30, 2023 and continuing through July 31,
before Medicaid/CHIP denial questions. Medicaid/CHIP "block" questions 2024, the question must reference the following date range: March 31,
must be asked prior to the preliminary eligibility determination.
2023 through 60 days after current date. Partners may choose to
include the date range in the question text and/or on-screen assistance

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

text. The date range must be visible without requiring a user to take
action to view it (e.g. - it cannot be hover text, inside an info drawer,
etc.)

Member

string

The application must collect the last day of Medicaid or CHIP coverage for each Medicaid/CHIP recently ending or ending soon questions must be asked
Flexible.
applicant who attests to losing Medicaid or CHIP coverage in the future or
before Medicaid/CHIP denial questions. Medicaid/CHIP "block" questions
recent past.
must be asked prior to the preliminary eligibility determination.

Flexible in the way the application collects the date. May collect date through
separate field for year, month, and day. May use a calendar widget to assist the
consumer with selecting a date.

Member

1. boolean

The application must ask if the household income or size changed since they
were notified their Medicaid or CHIP coverage was ending.

Medicaid/CHIP recently ending or ending soon questions must be asked
Flexible.
before Medicaid/CHIP denial questions. Medicaid/CHIP "block" questions
must be asked prior to the preliminary eligibility determination.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Member

boolean

Medicaid/CHIP recently ending or ending soon questions must be asked
Informational text must be included.
before Medicaid/CHIP denial questions. Medicaid/CHIP "block" questions
must be asked prior to the preliminary eligibility determination.

All applicant names must display as answer options. Answer format is flexible;
however, multi-selection must be enabled.

Member

string

The UI must collect the Medicaid or CHIP denial date from each
applicant that attests to being denied Medicaid or CHIP in the last 90
days.

Flexible.

Flexible in the way the application collects the date. May collect date through
separate field for year, month, and day. May use a calendar widget to assist the
consumer with selecting a date. The UI must have a field level validation to only
allow the consumer to provide a date within the last 90 days to prevent consumers
from providing dates that would cause a SES error.

Member

string

If multiple consumers attested to Medicaid or CHIP denial in the last 90
days, this question could be asked to collect the denial date for multiple
applicants. If the UI does not use this question, it must collect the denial
date for each consumer the that attests to Medicaid or CHIP denial.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Member

boolean

State Medicaid and CHIP program names can now be found
through using the State Reference Data API, and do not have to
be hard-coded. CMS advises the UI include (Medicaid) or (CHIP)
when a state Medicaid or CHIP program does not include it or the
state uses the same name for their Medicaid and CHIP
programs.

Leave medicaidDeniedDate = null
Set changeInCircumstance.changeDate = date selected
If the user indicates that all applicants lost/will lose their coverage on the same date, set
changeInCircumstance.changeDate=date selected for all applicants who attested to having Medicaid
or CHIP that recently ended or will end soon.
New Indicators:
1. If the date selected is in the future 60 days or the current date, set the changeInCircumstance to
FUTURE_LOSS_OF_MEC
2. If the date selected is in the past 60 days, set the
changeInCircumstance to LOSS_OF_MEC
3. Starting on May 31, 2023 and continuing through July 31, 2024, set changeInCircumstance to
LOSS_OF_MEC if the date selected is on March 31, 2023 through yesterday.
4. Set medicaidEndDate = date selected
5. Set changeInCircumstance.changeDate = date selected
If the user indicates that all applicants lost/will lose their coverage on the same date, set
changeInCircumstance.changeDate=date selected for all applicants who attested to having Medicaid
or CHIP that recently ended or will end soon.
These fields should be set regardless of a change in income or household size

139

Applicant information - Medicaid & CHIP
Denial

Phase 1, Phase 2, Phase 3

Has the household income or household size changed since
[FNLNS] was told [his/her] coverage was ending?

Did [FNLNS] have [state Medicaid program name] or [state CHIP
N/A
name] that will end soon or that recently ended because of a change
in eligibility? Yes

[Radio buttons]
Yes
No

Required

Required

Consumer is requesting financial assistance AND requesting coverage AND selected "Yes" for "Did Legacy Indicators:
[FNLNS] have [state Medicaid program name] or [state CHIP program name] that will end soon If user selected "Yes", set:
or that recently ended because of a change in eligibility?" AND provided a date for their last day of medicaidDeniedIndicator = false
coverage
If user selected "No", set:
medicaidDeniedIndicator = true
New Indicators:
If user selected "Yes", set:
informationChangeSinceMedicaidEndedIndicator = true
If user selected "No", set:
informationChangeSinceMedicaidEndedIndicator = false

133

Applicant information - Medicaid & CHIP
Denial

Phase 1, Phase 2, Phase 3

Were any of these people found not eligible for [state
Medicaid program name] or [state CHIP name] by [state]
since [date of 90 days ago]?

Did [FNLNS] have [state Medicaid program name] or [state CHIP
program name] that will end soon or that recently ended because of
a change in eligibility? Name not selected

Help Drawer: Learn more about Medicaid or CHIP denial
Select a person’s name if they:
- Were denied Medicaid or CHIP by the state since the date shown because their income is too high
- Were denied Medicaid or CHIP by the state because their state doesn’t cover people with their household type (for
example, some states don’t cover adults who aren’t taking care of children)
- Are a child denied CHIP coverage by the state since the date shown because he or she needs to wait a month or more
before starting CHIP coverage (called the CHIP waiting period)
- Had their Medicaid or CHIP coverage end since the date shown because a change in state rules makes them not eligible
for Medicaid or CHIP

[Checkboxes, multi-selection]
Display each applicant name
None of these people

Required

Required

Consumer is requesting financial assistance AND requesting coverage AND consumer did not
attest to having Medicaid or CHIP coverage that recently ended or will end soon AND requesting
coverage

Legacy Indicators:
medicaidDeniedIndicator = true for selected applicant
For any name not selected, set medicaidDeniedIndicator = false
New Indicators:
medicaidDeniedIndicator = true for selected applicant

This question is asked primarily so that the FFE can prevent a consumer The application must ask whether any applicants were recently found not
who has recently been denied Medicaid and CHIP by the state from
eligible for Medicaid or CHIP by the state to prevent a consumer who has
being again found eligible for Medicaid or CHIP by the FFE and sent
recently been denied Medicaid and CHIP by the state from being again found
back to the state. When a consumer attests yes to this question, they
eligible for Medicaid or CHIP by the FFE and sent back to the state. For nonwill be considered ineligible for Medicaid and CHIP by the system, so
citizen applicants, the application must ask whether the denial was due to
they can receive an accurate QHP, APTC and CSR determination.
immigration status.

State Medicaid and CHIP program names can now be found
through using the State Reference Data API, and do not have to
be hard-coded. CMS advises the UI include (Medicaid) or (CHIP)
when a state Medicaid or CHIP program does not include it or the
state uses the same name for their Medicaid and CHIP
programs.

medicaidDeniedIndicator = false for any applicant not selected

Don’t select a person’s name if they:
- Never applied for Medicaid or CHIP
- Were found not eligible for Medicaid or CHIP by the Marketplace, instead of the state Medicaid or CHIP agency
- Were denied or found no longer eligible for Medicaid or CHIP since the date shown but had changes in income or family
size since the denial or loss of coverage (unless the denial was based on immigration status)
- Applied for Medicaid or CHIP with the state but haven’t received a response
- Were denied Medicaid or CHIP coverage because they didn’t turn in paperwork that the state asked for
134

Applicant information - Medicaid & CHIP
Denial

Phase 1, Phase 2, Phase 3

When was [FNLNS] denied Medicaid or CHIP coverage?

Were any of these people found not eligible for [state Medicaid
program name] or [state CHIP name] by [state] since [date of 90
days ago]? Selected name

Enter the date listed on the letter [FNLNS] got from the [state Medicaid program name] or [state CHIP program name].
If you don’t have it, make your best estimate of the date.

OR

Answer Fields
Month: [Open text field]
Day: [Open text field]
Year: [Open text field]

Required

Required

135

Applicant information - Medicaid & CHIP
Denial

Phase 1, Phase 2, Phase 3

Was [FNLNS] also denied on the date entered above?

Were any of these people found not eligible for [state Medicaid
program name] or [state CHIP name] by [state] since [date of 90
days ago]? Selected multiple names

Consumer is requesting financial assistance AND requesting coverage AND consumer did not
attest to having Medicaid or CHIP coverage that recently ended or will end soon AND selected a
name for "Were any of these people found not eligible for [state Medicaid program name] or
[state CHIP name] by [state] since [date of 90 days ago]?"
OR

Was [FNLNS] also denied on the date entered above? No

N/A

[Radio buttons]
Yes
No

Optional

Optional

Legacy Indicators:
medicaidDeniedDate = date entered
New Indicators:
medicaidDeniedDate = date entered

Consumer is requesting financial assistance AND consumer is requesting coverage AND consumer
did not attest to having Medicaid or CHIP coverage that recently ended or will end soon AND
selected multiple names for "Were any of these people found not eligible for [state Medicaid
program name] or [state CHIP name] by [state] since [date of 90 days ago]?" AND selected "No"
for "Was [FNLNS] also denied on the date entered above?"
Consumer is requesting financial assistance AND requesting coverage AND consumer did not
Legacy Indicators:
attest to having Medicaid or CHIP coverage that recently ended or will end soon AND selected
If user selected "Yes", set:
multiple names for "Were any of these people found not eligible for [state Medicaid program
medicaidDeniedDate = date entered
name] or [state CHIP name] by [state] since [date of 90 days ago]?"
If user selected "No", display Item 134 for that applicant
New Indicators:
If user selected "Yes", set:
medicaidDeniedDate = date entered
If user selected "No", display Item #134 for that applicant

136

Applicant information - Medicaid & CHIP
Denial

Phase 1, Phase 2, Phase 3

Did any of these people apply for health coverage between
[most recent OE start date] – [most recent OE end date]?

Were any of these people found not eligible for Medicaid or the
Children's Health Insurance Program (CHIP) since [date of 90 days
ago]? Name selected

N/A

[Checkboxes, multi-selection]
Display each applicant name that attested to Medicaid or CHIP denial
None of these people

Required

Required

Consumer is requesting financial assistance AND requesting coverage AND consumer did not
attest to having Medicaid or CHIP coverage that recently ended or will end soon AND selected a
name for "Were any of these people found not eligible for Medicaid or the Children's Health
Insurance Program (CHIP) since [date of 90 days ago]?"

Legacy Indicators:
If name is selected, set:
appliedDuringOeOrLifeChangeIndicator = true for that applicant (set true if yes on Item 136 or Item
137)
If name is not selected:
Display Item 137 for that applicant

Per 45 CFR 155.420, consumers are eligible for an SEP if they apply for The application must ask if any applicants applied for coverage during Open
coverage during Open Enrollment or after a qualifying life event and
Enrollment or after a qualifying life event in order to determine eligibility for an
are assessed eligible for Medicaid or CHIP but then ultimately denied by SEP.
the state.
(See column S for additional implementation guidance)

Medicaid/CHIP recently ending or ending soon questions must be asked
Flexible; however, any tweaks to the question wording must meet the
before Medicaid/CHIP denial questions. Medicaid/CHIP "block" questions rules for the SEP in 45 CFR 155.420 (d)(11). The dates that would be premust be asked prior to the preliminary eligibility determination.
populated in the question are the dates of the most recent Open
Enrollment period prior to the application date.

All applicants that attest to Medicaid or CHIP denial in the past 90 days must
display as answer options. Answer format is flexible; however, multi-selection
must be enabled.

EDE Entities that use the the system reference data to populate
the Open Enrollment Period dates should implement logic to
subtract one day from the oeEndDate in order to display January
15 rather than January 16.
Alternative Recommended Implementation:
1) Inside OE and on or before 12/15:
-Start date: 11/1 of the prior OE (example: if applying on
11/20/22, start date should be 11/1/21)
-End date: oeEndDate minus one day, of the prior OE (example:
if applying on 11/20/22, end date should be 1/15/22)
-Example: someone applying on 11/20/22 would see: “Did any
of these people apply for health coverage between 11/1/2021 –
1/15/2022?”

New Indicators:
If name is selected, set:
appliedDuringOeOrLifeChangeIndicator = true for that applicant (set true if yes on Item 136 or Item
137)
If name is not selected:
Display Item 137 for that applicant

2) Inside OE period and after 12/15:
-Start date: 11/1 of this OE (i.e. if applying on 12/30/22, start
date should be 11/1/22)
-End date: yesterday's date (based on the user's system datetime)
-Example: someone applying on 12/30/22 would see: “Did any
of these people apply for health coverage between 11/1/2022 –
12/29/2022?”
3) Outside OE:
-Start date: 11/1 of the prior OE (i.e. if applying on 2/15/23, start
date should be 11/1/22)
-End date: oeEndDate minus one day, of the prior OE (example:
if applying on 2/15/23, end date should be 1/15/23)
-Example: someone applying on 2/15/23 would see: “Did any of
these people apply for health coverage between 11/1/2022 –
1/15/2023?”

137

Applicant information - Medicaid & CHIP
Denial

Phase 1, Phase 2, Phase 3

Did [FNLNS] apply through the Health Insurance
Marketplace after a qualifying life event?

Did any of these people apply for health coverage between [most
recent OE start date] – [most recent end date]? None of these
people

Qualifying life events include moving, marriage, birth or adoption, or loss of coverage.
Help Drawer: Learn more about qualifying life events

[Radio buttons]
Yes
No

Required

Required

Select a person’s name if they:
- Applied for coverage through HealthCare.gov outside of Open Enrollment because they qualified for a Special
Enrollment Period.
- Applied for coverage through HealthCare.gov less than 60 days after one of these qualifying life events:
o Move
o Marriage
o Birth of a child
o Gaining a dependent (or becoming a dependent) due to foster care placement, adoption, or court order
o Loss of health coverage
o Release from incarceration
o Gaining a new immigration status
141

Applicant information - Medicaid & CHIP
Denial

Phase 2, Phase 3

If multiple applicants attested to eligible immigration status:
Were any of these people found not eligible for [state
Medicaid program name] or [state CHIP program name]
based on their immigration status since [current year minus
5 years]?

N/A

You can usually find this information on the notice from the Medicaid or CHIP agency or the Marketplace saying they
weren’t eligible for coverage.

Consumer is requesting financial assistance AND requesting coverage AND consumer did not
Legacy Indicators:
attest to having Medicaid or CHIP coverage that recently ended or will end soon AND selected a
If name is selected, set:
name for "Were any of these people found not eligible for Medicaid or the Children's Health
appliedDuringOeOrLifeChangeIndicator = true for that applicant (set true if yes on item 136 or item
Insurance Program (CHIP) since [date of 90 days ago]?" AND selected "None of these people" for 137)
"Did any of these people apply for health coverage between [most recent OE start date] – [most
recent end date]?"
If name is not selected, set:
appliedDuringOeOrLifeChangeIndicator = false for that applicant

boolean

Medicaid/CHIP recently ending or ending soon questions must be asked
Wording must be exact.
before Medicaid/CHIP denial questions. Medicaid/CHIP "block" questions
must be asked prior to the preliminary eligibility determination.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Member

N/A

The flow of collecting applicant information is flexible and may be done
throughout the application. Medicaid/CHIP denial questions must be
asked prior to the preliminary eligibility determination. The immigration
denial questions are asked of all non-citizen applicants, whether or not
they answered yes to any previous Medicaid denial question.

Flexible. There is flexibility with how to ask this question, because the
current wording and compound questions in the classic application has
been difficult for consumers to understand.

All applicants who attested to eligible immigration status must display. Answer
format is flexible, as long as the consumer may select multiple names.

Member

boolean

Flexible. Note that the immigration part is only relevant for Phase 2 and
3 applications.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

1. member

1. boolean

Flexible. Note that the immigration part is only relevant for Phase 2 and
3 applications.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Member

N/A

The question must ask about income the consumer is getting during the
current calendar month. The application may first include a yes/no
question about whether the applicant has any income, especially for
kids.

Answer format is flexible. Answer options may be altered for compatibility with the
question wording.

If name is not selected:
appliedDuringOeOrLifeChangeIndicator = false for that applicant
If multiple applicants attested to eligible immigration status:
[Checkboxes, multi-selection]
Display applicants who attested to eligible immigration status
None of these people

Required

Required

Consumer is requesting coverage AND requesting financial assistance AND attested to eligible
immigration status

Legacy Indicators:
If "Yes" or name is selected, set:
medicaidDeniedDueToImmigrationIndicator = true

Consumers must have an opportunity to attest to Medicaid or CHIP
denial due to immigration status.

If "No" or "none of these people", set:
medicaidDeniedDueToImmigrationIndicator = false

If one applicant attested to eligible immigration status:
[Radio buttons]
Yes
No

If one applicant attested to eligible immigration status: Was
[FNLNS] found not eligible for [state Medicaid program
name] or [state CHIP program name] based on their
immigration status since [current year minus 5 years]?

Member

New Indicators:
If name is selected, set:
appliedDuringOeOrLifeChangeIndicator = true for that applicant (set true if yes on Item 136 or Item
137)

The application must ask if consumers were denied Medicaid or CHIP were
denied due to their immigration status.

State Medicaid and CHIP program names can now be found
through using the State Reference Data API, and do not have to
be hard-coded. CMS advises the UI include (Medicaid) or (CHIP)
when a state Medicaid or CHIP program does not include it or the
state uses the same name for their Medicaid and CHIP
programs.

New Indicators:
If "Yes" or name is selected, set:
medicaidDeniedDueToImmigrationIndicator = true
If "No" or "none of these people", set:
medicaidDeniedDueToImmigrationIndicator = false

142

Applicant information - Medicaid & CHIP
Denial

Phase 2, Phase 3

Has [FNLNS] had their current immigration status since
[current year minus 5 years]?

Were any of these people found not eligible for Medicaid or CHIP
based on immigration status since [current year minus 5 years]?
Name selected
OR
Was [FNLNS] found not eligible for [state Medicaid program name]
or [state CHIP program name] based on their immigration status
since [current year minus 5 years]? Yes

N/A

[Radio buttons]
Yes
No

Required

Required

Consumer is requesting coverage AND requesting financial assistance AND attested to eligible
immigration status AND selected a name for "Were any of these people found not eligible for
Medicaid or CHIP based on immigration status?"

Legacy Indicators:
If "Yes", set:
medicaidDeniedDueToImmigrationIndicator = false
If "No", set:
medicaidDeniedDueToImmigrationIndicator = true
New Indicators:
If "Yes", set:
immigrationStatusFiveYearIndicator = true
If "No", set:
immigrationStatusFiveYearIndicator = false

143

Applicant information - Medicaid & CHIP
Denial

Phase 2, Phase 3

Has [FNLNS] had a change in their immigration status since
they were not found eligible for [state Medicaid program
name] or [state CHIP program name]?

Has [FNLNS] had their current immigration status since [current
year minus 5 years]? No

N/A

OR

[Radio buttons]
Yes
No

Required

Required

Has [FNLNS] had their current immigration status since [current
year minus 5 years]? Yes

Consumer is requesting coverage AND requesting financial assistance AND attested to eligible
Legacy Indicators:
If "Yes", set:
immigration status AND selected a name for "Were any of these people found not eligible for
Medicaid or CHIP based on immigration status?" AND selected "Yes" or "No" for "Has [FNLNS] had medicaidDeniedIndicator = false
their current immigration status since [current year minus 5 years]?"
If "No", set:
medicaidDeniedIndicator = true
New Indicators:
If "Yes", set:
immigrationStatusChangeSinceDeniedIndicator = true
If "No", set:
immigrationStatusChangeSinceDeniedIndicator = false

153

Income
Income - current income

Phase 1, Phase 2, Phase 3

Will any of these people have income this month?

N/A

Help Drawer: Learn about types of income to report
Generally, if a person includes an income source on their federal tax return, enter it here. Refer to IRS instructions on
income for special situations . [Link to: https://www.irs.gov/forms-instructions]
Here we ask only for each person’s current monthly income. Later, we’ll show you a yearly income estimate based on
that amount. You’ll be able to adjust that estimate to account for changes you expect during the coverage year.
Report income from these sources:
Jobs, including wages, salary, tips, commissions, bonuses, and severance pay
Self-employment - income from a small business you run or from freelance, consulting, or contract work
Unemployment compensation
Pensions from former employers
Social Security
Capital gains
Investments, like interest on savings or dividends from stocks or mutual funds
Retirement, including withdrawals from most 401(k) and IRA accounts
Alimony
Farming or fishing
Rental or royalty
Other income, like canceled debts, court, jury duty pay, cash support, gambling, prizes, awards, taxable scholarships,
and grants
Don't report income from these sources:
Proceeds from loans (like student loans, home equity loans, bank loans, or personal loans)
Child support
Veterans payments
Workers compensation or injury damage awards
Supplemental Security Income (SSI)
Gifts, regardless of amount
Federal tax refunds and credits
How to handle a type of income you’re not getting this month

Call to Action button: ADD INCOME FOR [FNLNS]
[Checkboxes, multi-selection]
Display all household member names
None of these people

Required

Required

Consumer is requesting financial assistance

N/A

The application must request information about current monthly
income from each consumer because it will be used to calculate
Medicaid and CHIP eligibility. The application must request current
income information for every applicant and relevant non-applicant.

The current income question must ask about current month income, even if the Each applicant's and non-applicant's current income attestation must be
consumer is applying during open enrollment for coverage in the following year. collected one by one. The application must ask for current income line
items and send to SES prior to asking about annual income. The income
questions must occur after all applicant and non-applicant information is
collected. Income will be used to determine preliminary program
eligibility.

State Medicaid and CHIP program names can now be found
through using the State Reference Data API, and do not have to
be hard-coded. CMS advises the UI include (Medicaid) or (CHIP)
when a state Medicaid or CHIP program does not include it or the
state uses the same name for their Medicaid and CHIP
programs.

Auditor Compliance
Conclusion**

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor
Comments**

Item #

154

Application Section
* indicates features of this question may be
updated in future documentation

Applicable EDE Phase**

Question**

Answers to Previous Questions**

Informational Text**

Answer Options and Format**

Required/Optional to Display Question or
Corresponding Answer Fields to Collect
Information in Application UI**

Income - current income

Phase 1, Phase 2, Phase 3

Select a type of income [FNLNS] currently gets this month.

N/A

Help Text: If [FNLNS] has more than one source of income, you'll be able to enter more later.

[Drop-down, single selection]
Job (like salary, wages, commissions, or tips)
Self-employment (like your own business, consulting, or freelance work)
Farming or fishing
Unemployment
Social Security benefits (retirement and disability)
Retirement (like IRA and 401(k) withdrawals)
Pension benefits
Investment (including interest and dividend income)
Capital gains
Rental or royalty
Alimony received
Scholarship
Canceled debt
Cash support from claiming tax filer**
Court awards
Gambling, prizes, or awards
Jury duty pay
Other income

Required

Required/Optional for Consumer to Provide
Answer to Send to SES**
*if optional, consumer must be able to
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Required

Answer Fields
1. Employer name: [Open text field]
2. How often does [FNLNS] get paid? [Radio buttons, single-selection] Hourly,
Daily, Weekly, Every 2 weeks, Twice a month, Monthly, Yearly, One time only
3. Enter the amount [FNLNS] gets [frequency selected for how often] Amount:
[Open text field]

1. Required
2. Required
3. Required

You can enter amounts now, and you can update [FNLNS]'s income later in the year if [FNLNS]'s situation changes.
Help Drawer: Learn about types of income to report
Generally, if a person includes an income source on their federal tax return, enter it here. Refer to IRS instructions on
income for special situations. [Link to: https://www.irs.gov/forms-instructions]
Here we ask only for each person’s current monthly income. Later, we’ll show you a yearly income estimate based on
that amount. You’ll be able to adjust that estimate to account for changes you expect during the coverage year.
Report income from these sources:
- Jobs, including wages, salary, tips, commissions, bonuses, and severance pay
- Self-employment - income from a small business you run or from freelance, consulting, or contract work
- Unemployment compensation
- Pensions from former employers
- Social Security
- Capital gains
- Investments, like interest on savings or dividends from stocks or mutual funds
- Retirement, including withdrawals from most 401(k) and IRA accounts
- Alimony
- Farming or fishing
- Rental or royalty
- Other income, like canceled debts, court, jury duty pay, cash support, gambling, prizes, awards, taxable scholarships,
and grants

Conditional Display Logic in the UI**

Data Element(s) Name

Attestation Level

Data Element
Format

Consumer is requesting financial assistance. This should display for every household member on
the application, including those not applying for coverage.

currentIncome.incomeSourceType

Member

enum

1. Required
2. Required
3. Required

Consumer is requesting financial assistance AND selected "Job" as income source type

currentIncome.incomeSourceType.JOB
1. currentIncome.jobIncome.employerName
2. currentIncome.incomeFrequencyType
3. currentIncome.incomeAmount

Member

1. string
2. enum
3. number

Policy**

Question/Informational Text Wording Requirements**

Answer Options and Format Requirements**

The application must request information about current month income from
Each applicant's current income attestation must be collected one by
each relevant household member (as indicated by SES Update App call)
one. The application must ask for current income line items and send to
because it will be used to calculate Medicaid and CHIP eligibility. The application SES prior to asking about annual income. Each applicant must be able to
must request current month income information separately for every applicant add multiple sources of income.
and relevant non-applicant. The application needs to provide an opportunity to
add information about adjustments to income the consumer will take on the
front page of their 1040 tax return as well. In addition, each applicant must
have the opportunity to attest to an annual income amount for the coverage
year.

General Requirements**

Question Flow Requirements**

The application must ask about these same income types as these
income types are countable under MAGI rules and expected by SES.
The question functionality must allow for the consumer to attest to
multiple income types and to attest to more than one instance of each
type (such as if they have multiple jobs).

Answer format is flexible. The income types listed were decided on with the IRS so
there must be an opportunity to attest to each type listed, but the UI could
choose to group or order them in different ways as long as each attestation is
separately recorded. In general, the income collected should be all income that is
taxable under IRS rules, as well as non-taxable Social Security and interest income
and cash support, when provided by a non-parent tax filer to their tax dependent.
If the UI groups the income types differently, the UI should still collect the specific
income type that correlates to the enum values in SES. All answer options
displayed in column F correlate to a unique enum value in SES. The multiple
frequency options are provided so that consumers can tell us the amount they
actually receive and don't have to do math. An application UI could limit the
frequency options if still done in a consumer friendly way, but the frequencies
listed are those that SES will accept. If a phase 1 or 2 application will not include
cash support on the application, it must be removed from the drop-down list.

These income types are collected because they are the taxable
income types most often reported by consumers in the income range
to get help paying for coverage.

Every consumer should have a straightforward pathway to report job income
amount and frequency as well as Employer Name.

It is important to give some instruction so that the UI collects taxable job Name of employer: Must be an open text field
income, not take-home pay. So on an annual basis, this would be the
Amount: Must be an open text field
amount reported on a W2 form--i.e. total income before taxes are
How often?: Flexible format, however, all answer options must be presented.
taken out but after pre-tax deductions such as for retirement or health Wording may be altered, however all answer options must be present (i.e., using
insurance.
per week instead of weekly).

**Cash support should not be collected on phase 1 and 2 applications, but required
on all phase 3 applications.

Don’t report income from these sources:
- Proceeds from loans (like student loans, home equity loans, bank loans, or personal loans)
- Child support
- Veterans payments
- Workers compensation or injury damage awards
- Supplemental Security Income (SSI)
- Gifts, regardless of amount
- Federal tax refunds and credits
155

Income - current income

Phase 1, Phase 2, Phase 3

N/A

What type of income would you like to add? Job (like salary, wages,
commissions, or tips)

How to handle a type of income you’re not getting this month
Enter the amount: If [Name]’s pay stub lists “federal taxable wages” (or “taxable income”), enter that amount. If not,
enter [Name]’s gross income (before taxes are taken out) minus anything [Name]’s employer withholds for health
coverage, retirement savings, and dependent care. Not sure? Make your best estimate.
Help Drawer: Learn more about reporting job income.
What if job income is hard to predict?
If this person is paid commissions or bonuses, works seasonally, expects a job change, or has a changing work schedule, it
can be hard to estimate income for the year.

See Item #7 on the "Backend Responses for UI" tab

This should be included in the income section, and because it is the most
common income type the way to report it must be prominent and clear.
The application could collect additional information about the employer
like address, phone number, etc., when this question is asked.

Make your best estimate of current income and adjust the yearly estimate we show you later. If things change, come
back to update the income later in the year.
What if this person doesn’t get certain job income now, but will later?
If they don’t currently get a job’s income, don’t report it now. We’ll show you a yearly estimate later. Add the expected
job income to that total.
What if this person doesn’t get this income now, but did earlier in the year?
If they don’t currently get job income, don’t report it now. We’ll show you a yearly estimate later. Add the previous job
income to that total.
What if pay changes weekly?
Enter how much this person expects to earn for the whole month. You can do this by multiplying the average weekly
amount by 4.
How do I enter a one-time payment this month?
If the person got, or will get, a one-time amount (like a bonus or severance payment) from a current or former employer
this month, enter it here.
How do I enter tips & other cash from jobs?
Include all tip income, even it’s not reported to the employer. Include all jobs, even if they’re part-time or paid in cash.
Add each job separately by selecting “Add more income” for each job.
Should I include income from a work-study job?
Yes.
156

Income - current income

Phase 1, Phase 2, Phase 3

How much does [FNLNS] usually work per week at this job?

1. What type of income would you like to add? Job
2. How often does [FNLNS] get this amount? Hourly or Daily

N/A

Answer Fields
1. Hours per week: [Open text field]
2. Days per week: [Open text field]

1. Required
2. Required

1. Required
2. Required

1. Consumer is requesting financial assistance AND selected "Job" as income source type AND
selected "Hourly" for frequency
2. Consumer is requesting financial assistance AND selected "Job" as income source type AND
selected "Daily" for frequency

1. currentIncome.jobIncome.averageWeeklyWorkHours
2. currentIncome.jobIncome.averageWeeklyWorkDays

Member

1. number
2. number

These income types are collected because they are the taxable
income types most often reported by consumers in the income range
to get help paying for coverage.

This must be included as a follow-up if the consumer selects "Hourly" or "Daily" as The follow-up question on days per week is required for any applicant who Flexible.
their income frequency. It is recommended the "Hourly" and "Daily"
reports that they are paid daily, and the follow-up question on hours per
frequencies are only included for "Job" income, however, if EDE partners
week required for applicants who report that they are paid hourly.
choose to collect hourly and daily frequencies for other income types, they
must also set averageWeeklyWorkHours and averageWeeklyWorkDays,
respectively, in the currentIncome object.

157

Income - current income

Phase 1, Phase 2, Phase 3

N/A

What type of income would you like to add? Retirement

Enter withdrawals from retirement accounts, including money received as a distribution from a retirement investment
like IRAs and 401(k) accounts. Include the income even for people who aren’t retired. Don’t include distributions from
Roth accounts.

Answer Fields
1. How often does [FNLNS] get this income? [Drop-down, single-selection]
Weekly, Every 2 weeks, Twice a month, Monthly, Yearly, One time only
2. Enter the amount [FNLNS] gets [frequency selected in how often]. Not sure?
Make your best estimate.: [Open text field]

1. Required
2. Required

1. Required
2. Required

Consumer is requesting financial assistance AND selected "Retirement" as income source type

currentIncome.incomeSourceType.RETIREMENT
1. currentIncome.incomeFrequencyType
2. currentIncome.incomeAmount

Member

1. enum
2. number

These income types are collected because they are the taxable
income types most often reported by consumers in the income range
to get help paying for coverage.

All income types must be listed.

Answer Fields
1. How often does [FNLNS] get this income? [Drop-down, single-selection]
Weekly, Every 2 weeks, Twice a month, Monthly, Yearly, One time only
2. How much does [FNLNS] get from net rental income (after subtracting
property expenses) or royalty income [frequency selected in how often]? You can
enter a positive number (profit) or a negative number (loss). Not sure? Make your
best estimate.: [Open text field]

1. Required
2. Required

1. Required
2. Required

Consumer is requesting financial assistance AND selected "Rental or royalty income" as income
source type

currentIncome.incomeSourceType.RENTAL_OR_ROYALTY_INCOME
1. currentIncome.incomeFrequencyType
2. currentIncome.incomeAmount

Member

1. enum
2. number

Answer Fields
1. Describe the kind of work in a few words.: [Open text field]
2. Amount [Open text field]

1. Required
2. Required

currentIncome.incomeSourceType.SELF_EMPLOYMENT
Member
1. currentIncome.selfEmploymentIncomeDescription
2. currentIncome.incomeAmount
3. If using this wording, set currentIncome.incomeFrequencyType to monthly. If not using this
wording, the UI should collect the frequency and set currentIncome.incomeFrequencyType based on
the consumer's response

1. string
2. number
3. enum

Help Drawer: Learn more about retirement income
Include most IRA and 401(k) withdrawals as income. Refer to IRS rules to determine the portion that’s considered
income.

See Item #7 on the "Backend Responses for UI" tab

Hours per week: Could be a dropdown or open text field as long as it complies with
SES validations
Days per week: Could be drop-down or open text field as long as it complied with
SES validations

This must be included in the current income section if an applicant
indicates that they have retirement income.

Flexible. It is helpful to note that the consumer must not include nonAmount: Must be an open text field
taxable retirement income here, like a payment from a Roth IRA, where How often: Answer format is flexible. Answer option wording is flexible, however,
the income was already taxed in a previous year.
all options must be present (i.e., using per week rather than weekly).

These income types are collected because they are the taxable
income types most often reported by consumers in the income range
to get help paying for coverage.

This must be included in the current income section.

Flexible. This income type could be a positive or negative number (aka a
profit or a loss due to the deduction of rental expenses)

These income types are collected because they are the taxable
income types most often reported by consumers in the income range
to get help paying for coverage.

This must be included in the current income section.

Flexible. Can remove the "type of work" field. This income type could be Description of the work: Must be an open text field
a positive or negative number (aka a profit or a loss due to the deduction Amount: Must be an open text field
of expenses)
*Note that this wording includes references to adding self-employment income
for the month. If the wording is changed and the question no longer specifies a
month as the frequency, the answer options should collect the frequency of the
income. If used:

Report any withdrawals this month. Later, we’ll show you a yearly income estimate based on current income. If your
retirement income changes during the coverage year, you can adjust the yearly figure then.
Don’t include distributions from qualified Roth accounts as income.
What if there’s no retirement income now but there will be later in the coverage year?
If they don’t currently get retirement income, but expect it later in the coverage year, don’t report it now. We’ll show
you a yearly estimate later. Add the expected income to that total.
158

Income - current income

Phase 1, Phase 2, Phase 3

N/A

What type of income would you like to add? Rental or royalty
income

Rental income is the amount someone gets for use of their property. Royalty income includes any payment from a
patent, copyright, or a natural resource they own.
Help Drawer: Learn more about rental or royalty income
Include any net rental or royalty income (or loss) this person is currently getting. If they don’t currently get the rental or
royalty income but will later in the coverage year, don’t report it now. We’ll show you a yearly estimate later. Add the
expected rental or royalty income to that total.

See Item #7 on the "Backend Responses for UI" tab

Amount: Must be an open text field
How often: Answer format is flexible. Answer option wording is flexible, however,
all options must be present (i.e., using per week rather than weekly).

For more information, see [IRS Publication 17]( https://www.irs.gov/pub/irs-pdf/p17.pdf).
What if there’s no rental or royalty income now but there will be later in the coverage year?
If they don’t currently get rental or royalty income, but expect it later in the coverage year, don’t report it now. We’ll
show you a yearly estimate later. Add the expected income to that total.
159

Income - current income

Phase 1, Phase 2, Phase 3

How much net income (profits once expenses are paid) will What type of income would you like to add? Self-employment (like
[FNLNS] get from self-employment this month? You can
your own business, consulting, or freelance work)
enter a positive number (profit) or a negative number (loss).
Not sure? Make your best estimate. Learn how to report
self-employment income.

Enter the net income (profit) this person earns from their own trade or business, like profit earned from goods they sell or
services they provide.
If this person gets a regular paycheck from an employer, select “Job” above instead.

1. Optional
2. Required

Consumer is requesting financial assistance AND selected "Self-employment" a income source
type
See Item #7 on the "Backend Responses for UI" tab

Help Drawer: Learn how to calculate net income. If you're still not sure, make your best estimate
Enter this person’s net income. That’s their total self-employment income minus business expenses.
Business expenses must be considered ordinary and necessary:
-Ordinary expense: A common expense that's accepted in a trade or business.
-Necessary expense: A helpful and appropriate expense for your trade or business.

How often: Answer format is flexible. Answer option wording is flexible, however,
all options must be present (i.e., using per week rather than weekly).

Visit the IRS [Link to: https://www.irs.gov/businesses/small-businesses-self-employed/deducting-business-expenses] for
more information on what counts as a business expense.
Help Drawer: Learn more about self-employment income.
Self-employment is generally considered work done as an “independent contractor” or “sole proprietor” of a small
business. It may include freelance, consulting, or contract work.
Enter the net income (profit) or loss this person expects from the trade or business. Net self-employment income is what
they report on Schedule C of their federal tax return – all the money they take in minus their business expenses. If
expenses are more than the gross income, a person has a net loss.
What if this person is a partner?
Include their distributive share from the partnership as income.
What if the self-employment income is hard to predict?
Make your best estimate of current income and adjust the yearly estimate we show you later. If things change, come
back to update the income later in the year.
What if there’s no self-employment income now but there will be later in the coverage year?
If they don’t currently get self-employment income, but expect it later in the coverage year, don’t report it now. We’ll
show you a yearly estimate later. Add the expected income to that total.
160

Income - current income

Phase 1, Phase 2, Phase 3

N/A

What type of income would you like to add? Pension

Enter the current payments made to this person from their pension after they retire from work.
Help Drawer: Learn more about pension income
Include any pension payments this person is currently getting from a former employer. Don’t include designated Roth
accounts, which don’t count as income.

Answer Fields
1. How often does [FNLNS] get this amount? [ Drop-down, single-selection]
Weekly, Every 2 weeks, Twice a month, Monthly , Yearly, One time only
2. Enter the amount [FNLNS] gets [frequency selected in how often]. Not sure?
Make your best estimate.: [Open text field]

1. Required
2. Required

1. Required
2. Required

Consumer is requesting financial assistance AND selected "Pension" as income source type

Answer Fields
1. Required
1. How often does [FNLNS] get this income? [ Drop-down, single-selection]
2. Required
Weekly, Every 2 weeks, Twice a month, Monthly , Yearly, One time only
2. How much does {FNLNS] get from net farming or fishing income (the profit
after subtracting costs) [frequency selected in how often]. You can enter a positive
number (profit) or a negative number (loss). Not sure? Make your best estimate.:
[Open text field]
Answer Fields
1. Required
1. Enter the amount [FNLN] gets each [frequency selected for how often]. Not
2. Required
sure? Make your best estimate.: [Open text field]
2. How often does [FNLNS] get this income? [Drop-down, single-selection]
Monthly, Yearly, One time only

1. Required
2. Required

Consumer is requesting financial assistance AND selected "Farming or fishing income" as income
source type

Answer Fields
1. Amount: [Open text field]

1. Required

See Item #7 on the "Backend Responses for UI" tab

currentIncome.incomeSourceType.PENSION
1. currentIncome.incomeFrequencyType
2. currentIncome.incomeAmount

Member

1. enum
2. number

These income types are collected because they are the taxable
income types most often reported by consumers in the income range
to get help paying for coverage.

This must be included in the current income section.

Flexible.

currentIncome.incomeSourceType.FARMING_OR_FISHING_INCOME
1. currentIncome.incomeFrequencyType
2. currentIncome.incomeAmount

Member

1. enum
2. number

These income types are collected because they are the taxable
income types most often reported by consumers in the income range
to get help paying for coverage.

This must be included in the current income section.

Flexible. This income type could be a positive or negative number (aka a Amount: Must be an open text field
profit or a loss due to the deduction of expenses)
How often: Answer format is flexible. Answer option wording is flexible, however,
all options must be present (i.e., using per week rather than weekly).

currentIncome.incomeSourceType.SOCIAL_SECURITY_BENEFIT
1. currentIncome.incomeFrequencyType
2. currentIncome.incomeAmount

Member

1. enum
2. number

These income types are collected because they are the taxable
income types most often reported by consumers in the income range
to get help paying for coverage.

This must be included in the current income section.

Flexible.

Amount: Must be an open text field
How often: Answer format is flexible. Answer option wording is flexible, however,
all options must be present (i.e., using per week rather than weekly).

currentIncome.incomeSourceType.CAPITAL_GAINS
1. currentIncome.incomeAmount
2. If using this wording, set currentIncome.incomeFrequencyType to yearly. If using an alternate
wording the UI should collect the frequency type and set currentIncome.incomeFrequencyType
based on the consumer's response

Member

1. number
2. enum

These income types are collected because they are the taxable
income types most often reported by consumers in the income range
to get help paying for coverage.

This must be included in the current income section.

Flexible. Could make this one only have a frequency of "one time only"
rather than multiple options.

Amount: Must be an open text field

currentIncome.incomeSourceType.ALIMONY_PAYMENT
1. currentIncome.incomeFrequencyType
2. currentIncome.incomeAmount

Member

1. enum
2. number

These income types are collected because they are the taxable
income types most often reported by consumers in the income range
to get help paying for coverage. Alimony received from divorce
agreements, separation agreements, or court orders finalized January
1, 2019 and after is not includable as income under IRS rules.

This must be included in the current income section.

Flexible.

Amount: Must be an open text field
How often: Answer format is flexible. Answer option wording is flexible, however,
all options must be present (i.e., using per week rather than weekly).

Amount: Must be an open text field
How often: Answer format is flexible. Answer option wording is flexible, however,
all options must be present (i.e., using per week rather than weekly).

Most pensions are considered income. If this person claims a pension as income on their federal income tax return, enter
it here. If you’re not sure, contact the pension plan.
What if there’s no pension income now but there will be later in the coverage year?
If they don’t currently get pension income, but expect it later in the coverage year, don’t report it now. We’ll show you a
yearly estimate later. Add the expected income to that total.
161

Income - current income

Phase 1, Phase 2, Phase 3

N/A

What type of income would you like to add? Farming or fishing
income

162

Income - current income

Phase 1, Phase 2, Phase 3

N/A

What type of income would you like to add? Social Security benefits Enter the amount this person gets each month from Social Security disability (Social Security Disability Income (SSDI)),
retirement (including railroad retirement (RRB)), or survivor’s benefits. Include both taxable and non-taxable Social
Security income.

Enter farming or fishing income as either “farming or fishing” income or “self-employment” income, but not both.
Help Text: You can enter a positive number (profit) or a negative number (loss). If you're not sure, make your best
estimate.

Don’t include Supplemental Security Income (SSI). We don’t consider this income.

See Item #7 on the "Backend Responses for UI" tab

1. Required
2. Required

Consumer is requesting financial assistance AND selected "Social Security benefits" as income
source type
See Item #7 on the "Backend Responses for UI" tab

Help Drawer: Learn more about Social Security benefits
Enter the full amount of Social Security income before any deductions are taken out, like Medicare premiums, income
tax withholding, overpayments, child support, and alimony.
To estimate income for the coverage year, find the Social Security increase amount in the yearly cost-of-living increase
letter.
What if this person is getting an extra payment this month?
Include it now. We’ll show you a yearly estimate based on the monthly income, and you can adjust it based on payments
they won’t get other months.
What if there’s no Social Security benefits now but there will be later in the coverage year?
If they don’t currently get Social Security benefits, but expect it later in the coverage year, don’t report it now. We’ll
show you a yearly estimate later. Add the expected income to that total.
163

Income - current income

Phase 1, Phase 2, Phase 3

How much does [FNLNS] expect to get from net capital
gains this year? Enter their capital gains income after
subtracting capital losses. You can enter a positive number
(profit) or a negative number (loss). Not sure? Make your
best estimate.

What type of income would you like to add? Capital gains

Enter the income this person gets from selling property or investments. If they’ll pay taxes on it, include it here.
Help Drawer: Learn more about capital gains

1. Required

Consumer is requesting financial assistance AND selected "Capital gains" as income source type
See Item #7 on the "Backend Responses for UI" tab

Don’t include a capital gain expected from the sale of a main home, if the profit is less than $250,000 ($500,000 for
families filing jointly).
For more information on capital gains, view [IRS Publication 17]( https://www.irs.gov/pub/irs-pdf/p17.pdf) or [IRS
Publication 544]( https://www.irs.gov/pub/irs-pdf/p544.pdf).

*Note that this wording includes references to adding capital gains income for the
year. If the wording is changed and the question no longer specifies a year as the
frequency, the answer options should collect the frequency of the income. If
used:
How often: Answer format is flexible. Answer option wording is flexible, however,
all options must be present (i.e., using per week rather than weekly).

What if there’s no capital gains now but there will be later in the coverage year?
If they don’t currently get capital gains, but expect it later in the coverage year, don’t report it now. We’ll show you a
yearly estimate later. Add the expected income to that total.
164

Income - current income

Phase 1, Phase 2, Phase 3

How much does [FNLNS] get from alimony?

What type of income would you like to add? Alimony received

Only tell us about alimony if the divorce or separation was finalized before January 1, 2019. Enter the money this person
Answer Fields
gets from a spouse they no longer live with, or a former spouse, if paid to them as part of a divorce agreement, separation 1. How often does [FNLNS] get this income? [Drop-down, single-selection]
agreement, or court order if finalized before January 1, 2019.
Weekly, Every 2 weeks, Twice a month, Monthly, Yearly, One time only
2. Enter the amount [FNLNS] gets each [frequency selected for how often]. Not
Don’t include payments designated or ordered as child support or as a non-taxable property settlement.
sure? Make your best estimate.: [Open text field]

1. Required
2. Required

1. Required
2. Required

Consumer is requesting financial assistance AND selected "Alimony received" as income source
type

165

Income - current income

Phase 1, Phase 2, Phase 3

N/A

What type of income would you like to add? Unemployment

Enter unemployment compensation this person is currently getting. These payments from the government could also be
a result of the COVID-19 emergency.

Answer Fields
1.. How often does [FNLNS] get this income? [Drop-down, single-selection]
Weekly, Every 2 weeks, Twice a month, Monthly, Yearly, One time only
2. Enter the amount [FNLNS] gets each [frequency selected for how often]. Not
sure? Make your best estimate.: [Open text field]
3. Which state or employer provides [FNLNS] with unemployment benefits?
(optional) [Open text field]
4. Date that unemployment benefits are set to expire? (Optional) [Open text
field]: YYY-MM-DD

1. Required
2. Required
3. Required
4. Required

1. Required
2. Required
3. Optional
4. Optional

Consumer is requesting financial assistance AND selected "Unemployment" as income source
type

Answer Fields
1. Enter the amount [FNLNS] gets each [frequency selected for how often]. Not
sure? Make your best estimate.: [Open text field]
2. How often does [FNLNS] get this income? Drop-down, single-selection]
Monthly Quarterly Yearly One time only
Answer Fields
1. How often does [FNLNS] get this income? [Drop-down, single-selection]
Weekly, Every 2 weeks, Twice a month, Monthly, Yearly, One time only
2. Enter the amount [FNLNS] gets every [frequency selected for how often]. Not
sure? Make your best estimate: [Open text field]

1. Required
2. Required

1. Required
2. Required

Consumer is requesting financial assistance AND selected "Investment income" as income source
type

1. Required
2. Required

1. Required
2. Required

Consumer is requesting financial assistance AND selected "Cash Support" as income source type

Answer Fields
1. Describe the other income.: [Open text field]
2. How often does [FNLNS] get this income? [Drop-down, single-selection]
Weekly, Every 2 weeks, Twice a month, Monthly, Yearly, One time only
3. Enter the amount [FNLNS] gets [frequency selected in how often]. Not sure?
Make your best estimate.: [Open text field]

1. Required
2. Required
3. Required

1. Optional
2. Required
3. Required

Consumer is requesting financial assistance AND selected "Other income" as income source type
AND "Canceled debts, Court awards, Jury duty pay, Cash support from [Name of tax filer(s)], or
Gambling, prizes, or awards, Other" is selected as the other income type

If this person is getting unemployment compensation from their employer or union (not from the government), select
“Other income" and enter this income.

166

Income - current income

Phase 1, Phase 2, Phase 3

How much does [FNLNS] get from investment income, like What type of income would you like to add? Investment (including
interest and dividends?
interest and dividend income)

167

Income - current income

Phase 3

N/A

What type of income would you like to add? Cash Support

Enter the income this person currently gets from an investment, like interest from a bank account or dividends from
mutual funds or stocks. Include tax-exempt interest.

Enter the amount of cash support this person gets from the person who claims them as a tax dependent.
Help Drawer: Learn more about cash support
For example, if this person gets $200 per month for rent and other living costs, include it here. Don’t include “in-kind”
support, like the value of room and board or clothing.

168

Income - current income

Phase 1, Phase 2, Phase 3

N/A

Which type of income would you like to add? Other income

What if there’s no cash support now but there will be later in the coverage year?
If they don’t currently get cash support income, but expect it later in the coverage year, don’t report it now. We’ll show
you a yearly estimate later Add the expected income to that total
Enter any current foreign income that’s not taxable in the U.S.
Don’t enter child support, veterans payments, or Supplemental Security Income (SSI).
Help Drawer: Learn more about reporting other income
You can enter Alaska Permanent Fund Dividend (PFD) income here. To be eligible for a PFD, this person must have been
an Alaska resident for the entire calendar year before the date they apply for a dividend, and must intend to remain an
Alaska resident indefinitely.

See Item #7 on the "Backend Responses for UI" tab

See Item #7 on the "Backend Responses for UI" tab

See Item #7 on the "Backend Responses for UI" tab

See Item #7 on the "Backend Responses for UI" tab

See Item #7 on the "Backend Responses for UI" tab

currentIncome.incomeSourceType.UNEMPLOYMENT
1. currentIncome.incomeAmount
2. currentIncome.incomeFrequencyType
3. currentIncome.unemploymentIncome.incomeDescription
4. currentIncome.unemploymentIncome.expirationDate
5. On 2021 applications, set receivedUnemploymentCompensationIndicator = true

Member

1. number
2. enum
3. string
4. string
5. boolean

These income types are collected because they are the taxable
income types most often reported by consumers in the income range
to get help paying for coverage.

This must be included in the current income section.

Flexible.

State or former employer: Must be an open text field
Amount: Must be an open text field
How often: Answer format is flexible. Answer option wording is flexible, however,
all options must be present (i.e., using per week rather than weekly).

currentIncome.incomeSourceType.INVESTMENT_INCOME
1. currentIncome.incomeAmount
2. currentIncome.incomeFrequencyType

Member

1. number
2. enum

These income types are collected because they are the taxable
income types most often reported by consumers in the income range
to get help paying for coverage.

This must be included in the current income section.

Flexible.

Amount: Must be an open text field
How often: Answer format is flexible. Answer option wording is flexible, however,
all options must be present (i.e., using per week rather than weekly).

currentIncome.incomeSourceType.CASH_SUPPORT
1. currentIncome.incomeAmount
2. currentIncome.incomeFrequencyType

Member

1. number
2. enum

These income types are collected because they are the taxable
income types most often reported by consumers in the income range
to get help paying for coverage.

This must be included in the current income section for phase 3
applications. If cash support is included as an income type option for
phases 1 and 2, this follow-up information must be displayed in the
current income section.

Flexible.

Amount: Must be an open text field
How often: Answer format is flexible. Answer option wording is flexible, however,
all options must be present (i.e., using per week rather than weekly).

currentIncome.incomeSourceType.OTHER_INCOME
1. currentIncome
2. currentIncome.incomeAmount
3. currentIncome.incomeFrequencyType

Member

1. string
2. number
3. enum

These income types are collected because they are the taxable
income types most often reported by consumers in the income range
to get help paying for coverage.

This must be included in the current income section.

Flexible.

Income description: Must be an open text field
Amount: Must be an open text field
How often: Answer format is flexible. Answer option wording is flexible, however,
all options must be present (i.e., using per week rather than weekly).

currentIncome.incomeSourceType.SCHOLARSHIP
1. currentIncome.incomeAmount
2. currentIncome.incomeFrequencyType

Member

1. number
2. enum

These income types are collected because they are the taxable
income types most often reported by consumers in the income range
to get help paying for coverage.

This must be included in the current income section.

Flexible.

Amount of income: Must be an open text field
Amount for education expenses: Must be an open text field
How often: Answer format is flexible. Answer option wording is flexible, however,
all options must be present (i.e., using per week rather than weekly).

Member

1. number
2. enum

These income types are collected because they are the taxable
income types most often reported by consumers in the income range
to get help paying for coverage.

This must be included in the current income section.

Flexible.

Amount: Must be an open text field
How often: Answer format is flexible. Answer option wording is flexible, however,
all options must be present (i.e., using per week rather than weekly).

currentIncome.incomeSourceType.COURT_AWARDS
1. currentIncome.incomeAmount
2. currentIncome.incomeFrequencyType

Member

1. number
2. enum

These income types are collected because they are the taxable
income types most often reported by consumers in the income range
to get help paying for coverage.

This must be included in the current income section.

Flexible.

Amount: Must be an open text field
How often: Answer format is flexible. Answer option wording is flexible, however,
all options must be present (i.e., using per week rather than weekly).

What if there’s no other income now but there will be later in the coverage year?
If they don’t currently get other income, but expect it later in the coverage year, don’t report it now. We’ll show you a
yearly estimate later. Add the expected income to that total.
169

Income - current income

Phase 1, Phase 2, Phase 3

N/A

Which type of income would you like to add? Scholarship

Enter taxable scholarship and grant income. Many scholarships and grants aren’t taxable.
Help Drawer: Learn more about scholarships
If you’re not sure the scholarship or grant income is taxable, check with the granting institution.
What about work-study jobs?
Work-study jobs are considered income. Select “Job” above to enter this type of income.

170

Income - current income

Phase 1, Phase 2, Phase 3

N/A

Which type of income would you like to add? Gambling, prizes or
awards

What if there’s no scholarship now but there will be later in the coverage year?
If they don’t currently get scholarship income, but expect it later in the coverage year, don’t report it now. We’ll show
you a yearly estimate later Add the expected income to that total
Enter lottery winnings and other gambling proceeds. Don’t enter prizes that aren’t taxable, like most academic
scholarships.
Help Drawer: Learn more about gambling, prize, and award income
Report any lottery winnings or gambling proceeds this month. Later, we’ll show you a yearly income estimate based on
current income. If your lottery winnings or other gambling proceeds change during the coverage year, you can adjust
the yearly amount then.

Answer Fields
1. Required
1. How often does [FNLNS] get this income? [Drop-down, single-selection]
2. Required
Weekly, Every 2 weeks, Twice a month, Monthly, Yearly, One time only
3. Required
2. Enter the amount [FNLNS] gets [frequency selected in how often]. Not sure?
4. Required
Make your best estimate.: [Open text field]
3. Enter the amount [FNLNS] used to pay for education expenses. Not sure? Make
your best estimate.: [Open text field]

1. Required
2. Required
3. Required
4. Required

Consumer is requesting financial assistance AND selected "Scholarship" as income source type

Answer Fields
1. How often does [FNLNS] get this income? [Drop-down, single-selection]
Weekly, Every 2 weeks, Twice a month, Monthly, Yearly, One time only
2. Enter the amount [FNLNS] gets [frequency selected in how often]. Not sure?
Make your best estimate.: [Open text field]

1. Required
2. Required

1. Required
2. Required

Consumer is requesting financial assistance AND selected "Gambling, prizes, or awards" as income currentIncome.incomeSourceType.PRIZE_AWARDS_GAMBLING_WINNINGS
source type
1. currentIncome.incomeAmount
2. currentIncome.incomeFrequencyType
See Item #7 on the "Backend Responses for UI" tab

Answer Fields
1. How often does [FNLNS] get this income? [Drop-down, single-selection]
Weekly, Every 2 weeks, Twice a month, Monthly, Yearly, One time only
2. Enter the amount [FNLNS] gets [frequency selected in how often]. Not sure?
Make your best estimate.: [Open text field]

1. Required
2. Required

1. Required
2. Required

Consumer is requesting financial assistance AND selected "Court awards" as income source type

Consumer is requesting financial assistance AND selected "Jury duty pay" as income source type

See Item #7 on the "Backend Responses for UI" tab

Requestors should provide two separate currentIncome objects with the same
currentIncome.incomeFrequencyType; one where the currentIncome.incomeSourceType =
OTHER_INCOME (which should include all scholarship income both used for educational expenses or
not collected in answer field 2) and one where currentIncome.incomeSourceType = SCHOLARSHIP
(which should just include the amount used for educational expenses). The reported scholarship income
should not exceed the reported other income

What if there’s no gambling, prize, and award income now but there will be later in the coverage year?
If they don’t currently get gambling, prize, and award income, but expect it later in the coverage year, don’t report it
now. We’ll show you a yearly estimate later. Add the expected income to that total. Later, we’ll show you a yearly total
based on the current income. You can change it if you expect a different income total for the year.
171

Income - current income

Phase 1, Phase 2, Phase 3

N/A

Which type of income would you like to add? Court awards

Enter the money this person gets from a lawsuit, which may be taxable.
Help Drawer: Learn more about court rewards
Report any court awards this month. Later, we’ll show you a yearly income estimate based on current income. If your
awards income changes during the coverage year, you can adjust the yearly amount then.

See Item #7 on the "Backend Responses for UI" tab

Examples of court awards you should report:
- Compensation for lost wages
- Punitive damages
Examples of awards you shouldn’t report:
- Amounts for personal physical injury or sickness
- Compensation for damages to your property (if the amount is less than the amount you paid for the property)
For more information, view [IRS Publication 17](https://www.irs.gov/pub/irs-pdf/p17.pdf).
What if there’s no court awards income now but there will be later in the coverage year?
If they don’t currently get court awards income, but expect it later in the coverage year, don’t report it now. We’ll show
you a yearly estimate later. Add the expected income to that total.
172

Income - current income

Phase 1, Phase 2, Phase 3

N/A

Which type of income would you like to add? Jury duty pay

Enter the money this person expects to be paid for jury duty, including reimbursement for transportation. If the money
goes straight to an employer, don’t enter it.

Answer Fields
1. How often does [FNLNS] get this income? [Drop-down, single-selection]
Weekly, Every 2 weeks, Twice a month, Monthly, Yearly, One time only
2. Enter the amount [FNLNS] gets [frequency selected in how often]. Not sure?
Make your best estimate.: [Open text field]

1. Required
2. Required

1. Required
2. Required

173

Income - current income

Phase 1, Phase 2, Phase 3

N/A

Which type of income would you like to add? Canceled Debts

If this person incurred a debt from a loan or from buying something on credit, and part of the amount they owed was
discharged or forgiven, the amount forgiven is generally considered income. Enter this amount.

Answer Fields
1. How often does [FNLNS] get this income? [Drop-down, single-selection]
Weekly, Every 2 weeks, Twice a month, Monthly, Yearly, One time only
2. Enter the amount [FNLNS] gets [frequency selected in how often]. Not sure?
Make your best estimate.: [Open text field]

1. Required
2. Required

1. Required
2. Required

[Checkboxes, multi-selection]
Display all household member names
None of these people

Required

Required

Help Drawer: Learn more about canceled debt
Student loan debt amounts don’t need to be entered here if they were discharged because of a student’s death or
disability.

currentIncome.incomeSourceType.JURY_DUTY_PAY
1. currentIncome.incomeAmount
2. currentIncome.incomeFrequencyType

Member

1. number
2. enum

These income types are collected because they are the taxable
income types most often reported by consumers in the income range
to get help paying for coverage.

This must be included in the current income section.

Flexible.

Amount: Must be an open text field
How often: Answer format is flexible. Answer option wording is flexible, however,
all options must be present (i.e., using per week rather than weekly).

Consumer is requesting financial assistance AND selected "Canceled debts" as income source type currentIncome.incomeSourceType.CANCELED_DEBT
1. currentIncome.incomeAmount
2. currentIncome.incomeFrequencyType

Member

1. number
2. enum

These income types are collected because they are the taxable
income types most often reported by consumers in the income range
to get help paying for coverage.

This must be included in the current income section.

Flexible.

Amount: Must be an open text field
How often: Answer format is flexible. Answer option wording is flexible, however,
all options must be present (i.e., using per week rather than weekly).

Consumer is requesting financial assistance

Member

N/A

Adjustments to income that a consumer will take on their tax return
The application needs to provide an opportunity to add information about
(front page of 1040 only, not itemized deductions) must be subtracted adjustments to income the consumer will take on the front page of their 1040
from projected income in order to calculate MAGI used for Medicaid, tax return as well. In addition, each applicant must have the opportunity to
CHIP, and APTC eligibility.
attest to an annual income amount for the coverage year.

The flow of collecting income information from each household member Flexible.
is flexible (i.e., deductions may be collected first). If no consumers on the
application have current income, it is not necessary to ask about their
deductions. However, if at least one consumer on the application reports
current income, then all consumers must have the opportunity to report
deductions.

Alimony and student loan interest are the only common types of deductions
without complex rules, so they are the only ones the IRS recommends asking
about explicitly. That said, very few people actually have any of those, so its an
option to make this question a little easier to skip over than it is today. In addition,
some consumers may know that they will have other deduction types and they
must be able to report those as "other"

See Item #7 on the "Backend Responses for UI" tab

See Item #7 on the "Backend Responses for UI" tab

For more information, view [IRS Publication 17]( https://www.irs.gov/pub/irs-pdf/p17.pdf).
What if there’s no canceled debt income now but there will be later in the coverage year?
If they don’t currently get canceled debt income, but expect it later in the coverage year, don’t report it now. We’ll
show you a yearly estimate later. Add the expected income to that total.
174

Income - deductions

Phase 1, Phase 2, Phase 3

Do any of these people pay student loan interest, alimony,
educator expenses, or contribute to an IRA in [coverage
year]?

N/A

Help Text: If [FNLNS] has more than one expense, you'll be able to enter more later.
Help Drawer: Learn more about reporting these expenses
This person can deduct these expenses (known as deductions) from their income.
You can select these expenses:
Student loan interest
Alimony payments
Other expenses. Select this if this only if the person has any of these expenses:
IRA contributions
Educator expenses
Penalty on early withdrawal of savings
Someone who’s self-employed should account for business expenses when they enter net self-employment income.
They shouldn’t enter business expenses here.
If this person has only tax deductions that we don’t ask about here - including charitable donations, child or dependent
care, mortgage interest, property taxes, and state income taxes – don’t enter those expenses here. Select “Skip” to
move forward.

N/A

Notes

Auditor Compliance
Conclusion**

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor
Comments**

Item #

175

Application Section
* indicates features of this question may be
updated in future documentation

Applicable EDE Phase**

Question**

Answers to Previous Questions**

Informational Text**

Answer Options and Format**

Required/Optional to Display Question or
Corresponding Answer Fields to Collect
Information in Application UI**

Income - deductions

Phase 1, Phase 2, Phase 3

Select [FNLNS]'s current expense.

N/A

You can deduct only certain expenses from [FNLNS]'s income on this application.

[Radio buttons]
Student loan interest
Alimony payments
One of these expenses:
-IRA contributions (if [FNLNS] doesn't have a retirement account through a job)
-Educator expenses (if [FNLNS] is a teacher and pays for supplies out-of-pocket)
-Penalty on early withdrawal of savings

Required

Help Drawer: Learn more about reporting these expenses
This person can deduct these expenses (known as deductions) from their income.
You can select these expenses:
- Student loan interest
- Alimony payments
- Other expenses. Select this if this only if the person has any of these expenses:
o IRA contributions
o Educator expenses
o Penalty on early withdrawal of savings

Required/Optional for Consumer to Provide
Answer to Send to SES**
*if optional, consumer must be able to
ith t
idi
i UI
ti
Required

Conditional Display Logic in the UI**

Data Element(s) Name

Attestation Level

Data Element
Format

Consumer is requesting financial assistance AND selected "Yes" for "Does [FNLNS] pay for any of
these deductions?"

If consumer selects " Alimony": currentIncome.incomeSourceType.ALIMONY_PAYMENT
If consumer selects "Student loan interest":
currentIncome.incomeSourceType.STUDENT_LOAN_INTEREST
If consumer selects " Other": currentIncome.incomeSourceType.OTHER_DEDUCTION

Member

enum

See Item #7 on the "Backend Responses for UI" tab

Policy**

General Requirements**

Question Flow Requirements**

Question/Informational Text Wording Requirements**

The flow of collecting income information from each household member Flexible.
is flexible (i.e., deductions may be collected first). If no consumers on the
application have current income, it is not necessary to ask about their
deductions. However, if at least one consumer on the application reports
current income, then all consumers must have the opportunity to report
deductions.

Answer Options and Format Requirements**

Notes

Answer format is flexible. Answer option wording must be exact and all options
must be present. Alimony and student loan interest are the only common types of
deductions without complex rules, so they are the only ones the IRS recommends
asking about explicitly. Note- some deductions that were previously allowed are
no longer allowed per IRS rule changes-- specifically tuition and fees and moving
expenses are no longer allowable deductions.

Someone who’s self-employed should account for business expenses when they enter net self-employment income.
They shouldn’t enter business expenses here.
If this person has only tax deductions that we don’t ask about here - including charitable donations, child or dependent
care, mortgage interest, property taxes, and state income taxes – don’t enter those expenses here. Select “Skip” to
move forward.
176

Income - deductions

Phase 1, Phase 2, Phase 3

N/A

What type of deduction would you like to add? Alimony

Only tell us about alimony if the divorce or separation was finalized before January 1, 2019.

Answer Fields
1. How often does [FNLNS] pay alimony? [Radio buttons] Weekly, Every 2 weeks,
Monthly, Quarterly, Yearly
2. Enter the amount [FNLNS] pays [frequency selected for how often].: [Open
text field]

1. Required
2. Required

1. Required
2. Required

Consumer is requesting financial assistance AND selected "Yes" for "Does [FNLNS] pay for any of
these deductions?" AND selects "Alimony" as the deduction type

177

Income - deductions

Phase 1, Phase 2, Phase 3

N/A

What type of deduction would you like to add? Student loan interest

N/A

Answer Fields
1. How often does [FNLNS] pay student loan interest? [Radio buttons] Weekly,
Every 2 weeks, Monthly, Quarterly, Yearly
2. Enter the amount [FNLNS] pays [frequency selected for how often].: [Open
text field]

1. Required
2. Required

1. Required
2. Required

Consumer is requesting financial assistance AND selected "Yes" for "Does [FNLNS] pay for any of
these deductions?" AND selects "Student loan interest" as the deduction type

178

Income - deductions

Phase 1, Phase 2, Phase 3

N/A

What type of deduction would you like to add? One of these
expenses

N/A

Answer Fields
1. Describe the expense in a few words.: [Open text field]
2. How often does [FNLNS] pay this expense? [Radio buttons] Weekly, Every 2
weeks, Monthly, Quarterly, Yearly
3. Enter the amount [FNLNS] pays [frequency selected for how often].: [Open
text field]

1. Required
2. Required
3. Required

1. Required
2. Required
3. Required

Consumer is requesting financial assistance AND selected "Yes" for "Does [FNLNS] pay for any of
these deductions?" AND selects "One of these expenses" as the deduction type

currentIncome.incomeSourceType.OTHER_DEDUCTION
1. currentIncome.otherDeductionDescription
2. currentIncome.incomeFrequencyType
3. currentIncome.incomeAmount

[Radio buttons]
Yes
No

Required

Required

Consumer is requesting financial assistance AND selected "Yes" for "Are any of these people
American Indian or Alaska Native?" AND income amount is greater than 0 AND income source
type is not Social Security OR Unemployment

N/A

Answer Fields
Tribal Amount: [Open text field]

1. Required

1. Required

Consumer is requesting financial assistance AND selected "Yes" for "Are any of these people
American Indian or Alaska Native?" AND income amount is greater than 0 AND income source
type is not Social Security OR Unemployment AND consumer answered "Yes" for "Is any of this
income from these sources?"

currentIncome.tribalIncomeAmount

[Radio buttons]
Yes
No

Required

Required

Consumer is requesting financial assistance

If yes, set:
1. annualTaxIncome.incomeAmount
2. variableIncomeIndicator = false

179

180

Income - American Indian/Alaska Native
income

Phase 3

Income - American Indian/Alaska Native
income

Phase 3

Is any of this income from these sources?
• Per capita payments from the tribe that come from
natural resources, usage rights, leases or royalties.
• Payments from natural resources, farming, ranching,
fishing, leases, or royalties from land designated as Indian
land by the Department of Interior (including reservations
and former reservations).
• Money from selling things that have cultural significance.

Are any of these people American Indian or Alaska Native? Yes

N/A

Is any of this income from these sources? Yes

N/A

Display consumer entered income source, frequency, and income amount from the consumer's reported income.
Alert Message if tribal income is greater than total income: The amount you entered for this person's tribal income is
greater than the amount you entered above for their total income. If that's incorrect, change either amount.

See Item #7 on the "Backend Responses for UI" tab

See Item #7 on the "Backend Responses for UI" tab

Legacy Logic:
Required if tribalIncomeIndicator = True
(defaults value to $0.00)

If these amounts are correct, select "Save & continue."

See Item #7 on the "Backend Responses for UI" tab

If consumer selects " Alimony": currentIncome.incomeSourceType.ALIMONY_PAYMENT
1. currentIncome.incomeFrequencyType
2. currentIncome.incomeAmount

Member

1. enum
2. number

Adjustments to income that a consumer will take on their tax return
(front page of 1040 only, not itemized deductions) must be subtracted
from projected income in order to calculate MAGI used for Medicaid,
CHIP, and APTC eligibility. Alimony received from divorce agreements,
separation agreements, or court orders finalized January 1, 2019 and
after is not considered by the IRS as a tax-deductible income.

The flow of collecting income information from each household member Flexible.
is flexible (i.e., deductions may be collected first). If no consumers on the
application have current income, it is not necessary to ask about their
deductions. However, if at least one consumer on the application reports
current income, then all consumers must have the opportunity to report
deductions.

Amount: Must be an open text field
How often: Answer format is flexible. Answer option wording is flexible, however,
all options must be present (i.e., using per week rather than weekly).

currentIncome.incomeSourceType.STUDENT_LOAN_INTEREST
1. currentIncome.incomeFrequencyType
2. currentIncome.incomeAmount

Member

1. enum
2. number

Adjustments to income that a consumer will take on their tax return
(front page of 1040 only, not itemized deductions) must be subtracted
from projected income in order to calculate MAGI used for Medicaid,
CHIP, and APTC eligibility.

Amount: Must be an open text field
How often: Answer format is flexible. Answer option wording is flexible, however,
all options must be present (i.e., using per week rather than weekly).

Member

1. string
2. enum
3. number

Adjustments to income that a consumer will take on their tax return
(front page of 1040 only, not itemized deductions) must be subtracted
from projected income in order to calculate MAGI used for Medicaid,
CHIP, and APTC eligibility.

The flow of collecting income information from each household member Flexible.
is flexible (i.e., deductions may be collected first). If no consumers on the
application have current income, it is not necessary to ask about their
deductions. However, if at least one consumer on the application reports
current income, then all consumers must have the opportunity to report
deductions
The flow of collecting income information from each household member Flexible.
is flexible (i.e., deductions may be collected first). If no consumers on the
application have current income, it is not necessary to ask about their
deductions. However, if at least one consumer on the application reports
current income, then all consumers must have the opportunity to report
deductions.

Member

N/A

This question aims to flag whether any of the income the consumer has On financial assistance applications, it is important that AI/AN household
listed so far is considered tribal income under Medicaid/CHIP rules. If
members, including non-applicants, have the opportunity to flag whether any
so, it will be counted when SES counts up household income for APTC
of their attested income falls into the tribal income categories. In addition, for
eligibility, but will not be counted when SES is counting income for
applicants who are potentially Medicaid/CHIP eligible, the application must ask
Medicaid/CHIP eligibility.
about eligibility and receipt of Indian Health Services using the FFE language.

If the consumer identifies as American Indian/Alaska Native, or we don't Wording must be exact.
know whether or not they do because they were not asked, then these
questions need to be asked at some point after other income information
is collected. They cannot be stand-alone income questions like other
income types, because for example, income could be job income or selfemployment, but also be money that the consumer gets from selling
culturally-significant items and therefore not counted for
Medicaid/CHIP.

Answer format is flexible. Answer option wording must be exact and all options
must be present.

Member

string

This question aims to flag whether any of the income the consumer has On financial assistance applications, it is important that AI/AN household
listed so far is considered tribal income under Medicaid/CHIP rules. If
members, including non-applicants, have the opportunity to flag whether any
so, it will be counted when SES counts up household income for APTC
of their attested income falls into the tribal income categories. In addition, for
eligibility, but will not be counted when SES is counting income for
applicants who are potentially Medicaid/CHIP eligible, the application must ask
Medicaid/CHIP eligibility.
about eligibility and receipt of Indian Health Services using the FFE language.

If the consumer identifies as American Indian/Alaska Native, or we don't Wording must be exact.
know whether or not they do because they were not asked, then these
questions need to be asked at some point after other income information
is collected. They cannot be stand-alone income questions like other
income types, because for example, income could be job income or selfemployment, but also be money that the consumer gets from selling
culturally-significant items and therefore not counted for
Medicaid/CHIP.

Amount: Must be an open text field.

Member

1. number
2. boolean
3. boolean

The FFE uses annual income for APTC determinations and sometimes
for Medicaid/CHIP based on state option. This yes/no question allows
the UI to set the indicator for variable income--it should be set to true if
the consumer does not agree with the calculated annual income
because in that case the consumer's monthly income x 12 does not
equal annual income. All consumers need the opportunity to attest to
their annual income here, even if they didn't attest to current income
in Item 153.

Must be included at the end of the income section, after the consumer
has provided their income, deductions, and any tribal income, if
applicable.

Answer format is flexible. Answer options may be altered for consistency with
question wording.

Help Drawer: See what counts as American Indian or Alaska Native income
Enter an income amount if this person can claim income from any of these sources:
-Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties: These are
payments from certain legal settlements. Next, you’ll enter any per capita payments that this person gets from certain
settlements of tribal trust cases between the U.S. and those Indian tribes.

Description: Must be an open text field
Amount: Must be an open text field
How often: Answer format is flexible. Answer option wording is flexible, however,
all options must be present (i.e., using per week rather than weekly).

-Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust
land by the Department of Interior (including reservations and former reservations): These are payments from land held
in trust by the Interior Department for a member of an Indian tribe. If this person gets this type of payment, you’ll enter
payments from natural resources, farming, and ranching on allotted land held in trust for them by the Interior
Department.
-Money from selling items that have cultural significance: These are payments from selling tangible items that have
cultural significance, like documents, art work, or clothing.
If you enter an income amount, we won’t count this income when we check to see if this person is eligible for Medicaid or
the Children’s Health Insurance Program (CHIP). This income will still be included when their yearly income is calculated to
see if they’re eligible for savings. You may need to submit documents to confirm this person’s income later.
181

Income - annual income

Phase 1, Phase 2, Phase 3

We calculated this expected yearly income amount based
on what you entered for [FNLNS]'s monthly income and
expenses. Is this correct?

N/A

Help Drawer: I'm not sure if this amount is correct.
We know some people’s income and expenses may change throughout the year or be hard to estimate.
If a person's income is hard to predict, base your estimate on past experience and what you know about possible changes.

If no, set:
3. variableIncomeIndicator = true

It's important to enter your best estimate, not $0, so you get the right amount of savings. Use our income calculator for
help. [Link to: https://www.healthcare.gov/income-calculator]
Remember: If your household's income changes after you submit an application, come back to the Marketplace and
update your application. This will help make sure you're getting the right amount of savings.

183

Income - annual income

Phase 1, Phase 2, Phase 3

Enter your best estimate of [FNLNS] expected yearly
income for [coverage year].

Include any expected changes in pay or work schedule, bonuses, or commissions, and one-time or occasional payments
[FNLNS] isn't currently getting. If anything changes later in the year, you can come back and update this information.

[Radio buttons]
Yes
No
Answer Fields
[Open text fields]

Required

Required

184

182

Income - annual income

Income - annual income

Phase 1, Phase 2, Phase 3

Phase 1, Phase 2, Phase 3

That's okay. Make your best estimate of [FNLNS]'s total
income for [coverage year].

Is [FNLNS]'s income for [coverage year] hard to predict?

Is [FNLNS]'s income for [coverage year] hard to predict? Yes

We calculated this expected yearly income amount based on what
you entered for [FNLNS]'s monthly income and expenses. Is this
correct? No
Is [FNLNS]'s income for [coverage year] hard to predict? No

It's fine is this isn't exact. You can base this amount on what you know today. If anything changes later in the year, you
can come back and update this estimate.

N/A

Answer Fields
[Open text fields]

Required

Required

185

Income - Discrepancies*

Phase 1, Phase 2, Phase 3

The income you entered for [Employer
Name] is lower than what our records
show. Is there a reason why?

N/A

Help Text: Select the option that most accurately describes this person's situation.

[Radio buttons]
Hours at [Employer] were reduced
Cut wages or salary at [Employer]
Stopped working at [Employer]
A reason not listed above

Required

Optional

Required

Optional

Required

Required

Consumer is requesting financial assistance AND selected "No" for "We calculated this expected
yearly income amount based on what you entered for [FNLNS]'s monthly income and expenses.
Is this correct?"
Consumer is requesting financial assistance AND consumer answered "No" for "We calculated this
expected yearly income amount based on what you entered for [FNLNS]'s monthly income and
expenses. Is this correct?" AND selected "No" for "Is [FNLNS]'s income for [coverage year] hard
to predict?"
Consumer is requesting financial assistance AND consumer answered "No" for "We calculated this
expected yearly income amount based on what you entered for [FNLNS]'s monthly income and
expenses. Is this correct?" AND selected "Yes" for "Is [FNLNS]'s income for [coverage year] hard
to predict?"

Income - Discrepancies*

Phase 1, Phase 2, Phase 3

[FNLN]'s or (and [FNLNS's Spouse] if married)'s household
income in [coverage year] seems like it will be lower than
what our records from the past 2 years show. Is there a
reason why?

N/A

Help Text if "A reason not listed above" is selected: Be sure to include this information in your explanation:
-How much income the household expects to get in [coverage year]
-When [FNLNS] will get the income
-Where that income comes from
Help Drawer if "A reason not listed above" is selected: See an example of a full answer
Use the box to tell us why this person's income will be lower.

With checkboxes with options as follows:
My household members have changed.
My income will be lower due to a change in my, for reasons such as a new job, a
decrease in hours, loss of employment, use of Family Medical Leave Act (FMLA),
disability, retirement, or sabbatical.
My income fluctuates due to self-employment.
A reason not listed above

boolean

Must be included at the end of the income section, after the consumer
has provided their income, deductions, and any tribal income, if
applicable
Must be included at the end of the income section, after the consumer
has provided their income, deductions, and any tribal income, if
applicable.

1. boolean
2. number

Flexible.

Answer format is flexible. Answer options may be altered for consistency with
question wording.
Must include free text field option to include a number. The UI could help the
consumer project their best guess before continuing.
Answer format is flexible. Answer options may be altered for compatibility with the
question wording

If Hours at [Employer] were reduced set
(currentIncome.jobIncome.incomeDifferenceReason= Decrease_Hours)
If Cut wages or salary at [Employer] set
(currentIncome.jobIncome.incomeDifferenceReason= Wage_Cut)
If Stopped working at [Employer] set
(currentIncome.jobIncome.incomeDifferenceReason= Stopped_Working)
Then: The income calculation flow checks whether the
incomeDifferenceReason is either Decreased Hours, Wage Cut or
Stopped Working then re-calculates the external income amount for the
member and re-verifies the attested income for the Medicaid household.
Just for Medicaid/CHIP - Did not go through Gap Filing
Substitutes attested for the external and then recalculate and re-verify
Attested for verification for Medicaid/CHIP to the State
A Reason Not Listed Above
Then the UI does not return the
currentIncome.jobIncome.incomeDifferenceReason to SES

enum

Must be included at the end of the income section, after the consumer
Flexible.
has provided their income, deductions, and any tribal income, if
applicable based on SES indicators passed from Update App API. Question
flow for reasons why income varies from the data source is flexible.

Answer format is flexible. Answer option wording must be exact and all options
must be present.

See Item #9 & #10 on the "Backend Responses for UI" tab

If A Tax Household has the following status:
Member
and
= INCOME_LOWER_THAN_SOURCE, then:
If any selection was made other than "A reason not listed above", set
members.income. = "True"
Additionally,
· If "My household members have changed." was selected, set
= "HOUSEHOLD_MEMBER_CHANGE"
· If "My income will be higher lower due to a change in my job, for reasons such as a new job, a decrease
in hours, loss of employment, use of FMLA, disability, retirement, or sabbatical" was selected, set
= "JOB_CHANGE"
· If "My income fluctuates due to self-employment." was selected, set
= "SELF_EMPLOYMENT_INCOME_FLUCTUATION"
If "A reason not listed above" was selected, set
= "OTHER" AND
members.income. = "False"
Text input to the freeform box should be saved as

1. boolean
2. boolean

Must be included at the end of the income section, after the consumer
Wording must be similar.
has provided their income, deductions, and any tribal income, if
applicable based on SES indicators passed from Update App API. Question
flow for reasons why income varies from the data source is flexible.

Answer format is flexible. Answer options may be altered for compatibility with the
question wording

Answer format must be an open text field.

*This question should only display ONCE per tax household, to collect the information for the
entire tax household

Must be included at the end of the income section, after the consumer
has provided their income, deductions, and any tribal income, if
applicable if they need help projecting an annual income

Flexible.

See Item #7 on the "Backend Responses for UI" tab

Member

Flexible for any consumer-friendly tool to calculate an accurate MAGI annual
income

Flexible.

1. boolean
2. number, enum,
boolean

If any member of a tax household has the following status:
OR
A Tax Household has the following status:
and
= INCOME_LOWER_THAN_SOURCE

Here's an example:
If a reason not listed above is checked, an input box should appear which allows for
John washed cars from January - May, but then lost his job. He made $5,000 during this time, but doesn't know how much freeform text input
he'll earn for the rest of the year.

Member
Member

1. annualTaxIncome.unknownIncomeIndicator = true
Member
2. Create an additional current income record with incomeSourceType = OTHER_INCOME and
incomeFrequencyType = ANNUALLY where estimatedForAptcIndicator = true and the amount is set to
the attested estimated annual income

If a reason not listed above is checked, an input box should appear which allows for
freeform text input

186

If yes, set annualTaxIncome.unknownIncomeIndicator = true
If no, set annualTaxIncome.unknownIncomeIndicator = false
1. annualTaxIncome.unknownIncomeIndicator = false
2. annualTaxIncome.incomeAmount

Flexible. Must use SES calculated annual income amount.

Also, If any member(s) of that tax household has the following status:

Copy the same answer that was saved to to
for those member(s)
If No Tax Household has the following status:
and
= INCOME_LOWER_THAN_SOURCE, then:
Save the response that we would save to via logic
above to for that member instead.
187

Income - Discrepancies*

Phase 1, Phase 2, Phase 3

191

APTC & Medicaid & CHIP program questions Phase 1, Phase 2, Phase 3
current coverage

Why is [FNLNS]’s income in months during [coverage year]
different than this month’s income?

N/A

Are any of these people currently enrolled in health
coverage?

N/A

N/A

[Open text field]

Required

Required

See Item #11 on the "Backend Responses for UI" tab

Save free-form input box as

Member

boolean

Must be included at the end of the income section, after the consumer
has provided their income, deductions, and any tribal income, if
applicable. Question flow for reasons why income varies from the data
source is flexible

Marketplace coverage: If a person currently has coverage through the Marketplace, select their name.

[Checkboxes, multi-selection]
Display all applicants who are preliminarily eligible for APTC, Medicaid, and/or CHIP
None of these people

Required

Required

See Item #13 on the "Backend Responses for UI" tab

For each name not selected, or if none of these people is selected,
Set escEnrolledIndicator to false
Select the appropriate enum for enrolledCoverages.insuranceMarketType for Non-ESC coverage
types

Member

N/A

Program questions may collected at any point in the application. The flow Flexible, but partners must make it clear that an applicant should be
of the program questions section is flexible.
selected only if their other coverage is not ending in the next 60 days.
This can be achieved through adjustments to the existing question text,
help text, or by implementing a follow-up question.

Answer format is flexible. Answer option wording must be exact and all options
must be present.

Member

1. array, enum
2.boolean
3.boolean
4. boolean
5. array, enum

Program questions may collected at any point in the application. The flow Flexible, but partners must make it clear that an applicant should be
of the program questions section is flexible.
selected only if their other coverage is not ending in the next 60 days.
This can be achieved through adjustments to the existing question text,
help text, or by implementing a follow-up question.

Answer format is flexible. For all phases, limited benefit coverage and full benefit State Medicaid and CHIP program names can now be found
coverage can be standalone answer options, as shown in the answer options for
through using the State Reference Data API, and do not have to
Phases 1 and 2, or limited benefit coverage could be nested within other
be hard-coded. CMS advises the UI include (Medicaid) or (CHIP)
coverage, as shown in the answer options for Phase 3. Note that the follow-up
when a state Medicaid or CHIP program does not include it or the
questions for limited benefit coverage, full benefit coverage, and other coverage state uses the same name for their Medicaid and CHIP
are different and the appropriate follow-up questions must be implemented. All
programs.
other answer options cannot be changed. Applications must implement the
answer options for their corresponding phase.

Member

1. array, enum
2. array, enum

If multiple applicants attest to having current coverage, this question
could be asked to determine what coverage they have a reduce data
entry for the consumer. If the UI does not include this question, the UI
must ask each applicant whether or no they are also enrolled in other
coverage.

Can provide options to consumer based on known information about insurance in
that state, rather than free text field.

Other types of health coverage: Select a person's name only if they'll have their coverage on or after [60 days after the
current date]. Select a person’s name if they’re enrolled in any of these other types of health coverage, only if their
coverage won’t end on or before [60 days after the current date].

If Medicaid or CHIP prelim eligible, set enrolledInHealthCoverageIndicator to true. This data element is
not relevant for preliminary APTC eligibility.

[State Medicaid program name]
[State CHIP program name]
Medicare
TRICARE
Veterans Affairs (VA) health care program
Peace Corps
COBRA
Retiree health benefits
Coverage through a job
Other full or limited benefit coverage

192

APTC & Medicaid & CHIP program questions Phase 1, Phase 2, Phase 3
current coverage

What type of coverage does [FNLNS] have?

Are any of these people currently enrolled in health coverage?
Selected a name

Phases 1 and 2
Marketplace coverage: Select if [FNLNS] has coverage through HealthCare.gov or a state-based Marketplace
[State Medicaid program name]: Don't check this box if one of these applies to [FNLNS]'s coverage: 1) Their coverage
pays for only limited benefits, like family planning services, emergency services, outpatient hospital services, or
treatment of tuberculosis. 2) Their Medicaid coverage doesn't pay for inpatient hospital services.
TRICARE: Don't select if [FNLNS] has Direct Care or Line of Duty.
Other full benefit coverage: Covers doctor's visits, hospitalizations, and prescription drugs
Other limited benefit coverage: Like a school accident policy
Phase 3
Marketplace coverage: Select if [FNLNS] has coverage through HealthCare.gov or a state-based Marketplace
[State Medicaid program name]: Don't check this box if one of these applies to [FNLNS]'s coverage: 1) Their coverage
pays for only limited benefits, like family planning services, emergency services, outpatient hospital services, or
treatment of tuberculosis. 2) Their Medicaid coverage doesn't pay for inpatient hospital services.
TRICARE: Don't select if [FNLNS] has Direct Care or Line of Duty.
COBRA: Don’t check this box if this person will end COBRA coverage once they enroll in Marketplace coverage. Select if
[FNLNS] is enrolled in COBRA (and plans to keep it during [coverage year]). They won’t qualify for a premium tax credit,
but may be eligible to enroll in a Marketplace health plan or other programs. [Learn more about COBRA] (Link to:
https://www.healthcare.gov/unemployed/cobra-coverage/)
Retiree Health Benefits: Select if [FNLNS] is enrolled in a retiree health plan (an employer-provided health care plan that
carries over to retirement) and plans to keep it during [coverage year]. They won’t qualify for a premium tax credit, but
may be eligible to enroll in a Marketplace health plan or other programs.
Coverage through a job (or another person's job, like a spouse or parent): Select if [FNLNS] is currently enrolled in a jobbased plan and can use their health benefits.
Other coverage: Can cover doctor's visits, hospitalizations, and prescription drugs

193

APTC & Medicaid & CHIP program questions Phase 1, Phase 2, Phase 3
current coverage

Are any of these people also enrolled in this coverage?

What type of coverage does [FNLNS] have? Selected any type of
coverage (except for Medicare - if Medicare is selected, the "is
anyone else on this plan" question is not asked because there can
only be one person on a Medicare plan)

All Phases
Help Drawer: Select the type of coverage this person is currently enrolled in:
- Marketplace coverage: Select this if they currently have coverage through a Marketplace plan. If their coverage ends
before [January 1, 2018], select “Back” at the top of the screen and uncheck this person’s name.
- Medicaid
- Children’s Health Insurance Program (CHIP)
- Medicare
- TRICARE: A health care program for uniformed services members, retirees, and their families
- Veterans Affairs (VA) Health Care Program: Health coverage for veterans (and in certain circumstances their
N/A

Flexible.

The same fields for prelim APTC and prelim Medicaid or CHIP may be collected for all applicants to
minimize UI logic.

Phases 1 and 2
[Checkboxes, multi-selection]
Marketplace coverage
[State Medicaid program name]
[State CHIP program name]
Medicare
TRICARE
Veterans Affairs (VA) Health Care Program
Peace Corps
Other full benefit coverage
Other limited benefit coverage

Required

Required

See Item #13 on the "Backend Responses for UI" tab
Consumer selected a name for "Are any of these people currently enrolled in health coverage?"

If prelim Medicaid or CHIP (or whenever question is answered):
1. Set medicaid.insuranceMarketType to the insurance type selected except if attested to being
enrolled in COBRA, set:
medicaid.insuranceCoverage.insuranceMarketType.OTHER_LIMITED_BENEFIT_COVERAGE
If prelim APTC (or whenever question is answered) and a Phase 3 app where Cobra, retiree or employer
coverage is selected by consumer:

Phase 3
[Checkboxes, multi-selection]
Marketplace coverage
[State Medicaid program name]
[State CHIP program name]
Medicare
TRICARE
Veterans Affairs (VA) Health Care Program
Peace Corps
COBRA
Retiree Health Benefits
Coverage through a job (or another person's job, like a spouse or parent)
Other coverage

[Checkboxes, multi-selection]
Display all other applicant names
None of these people

The appropriate indicators may be set based on the applicant's program eligibility; or, the same
indicators may be set for both preliminary Medicaid/CHIP eligible applicants and preliminary APTC
eligible applicants, which is recommended in case of program-switching that may occur after
subsequent questions.

-2. If Cobra is selected, set cobraAvailableIndicator = true and
-3. If retiree is selected, set retireePlanCoverageIndicator = true AND
---4. If prelim APTC, and Employer coverage, Cobra coverage, OR retiree coverage are selected, set
escEnrolledIndicator to true and offeredEmployeeCoverage to YES or leave null
If prelim APTC (or whenever question is answered) and Phase 1 or 2 or Phase 3 and Cobra, retiree or
employer coverage NOT selected:
-4. set escEnrolledIndicator to false
-5. Select the appropriate enum for enrolledCoverages.insuranceMarketType for Non-ESC coverage
types (See FAQ)

Optional

Optional

Consumer is requesting financial assistance AND requesting coverage AND consumer is
preliminarily APTC OR Medicaid OR CHIP eligible AND selected multiple names for applicants with
current coverage AND selected any type of coverage other than Medicare

If prelim Medicaid or CHIP (or whenever question is answered):
1. Set medicaid.insuranceMarketType to the insurance type selected
If prelim APTC (or whenever question is answered) and a Phase 3 app where Cobra, retiree or employer
coverage is selected by consumer:

Flexible.

-2. If Cobra is selected, set cobraAvailableIndicator = true and
-3. If retiree is selected, set retireePlanCoverageIndicator = true AND
---4. If prelim APTC, and Employer coverage, Cobra coverage, OR retiree coverage are selected, set
escEnrolledIndicator to true.
If prelim APTC (or whenever question is answered) and Phase 1 or 2 or Phase 3 and Cobra, retiree or
employer coverage NOT selected:
-4. set escEnrolledIndicator to false
-5. Select the appropriate enum for enrolledCoverages.insuranceMarketType for Non-ESC coverage
types (See FAQ)

194

APTC & Medicaid & CHIP program questions Phase 1, Phase 2, Phase 3
current coverage

Tell us about [FNLNS]'s Medicare coverage.

What type of coverage does [FNLNS] have? Medicare

Flexible.

The free text field for the Medicare number should have validations to ensure a
valid Medicare number is entered.

195

APTC & Medicaid & CHIP program questions Phase 1, Phase 2, Phase 3
current coverage

Tell us about [FNLNS]'s TRICARE coverage.

What type of coverage does [FNLNS] have? TRICARE

N/A

Answer Fields
1. Policy number: [Open text field]
2. Member ID: [Open text field]

1. Required
2. Required

1. Optional
2. Optional

Consumer is requesting financial assistance AND requesting coverage AND consumer is
preliminarily Medicaid OR CHIP eligible AND selected "TRICARE" for "What type of coverage does
[FNLNS] have?"

If prelim Medicaid or CHIP (or whenever question is answered):
1. medicaid.insurancePolicyNumber
2. medicaid.insurancePolicyMemberId

Member

1. string
2. string

May be asked earlier, when asking questions about current enrollment in
other coverage.

Flexible.

196

APTC & Medicaid & CHIP program questions Phase 1, Phase 2, Phase 3
current coverage

Tell us about [FNLNS]'s VA Health Care Program coverage.

What type of coverage does [FNLNS] have? Veterans Affairs (VA)
Health Care Program

N/A

You can find this person’s Medicare Number by looking at their red, white, and blue Medicare card. If this person already
has Medicare coverage, they can’t enroll in a Marketplace health plan instead. [Learn more about how Medicare works
with the Marketplace](Link to: https://www.healthcare.gov/help/information-on-medicare)

Answer Fields
1. Plan ID: [Open text field]
2. Member ID: [Open text field]

Medicare Number: [Open text field]

1. Required
2. Required

Required

1. Optional
2. Optional

Optional

Consumer is requesting financial assistance AND requesting coverage AND consumer is
preliminarily Medicaid OR CHIP eligible AND selected "VA Health Care Program for "What type of
coverage does [FNLNS] have?"

Consumer is requesting financial assistance AND requesting coverage AND consumer is
preliminarily Medicaid OR CHIP eligible AND selected Medicare for "What type of coverage does
[FNLNS] have?"

If prelim Medicaid or CHIP (or whenever question is answered):
1. medicaid.insurancePolicyNumber
2. medicaid.insurancePolicyMemberId

If prelim Medicaid or CHIP (or whenever question is answered):
1. medicaid.insurancePolicyNumber

Member

Member

1. string
2. string

1. string

May be asked earlier, when asking questions about current enrollment in
other coverage.

May be asked earlier, when asking questions about current enrollment in
other coverage.

Flexible.

Can provide options to consumer based on known information about insurance in
that state. If no information is known about insurance:
Policy number: Must be open text field
Member ID: Must be open text field
Can provide options to consumer based on known information about insurance in
that state. If no information is known about insurance:
Plan ID: Must be open text field
Member ID: Must be open text field
Can provide options to consumer based on known information about insurance in
that state. If no information is known about insurance:
Name of health plan: Must be open text field
Policy number: Must be open text field
Member ID: Must be open text field

197

APTC & Medicaid & CHIP program questions Phase 1, Phase 2, Phase 3
current coverage

Tell us about [FNLNS]'s full benefit coverage.

What type of coverage does [FNLNS] have? Other full benefit
coverage

This information is usually on this person’s insurance card.

Answer Fields
1. Name of health plan: [Open text field]
2. Policy number [Open text field]
3. Member ID: [Open text field]

1. Required
2. Required
3. Required

1. Optional
2. Optional
3. Optional

Consumer is requesting financial assistance AND consumer is preliminarily Medicaid OR CHIP
eligible AND selected "Other full benefit coverage" for "What type of coverage does [FNLNS]
have?"

If prelim Medicaid or CHIP (or whenever question is answered):
1.medicaid.insurancePlanName
2. medicaid.insurancePolicyNumber
3. medicaid.insurancePolicyMemberId

Member

1. string
2. string
3. string

May be asked earlier, when asking questions about current enrollment in Flexible.
other coverage. This must be asked as a follow-up if the partner opted to
include limited benefit coverage and full benefit coverage as a
standalone answer options when asking the consumer about their current
coverage, and full benefit coverage was selected.

198

APTC & Medicaid & CHIP program questions Phase 1, Phase 2, Phase 3
current coverage

Tell us about [FNLNS]'s limited benefit coverage.

What type of coverage does [FNLNS] have? Other limited benefit
coverage

This information is usually on this person’s insurance card.

Answer Fields
1. Name of health plan: [Open text field]
2. Policy number: [Open text field]
3. Member ID: [Open text field]

1. Required
2. Required
3. Required

1. Optional
2. Optional
3. Optional

Consumer is requesting financial assistance AND requesting coverage AND consumer is
preliminarily Medicaid or CHIP eligible AND selected "Other limited benefit coverage" for "What
type of coverage does [FNLNS] have?"

If prelim Medicaid or CHIP (or whenever question is answered):
1.medicaid.insurancePlanName
2. medicaid.insurancePolicyNumber
3. medicaid.insurancePolicyMemberId

Member

1. string
2. string
3. string

May be asked earlier, when asking questions about current enrollment in Flexible.
other coverage. This must be asked as a follow-up if the partner opted to
include limited benefit coverage and full benefit coverage as a
standalone answer options when asking the consumer about their current
coverage, and limited benefit coverage was selected.

Can provide options to consumer based on known information about insurance in
that state. If no information is known about insurance:
Name of health plan: Must be open text field
Policy number: Must be open text field
Member ID: Must be open text field

267

APTC & Medicaid & CHIP program questions Phase 3
current coverage

Tell us about [FNLNS]'s coverage.

What type of coverage does [FNLNS] have? Coverage through a
job (or another person's job, like a spouse or parent) OR COBRA OR
Retiree Health Benefits

N/A

Answer Fields
If Prelim APTC
1. Employer Name: [Open text field] Can be prepopulated from income section

1. Required
2. Required
3. Required
4. Required

1. Required
2. Optional
3. Optional
4. Optional

For Prelim APTC
Consumer is requesting financial assistance AND requesting coverage AND consumer is
preliminary APTC AND selected "Coverage through a job (or another person's job, like a spouse or
parent" for "What type of coverage does [FNLNS] have?"

If Prelim APTC (or whenever question is answered)*
employerSponsoredCoverageOffers.escOffer.employer.name
1. employerSponsoredCoverageOffers.escOffer[n].insurancePlanName
2. employerSponsoredCoverageOffers.escOffer[n].insurancePolicyNumber
3. employerSponsoredCoverageOffers.escOffer[n].insurancePolicyMemberId

Member

1. string
2. string
3. string
4. array, enum
5. array, enum

May be asked earlier, when asking questions about current enrollment in
other coverage.

Name of Employer: Must be open text field and can be prepopulated from the
income section
Name of Health Plan: Must be open text field
Policy number: Must be open text field
Member ID: Must be open text field

If Medicaid/CHIP prelim eligible
1. Employer Name: [Open text field] Can be prepopulated from income section
2. Name of health plan: [Open text field]
3. Policy number: [Open text field]
4. Member ID: [Open text field]

For Prelim Medicaid CHIP
Consumer is requesting financial assistance AND requesting coverage AND consumer is
preliminarily Medicaid or CHIP eligible AND selected "Coverage through a job (or another person's
job, like a spouse or parent" for "What type of coverage does [FNLNS] have?"

Flexible.

[n] = number of ESC types, if the same applicant attests to being enrolled in multiple types of ESC
If prelim Medicaid or CHIP (or whenever question is answered):
1. medicaid.insuranceCoverage.insurancePlanName
2. medicaid.insuranceCoverage.insurancePolicyNumber
3. medicaid.insuranceCoverage.insurancePolicyMemberId
If prelim Medicaid or CHIP (or whenever question is answered) and attested to being enrolled in
Employer Sponsored Coverage or Retiree health plan and consumer selects checkbox, set:
4. medicaid.insuranceCoverage.insuranceMarketType.EMPLOYER_SPONSORED
If prelim Medicaid or CHIP and attested to being enrolled in COBRA, set:
5. medicaid.insuranceCoverage.insuranceMarketType.OTHER_LIMITED_BENEFIT_COVERAGE
*It is not required to collect Employer Name for prelim Medicaid or CHIP individuals. The same fields for
prelim APTC and prelim Medicaid or CHIP may be collected for all applicants to minimize UI logic. In this
case, the Employer Name attestation will always map to
employerSponsoredCoverageOffers.escOffer.employer.name

199

APTC & Medicaid & CHIP program questions Phase 1, Phase 2, Phase 3
current coverage

Tell us about [FNLNS]'s coverage.

What type of coverage does [FNLNS] have? Other coverage

285

APTC program questions - current coverage

Do any of these people have an individual coverage Health
Reimbursement Arrangement (HRA) through their job, or
through the job of another person, like a spouse or parent?

N/A

Phase 3

N/A

Answer Fields
1. Coverage Name: [Open text field]
2. Policy number: [Open text field]
3. Member ID: [Open text field]
4. This is limited benefits coverage (like a school accident policy). [Checkbox]

1. Required
2. Required
3. Required
4. Required

1. Optional
2. Optional
3. Optional
4. Optional

Consumer is requesting financial assistance AND requesting coverage AND consumer is
preliminarily Medicaid or CHIP eligible AND selected "Other coverage" for "What type of
coverage does [FNLNS] have?"

Before you start this section, gather HRA information.

[Checkboxes, multi-selection]
Display all applicants who are preliminarily eligible for APTC
None of these people

Required

Required

Consumer is requesting financial assistance AND requesting coverage AND consumer is
preliminarily APTC eligible

You'll need any information about Health Reimbursement Arrangements (HRAs) that the people on this application may
have gotten from an employer.

If you're offered or provided an HRA, it could be an individual coverage HRA or a qualified small employer HRA (QSEHRA).
If you're offered an individual coverage HRA, the notice from your employer should state that you're not being offered a
QSEHRA.
If you're provided a QSEHRA, the notice from your employer might call it a QSEHRA, or might call it something else.
QSEHRAs can only be provided by employers with fewer than 50 full-time employees.
If you have questions about the HRA, like what type it is, look at the employer's HRA notice or check with the employer.
Help Drawer 2: What's the difference between a current HRA and an HRA offer?
Current HRAs
Select every person who's currently enrolled in an HRA. A person is considered currently enrolled in an HRA if either of
these apply:
-Today, they can request reimbursement from an employer for qualifying health care costs, like their monthly premium,
in some cases. Their HRA is not ending in the next 60 days.
-They've signed up for an HRA that hasn't started yet, but they'll be able to request reimbursements within the next 60
days, or by January 1 if applying during Open Enrollment.
HRA offers
Phase 3

Has [FNLNS] ever gotten a health service from the Indian
Health Service, a tribal health program, or urban Indian
health program or through a referral from one of these
programs?

Consumer previously attested to being American Indian or Alaska
Native

N/A

[Radio buttons]
Yes
No

If an applicant name is selected, set:
insuranceCoverage.enrolledInIchraIndicator = true
If "none of these people" or an applicant's name is not selected, set:
insuranceCoverage.enrolledInIchraIndicator = false

If you have questions about the HRA, you can also check with the employer.
Help Drawer 1: Learn more about HRAs.
An HRA is type of group health plan that lets an employer reimburse a person for qualifying medical expenses, including
their monthly health plan premium, in some cases.

Medicaid & CHIP program questions

Member

1. string
2. string
3. string
4. array, enum

Member

boolean

If prelim Medicaid or CHIP (or whenever question is answered) and consumer selects checkbox, set:
4. medicaid.insuranceMarketType.OTHER_LIMITED_BENEFIT_COVERAGE

These documents should include start and end dates, and the maximum amount employers will reimburse for health care
costs.

237

If prelim Medicaid or CHIP (or whenever question is answered):
1.medicaid.insurancePlanName
2. medicaid.insurancePolicyNumber
3. medicaid.insurancePolicyMemberId

Required

Required

Consumer is requesting financial assistance AND preliminarily eligible for Medicaid OR CHIP AND
answered "Yes" for "Are any of these people American Indian

This question should be asked of consumers who are preliminarily eligible for
APTC and must be a separate question from the "Current Coverage" question
(item #191).
This question should display even if a consumer who is preliminarily eligible for
APTC attests to being enrolled in "current coverage" (item #191) that would
disqualify them from APTC.

May be asked earlier, when asking questions about current enrollment in
other coverage. This must be asked as a follow-up if the partner opted to
nest the option for limited benefit coverage within other coverage when
asking the consumer about their current coverage, and the consumer
selected other coverage.

Flexible.

Can provide options to consumer based on known information about insurance in
that state. If no information is known about insurance:
Name of health plan: Must be open text field
Policy number: Must be open text field
Member ID: Must be open text field
Limited benefits coverage: format for indicating the coverage is limited benefits
coverage is flexible

Program questions may be collected after the preliminary eligibility
determination is made. This question may be grouped with other APTCprogram HRA questions (items 286-293).

Flexible. The DE entity may use "individual coverage HRA" instead of
individual coverage Health Reimbursement Arrangement.

All applicants who are preliminary eligible for APTC must display. Answer format is
flexible; however, multi-selection must be enabled.

Auditor Compliance
Conclusion**

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor
Comments**

Item #

240

Application Section
* indicates features of this question may be
updated in future documentation

Applicable EDE Phase**

Question**

Answers to Previous Questions**

Informational Text**

Answer Options and Format**

Required/Optional to Display Question or
Corresponding Answer Fields to Collect
Information in Application UI**

Medicaid & CHIP program questions Medicaid specific questions

Phase 1, Phase 2, Phase 3

Do any of these people have health coverage now?

N/A

N/A

[Checkboxes, multi-selection]
Display each relevant non-applicant child name
None of these people

Required

241

Medicaid & CHIP program questions Medicaid specific questions

Phase 1, Phase 2, Phase 3

Does [Child name] have a parent living outside the home?

N/A

121

Medicaid & CHIP program questions Medicaid specific questions

Phase 3

Do any of these children live with more than one parent,
through birth or adoption? (optional)

N/A

Required/Optional for Consumer to Provide
Answer to Send to SES**
*if optional, consumer must be able to
ith t
idi
i UI
ti
Required

Conditional Display Logic in the UI**

Data Element(s) Name

Consumer is requesting financial assistance AND preliminarily eligible for Medicaid AND added non coveredDependentChildIndicator
applicant children to the application

Attestation Level

Data Element
Format

Policy**

General Requirements**

Question Flow Requirements**

Question/Informational Text Wording Requirements**

Answer Options and Format Requirements**

Member

boolean

When an applicant is preliminarily eligible for Medicaid through the
new adult Medicaid expansion group, and that applicant is the parent
or caretaker of a non-applicant child who is on the application, then
the applicant is only Medicaid eligible for the new adult group if the nonapplicant child already has some type of health coverage
This question is asked so that the application can queue the
attestation/agreement about cooperating with child support
enforcement for appropriate consumers and so the information can
be passed on to the state.

This question must be asked to help determine Medicaid eligibility. This question
will appear if applicants are potentially Medicaid eligible in Medicaid expansion
states and added non-applicant children to the application.

This question must be asked after the Medicaid preliminary eligibility
determination.

Must use same question wording.

Non-applicant child names must display. Answer format is flexible; however, mult
selection must be enabled.

See Item # 17 on the "Backend Responses for UI" tab.

N/A

[Radio buttons]
Yes
No

Required

Required

See Item #18 on the "Backend Responses for UI" tab.

Member

boolean

Help Drawer: Learn who's considered a parent
Select "Yes" if this person lives with 2 parents, including 1 or 2 stepparents.

[Checkboxes, multi-selection]
Display list of children from whom the applicant assumes primary responsibility and
who are under age 19 and who meets the state's relationship test.

Required

Optional

An applicant is preliminary eligible for Medicaid or emergency Medicaid
For each name selected, set resideWithBothParentIndicator = true
(preliminaryMedicaidStatus = yes or emergencyMedicaidStatus = yes) AND
For each name not selected, set resideWithBothParentIndicator = false
The applicant is a PC/R (parentCaretakerIndicator = true) AND the child for whom the applicant is
caring for lives in a deprivation state (deprivationRequirementRetained = T) AND the applicant has
not been identified as unemployed/underemployed in the income section
(childCaretakerDeprivedStatus = T) AND we don't already know if the child lives with both parents

Member

boolean

In some states, the applicant can only get the P/CR Medicaid category Questions about who lives together may be asked on an as-needed basis as seen
if the child they take care of is considered to be deprived of parental
here, or may be inferred based on information provided about who lives at
support. In those states DE entities need to ask this question if the UI
which address. This question would only be needed in a state with a deprivation
has not already collected information about whether or not the child
requirement, where the parent or caretaker is applying for coverage.
lives with his or her parents. A child is considered deprived if he or she
lives with less than two parents, or if he or she lives with two parents but
at least one is unemployed or underemployed.

Answer Fields
1. Required
2. Required

Answer Fields
1. Required
2. Required

Consumer is requesting financial assistance AND preliminarily eligible for Medicaid AND the
applicant is potentially eligible for the parent/caretaker relative category AND the dependent
child lives with 2 parents AND the state has a deprivation requirement
(deprivationRequirementRetained = Y) AND no parent has been identified as underemployed or
unemployed via the income section.
OR
An adult is potentially a parent/CR, the child in question lives with two parents, and only in the
handful of states with a deprivation requirement we directly ask the question.

Member

1. number
2. number

This question is asked when an adult on the application may qualify as a This question must be asked to help determine Medicaid eligibility in some states. If the child's parents are on the application, this information can be
parent/caretaker relative, and the dependent child lives with two
This question will appear if applicants are potentially Medicaid eligible based on
collected in the income section. This question is part of the
parents and the state Medicaid agency has a deprivation requirement the Update App SES call. Display the question for any child in the applicant's
Medicaid/CHIP path.
for the parent/caretaker relative category.
parentCaretakerChildList with: childCaretakerDeprivedStatus = Temporary

Required

See Item #20 on the "Backend Responses for UI" tab.

Don't select a person's name if they live with 1 or 2 foster parents.

242

Medicaid & CHIP program questions Medicaid specific questions

Phase 1, Phase 2, Phase 3

How many hours per week do [Child’s name]’s parents
work?

Do any of these children live with more than one parent, through
birth or adoption? Name selected
OR
It is already known the child lives with two parents

N/A

Answer Fields.
1. [Parent 1 FNLNS]'s hours per week: [Open text field]
2. [Parent 2 FNLNS]'s hours per week: [Open text field]

243

Medicaid & CHIP program questions - CHIP
specific questions

Phase 1, Phase 2, Phase 3

Did any of these people have coverage through a job that
ended in the last [waiting period] months?

N/A

N/A

[Checkboxes, multi-selection]
Required
Display applicants who are preliminarily eligible for CHIP and not pregnant in a state
with a CHIP waiting period
None of these people

If "yes" is selected, set: absentParentIndicator = true for that applicant child

1. parent1WeeklyWorkHourQuantity
2. parent2WeeklyWorkHourQuantity

This question will appear if the application filer and a child applicant under age 18 This question is part of the Medicaid path and only required when there is
are potentially Medicaid eligible based on the Update App SES call and the
a Medicaid eligible child under age 18 with a Medicaid eligible application
Medicaid eligible child lives with 0 or 1 parent, and will prompt the proper
filer where the child lives with 0 or 1 parent.
attestation/agreement.

Notes

Flexible. Must use generic phrases here such as the phrase "living outside Answer format is flexible. Answer options may be altered for compatibility with
the home".
question wording.

This question must be asked for each child added through the parent
Flexible.
caretaker question as needed based on the state and the information
already available on the application about the child's parents. After
affirmatively answering to caring to a child, the parent care taker
question flow is flexible. Questions about parent/caretaker relatives must
be asked prior to the preliminary eligibility determination.
Flexible.

Answer format is flexible, however, multi-selection must be enabled.

Answer format is flexible as long as the consumer is able to enter as many hours as
there are in a week. If not an [Open text field], answer options may be altered for
compatibility with question wording.

When the parent is in the household, sometimes we derive the data element from the income
section if the parent works hourly.
Or, see item #19 on "Backend Responses for UI" tab.
coverageEndedIndicator

Member

boolean

In states with waiting periods for their CHIP programs, past enrollment
in other coverage within the last few months is a factor of eligibility for
CHIP.

1. coverageEndedReasonType

Member

1. enum
2. string

The consumer may qualify for one of the federal or state exceptions to This question must be asked to help determine CHIP eligibility in some states. This Program questions must be included at the end of the application after
the waiting period, which would enable the child to get CHIP right away question must appear if the applicant answers yes to the waiting period question applicant data is collected for preliminary program eligibility. This
described above on Item 243.
question must be asked before the preliminary QHP program questions
are asked.

Display the CHIP waiting period question IF [application state]’s StateCHIPWaitingPeriod > 0 AND
preliminaryCHIPStatus = Y AND pregnancyCategoryStatus <> Y

This question must be asked to help determine CHIP eligibility in some states.

This question must be included after the preliminary eligibility
determination is made and before the preliminary QHP program
questions are asked.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Flexible. This question must be clearly labeled as optional.

Answer format is flexible. Answer option wording could use "my" or "their" in place
of the parent or dependents name. All answer options must be present. If other is
selected, an open text field must display.

stateCHIPWaitingPeriod in the state/reference API will return a value of 0, 1, 2, or 3. If the value is
0, there is no waiting period and this question doesn't need to display. If the value is 1, 2, or 3 that
represents the number of months that should populate in the question.
244

Medicaid & CHIP program questions - CHIP
specific questions*

Phase 1, Phase 2, Phase 3

Why did [FNLNS]'s coverage end?

Did any of these people have coverage through a job that ended in
the last [waiting period] months? Selected name

Coverage wasn't affordable: Learn what coverage is considered not affordable
Select this option if this child's coverage ended because it wasn't affordable.
Coverage is considered not affordable if at least one of these applies:
The cost of the child's coverage was more than 5% of the household's income.
The cost of the household's coverage was more than 9.5% of the household's income.
The cost of the coverage for the parent makes the parent eligible for advance payment of the premium tax credit when
enrolling in a Marketplace plan.
If you select this option, the state may follow up with you for more information about the cost of this child's coverage.

[Radio buttons]
Required
Coverage wasn't affordable
[Parent FNLNS]'s employer no longer provided coverage to [Parent FNLNS] and
[parent FNLNS]'s dependents
[Parent FNLNS]'s employment status changed, and now [Parent FNLNS]'s children
aren't eligible for coverage through [Parent FNLNS ]'s employer
[Parent FNLNS]'s child has special health care needs that are not being met by
employer coverage
[Parent FNLNS]'s child lost coverage because of divorce or death of a parent
Other: [Open text field]

Optional

Consumer selected a name for "Did any of these people have coverage through a job that ended
in the last [waiting period] months?"

If user selects "Coverage wasn't affordable", set:
coverageEndedReasonType.INSURANCE_TOO_EXPENSIVE
If user selects "[Parent FNLNS]'s employer no longer provided coverage to [Parent FNLNS] and
[parent FNLNS]'s dependents", set:
coverageEndedReasonType.COMPANY_STOPPED_OFFERING_INSURANCE
If user selects "[Parent FNLNS]'s employment status changed, and now [Parent FNLNS]'s children
aren't eligible for coverage through [Parent FNLNS ]'s employer", set:
coverageEndedReasonType.PARENT_NO_LONGER_WORKS_FOR_THE_COMPANY
If user selects "[Parent FNLNS]'s child has special health care needs that are not being met by employer
coverage", set:
coverageEndedReasonType.MEDICAL_NEEDS_NOT_COVERED
If user selects "[Parent FNLNS]'s child lost coverage because of divorce or death of a parent", set:
coverageEndedReasonType.COMPANY_STOPPED_OFFERING_INSURANCE_TO_DEPENDENTS
If consumer selects "Other" set:
coverageEndedReasonType.Other

245

284

201

Medicaid & CHIP program questions - CHIP
specific questions

Medicaid & CHIP program questions - CHIP
specific questions

APTC program questions - Employer health
coverage detail*

Phase 3

Phase 3

Phase 3

Is [FNLNS] offered the [state of application] state
employee health benefit plan through a job or a family
member’s job?

N/A

Is [FNLNS] enrolled in the [state of application] state
employee health benefit plan through a job or family
member's job (like a parent)?

N/A

Which of [Name selected in Item #200]'s employers offer
[Name selected in Item #200] health coverage?

Help Drawer: Learn more about state employee health benefit plans
Select a person's name if they're offered state employee health benefit coverage, even if they're not currently enrolled.
Most people who work for the state or local government have the option to be covered through the state employee
health benefit plan. These workers can usually cover their spouses and children through the plan. People who work at
state universities may also be able to get this plan
Help Drawer: Learn more about state employee health benefit plans
Select a person's name if they're enrolled in state employee health benefit coverage.
Most people who work for the state or local government have the option to be covered through the state employee
health benefit plan. These workers can usually cover their spouses and children through the plan. People who work at
state universities may also be able to get this plan.

Will any of these people be offered health coverage through their
own job? Tell us about coverage offers that apply to them starting
[January 1st, [coverage year] if during OE and before 1/1 of
coverage year or first day of following month after coverage year
begins]. Name selected

Hint Text: If [Name selected in Item #200] can get health coverage through someone else’s job, we’ll ask about that
later.
Help Drawer: Learn more about which employers to select
Select or add [Name selected in Item #200]'s employers who offer them health coverage, even if:
-They aren't enrolled in coverage through that job
-They have an offer, but don't plan to enroll
-The employer's open enrollment period has ended

202

APTC program questions - Employer health
coverage detail*

Phase 3

Enter the name of the employer who offers this insurance.

Which of [Name selected in Item #200]'s employers offer [Name
selected in Item #200] health coverage? Another employer not
listed here

N/A

203

APTC program questions - Employer health
coverage detail*

Phase 3

Does [Employer Name] also offer coverage to any of these
people?

Will any of these people be offered health coverage through their
own job? Tell us about coverage offers that apply to them starting
[January 1st, [coverage year] if during OE and before 1/1 of
coverage year or first day of following month after coverage year
begins]. Name selected

Hint Text: Select everyone who's included in the offer of health coverage. If the offer is only for [Name selected in Item
#200], select "None of these people."

AND

[Radio buttons]
Yes
No

Required

Required

See Item #21 on the "Backend Responses for UI" tab.

stateHealthBenefitIndicator

Member

boolean

In some states, access to state employee health benefits is a factor of
eligibility for CHIP.

This question must be asked to help determine CHIP eligibility in some states.

Program questions must be included at the end of the application after
applicant data is collected for preliminary program eligibility. The flow of
the program questions section is flexible. It is a best practice to keep
Medicaid & CHIP program questions together.

Wording must be similar.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

The reason code used to determine whether to display this
question uses the state reference data before setting the status.
So there is no need for the requester to use state reference data
to display the question.

[Radio buttons]
Yes
No

Required

Required

Display the enrolled in state employee health benefits question IF (preliminaryCHIPStatus = Y OR
pregnancyIndicator = true) AND the application state doesn't block CHIP for state employees or
dependents AND any preliminary CHIP eligible applicants OR pregnant applicants attested to
being enrolled in employer-sponsored coverage, or retiree health benefits.

If user selects "Yes", set:
1. enrolledinHealthCoverageIndicator = false
2. stateHealthBenefitIndicator = true

Member

boolean

In some states, enrollment in state employee health benefits is not
treated as disqualifying factor of eligibility for CHIP the way that other
types of ESC would be.

This question must be asked to help determine CHIP eligibility in some states. In Program questions must be included at the end of the application after
states with the state option 02 this question must appear if applicants are
applicant data is collected for preliminary program eligibility. The flow of
potentially CHIP eligible based on the Update App SES call and such applicant has the program questions section is flexible, but this question can only
attested to current enrollment in Employer Sponsored Coverage.
appear after the current coverage question flow.

Wording must be similar.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

The reason code used to determine whether to display this
question uses the state reference data before setting the status.
So there is no need for the requester to use state reference data
to display the question.

For any name selected, set insuranceCoverage.offeredEmployeeCoverage to YES

Member

enum
boolean

This is asked because for applicants who are not enrolled in other
This question will appear if applicants are potentially APTC eligible based on the
qualifying coverage, having an offer of coverage from their employer Update App SES call.
can impact their APTC eligibility.

ChipForStateHealthBenefits in the state/reference API will return a value of 01, 02, or 03. If the
value is 02, applicants with access to State Health Benefits may be eligible for CHIP and this
question should display.
An applicant is requesting financial assistance AND is preliminarily APTC eligible AND does not have
coverage through Medicare, TRICARE, Peace Corps, VA Health Care Program, Employer
Sponsored Coverage, COBRA, Retiree health Benefits, or an individual coverage Health
Reimbursement Arrangement (HRA)

For any selected preliminarily APTC eligible applicant who does not have coverage through Employer
Sponsored Coverage, COBRA, or Retiree health Benefits, set escEnrolledIndicator to false

APTC program questions - Employer health
coverage detail*

Phase 3

Who can we contact about [employer name]'s health
coverage?

Which of [Name selected in Item #200]'s employer offers [Name
selected in Item #200] health coverage? Any value selected

Required

Required

An applicant is requesting financial assistance AND is preliminarily APTC eligible AND does not have
coverage through Medicare, TRICARE, Peace Corps, VA Health Care Program, Employer
Sponsored Coverage, COBRA, or Retiree health Benefits AND selected a name for "Will any of
these people be offered health coverage through their own job?"

1. employerSponsoredCoverageOffers.escOffer.employer.name
2. employerSponsoredCoverageOffers.escOffer.employer.employerPhoneNumber
3. Set employerSponsoredCoverageOffers.escOffer.primaryInsuredMemberIdentifier to the
member who attested to being offered coverage through their employer in Item #200

Member

1. string
2. string
3. string

Program questions must be included at the end of the application after
applicant data is collected for preliminary program eligibility. The flow of
the program questions section is flexible.

Flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Answer Fields
Employer name: [Open text field]

Required

Required

An applicant is requesting financial assistance AND is preliminarily APTC eligible AND does not have
coverage through Medicare, TRICARE, Peace Corps, VA Health Care Program, Employer
Sponsored Coverage, COBRA, or Retiree health Benefits AND selected a name for "Will any of
these people be offered health coverage through their own job?" AND selected "Another
employer not listed here" for "Which of [Name selected in Item #200]'s employer offers [Name
selected in Item #200] health coverage?"

1. employerSponsoredCoverageOffers.escOffer.employer.name
2. Set employerSponsoredCoverageOffers.escOffer.primaryInsuredMemberIdentifier to the
member who attested to being offered coverage through their employer in Item #200

Member

1. string
2. string

Program questions must be included at the end of the application after
applicant data is collected for preliminary program eligibility. The flow of
the program questions section is flexible.

Flexible.

Must be an open text field.

Required

Required

The member's name who was selected in Item #200 has at least one other member of their tax
household who is preliminarily APTC eligible AND who does not have coverage through Medicare,
TRICARE, Peace Corps, VA Health Care Program, Employer Sponsored Coverage, COBRA, or
Retiree health Benefits

1. employerSponsoredCoverageOffers.escOffer.employer.name
2. insuranceCoverage.offeredEmployeeCoverage to YES
3. Set employerSponsoredCoverageOffers.escOffer.primaryInsuredMemberIdentifier to the
member who attested to being offered coverage through their employer in Item #200

Member

1. string
2. string
3. string

This is asked because for applicants who are not enrolled in other
qualifying coverage, having an offer of coverage from the employer
of someone in their tax household can impact their APTC eligibility.

Must determine whether the employer-sponsored coverage offer is offered to
multiple members in a tax household to determine if affordability of the offer
should be calculated based on the lowest-cost family premium.

The flow of the ESC questions is flexible. This question could be asked
anytime after a consumer provides employer information.

Flexible

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Member

1. string
2. string
3. string
4. string
5. string
6. string
7a. string
7b. string
7c. string
7d. enum
7e. string
8. string

Needed for employer sampling and noticing.

Must provide applicants with an opportunity to enter employer contact
information. Employer phone number must be a required fields, while other
information such as address and EIN may be optional for the consumer. This
question will appear if applicants are potentially APTC eligible based on the
Update App SES call.

Employer contact information may be collected as part of the employer
coverage program questions or may be captured after a consumer has
indicated they have income from a job (Item 155). If this information
was collected earlier in the application, it may be pre-populated and
displayed back to the consumer.

Flexible.

Employer phone number is the minimum required field.

[Checkboxes, multi-selection]
Show a list of everyone in the tax household of the member who attested to being
offered coverage from their own employer in Item #200
Alert Text [If there's more than one health coverage offer from [Employer Name]]:
None of these people
You told us [Name selected in Item #200] & [household member name] both work at [Employer Name]. On this page, tel
us about [Name selected in Item #200]'s coverage offer only. If [household member name] has their own coverage offer
through [Employer Name] we'll ask about it later.

For anyone's name not selected in Item #200 or Item #203 (or "none of these is selected"), set
insuranceCoverage.offeredEmployeeCoverage to No
If none of the names selected in #200 and #203 are preliminarily APTC eligible applicants, discontinue
the questions.

We may contact this person or department for information about any health coverage offered.
Help Drawer: Learn more about whose information to add
If the employer gave you the contact information for the person at the job or a third party administrator that helps with
providing health benefits, add the contact information.
If the employer didn't give you this information, you can either contact them or leave these fields blank.

207

APTC program questions - Employer health
coverage detail*

Phase 3

Do the plans offered by [Employer name] meet the
minimum value standard?

N/A

Answer Fields
1. First Name: [Open text field]
2. Middle Name: [Open text field]
3. Last Name: [Open text field]
4. Suffix: [drop-down, single selection]: Jr., Sr., III, IV
5. Phone number: [Open text field] (xxx)-xxx-xxxx
6. Contact email address: [Open text field]
7a. Street address: (optional) [Open text field]
7b. Suite number: (optional) [Open text field]
7c. City: (optional) [Open text field]
7d. State: (optional) [Drop-down, single-selection] Display all states
7e. ZIP code: (optional) [Open text field]
8. Employer Identification Number (EIN): (optional): [Open text field]

Most job-based plans meet the minimum value standard.

[Radio buttons]
Yes
Help Drawer: Learn more about the minimum value standard
No
A health plan meets the minimum value standard if it's designed to pay at least 60% of the total cost of medical services for
a standard population, and if its benefits include substantial coverage of inpatient hospital and physician services.

1. Required
2. Required
3. Required
4. Required
5. Required
6. Required
7a. Required
7b. Required
7c. Required
7d. Required
7e. Required
8. Required

1. Optional
2. Optional
3. Optional
4. Optional
5. Required
6. Optional
7a. Optional
7b. Optional
7c. Optional
7d. Optional
7e. Optional
8. Optional

Selected a name for "Will any of these people be offered health coverage through their own job?" 1. employerSponsoredCoverageOffers.escOffer.employer.contact.firstName
AND selected any value for "Which of [Name selected in Item #200]'s employer offers [Name
2. employerSponsoredCoverageOffers.escOffer.employer.contact.middleName
selected in Item #200] health coverage?"
3. employerSponsoredCoverageOffers.escOffer.employer.contact.lastName
4. employerSponsoredCoverageOffers.escOffer.employer.contact.suffix
5. employerSponsoredCoverageOffers.escOffer.employer.contact.phoneNumber
6. employerSponsoredCoverageOffers.escOffer.employer.contact.email
7a. employerSponsoredCoverageOffers.escOffer.employer.streetName1
7b. employerSponsoredCoverageOffers.escOffer.employer.streetName2
7c. employerSponsoredCoverageOffers.escOffer.employer.cityName
7d. employerSponsoredCoverageOffers.escOffer.employer.stateCode
7e. employerSponsoredCoverageOffers.escOffer.employer.zipCode
8. employerSponsoredCoverageOffers.escOffer.employer.employerIdentificationNumber

Required

Required

Member
Consumer selected a name for "Will any of these people be offered health coverage through their If consumer selects "Yes", set:
own job?” or for “Does [Employer Name] also offer coverage to any of these people?” that is the 1. employerSponsoredCoverageOffers.escOffer.employerOffersMinValuePlan to true for applicant
selected in Item #200
name of an applicant who is requesting financial assistance AND is preliminarily APTC eligible AND
2. employerSponsoredCoverageOffers.escOffer.employerOffersFamilyMinValuePlanIndicator to true
does not have coverage through Medicare, TRICARE, Peace Corps, VA Health Care Program,
Employer Sponsored Coverage, COBRA, or Retiree health Benefits
for all members selected in Item #203

Print or download the Employer Coverage Tool (PDF). (https://marketplace.cms.gov/applications-and-forms/employercoverage-tool.pdf)

APTC program questions - Employer health
coverage detail*

Phase 3

Does any plan meet the minimum value standard?

Do the plans offered by [Employer name] meet the minimum value
standard? No

N/A

AND
The conditions in column J are met

First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer
Phone number: Must be an open text field
Contact email address: Must be an open text field
Street address: Must be an open text field
Suite number: Must be an open text field
City: Must be an open text field
State: Consumer must be able to select any state. DE entities must use a single
selection drop-down menu with all 50 states and U.S. territories. The DE entity
may provide state abbreviations or the full state name in the drop-down menu.
ZIP code: Must be an open text field
Employer Identification Number (EIN): Must be an open text field

enum

This question may only be asked for applicants who appear eligible for
Flexible.
APTC based on SES responses (aka Prelim APTC= true). Program questions
must be included at the end of the application after applicant data is
collected for preliminary program eligibility. The flow of the program
questions section is flexible. It is a best practice to keep APTC program
questions together.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Member

enum

Program questions must be included at the end of the application after
Flexible.
applicant data is collected for preliminary program eligibility. The flow of
the program questions section is flexible. It is a best practice to keep APTC
program questions together.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Member

1. number
2. enum

Determines the premium for an ESI offer, which is used in calculating
Must collect enough information to determine monthly cost of the minimum
Program questions must be included at the end of the application after
Flexible.
the offer's affordability. Only affordable offers prevent APTC eligibility. value plan. This question flow will appear if applicants are potentially APTC eligible applicant data is collected for preliminary program eligibility. The flow of
based on the Update App SES call.
the program questions section is flexible. It is a best practice to keep APTC
program questions together.

Amount: Must be an open text field
How often: answer format is flexible. Answer option wording is flexible, however,
all options must be present.

If consumer selects "No", and none of the members selected in Item #203 are preliminarily APTC
eligible and not enrolled in other qualifying coverage, set:
employerSponsoredCoverageOffers.escOffer.employerOffersMinValuePlan to false, and do not
display Item #303

If a person is offered affordable coverage that meets the minimum value standard, they won't be eligible for a premium
tax credit. For help determining if a plan meets the minimum value standard, look at the Summary of Benefits and
Coverage (SBC) from the employer, or ask them to fill out the [Employer Coverage Tool] (Link to
https://marketplace.cms.gov/applications-and-forms/employer-coverage-tool.pdf).

303

F

[Checkboxes, multi-selection]
Show a list of only the employers the applicant attested to working for in the
income section
Another employer not listed here

The conditions in column J are met

204

Program questions must be included at the end of the application after
applicant data is collected for preliminary program eligibility. The flow of
the program questions section is flexible.

If consumer selects "No", and selected a name of a preliminarily APTC applicant who is not enrolled in
other qualifying coverage for Item #203, display Item #303

[Radio buttons]
A plan for [member who attested to an offer in Item #200]
A plan for [list of all members in the tax household who attested to an offer in Item
#203]
None of the plans meet the minimum value standard

Required

Required

Selected a name for "Will any of these people be offered health coverage through their own job?" If consumer selects "A plan for [member who attested to an offer in Item #200]", set:
AND selected a name of a preliminarily APTC applicant who does not have coverage through
1. For member selected in Item #200, set
Medicare, TRICARE, Peace Corps, VA Health Care Program, Employer Sponsored Coverage,
employerSponsoredCoverageOffers.escOffer.employerOffersMinValuePlan to true
COBRA, or Retiree health Benefits for "Does [Employer Name] also offer coverage to any of these 2. For members selected in Item #203, set
people?"
employerSponsoredCoverageOffers.escOffer.employerOffersFamilyMinValuePlanIndicator to false
If consumer selects "A plan for [list of all members in the tax household who attested to an offer in Item
#203]", set:
1. For member selected in Item #200, set
employerSponsoredCoverageOffers.escOffer.employerOffersMinValuePlan to false
2. For members selected in Item #203, set
employerSponsoredCoverageOffers.escOffer.employerOffersFamilyMinValuePlanIndicator to true
If consumer selects "None of the plans meet the minimum value standard", set:
1. For member selected in Item #200, set
employerSponsoredCoverageOffers.escOffer.employerOffersMinValuePlan to false
2. For members selected in Item #203, set
employerSponsoredCoverageOffers.escOffer.employerOffersFamilyMinValuePlanIndicator to false

208

APTC program questions - Employer health
coverage detail*

Phase 3

How much would [Name selected in Item #200] pay for the Do the plans offered by [Employer name] meet the minimum value
lowest-cost health plan at [Employer name] just for
standard? Yes
themself?
OR

Hint Text: Only enter the amount [Name selected in Item #200] would pay. Don't include any amount paid by [Employer Answer Fields
Amount: [Open text field]
Name].
How often would [FNLNS] pay this amount? [Drop-down, single-selection]
Weekly, Biweekly, Twice a month, Monthly, Quarterly, Yearly

Required

Required

Selected a name of a preliminarily APTC applicant who does not have coverage through
Medicare, TRICARE, Peace Corps, VA Health Care Program, Employer Sponsored Coverage,
COBRA, or Retiree health Benefits for "Will any of these people be offered health coverage
through their own job?" AND selected "Yes" for "Do the plans offered by [Employer name] meet
the minimum value standard?" OR selected "No" for "Do the plans offered by [Employer name]
meet the minimum value standard?" and selected "A plan for [member who attested to an offer
in Item #200]" for "Does any plan meet the minimum value standard?"

Required

Required

Selected a name of a preliminarily APTC applicant who does not have coverage through
If consumer enters an amount and frequency, set:
Medicare, TRICARE, Peace Corps, VA Health Care Program, Employer Sponsored Coverage,
1. employerSponsoredCoverageOffers.escOffer.familyPlanPremiumAmount
COBRA, or Retiree health Benefits for "Does [Employer Name] also offer coverage to any of these 2. employerSponsoredCoverageOffers.escOffer.familyPlanPremiumFrequencyType
people?" AND selected "Yes" for "Do the plans offered by [Employer name] meet the minimum
value standard?" OR selected "No" for "Do the plans offered by [Employer name] meet the
minimum value standard?" and selected "A plan for [list of all members in the tax household who
attested to an offer in Item #203]" for "Does any plan meet the minimum value standard?"

Member

1. number
2. enum

Determines the premium for an ESI offer, which is used in calculating
the offer's affordability for the family. Only affordable offers prevent
APTC eligibility.

Must collect enough information to determine monthly cost of the minimum
Program questions must be included at the end of the application after
Flexible.
value plan. This question flow will appear if applicants are potentially APTC eligible applicant data is collected for preliminary program eligibility. The flow of
based on the Update App SES call.
the program questions section is flexible. It is a best practice to keep APTC
program questions together.

Amount: Must be an open text field
How often: answer format is flexible. Answer option wording is flexible, however,
all options must be present.

Answer Fields
1. Employer name: [Open text field]
2. Employer's address:
2a. Street address: (optional) [Open text field]
2b. Suite number: (optional) [Open text field]
2c. City: (optional) [Open text field]
2d. State: (optional) [Drop-down, single-selection] Display all states
2e. ZIP code: (optional) [Open text field]
3. Employer's phone number: [Open text field] (xxx)-xxx-xxxx
4. Employer Identification Number (EIN): (optional) [Open text field]

1. Required
2a. Required
2b. Required
2c. Required
2d. Required
2e. Required
3. Required
4. Required

1. Required
2a. Optional
2b. Optional
2c. Optional
2d. Optional
2e. Optional
3. Required
4. Optional

Consumer selected "Job" for income type and did not provide employer contact information OR
consumer is offered employer coverage and adds an employer that wasn’t added in the income
section of the application

1. employerSponsoredCoverageOffers.escOffer.employer.name
2a. employerSponsoredCoverageOffers.escOffer.employer.streetName1
2b. employerSponsoredCoverageOffers.escOffer.employer.streetName2
2c. employerSponsoredCoverageOffers.escOffer.employer.cityName
2d. employerSponsoredCoverageOffers.escOffer.employer.stateCode
2e. employerSponsoredCoverageOffers.escOffer.employer.zipCode
3. employerSponsoredCoverageOffers.escOffer.employer.employerPhoneNumber
4. employerSponsoredCoverageOffers.escOffer.employer.employerIdentificationNumber

Member

1. string
2a. string
2b. String
2c. String
2d. enum
2e. String
3. string
4. string

Allows applicants offered ESI to enter employer information not
previously entered.

Must provide applicants with an opportunity to enter employer information. For This may appear anytime after a consumer has entered income from a
APTC eligible applicants who add a job as an income source, employer phone
job. If the employer phone number is collected in the income section,
number must be a required field.
before the preliminary eligibility determination, it would be required of all
applicants for all jobs. If collected after the preliminary eligibility
determination, it would only be required for jobs added by APTC eligible
applicants. For all applicants, all fields other than employer name and
phone number must be optional.

[Checklist, multi-selection]
Show a list of all applicants who are preliminary eligible for APTC/QHP and did not
attest to being currently covered by an individual coverage HRA (Item 285)
None of these people

Required

Required

Consumer is requesting financial assistance AND consumer is preliminarily APTC eligible AND
consumer does not have an individual coverage HRA

If applicant name is selected, set:
1. insuranceCoverage.offeredIchraIndicator = true
2. insuranceCoverage.hraOffers.hraType = ICHRA

Member

1. boolean
2. array, enum
3. boolean

As of January 1, 2020 employers of all sizes can offer a new “Individual
Coverage Health Reimbursement Arrangement” (ICHRA) instead of
offering traditional group health plan coverage for their employees
(and any dependents, like a spouse).

Employer name: Must be an open text field
Employer's address: Must be an open text field
Street address: Must be an open text field
Suite number: Must be an open text field
City: Must be an open text field
State: Consumer must be able to select any state. DE entities must use a single
selection drop-down menu with all 50 states and U.S. territories. The DE entity
may provide state abbreviations or the full state name in the drop-down menu.
ZIP code: Must be an open text field
Employer's phone number: Must be an open text field
Employer Identification Number (EIN): Must be an open text field
Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Help Drawer: Learn more about entering premium amounts
Enter the regular amount the employee would have to pay for their health coverage (the "premium") if they enrolled.
(Do the plans offered by [Employer name] meet the minimum value
Enter the amount of the lowest-cost plan offered by the employer that would cover the employee only.
standard? No
AND
If the employer has wellness programs
Does any plan meet the minimum value standard? A plan for
Enter the premium this person would pay if they got the maximum discount for any tobacco cessation programs
[member who attested to an offer in Item #200])
(counseling to stop smoking), but no other programs.

If consumer enters an amount and frequency, set:
1. employerSponsoredCoverageOffers.escOffer.lcsopPremium
2. employerSponsoredCoverageOffers.escOffer.lcsopPremiumFrequencyType

If the employee is offered an HRA
If the employer offers an amount through a Health Reimbursement Arrangement (HRA), the employee can use this
amount to pay their premiums.
Subtract the self-only HRA amount from the self-only premium amount. Enter that amount here.
These amounts should be listed in a notice from the employer. But, if you don't have a notice or you're not sure what these
amounts are, ask the employer.

304

APTC program questions - Employer health
coverage detail*

Phase 3

How much would the lowest-cost health plan at [Employer
Name] that covers [list all members selected in Items #200
and #203 for this employer] cost?

Do the plans offered by [Employer name] meet the minimum value
standard? Yes
OR

Hint Text: Only enter the amount [Name selected in Item #200] would pay. Don't include any amount paid by [Employer Answer Fields
Amount: [Open text field]
Name].
How often would [FNLNS] pay this amount? [Drop-down, single-selection]
Help Drawer: Learn more about entering premium amounts
Weekly, Biweekly, Twice a month, Monthly, Quarterly, Yearly
Enter the regular amount the employee would have to pay for their health coverage (the "premium") if they enrolled.

(Do the plans offered by [Employer name] meet the minimum value
Enter the amount of the lowest-cost plan offered by the employer that would cover the employee plus the other people
standard? No
selected.
AND
Does any plan meet the minimum value standard? A plan for [list of
If the employer has wellness programs
all members in the tax household who attested to an offer in Item
Enter the premium this person would pay if they got the maximum discount for any tobacco cessation programs
#203])
(counseling to stop smoking), but no other programs.
If the employee is offered an HRA
If the employer offers an amount through a Health Reimbursement Arrangement (HRA), the employee can use this
amount to pay their premiums.
Subtract the self-only HRA amount from the self-only premium amount. Enter that amount here.

These amounts should be listed in a notice from the employer. But, if you don't have a notice or you're not sure what these
amounts are, ask the employer.

209

286

Income - Employer contact information

APTC program questions - HRA detail

Phase 1, Phase 2, Phase 3

Phase 3

Tell us more about [FNLNS]'s employer.

Have any of these people been offered an individual
coverage Health Reimbursement Arrangement (HRA) they
haven't yet accepted through their job, or through the job
of another person, like a spouse or parent?

N/A

Do any of these people currently get help paying for coverage
through an individual coverage Health Reimbursement
Arrangement (HRA) from their job or through the job of another
person, like a spouse or parent? Name not selected

N/A

Only select a person's name if the person will be able to use their individual coverage HRA on [60 days from current date].
Select all that apply.
Help Drawer: Learn more about "accepting" an offer
To "accept" an HRA offer, a person must tell the employer that they plan to use the HRA.
If an HRA is available through an employer, but a person hasn't yet told the employer that they want to sign up for it, they
aren't considered to be enrolled in an HRA.

(Display if no employer contact information has been provided.)

If applicant name is not selected, set:
3. insuranceCoverage.offeredIchraIndicator = false

This question should be asked even if the applicant attested to being enrolled in a
coverage option that disqualifies them for APTC (Medicare, Tricare, Veteran
Health Program, Peace Corps, Employer Sponsored Coverage, COBRA, or Retiree
Care)

An applicant's ICHRA offer can be determined to be either Affordable
or Unaffordable. When an applicant's ICHRA offer is determined to be
Affordable, the applicant being offered the ICHRA is not eligible for
APTC. In addition, when an applicant has already accepted an ICHRA
offer from an employer, they are considered to be currently covered
by the ICHRA, and are not eligible for APTC.

*If Item 287 is implemented in the UI, use the attestation in Item 287 to set the above indicators. If
Item 287 is not implemented in the UI, use the attestation in Item 286 to set the indicators.

In some cases, a person may be able change their mind about enrolling in an HRA they've signed up for, but hasn't started
yet. If interested, ask the employer if this is an option.

Flexible.

This question may only be asked for applicants who are potentially APTC
Flexible.
eligible based on the Update App SES call. Program questions must be
included at the end of the application after applicant data is collected for
preliminary program eligibility. The flow of the program questions section
is flexible. The UI could use this question to determine who to ask followup offers of ICHRA questions for or it could ask each APTC eligible
applicant individually if they are offered an ICHRA.

If you have questions about the HRA, check with the employer.
287

APTC program questions - HRA detail

Phase 3

On [date 60 days from current date or January 1 if applying
on November 1], will [FNLNS] be able to use this HRA?

Have any of these people been offered an individual coverage
Health Reimbursement Arrangement (HRA) they haven't yet
accepted through their job, or through the job of another person,
like a spouse or parent? Name Selected

N/A

[Radio buttons]
Yes
No

Optional

Required (if displayed)

Consumer is requesting financial assistance AND consumer is preliminarily APTC eligible AND
consumer does not have coverage through an individual coverage HRA AND selected a name for
"Have any of these people been offered an individual coverage Health Reimbursement
Arrangement (HRA) they haven't yet accepted through their job, or through the job of another
person, like a spouse or parent?"

If "yes", set:
1. insuranceCoverage.offeredIchraIndicator = true
2. insuranceCoverage.hraOffers.hraType = ICHRA

Member

1. boolean
2. array, enum
3. boolean

Member

1. boolean
2. boolean
3. string

If "no", set:
3. insuranceCoverage.offeredIchraIndicator = false
If "no" then requestors discontinue ICHRA questions for this offer.

288

APTC program questions - HRA detail

Phase 3

Which employers offer [FNLNS] an individual coverage
HRA?

If item 287 is implemented: Have any of these people been offered
an individual coverage Health Reimbursement Arrangement (HRA)
they haven't yet accepted through their job, or through the job of
another person, like a spouse or parent? Name Selected AND On
[date 60 days from current date or January 1 if applying on
November 1], will [FNLNS] be able to use this HRA? Yes
If item 287 is not implemented: Have any of these people been
offered an individual coverage Health Reimbursement Arrangement
(HRA) they haven't yet accepted through their job, or through the
job of another person, like a spouse or parent? Name Selected

Select all that apply.

[Checkboxes, multi-selection]
Where possible, prepopulate check box list of the employers provided in income
section
Another employer not listed here

Required

Required

Consumer is requesting financial assistance AND consumer is preliminarily APTC eligible AND
If the employer is known because the employer was added in the income section, then set
consumer does not have coverage through an ICHRA AND selected a name for "Have any of
primaryInsuredMemberIdentifier = memberId of that consumer.
these people been offered an individual coverage Health Reimbursement Arrangement (HRA)
they haven't yet accepted through their job, or through the job of another person, like a spouse or If an applicant selects an existing employer who employs someone in the applicant's Tax Household,
parent?" AND if Item 287 was displayed selected "Yes" for "On [date 60 days from current date or set:
January 1 if applying on November 1], will [FNLNS] be able to use this HRA?"
1. primaryInsuredMemberNotInTaxHhIndicator = false
If an applicant selects an existing employer who employs someone oustide the applicant's Tax
Household, set:
2. primaryInsuredMemberNotInTaxHhIndicator = true
If the applicant selects an existing employer who employs someone outside the applicant's Tax
Household, the requestors discontinue asking ICHRA questions for this offer.
If the applicant selects an existing employer, set:
3. insuranceCoverage.hraOffers.employer.name

Determines whether the applicant will be able to access their ICHRA
offer in 60 days from the current date, or by January 1 if the consumer
is applying on November 1. This is collected so that the system can
disregard ICHRA offers that will be inaccessible by 60 days from the
current date.

This question could be asked to determine whether an applicant's HRA
Wording must be similar.
offer will be accessible in the next 60 days or by January 1 if the consumer
is applying on November 1, and if the system should continue the ICHRA
questions for this offer. If the UI does not use this question, it should
include help text in Item 286 indicating that applicants should only attest
"yes" for ICHRAs that they'll be able to use 60 days from now, or by
January 1 if the consumer is applying on November 1.

Flexible.

Answer format is flexible.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Auditor Compliance
Conclusion**

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor
Comments**

Item #

Application Section
* indicates features of this question may be
updated in future documentation

Applicable EDE Phase**

Question**

Answers to Previous Questions**

Answer Options and Format**

Required/Optional to Display Question or
Corresponding Answer Fields to Collect
Information in Application UI**

289

APTC program questions - HRA detail

Phase 3

Tell us about this employer.

Which employer(s) offer [FNLNS] an ICHRA? Another employer not N/A
listed here

Answer Fields
Employer name: [Open text field]

Required

Required/Optional for Consumer to Provide
Answer to Send to SES**
*if optional, consumer must be able to
ith t
idi
i UI
ti
Required

290

APTC program questions - HRA detail

Phase 3

Who works for this employer?

Which employer(s) offer [FNLNS] an ICHRA? Another employer not N/A
listed here

[Drop-down, single-selection]
Display any tax household members
None of these people

Required

Required

Answer Fields
Start date: [YYYY-MM-DD]
End date: [YYYY-MM-DD]

Required

291

APTC program questions - HRA detail

Phase 3

Tell us about the ICHRA offered by [employer (FNLNS's
job)].

Which employer(s) offer [FNLNS] an ICHRA? Employer selected OR
Another employer not listed here

Informational Text**

Help Drawer: Where can I find this information?
Employers that offer individual coverage HRAs must send written notices that include the HRA starts and end dates.

Required

If you have questions about the HRA, check with the employer.

292

APTC program questions - HRA detail

Phase 3

What's the maximum self-only amount of reimbursement
offered by [employer (FNLNS's job)]?

Tell us about the ICHRA offered by [employer (FNLNS's job)] Start
date provided and the end date is more than 60 days from the
current date

Help Drawer: Where can I find this information?
Employers that offer individual coverage HRAs must send written notices that include the maximum self-only
reimbursement amount.
If you have questions about the HRA, like what this amount is, look at the employer's HRA notice or check with the
employer.

293

APTC program questions - HRA detail

Phase 3

Tell us how to contact [employer (person's job)].

N/A

We may contact this person or department for information about HRA offers.
Help Drawer: Learn more about whose information to add
If the employer gave you the contact information for the person at the job or a third party administrator that helps with
providing health benefits, add the contact information.
If the employer didn't give you this information, you can either contact them or leave these fields blank.

210

QHP/APTC Program Questions
APTC program questions - American
Indian/Alaska Native

Phase 3

If more than one applicant or non-applicant:
Which of these people are members of a federally
recognized tribe?

N/A

If one applicant or non-applicant:
Is [Name selected in item 146] a member of a federally
recognized tribe?

Help Drawer: Learn more about federally recognized tribes.
A federally recognized tribe is an Indian or Alaska Native tribe, band, nation, pueblo, village, or community that’s
acknowledged by the U.S. Department of the Interior as an Indian tribe.
Why we're asking this question
If this person is an American Indian or Alaska Native, a member of a federally recognized tribe, and enrolls in a
Marketplace plan, they may get extra savings and monthly Special Enrollment Periods.

Conditional Display Logic in the UI**

Data Element(s) Name

Data Element
Format

Member

string

Consumer is requesting financial assistance AND consumer is preliminarily APTC eligible AND
If an applicant selects a tax household member, set:
consumer does not have coverage through an ICHRA AND name was selected for "Have any of
1. primaryInsuredMemberNotInTaxHhIndicator = false
these people been offered an individual coverage Health Reimbursement Arrangement (HRA)
2. primaryInsureMemberIdentifier = memberId of selected Tax Household member
they haven't yet accepted through their job, or through the job of another person, like a spouse or
parent?" AND if Item 287 was displayed selected "Yes" for "On [date 60 days from current date or If an applicant selects "None of these people", set:
January 1 if applying on November 1], will [FNLNS] be able to use this HRA?" AND consumer
1. primaryInsuredMemberNotInTaxHhIndicator = true
selected "Another employer not listed here" for "Which employer(s) offer [FNLNS] an ICHRA?"
2. primaryInsuredMemberIdentifier = null
AND consumer provided employer name for "Tell us about [FNLNS]'s ICHRA offer(s)."
If "none of these people" is selected, then requestors discontinue ICHRA questions for this offer.

Member

1. boolean
2. string

Consumer is requesting financial assistance AND consumer is preliminarily APTC eligible AND
1. insuranceCoverage.hraOffers.startDate
consumer does not have coverage through an ICHRA AND name was selected for "Have any of
2. insuranceCoverage.hraOffers.endDate
these people been offered an individual coverage Health Reimbursement Arrangement (HRA)
they haven't yet accepted through their job, or through the job of another person, like a spouse or If the attested end date is less than 60 days from the current date, then requestors discontinue ICHRA
parent?" AND if Item 287 was displayed selected "Yes" for "On [date 60 days from current date or questions for this offer.
January 1 if applying on November 1], will [FNLNS] be able to use this HRA?" AND consumer
selected an existing employer or "Another employer not listed here" for "Which employer(s) offer
[FNLNS] an ICHRA?" AND consumer provided employer name for "Tell us about [FNLNS]'s ICHRA
offer(s)." AND a name was selected for "Who works for this employer?" AND the person who
works for the employer is in the applicant's tax household

Member

Policy**

Question/Informational Text Wording Requirements**

Answer Options and Format Requirements**

Flexible.

Must be an open text field. The UI must impose field-level validations to ensure
1. employer name is <= 256 characters in length
2. employer name does not contain characters that are not a-z OR A-Z OR space
OR diacritics OR special characters of ( _ . @ - ! " # $ % & ' ( ) * + / = ? ^ ` { } ~ : ; , [ ] )
3. employer name does not contain combination of two dots and a forward slash
..\

Must provide an opportunity to identify the employee with the coverage offer
that extends to the applicant. This question will appear if applicants are
potentially APTC eligible based on the Update App SES call. If it is known who
works for this employer, this question does not need to be asked.

Flexible.

Answer format is flexible. Answer options must include all household members
(applicants and non-applicants) and an option for none of these people.

Start dates are collected so that the system can determine on a
Must provide applicants with an opportunity to enter information for all ICHRA
versioned application whether the consumer is attesting to a new or an offers where the employed member is in the applicant's tax household.
existing ICHRA offer. In some cases, existing offers will not have
affordability recalculated because an affordability safe harbor applies.

Flexible.

Date: Flexible in the way the application collects the date. May collect date
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a date.
Start date: The UI must have a field level validation to only allow the consumer to
provide a start date up to 60 days from the current date or up to January 1 if
applying on November 1 (November 1 + 60 days = December 31), to prevent
consumers from providing dates that would cause a SES error.
End date: The UI must have a field level validation to only allow the consumer to
provide an end date after the attested start date to prevent consumers from
providing dates that would cause a SES error.

Determines who is the employee with the ICHRA offer to facilitate
employer sampling and noticing.
If the offer is not through someone in the applicant's tax HH, the offer
does not count as MEC and does not disqualify the applicant for APTC.

1. string
2. string

General Requirements**

Question Flow Requirements**

End dates are collected so that the system can disregard ICHRA offers
that will end in the next 60 days.
Start and end dates may be used to allow the consumer to attest to an
ICHRA amount for the duration of the ICHRA, rather then another
frequency (monthly, yearly, etc).

Answer Fields
Required
Amount: [Open text field]
How often would [FNLNS] get this amount? [Drop-down, single-selection] Weekly,
Biweekly, Twice a month, Monthly, Quarterly, Yearly, This is a pro-rated amount
for partial-year coverage.

Required

Consumer is requesting financial assistance AND consumer is preliminarily APTC eligible AND
1. insuranceCoverage.hraOffers.employeeSelfOnlyOfferAmount
consumer does not have coverage through an ICHRA AND name was selected for "Have any of
2. insuranceCoverage.hraOffers.employeeSelfOnlyOfferFrequencyType
these people been offered an individual coverage Health Reimbursement Arrangement (HRA)
they haven't yet accepted through their job, or through the job of another person, like a spouse or
parent?" AND if Item 287 was displayed selected "Yes" for "On [date 60 days from current date or
January 1 if applying on November 1], will [FNLNS] be able to use this HRA?" AND consumer
selected an existing employer or "Another employer not listed here" for "Which employer(s) offer
[FNLNS] an ICHRA?" AND consumer provided employer name for "Tell us about [FNLNS]'s ICHRA
offer(s)." AND a name was selected for "Who works for this employer?" AND a start date and end
date were provided for "Tell us about the ICHRA offered by [employer (FNLNS's job)]" AND the
end date is more than 60 days from the current date

Member

1. number
2. enum

Determines the amount given for an ICHRA offer, which is used in
calculating the offer's affordability. Only affordable offers prevent
APTC eligibility.

Must collect enough information to determine monthly amount given for the
ICHRA. This question flow will appear if applicants are potentially APTC eligible
based on the Update App SES call.

Flexible.

Amount: Must be an open text field. Must have UI validation that amount must
be greater than 0 and less than 1,000,000.
How often: answer format is flexible. Answer option wording is flexible, however,
all options must be present.

Answer Fields
1. Phone number: [Open text field] (xxx)-xxx-xxxx
2. Contact email address: [Open text field]
3. Employer Identification Number (EIN): (optional): [Open text field]
4. First Name: [Open text field]
5. Middle Name: [Open text field]
6. Last Name: [Open text field]
7. Suffix: [drop-down, single selection]: Jr., Sr., III, IV
8a. Street address: [Open text field]
8b. Suite number: [Open text field]
8c. City: [Open text field]
8d. State: [Drop-down, single-selection] Display all states
8e. ZIP code: [Open text field]

1. Required
2. Required
3. Required
4. Required
5. Required
6. Required
7. Required
8a. Required
8b. Required
8c.. Required
8d. Required
8e. Required

1. Required
2. Optional
3. Optional
4. Optional
5. Optional
6. Optional
7. Optional
8a. Optional
8b. Optional
8c. Optional
8d. Optional
8e. Optional

Consumer selected "Job" for income type and did not provide employer contact information OR
consumer is offered an ICHRA and the employed member is in the applicant's tax household and
the end date is more than 60 days from the current date

Member

1. string
2. string
3. string
4. string
5. string
6. string
7. string
8a. string
8b. string
8c. string
8d. enum
8e. string
8f. enum
8g. string
8h. string
8i. Enum

Allows applicants offered an ICHRA to enter employer information not
previously entered.

Must provide applicants with an opportunity to enter employer information. For Employer contact information may be collected as part of the employer
APTC eligible applicants who add a job as an income source, employer phone
coverage program questions or may be captured after a consumer has
number must be a required field.
indicated they have income from a job (Item 155). If this information
was collected earlier in the application, it may be pre-populated and
displayed back to the consumer. If the employer phone number is
collected in the income section, before the preliminary eligibility
determination, it would be required of all applicants for all jobs. If
collected after the preliminary eligibility determination, it would only be
required for jobs added by APTC eligible applicants. For all applicants, all
fields other than phone number must be optional.

Flexible.

Employer phone number is the minimum required field.

If more than one applicant or non-applicant name is selected:
[Checkboxes, multi-selection]
Display all applicants and non-applicants who attested yes to item 146
None of these people

Required

Required

Consumer is requesting coverage AND consumer name was selected for "Is American Indian or
personRecognizedTribeIndicator
Alaskan Native" AND a name was selected for "Which of these people are American Indians or
Alaskan Natives? (If more than one applicant) OR consumer attested to being an American Indian
or Alaskan Native (If one applicant)" AND consumer did not attest to being currently incarcerated
AND consumer is preliminarily eligible for QHP or APTC

boolean

Membership in a federally recognized tribe allows for SEP eligibility and
CSR eligibility.

QHP eligible applicants who indicate AI/AN status must have the opportunity to
attest to being a member of a federally recognized tribe. This question will
appear if applicants are potentially QHP eligible based on the Update App SES
call.

If one applicant or non-applicant name is selected:
[Radio buttons]
Yes
No

211

APTC program questions - American
Indian/Alaska Native

Phase 3

Where's [Name selected in item 210] tribe located?

If more than one applicant or non-applicant:
Which of these people are members of a federally recognized tribe?
Name selected

N/A

Answer Fields
1. Select a state: [Drop-down single selection] Display all states

Required

Required

APTC program questions - American
Indian/Alaska Native

Phase 3

Which federally recognized tribe does [Name selected in
item 211] belong to?

Where's [Name selected in item 210] tribe located? State selected

N/A

Answer Fields
1. Select tribe name: [Radio button] Display all tribe names from the selected
state*

Required

Required

294

QHP & APTC program questions - Special
Enrollment Periods

Phase 3

Have any of these people been offered an individual
coverage HRA or Qualified Small Employer Health
Reimbursement Arrangement (QSEHRA) with a start date
between [current date - 60 days] and [current date + 60
days]?

N/A

A person may have more than one health coverage offer.

Required

Required

If one applicant or non-applicant:
Is [Name selected in item 146] a member of a federally recognized
tribe? Yes

*See "Notes" column

[Checkboxes, multi-selection]
Display list of all QHP eligible individuals
None of these people

(Display if no employer contact information has been provided.)

1. insuranceCoverage.hraOffers.employer.employerPhoneNumber
2. insuranceCoverage.hraOffers.employer.contact.email
3. insuranceCoverage.hraOffers.employer.employerIdentificationNumber
4. insuranceCoverage.hraOffers.employer.contact.firstName
5. insuranceCoverage.hraOffers.employer.contact.middleName
6. insuranceCoverage.hraOffers.employer.contact.lastName
7. insuranceCoverage.hraOffers.employer.contact.suffix
8a. insuranceCoverage.hraOffers.employer.streetName1
8b. insuranceCoverage.hraOffers.employer.streetName2
8c. insuranceCoverage.hraOffers.employer.cityName
8d. insuranceCoverage.hraOffers.employer.stateCode
8e. insuranceCoverage.hraOffers.employer.zipCode
8f. insuranceCoverage.hraOffers.employer.plus4Code
8g. insuranceCoverage.hraOffers.employer.countryCode
8h. insuranceCoverage.hraOffers.employer.countyName
8i. insuranceCoverage.hraOffers.employer.countyFipsCode

Member

Consumer is requesting coverage AND consumer name was selected for "Is American Indian or
Not sent to SES-- Note, since this is not sent to SES, this field will not be available in Get App for preAlaskan Native" AND a name was selected for "Which of these people are American Indians or
population on subsequent app versions.
Alaskan Natives? (If more than one applicant) OR consumer attested to being an American Indian
or Alaskan Native (If one applicant)" AND consumer did not attest to being currently incarcerated
AND consumer is preliminarily eligible for QHP or APTC AND consumer name was selected for
"Which of these people are members of a federally recognized tribe?" OR consumer selected
"Yes" for "Is [FNLNS] a member of a federally recognized tribe?"
See Item #25 on the "Backend Responses for UI" tab
Consumer is requesting coverage AND consumer name was selected for "Is American Indian or
federallyRecognizedTribeName
Alaskan Native" AND a name was selected for "Which of these people are American Indians or
Alaskan Natives? (If more than one applicant) OR consumer attested to being an American Indian If consumer name, state, and tribe are selected, set:
or Alaskan Native (If one applicant)" AND consumer did not attest to being currently incarcerated personRecognizedTribeIndicator = True
AND consumer is preliminarily eligible for QHP or APTC AND consumer name was selected for
"Which of these people are members of a federally recognized tribe?" OR consumer selected
"Yes" for "Is [FNLNS] a federally recognized tribe?" AND a state was selected for "Where's
[FNLNS] tribe located?"
See Item #25 on the "Backend Responses for UI" tab
Consumer is requesting coverage AND is preliminarily QHP eligible

N/A

Member

string

Member

string

Member

N/A

See Item #26 on the "Backend Responses for UI" tab

- They’ve been offered an individual coverage HRA or QSEHRA, which provides reimbursement for certain health care
costs.
- At least one offer's start date is within the date range above.

Phone number: Must be an open text field
Contact email address: Must be an open text field
Employer Identification Number (EIN): Must be an open text field
First Name: Must be an open text field
Middle Name: Must be an open text field
Last Name: Must be an open text field
Suffix: The answer format (i.e., toggle button, drop-down, etc.) for the suffix is
flexible as long as all answer options are presented to the consumer
Street address: Must be an open text field
Suite number: Must be an open text field
City: Must be an open text field
State: Consumer must be able to select any state. DE entities must use a single
selection drop-down menu with all 50 states and U.S. territories. The DE entity
may provide state abbreviations or the full state name in the drop-down menu.
ZIP code: Must be an open text field

This may be asked in conjunction with the AI/AN status question prior to
Must use same question wording.
the preliminary eligibility determination for all applicants, or may asked
later just for QHP eligible applicants. It is recommended to ask it later, just
for QHP eligible applicants, so that it is asked of fewer people.

This may be asked in conjunction with the AI/AN status question prior to
the preliminary eligibility determination, or may asked later just for QHP
eligible applicants. It is recommended to ask it later, just for QHP eligible
applicants, so that it is asked of fewer people.

As of January 1, 2020 employers of all sizes can offer a new “individual
coverage health reimbursement arrangement” (sometimes referred
to as an “ICHRA") instead of offering traditional group health plan
coverage for their employees (and any dependents or a spouse).

The application must ask SEP questions during Open Enrollment as well as during
the rest of the year.

Additionally, beginning on January 1, 2017, the 21st Century Cures Act
permitted small employers who don't offer group health plan coverage
to any of their employees to provide a qualified small employer health
reimbursement arrangement (QSEHRA) to their eligible employees to
help employees pay for medical care expenses.

Select all that apply.
Help Drawer: Learn more about HRA coverage types.
An HRA is type of group health plan that lets an employer reimburse a person for qualifying medical expenses, including
their monthly health plan premium, in some cases.

Must use same answer options.

Flexible.

Answer format should display all 50 states.

Flexible.

Answer format is flexible. This field could be an open text field or the UI could
The link below should be used to populate tribe names.
display a dropdown menu of the tribe names. If tribe names are displayed to the
http://www.ncsl.org/research/state-tribal-institute/list-ofconsumer, all tribe options must display. If the UI displays tribe names to the
consumer, the display format is flexible. For example, the tribes do not have to be federal-and-state-recognized-tribes.aspx
organized according to state and could be listed out alphabetically.

All QHP-eligible consumer names must display. Answer format is flexible;
however, multi-selection must be enabled.

May be asked of QHP-eligible applicants earlier, when asking questions
about current enrollment in other coverage. For non-FA applications, the
question placement is flexible. For FA applications, the question must be
asked after preliminary eligibility results so that it can be asked of QHP
eligible applicants.

Under certain circumstances, employees and their dependents who
are newly offered an ICHRA or provided a QSEHRA are eligible for a
Special Enrollment Period (SEP).

If the employer is offering this person an HRA, they should have received a notice with information about when it starts. If
a person has an HRA start date within 60 days before or after today, select their name, even if they're offered the HRA
through another person, like a spouse or parent.
If you have questions about the HRA, like what type it is or when it starts, look at the employer's HRA notice or check with
the employer.
295

QHP & APTC program questions - Special
Enrollment Periods

Phase 3

Which type of HRA coverage has [FNLNS] been offered?

Have any of these people been offered an individual coverage HRA
or Qualified Small Employer Health Reimbursement Arrangement
(QSEHRA) with a start date between [current date - 60 days] and
[current date + 60 days]? Name selected

Select all that apply.
Help Drawer: Learn more about HRA types.
If you're offered or provided an HRA, it could be an individual coverage HRA or a QSEHRA.

[Checkboxes, multi-selection]
Individual coverage HRA
Qualified Small Employer HRA (QSEHRA)

Required

Required

Consumer is requesting coverage AND is preliminarily QHP eligible AND selected a name for "Have If "ICHRA" is selected, set:
any of these people been offered an individual coverage HRA or Qualified Small Employer Health insuranceCoverage.hraOffers.hraType = ICHRA
Reimbursement Arrangement (QSEHRA) with a start date between [current date - 60 days] and
[current date + 60 days]?"
If "QSEHRA" is selected, set:
insuranceCoverage.hraOffers.hraType = QSEHRA

Member

array, enum

The application must ask SEP questions during Open Enrollment as well as during
the rest of the year. The applicant must be able to select either Individual
coverage HRA, or Qualified Small Employer HRA (QSEHRA), or both.

[Open text field]: YYYY-MM-DD

Required

Required

Consumer is requesting coverage AND is preliminarily QHP eligible AND selected a name for "Have insuranceCoverage.hraOffers.startDate
any of these people been offered an individual coverage HRA or Qualified Small Employer Health
Reimbursement Arrangement (QSEHRA) with a start date between [current date - 60 days] and
[current date + 60 days]?" AND selected "individual coverage HRA" or "QSEHRA" for "Which type
of HRA has [FNLNS] been offered?"

Member

string

The application must ask SEP questions during Open Enrollment as well as during
the rest of the year. Follow-up questions for certain SEP types are critical for SEP
eligibility, such as questions about notice and start dates and current HRA usage.
This question flow will appear if applicants are potentially QHP eligible based on
the Update App SES call.

[Open text field]: YYYY-MM-DD

Required

Required

Consumer is requesting coverage AND is preliminarily QHP eligible AND selected a name for "Have insuranceCoverage.hraOffers.noticeDate
any of these people been offered an individual coverage HRA or Qualified Small Employer Health
Reimbursement Arrangement (QSEHRA) with a start date between [current date - 60 days] and
[current date + 60 days]?" AND selected "individual coverage HRA" or "QSEHRA" for "Which type
of HRA has [FNLNS] been offered?"

Member

string

If you're offered an individual coverage HRA, the notice from your employer should state that you're not being offered a
qualified small employer HRA (or QSEHRA).

Individual coverage HRA and Qualified Small Employer HRA (QSEHRA) must
display. Answer format is flexible; however, multi-selection must be enabled.

If you're provided a QSEHRA, the notice from your employer might call it a QSEHRA, or might call it something else.
QSEHRAs can only be provided by employers with fewer than 50 full-time employees.
If you have questions about the HRA, like what type it is, look at the employer's HRA notice or check with the employer.
If no one is offered an individual coverage HRA or provided a QSEHRA, select "None of these people."

296

QHP & APTC program questions - Special
Enrollment Periods

Phase 3

Enter the date [FNLNS]'s [individual coverage
HRA/QSEHRA] will start.

Which type of HRA coverage has [FNLNS] been offered? Individual
coverage HRA
OR
Qualified Small Employer HRA (QSEHRA)

To find the dates needed below, look at the notice [FNLNS] got from the employer offering the [individual coverage
HRA/QSEHRA].
Help Drawer: Learn more about HRA notices.
If an employer is offering or providing an HRA, they generally must provide a written notice at least 90 days before the
start of the HRA’s plan year.

Flexible.

Date: Flexible in the way the application collects the date. May collect date
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a date. The UI must have a field level validation
to only allow the consumer to provide a start date within the last 60 days through
the next 60 days to prevent consumers from providing dates that would cause a
SES error.

Flexible.

Date: Flexible in the way the application collects the date. May collect date
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a date. The UI must have a field level validation
to only allow the consumer to provide a notice date that is on or prior to the
current date to prevent consumers from providing dates that would cause a SES
error.

But, if a person becomes eligible during the HRA plan year or during the 90 days before the plan year (like if they're a new
employee), they'll get their notice no later than the first day their HRA coverage can start.
When they get this notice, they should keep it with other important documents. It includes information they might need
to enroll in coverage.
If you have questions about the HRA, like when it starts, look at the employer's HRA notice or check with the employer.
297

QHP & APTC program questions - Special
Enrollment Periods

Phase 3

Enter the notice date on [FNLNS]'s [individual coverage
HRA / QSEHRA] offer.

Which type of HRA coverage has [FNLNS] been offered? Individual
coverage HRA
OR
Qualified Small Employer HRA (QSEHRA)

To find the dates needed below, look at the notice [FNLNS] got from the employer offering the [individual coverage
HRA/QSEHRA].
Help Drawer: Learn more about HRA notices.
If an employer is offering or providing an HRA, they generally must provide a written notice at least 90 days before the
start of the HRA’s plan year.
But, if a person becomes eligible during the HRA plan year or during the 90 days before the plan year (like if they're a new
employee), they'll get their notice no later than the first day their HRA coverage can start.
When they get this notice, they should keep it with other important documents. It includes information they might need
to enroll in coverage.
If you have questions about the HRA, like when it starts, look at the employer's HRA notice or check with the employer.

298

QHP & APTC program questions - Special
Enrollment Periods

Phase 3

Is [FNLNS] currently enrolled in an [individual coverage HRA Which type of HRA coverage has [FNLNS] been offered? Individual
/ QSEHRA] through this employer?
coverage HRA
OR
Qualified Small Employer HRA (QSEHRA)

N/A

[Radio buttons]
Yes
No

Required

Required

Consumer is requesting coverage AND is preliminarily QHP eligible AND selected a name for "Have If "Yes", set:
any of these people been offered an individual coverage HRA or Qualified Small Employer Health enrolledInOfferFromSameEmployerIndicator = true
Reimbursement Arrangement (QSEHRA) with a start date between [current date - 60 days] and
[current date + 60 days]?" AND selected "individual coverage HRA" or "QSEHRA" for "Which type If "No", set:
of HRA has [FNLNS] been offered?"
enrolledInOfferFromSameEmployerIndicator = false

Member

boolean

299

QHP & APTC program questions - Special
Enrollment Periods

Phase 3

Will [FNLNS] stay enrolled in the current [individual
coverage HRA / QSEHRA] until the new one begins on
[attested start date]?

Is [FNLNS] currently enrolled in an [individual coverage HRA /
QSEHRA] through this employer? Yes

N/A

[Radio buttons]
Yes
No

Required

Required

Member

boolean

213

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

Did any of these people lose qualifying health coverage
between [60 days prior to current date] - [current date]?
Learn more about qualifying health coverage

N/A

Help Drawer: Learn more about recent loss of coverage
Select the name of each person whose qualifying health coverage ended between [60 days prior to current date] [current date]. Select their name if they lost coverage or chose to drop it.

Consumer is requesting coverage AND is preliminarily QHP eligible AND selected a name for "Have If "Yes", set:
any of these people been offered an individual coverage HRA or Qualified Small Employer Health enrolledInOfferFromSameEmployerUntilStartDateIndicator = true
Reimbursement Arrangement (QSEHRA) with a start date between [current date - 60 days] and
[current date + 60 days]?" AND selected "individual coverage HRA" or "QSEHRA" for "Which type If "No", set:
of HRA has [FNLNS] been offered?"AND selected "Yes" for "Is [FNLNS] currently enrolled in an
enrolledInOfferFromSameEmployerUntilStartDateIndicator = false
[individual coverage HRA/QSEHRA] through this employer?"

N/A

A person may have lost coverage for many reasons, like losing or leaving a job that offered health coverage, turning 26
and no longer being covered under a parent’s plan, or the end of COBRA or Medicaid coverage (including the loss of
Medicaid coverage for a someone required to meet a new “spend down”).

The application must ask about an applicant's current ICHRA/QSEHRA usage.
This information will be used to determine if the HRA being offered is a new HRA
or a renewal of an existing HRA, and it factors in to whether or not an applicant
qualifies for a SEP based on their HRA offer.

These questions are necessary for SEP eligibility. They must be asked
during Open Enrollment as well as during the rest of the year. The
trigger event generally must be within the last 60 days, or for some
SEPs in the next 60 days, per 45 CFR 155.420.

Wording must be similar.

Answer format is flexible.

Wording must be similar.

Answer format is flexible.

May be asked of QHP or APTC eligible applicants earlier, when asking
Wording must be similar. The application may provide a specific date in
questions about current enrollment in other coverage. For non-FA
place of 60 days. The application may ask as a stand-alone question or
applications, the question placement is flexible. For FA applications, the
may ask it as part of question asking about other life changes. The
question must be asked after preliminary eligibility results so that it can be application may ask once per application or ask each QHP- or APTCasked of QHP or APTC eligible applicants.
eligible applicant separately.

We’re asking this question to see if anyone on your application is eligible for a Special Enrollment Period allowing them to
enroll outside the yearly Open Enrollment Period.

All QHP and APTC eligible consumer names must display. Answer format is flexible;
however, multi-selection must be enabled.
Starting on May 31, 2023 and continuing through July 31, 2024, if an applicant
attested to having Medicaid or CHIP that ended on March 31, 2023 through
yesterday, the application must not display the applicant's name. Partners may
include on-screen messaging to assure agents-brokers or consumers that their
qualifying life event was already recorded. For example, "[FNLNS] already told us
they recently lost Medicaid/CHIP."

If they lost job-based coverage
Select a person’s name if they lost coverage between [60 days prior to current date] - [current date] through their (or a
household member’s) employer, including if:
- The employer stopped offering coverage.
- They left a job (no matter why they left).
- Their work hours were reduced, causing them to lose coverage.
- The job-based plan stopped offering qualifying health coverage, and now they're applying for savings to pay for a
Marketplace plan.
- The person's income decreased, they couldn't pay their premiums for their job-based plan, they dropped or opted-out of
the coverage, and now they're applying for savings to pay for a Marketplace plan.
- They lost job-based coverage because their employer didn’t pay premiums.
- The job-based health plan was a non-calendar year plan, and they chose not to renew it when it ended. This qualifies
them for a Special Enrollment Period, but not a premium tax credit.
If they lost COBRA coverage
Select a person’s name if they lost COBRA coverage between [60 days prior to current date] - [current date] because:
- The COBRA coverage ran out.
- The person now has to pay the full cost for their COBRA coverage, because the former employer stopped contributing to
the COBRA coverage, or because a government subsidy for COBRA payments, like COBRA premium assistance, ended.
The date of coverage loss is the last day that they’ll have COBRA coverage that’s paid for with an employer contribution or
government subsidy.
- Their household income decreased, which caused their COBRA coverage to end, and they’re now applying for savings to
pay for a Marketplace plan.
[Learn more about COBRA and Marketplace coverage](Link to: HealthCare.gov/unemployed/cobra-coverage)
If they lost Marketplace or other health plan coverage they bought themselves
Select a person’s name if they lost health coverage they bought themselves, through the Marketplace or elsewhere,
between [60 days prior to current date] - [current date], including if:
- The individual or household plan was discontinued (no longer exists).
- The health plan coverage year ended in the middle of the calendar year.
-Their household income decreased, which caused their health plan coverage to end, and they’re now applying for
savings to pay for a Marketplace plan.
Don’t select a person’s name if they lost coverage because they didn’t submit documents for the Marketplace to
confirm their application information.
If they lost coverage because they turned 26
Select the name of any child on a job-based Marketplace plan who aged off of the plan between [60 days prior to current
date] - [current date].
- Job-based plans usually end coverage the month the child turns 26. But check with the employer or plan. Some states
and plans have different rules.
- If the child has coverage through a Marketplace plan, the child can remain covered through December 31 of the year
the child turns 26 (or the age permitted in your state).
If they lost Medicaid or CHIP coverage
Select a person’s name if they lost coverage throug

214

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

When did [FNLNS] lose coverage?

Did any of these people lose qualifying health coverage between [60 N/A
days prior to current date] - [current date]? Name selected

[Open text field]: YYYY-MM-DD

Required

Required

If an applicant attested to having Medicaid or CHIP that ended in the last 60 days
(Item 138 and 140) the date they attested to in Item 140
(changeInCircumstance changeDate) may be pre-populated
[Open text field]

Consumer is requesting coverage AND is preliminarily QHP or APTC eligible AND selected a name
for "Did any of these people lose qualifying health coverage between [60 days prior to current
date] - [current date]?"

Required

Optional

Optional

Optional

Consumer is requesting coverage AND is preliminarily QHP or APTC eligible AND selected a name
for "Did any of these people lose qualifying health coverage between [60 days prior to current
date] [current date]?"
Consumer is requesting coverage AND is preliminarily QHP or APTC eligible AND selected multiple
names for "Did any of these people lose qualifying health coverage between [60 days prior to
current date] - [current date]?" AND provided information for one consumer

Optional

Optional

Consumer is requesting coverage AND is preliminarily QHP or APTC eligible AND selected multiple changeInCircumstance.LOSS_OF_MEC.changeDate
names for "Did any of these people lose qualifying health coverage between [60 days prior to
current date] - [current date]?" AND provided information for one consumer AND name selected
for "Was anyone else on this plan?"

Member

string

Required

Required

Consumer is requesting coverage AND is preliminarily QHP or APTC eligible

Member

N/A

215

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

Enter the name of the plan. Optional

Did any of these people lose qualifying health coverage between [60 N/A
days prior to current date] - [current date]? Name selected

216

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

Was anyone else on this plan?

Did any of these people lose qualifying health coverage between [60 N/A
days prior to current date] - [current date]? Additional names
selected

217

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

Did any of these people also lose coverage on [date
provided for loss of coverage]?

Was anyone else on this plan? Name selected

N/A

218

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

Will any of these people lose qualifying health coverage
between [current date] - [60 days after current date]?

N/A

Help Drawer: Learn more about upcoming loss of coverage.
[Checkboxes, multi-selection]
Select the name of each person whose qualifying health coverage is going to end between [current date] – [60 days after Display list of all QHP and APTC eligible individuals
current date]. Select their name if they’re losing coverage or choosing to drop it.
None of these people
A person may lose health coverage for many reasons, including leaving a job that offers health coverage, or the end of
COBRA, school coverage, or Medicaid (including the loss of Medicaid coverage for someone required to meet a new
“spend down”).

[Checkboxes, multi-selection]
Display list of all other QHP and APTC eligible individuals who attested to loss of
coverage
None of these people
[Checkboxes, multi-selection]
Display list of all other QHP and APTC eligible individuals who attested to having the
same plan
None of these people

Notes

See Item #25 on the "Backend Responses for UI" tab

270

Only choose "Yes" if both of these apply:

Attestation Level

Consumer is requesting financial assistance AND consumer is preliminarily APTC eligible AND
insuranceCoverage.hraOffer.employer.name
consumer does not have coverage through an ICHRA AND name was selected for "Have any of
these people been offered an individual coverage Health Reimbursement Arrangement (HRA)
they haven't yet accepted through their job, or through the job of another person, like a spouse or
parent?" AND if Item 287 was displayed selected "Yes" for "On [date 60 days from current date or
January 1 if applying on November 1], will [FNLNS] be able to use this HRA?" AND consumer
selected "Another employer not listed here" for "Which employer(s) offer [FNLNS] an ICHRA?"

changeInCircumstance.LOSS_OF_MEC.changeDate

Member

string

These questions are necessary for SEP eligibility. They must be asked
during Open Enrollment as well as during the rest of the year. The
trigger event generally must be within the last 60 days, or for some
SEPs in the next 60 days, per 45 CFR 155.420.

Flexible.

changeInCircumstance.LOSS_OF_MEC.lossMecIssuerName

Member

string

Flexible.

changeInCircumstance.LOSS_OF_MEC.lossMecIssuerName

Member

string

Flexible.
These questions could be included to collect information about the plan
type and date of loss of coverage if multiple applicants attest to loss of
coverage to reduce data entry. If not included in the UI, the application
must display the questions to collect the date of loss of coverage and plan
name to each consumer who attests to a loss of coverage.
Flexible.

N/A

See Item #26 on the "Backend Responses for UI" tab

If an applicant attested to having Medicaid or CHIP that will end in the next 60 days
(changeInCircumstance set to FUTURE_LOSS_OF_MEC in Item 138 and 140), the
UI may pre-select applicant's name.

Wording must be similar. The application may provide a specific date in
May be asked of QHP or APTC eligible applicants earlier, when asking
place of 60 days. The application may ask as a stand-alone question or
questions about current enrollment in other coverage. For non-FA
may ask it as part of question asking about other life changes. The
applications, the question placement is flexible. For FA applications, the
question must be asked after preliminary eligibility results so that it can be application may ask once per application or ask each QHP- or APTCasked of QHP or APTC eligible applicants.
eligible applicant separately.

Date: Flexible in the way the application collects the date. May collect date
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a date. The UI must have a field level validation
to only allow the consumer to provide a date within the last 60 days to prevent
consumers from providing dates that would cause a SES error
Answer format must be open text field.
Answer format is flexible. Answer options may be altered for compatibility with
question wording.
Answer format is flexible. Answer options may be altered for compatibility with
question wording.

All QHP and APTC eligible consumer names must display. Answer format is flexible;
however, multi-selection must be enabled.

We’re asking this question to see if anyone on your application is eligible for a Special Enrollment Period allowing them to
enroll outside the yearly Open Enrollment Period.
If you select a name, you’ll be asked for the name of this person’s health coverage. Enter the name, like “Medicaid” or
the name of the insurance company, in the box.
Don’t select a person’s name if any of these apply:
- Their coverage will stop at the end of the plan year, December 31.
- Their Medicare coverage will start in the next 60 days.
- They’re newly required to pay Medicare Part A premiums and they drop Medicare.
If they’ll lose job-based coverage
Select a person’s name if they’ll lose coverage between [current date] - [60 days after current date] through their (or a
household member’s employer), including if:
- The employer stops offering coverage.
- They’re losing coverage because they're leaving a job (no matter why they leave).
- Their work hours are reduced, causing them to lose job-based coverage.
- The job-based plan stops offering qualifying health coverage, and now they're applying for savings to pay for a
Marketplace plan.
- The person's income decreased, they can't pay their premiums for their job-based plan, they'll drop or opt-out of
coverage, and now they're applying for savings to pay for a Marketplace plan.
- They’re losing job-based coverage because their employer didn’t pay premiums.
- The job-based health plan is a non-calendar year plan, and they choose not to renew it when it ends. This qualifies them
for a Special Enrollment Period, but not a premium tax credit.
If they’ll lose COBRA coverage
Select a person’s name if they’ll lose COBRA coverage between [current date] - [60 days after current date] because:
- The COBRA coverage runs out.
- The person now has to pay the full cost for their COBRA coverage, because the former employer stopped contributing to
the COBRA coverage, or because a government subsidy for COBRA payments, like COBRA premium assistance, ended.
The date of coverage loss is the last day that they’ll have COBRA coverage that’s paid for with an employer contribution or
government subsidy.
- Their household income decreases, which causes their COBRA coverage to end, and now they're applying for savings to
pay for a Marketplace plan.
[Learn more about COBRA and Marketplace coverage](Link to: HealthCare.gov/unemployed/cobra-coverage)
If they’ll lose Marketplace or other health plan coverage they buy themselves
Select a person’s name if they’ll lose health coverage they buy themselves, through the Marketplace or elsewhere,
between [current date] - [60 days after current date], including if:
- The individual or household plan will be discontinued (no longer exist).
- The health plan coverage year is ending in the middle of the calendar year.
- Their household income decreases, which causes their health plan coverage to end, and now they're applying for savings
to pay for a Marketplace plan.
Don’t select a person’s name if they’ll lose coverage because they didn’t submit documents for the Marketplace to
confirm their application information.
If they’ll lose coverage because they’ll turn 26
Select the name of any child on a job-based Marketplace plan who will age off of the plan between [current date] - [60
days after current date].

219

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

When will [FNLNS]'s coverage end?

Will any of these people lose qualifying health coverage between
[current date] - [60 days after current date]? Name selected

N/A

[Open text field]: YYYY-MM-DD

Required

Required

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

What was the name of [FNLNS]'s health coverage?
(optional)

Will any of these people lose qualifying health coverage between
[current date] - [60 days after current date]? Name selected

N/A

If an applicant attested to having Medicaid or CHIP that will end in the next 60 days
(Item 138 and 140) the date they attested to in Item 140
(changeInCircumstance changeDate) may be pre populated
[Open text field]
Required

Consumer is requesting coverage AND is preliminarily QHP or APTC eligible AND selected a name
for "Will any of these people lose qualifying health coverage between [current date] - [60 days
after current date]?"

220

Optional

221

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

Were any of these people on this plan?

Will any of these people lose qualifying health coverage between
[current date] - [60 days after current date]? Additional names
selected

N/A

[Checkboxes, multi-selection]
Display list of all other QHP and APTC eligible individuals who attested to future loss
of coverage
None of these people

Optional

Optional

222

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

Will any of these people lose coverage on [date provided]
too?

Were any of these people on this plan? Name selected

N/A

[Checkboxes, multi-selection]
Display list of all other QHP and APTC eligible individuals who attested to having the
same plan
None of these people

Optional

Optional

Consumer is requesting coverage AND is preliminarily QHP or APTC eligible AND selected a name
for "Will any of these people lose qualifying health coverage between [current date] - [60 days
after current date]?"
Consumer is requesting coverage AND is preliminarily QHP or APTC eligible AND selected a name
for "Will any of these people lose qualifying health coverage between [current date] - [60 days
after current date]?" AND provided information for one consumer AND selected more than one
name for "Will any of these people lose qualifying health coverage between [current date] - [60
days after current date]?"
Consumer is requesting coverage AND is preliminarily QHP or APTC eligible AND selected a name
for "Will any of these people lose qualifying health coverage between [current date] - [60 days
after current date]?" AND provided information for one consumer AND selected more than one
name for "Will any of these people lose qualifying health coverage between [current date] - [60
days after current date]?" AND selected a name for "Were any of these people on this plan?"

changeInCircumstance.FUTURE_LOSS_OF_MEC.changeDate

Member

string

Flexible.

changeInCircumstance.FUTURE_LOSS_OF_MEC.lossMecIssuerName

Member

string

Flexible.

changeInCircumstance.FUTURE_LOSS_OF_MEC.lossMecIssuerName

Member

string

changeInCircumstance.FUTURE_LOSS_OF_MEC.changeDate

Member

string

Flexible.
These questions could be included to collect information about the plan
type and date of loss of coverage if multiple applicants attest to future
loss of coverage to reduce data entry. If not included in the UI, the
application must display the questions to collect the date of loss of
coverage and plan name to each consumer who attests to a future loss of
coverage.
Flexible.

Date: Flexible in the way the application collects the date. May collect date
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a date. The UI must have a field level validation
to only allow the consumer to provide a date within the next 60 days to prevent
consumers from providing dates that would cause a SES error
Answer format must be open text field.
Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Auditor Compliance
Conclusion**

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor
Comments**

Item #

Application Section
* indicates features of this question may be
updated in future documentation

Applicable EDE Phase**

Question**

Answers to Previous Questions**

Informational Text**

Answer Options and Format**

Required/Optional to Display Question or
Corresponding Answer Fields to Collect
Information in Application UI**

QHP & APTC program questions - Special
Enrollment Periods

Phase 1

Has [FNLNS] had any of these changes since [date 60 days
from current date]?

N/A

N/A

Required

224

QHP & APTC program questions - Special
Enrollment Periods

Phase 2, Phase 3

Has [FNLNS] had any of these changes since [date 60 days
from current date]?

N/A

N/A

225

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

When did [FNLNS] (include spouses name if added to the
application) get married?

Has [FNLNS] had any of these changes since [date 60 days from
current date]? Got married

You may need to submit documents to confirm the recent marriage.

[Checkboxes, multi-selection]
Got married
Gained a dependent (or became a dependent) due to an adoption, foster care
placement, or court order
Moved
Was released from incarceration (detention or jail)
None of these changes
[Checkboxes, multi-selection]
Got married
Gained a dependent (or became a dependent) due to an adoption, foster care
placement, or court order
Moved
Was released from incarceration (detention or jail)
Gained eligible immigration status
None of these changes
[Open text field]: YYYY-MM-DD

226

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

Did [FNLNS] or [his/her spouse] have qualifying health
coverage at any time in the 60 days before the marriage?

Has [FNLNS] had any of these changes since [date 60 days from
current date]? Got married

N/A

[Radio buttons]
Yes
No

227

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

Did [FNLNS] or [his/her] spouse live in a foreign country or a
U.S. territory for at least one of the 60 days before the
marriage?

Did [FNLNS] or [his/her spouse] have qualifying health coverage at
any time in the 60 days before the marriage? No

N/A

[Radio buttons]
Yes
No

223

Required/Optional for Consumer to Provide
Answer to Send to SES**
*if optional, consumer must be able to
ith t
idi
i UI
ti
Required

Conditional Display Logic in the UI**

Data Element(s) Name

Attestation Level

Data Element
Format

Policy**

Consumer is requesting coverage AND is preliminarily QHP or APTC eligible

changeInCircumstance

Member

enum

These questions are necessary for SEP eligibility. They must be asked
during Open Enrollment as well as during the rest of the year.

changeInCircumstance

Member

enum

These questions are necessary for SEP eligibility. They must be asked
during Open Enrollment as well as during the rest of the year.

changeInCircumstance.MARRIAGE.changeDate

Member

string

For the consumer to be eligible for a SEP based on Move or marriage,
the consumer must either be a member of a tribe, have had prior
coverage within the last 60 days, or have moved from a foreign
country.

See Item #26 on the "Backend Responses for UI" tab

Required

Required

Required

Required

Consumer is requesting coverage AND is preliminarily QHP or APTC eligible

Consumer is requesting coverage AND is preliminarily QHP or APTC eligible AND selected "Got
married" for "Has [FNLNS] had any of these changes since [date 60 days from current date]?"

Required

Required

Required

Required

Consumer is requesting coverage AND is preliminarily QHP or APTC eligible AND selected "Got
married" for "Has [FNLNS] had any of these changes since [date 60 days from current date]?"
AND provided a date within the last 60 days for "When did [FNLNS] get married?" AND consumer
did not attest to being a member of a federally recognized tribe
Consumer is requesting coverage AND is preliminarily QHP or APTC eligible AND selected "Got
married" for "Has [FNLNS] had any of these changes since [date 60 days from current date]?"
AND provided a date within the last 60 days for "When did [FNLNS] get married?" AND consumer
selected "No" for "Did [FNLNS] or [his/her spouse] have qualifying health coverage at any time in
the 60 days before the marriage?"
Consumer is requesting coverage AND is preliminarily QHP or APTC eligible AND selected "Gained a
dependent due to an adoption, foster care placement, or court order" for "Has [FNLNS] had any
of these changes since [date 60 days from current date]?"

See Item #26 on the "Backend Responses for UI" tab

228

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

Which of these people were adopted, placed in foster care,
or became a dependent through a child support or other
court order on or after [date 60 days from current date]?

Has [FNLNS] had any of these changes since [date 60 days from
current date]? Gained a dependent (or became a dependent) due
to an adoption, foster care placement, or court order

You may need to submit documents to confirm the recent adoption, foster care placement, or court order before their
new coverage can start.

[Checkboxes, multi-selection]
Display all applicant and non-applicant names (regardless of age)
None of these people

Required

Required

229

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

When did [FNLNS] become a dependent?

Has [FNLNS] had any of these changes since [date 60 days from
current date]? Gained a dependent (or became a dependent) due
to an adoption, foster care placement, or court order

N/A

[Open text field]: YYYY-MM-DD

Required

Required

230

QHP & APTC program questions - Special
Enrollment Periods

Phase 2, Phase 3

When did [FNLNS] get immigration status?

Has [FNLNS] had any of these changes since [date 60 days from
current date]? Gained eligible immigration status

N/A

[Open text field]: YYYY-MM-DD

Required

Required

231

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

What's the ZIP code of [FNLNS]'s previous address?

Has [FNLNS] had any of these changes since [date 60 days from
You must have moved to a different ZIP code or county, or moved to the U.S. from a foreign country or a U.S. territory
current date]? Moved
to be eligible for a Special Enrollment Period because you moved.
Check here if [FNLNS] moved from a foreign country. Not checked

Answer Fields
1. State: [Drop-down, single-selection]
2. U.S. ZIP code: [Open text field]
3. County: [Drop-down, single-selection]

1. Required
2. Required
3. Required if the system verified an address
and finds that ZIP code covers more than
one county

1. Required if name selected
2. Required if name selected
3. Required if multiple counties returned for
provided ZIP code

232

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

Check this box if [FNLNS] moved from a foreign country or
U.S. territory. If so, you don’t need to enter a ZIP code
above.

Has [FNLNS] had any of these changes since [date 60 days from
current date]? Moved

Checkbox

Required

Optional

Has [FNLNS] had any of these changes since [date 60 days from
current date]? Moved

changeInCircumstance.MARRIAGE.coverage60DayBeforeMarriageIndicator

Member

boolean

changeInCircumstance.MARRIAGE.liveInForeignCountry60DayBeforeMarriageIndicator

Member

boolean

The answer here determines which member should have the
changeInCircumstance.ADOPTION.changeDate set for them below

Member

N/A

Member

string

See Item #26 on the "Backend Responses for UI" tab
Consumer is requesting coverage AND is preliminarily QHP or APTC eligible AND selected "Gained a changeInCircumstance.ADOPTION.changeDate
dependent due to an adoption, foster care placement, or court order" for "Has [FNLNS] had any
of these changes since [date 60 days from current date]?" AND selected a household member for
"Which of these people were adopted, placed in foster care, or became a dependent through a
child support or other court order on or after [date 60 days from current date]?"
Consumer is requesting coverage AND is preliminarily QHP or APTC eligible AND selected "Gained changeInCircumstance.GAINING_LAWFUL_PRESENCE.changeDate
eligible immigration status" for "Has [FNLNS] had any of these changes since [date 60days from
current date]"

If a QHP eligible applicant has become a dependent, then he or she
qualifies for an SEP. Birth is not listed here because the application logic
determines that SEP based on birthdates of consumers.

Member

string

If a QHP eligible applicant has gained lawful presence status in the past
60 days, then he or she qualifies for an SEP.

changeInCircumstance.RELOCATION.precedingZipCode
changeInCircumstance.RELOCATION.precedingCounty

Member

string

For the consumer to be eligible for an SEP based on Move, the
consumer must have moved to a different zip code or county.

changeInCircumstance.RELOCATION.movedFromForeignCountryIndicator

Member

boolean

For the consumer to be eligible for an SEP based on Move or marriage,
the consumer must either be a member of a tribe, have had prior
coverage within the last 60 days, or have moved from a foreign
country
The trigger event must be within the last 60 days to qualify for the SEP.

Display the county field if system verifies address and finds that ZIP code covers more than one
county, the system will provide an option for the user to select the correct county
See Item #26 on the "Backend Responses for UI" tab

N/A

Consumer is requesting coverage AND is preliminarily QHP or APTC eligible AND selected "Moved"
for "Has [FNLNS] had any of these changes since [date 60 days from current date]?"
See Item #26 on the "Backend Responses for UI" tab
Consumer is requesting coverage AND is preliminarily QHP or APTC eligible AND selected "Moved"
for "Has [FNLNS] had any of these changes since [date 60 days from current date]?"

233

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

When did [FNLNS] move?

You may need to submit documents to confirm the recent move, and show that this person had qualifying health
coverage at some point during the 60 days before their move.

[Open text field]: YYYY-MM-DD

Required

Required

changeInCircumstance.RELOCATION.changeDate

Member

string

234

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

Did [FNLNS] have qualifying health coverage at any time in Has [FNLNS] had any of these changes since [date 60 days from
the 60 days before [he/she] moved?
current date]? Moved

N/A

[Radio buttons]
Yes
No

Required

Required

Consumer is requesting coverage AND is preliminarily QHP or APTC eligible AND selected "Moved"
for "Has [FNLNS] had any of these changes since [date 60 days from current date]?" AND
consumer did not attest to being a member of a federally recognized tribe.

changeInCircumstance.RELOCATION.coverage60DayBeforeMoveIndicator

Member

boolean

QHP & APTC program questions - Special
Enrollment Periods

Phase 1, Phase 2, Phase 3

When was [FNLNS] released from incarceration?

N/A

[Open text field]: YYYY-MM-DD

Required

Required

Consumer is requesting coverage AND is preliminarily QHP or APTC eligible AND selected "Was
released from incarceration (detention or jail)" for "Has [FNLNS] had any of these changes since
[date 60 days from current date]?"

changeInCircumstance.RELEASE_FROM_INCARCERATION.changeDate

Member

string

235

Has [FNLNS] had any of these changes since [date 60 days from
current date]? Was released from incarceration (detention or jail)

For the consumer to be eligible for an SEP based on Move or marriage,
the consumer must either be a member of a tribe, have had prior
coverage within the last 60 days, or have moved from a foreign
country
The trigger event must be within the last 60 days to qualify for the SEP.

See Item #26 on the "Backend Responses for UI" tab

246

Agree/Sign/Submit
Review application

Phase 1, Phase 2, Phase 3

Review application

247

Sign & Submit

Phase 1, Phase 2, Phase 3

If anyone on this application enrolls in Medicaid, I’m giving
N/A
the Medicaid agency the right to pursue and get any money
from other health insurance, legal settlements, or other
third parties. I’m also giving the Medicaid agency rights to
pursue and get medical support from a spouse or parent
If a child on this application has a parent living outside of the N/A
home, I know I’ll be asked to cooperate with the agency
that collects medical support from an absent parent. If I
think that cooperating to collect medical support will harm
me or my children, I can tell the agency and I may not have
to cooperate
To make it easier to determine my eligibility for help paying N/A
for coverage in future years, I agree to allow the
Marketplace to use my income data, including information
from tax returns, for the next 5 years. The Marketplace will
send me a notice and let me make changes. I can opt out at
any time.

N/A

248

Sign & Submit

Phase 1, Phase 2, Phase 3

252

Sign & Submit

Phase 1, Phase 2, Phase 3

253

Sign & Submit

Phase 1, Phase 2, Phase 3

How long would you like your eligibility for help paying for
coverage to be renewed?

254

Sign & Submit

Phase 1, Phase 2, Phase 3

I know that I must tell the program I’ll be enrolled in if
N/A
information I listed on this application changes. I know I can
make changes in my Marketplace account or by calling the
Marketplace Call Center at 1-800-318-2596 (TTY: 1-855889-4325). I know a change in my information could affect
eligibility for member(s) of my household.

255

Sign & Submit

Phase 1, Phase 2, Phase 3

256

Sign & Submit

Phase 1, Phase 2, Phase 3

257

Sign & Submit

Phase 1, Phase 2, Phase 3

258

Sign & Submit

Phase 1, Phase 2, Phase 3

To make it easier to determine my eligibility for help paying for
coverage in future years, I agree to allow the Marketplace to use
my income data, including information from tax returns, for the
next 5 years. The Marketplace will send me a notice and let me
make changes. I can opt out at any time. Disagree

If anyone on your application is enrolled in Marketplace
N/A
coverage and is later found to have other qualifying health
coverage (like Medicare, Medicaid, or CHIP), the
Marketplace will automatically end their Marketplace plan
coverage. This will help make sure that anyone who’s found
to have other qualifying coverage won’t stay enrolled in
Marketplace coverage and have to pay full cost
I’m signing this application under penalty of perjury, which N/A
means I’ve provided true answers to all of the questions to
the best of my knowledge. I know I may be subject to
penalties under federal law if I intentionally provide false
information
N/A
Any attestation that impacts eligibility in the "Sign & Submit" section:
Disagree
[FNLNS], type your full name below to sign electronically.

N/A

Help Drawer: Before you sign and submit your application, you’ll be asked to check if you agree or disagree with a few
statements (also called “attestations”). If you disagree with any of the attestations, you may be asked to provide
additional information. In some cases, you must agree with the statement to continue your Marketplace application.

User may click to navigate back to the section to make changes.

Question Flow Requirements**

Question/Informational Text Wording Requirements**

Answer Options and Format Requirements**

SEP questions should be displayed anytime after the preliminary eligibility
determination. These questions must be asked of each QHP and APTC
eligible applicant. This variation is specific to Phase 1 applications.
Including this comprehensive question is optional. The application could
use this question to determine which SEP follow up questions to display to
the consumer. If this question is not used, the application must ask about
each SEP individually
SEP questions should be displayed anytime after the preliminary eligibility
determination. These questions must be asked of each QHP and APTC
eligible applicant. This variation is specific to Phase 2 and 3 applications.
Including this comprehensive question is optional. The application could
use this question to determine which SEP follow up questions to display to
the consumer. If this question is not used, the application must ask about
each SEP individually.

Wording must be similar.

Answer option wording must be exact and all options must be present. Answer
format is flexible; however, consumers must be able to attest to multiple SEPs.

Wording must be similar.

Answer option wording must be exact and all options must be present. Answer
format is flexible; however, consumers must be able to attest to multiple SEPs.

The application must ask SEP questions during Open Enrollment as well as during Flexible. Best practice is to ask for married applicants only. For non-FA
the rest of the year. Follow-up questions for certain SEP types are critical for SEP applications, the question placement is flexible. For FA applications, the
eligibility, such as questions about prior coverage for move and marriage. Some question should be asked after preliminary eligibility results so that it can
SEP questions only need to be asked for some people: the marriage SEP question be asked of QHP eligible applicants. Questions about prior coverage (and
can be asked of married applicants only, and the immigration SEP question can the exception to prior coverage related to moves from a foreign
be asked of non-citizen applicants only. This question flow will appear if
country) can be skipped for attested members of federally recognized
applicants are potentially QHP eligible based on the Update App SES call.
tribes.

Wording must be similar.

Wording must be similar. The application may provide a specific date in
place of 60 days.
Wording must be similar.

See Item #26 on the "Backend Responses for UI" tab

Consumer is requesting coverage AND is preliminarily QHP or APTC eligible AND selected "Moved"
for "Has [FNLNS] had any of these changes since [date 60 days from current date]?"

General Requirements**

Required

N/A

Display once consumer has completed the application, prior to the penalty of perjury attestation
and electronic signature.

N/A

Application

N/A

The consumer must be given a chance to review a summary of the
information in their application and make adjustments as needed prior
to submission.

Help Drawer: If you enroll in Medicaid and have any other health coverage or legal settlements that pay medical
[Checkbox]
expenses, the money will go to Medicaid because Medicaid is paying for your medical bills (or as much as it can). Medicaid I agree to this statement.
will then pay the rest of the medical bill.

Required

Required

See Item #29 on the "Backend Responses for UI" tab

medicaidRequirementAgreementIndicator

Application

boolean

In order to be eligible for Medicaid, consumers must agree to
subrogation.

Help Drawer: If your child or children can get medical support from a parent living outside the home, you’ll need to
cooperate with the Medicaid and child support agencies to get that support when needed. But, if you think that
cooperating to collect medical support will harm you or your children, you can tell Medicaid when it contacts you, and
you may not have to cooperate. Whether you cooperate won’t affect your child’s eligibility. But a parent needs to
cooperate or have a good reason not to cooperate to be able to get Medicaid for themselves.

[Radio buttons]
Agree
Disagree

Required

Required

See Item #30 on the "Backend Responses for UI" tab

absentParentAgreementIndicator

Application

boolean

In order to be eligible for Medicaid, consumers who are applying for a
Medicaid eligible child under age 18 with an absent parent must agree
to cooperate

[Radio buttons]
Help Drawer: Learn more about letting us use your income data
If you enroll in coverage through the Marketplace, Medicaid, or CHIP we want to help you keep your coverage. One way I Agree
to do that is to allow us or your state to check electronically available income data in the future, instead of asking you to
I Disagree
verify that your income still qualifies. Agreeing to this statement allows us to use available income information from the
IRS for up to 5 years to renew your application.

Required

Required

Consumer is requesting financial assistance

If "Yes" set:
1. renewalAgreementIndicator to true
2. renewEligibilityYearQuantity to 5

Application

1. boolean
2. number

For the FFE to be able to use tax data in future years for re-enrollment
purposes, the consumer must agree to allow use of their tax data in
future years. If not, the consumer cannot be passively re-enrolled.

Application

1. boolean
2. number

Date: Flexible in the way the application collects the date. May collect date
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a date. The UI must have a field level validation
to only allow the consumer to provide a date within the last 60 days to prevent
consumers from providing dates that would cause a SES error
Can be pre-populated based on information the DE partner has about past
enrollment.
Answer format is flexible. Answer options may be altered for compatibility with
question wording.

Flexible, but must include child support or court order placement in
When asking who became a dependent, all consumer names must display
addition to adoption and foster care placement. The application may
including consumers who are not QHP eligible. Answer format is flexible; however,
ask as a stand-alone question or may ask it as part of question asking
multi-selection must be enabled.
about other life changes. The application may ask once per application
or ask each QHP-eligible applicant separately. The application may
provide a specific date (60 days before date of application) in place of 60 Date: Flexible in the way the application collects the date. May collect date
days.
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a date. The UI must have a field level validation
to only allow the consumer to provide a date within the last 60 days to prevent
consumers from providing dates that would cause a SES error
The application must ask SEP questions during Open Enrollment as well as during The application must ask SEP questions during Open Enrollment as well as Wording must be similar. The application may ask as a stand-alone
Date: Flexible in the way the application collects the date. May collect date
the rest of the year. Follow-up questions for certain SEP types are critical for SEP during the rest of the year. Follow-up questions for certain SEP types are question or may ask it as part of question asking about other life
through separate field for year, month, and day. May use a calendar widget to
eligibility, such as questions about prior coverage for move and marriage. Some critical for SEP eligibility, such as questions about prior coverage for move changes. The application may ask once per application or ask each QHP- assist the consumer with selecting a date. The UI must have a field level validation
SEP questions only need to be asked for some people: the marriage SEP question and marriage. Some SEP questions only need to be asked for some
eligible applicant separately. The application may provide a specific date to only allow the consumer to provide a date within the last 60 days to prevent
can be asked of married applicants only, and the immigration SEP question can people: the marriage SEP question can be asked of married applicants
(60 days before date of application) in place of 60 days.
consumers from providing dates that would cause a SES error.
be asked of non-citizen applicants only. This question flow will appear if
only, and the immigration SEP question can be asked of non-citizen
applicants are potentially QHP eligible based on the Update App SES call.
applicants only. This question flow will appear if applicants are potentially
QHP eligible based on the Update App SES call.

The application must ask SEP questions during Open Enrollment as well as during For non-FA applications, the question placement is flexible. For FA
the rest of the year. Follow-up questions for certain SEP types are critical for SEP applications, the question should be asked after preliminary eligibility
eligibility, such as questions about prior coverage for move and marriage. Some results so that the first question about whether the consumers either
SEP questions only need to be asked for some people: the marriage SEP question gained or became a dependent can be asked of QHP eligible applicants
can be asked of married applicants only, and the immigration SEP question can only. Then, once you know that a QHP eligible applicant either gained or
be asked of non-citizen applicants only. This question flow will appear if
became a dependent, you can ask who became a dependent, and
applicants are potentially QHP eligible based on the Update App SES call.
include all household members as options.

May be tied more closely with address collection on the application. The
Flexible. For non-FA applications, the question placement is flexible. For
application must ask SEP questions during Open Enrollment as well as during the FA applications, the question should be asked after preliminary eligibility
rest of the year. Follow-up questions for certain SEP types are critical for SEP
results so that it can be asked of QHP eligible applicants. It is fine to only
eligibility, such as questions about prior coverage for move and marriage. Some request zip code and derive the state on that basis. Questions about prior
SEP questions only need to be asked for some people: the marriage SEP question coverage can be skipped for attested members of federally recognized
can be asked of married applicants only, and the immigration SEP question can tribes. Consumers should be able to either enter a US zip code or check
be asked of non-citizen applicants only. This question flow will appear if
the box indicating a move from a foreign country- not both.
applicants are potentially QHP eligible based on the Update App SES call.

Wording must be similar.

State: Consumer must be able to select any state. DE entities must use a single
selection drop-down menu with all 50 states. The DE entity may provide state
abbreviations or the full state name in the drop-down menu.
ZIP Code: Must be an open text field
County: Answer format is flexible. Counties should only be asked when address
validation response indicates that the zip code crosses into multiple counties; in
that case, the application filer should be given the choice between the two
counties to select from
Answer format is flexible.

Wording must be similar.

Date: Flexible in the way the application collects the date. May collect date
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a date. The UI must have a field level validation
to only allow the consumer to provide a date within the last 60 days to prevent
consumers from providing dates that would cause a SES error
Answer format is flexible.

Wording must be similar.

The application must ask SEP questions during Open Enrollment as well as during Flexible. For non-FA applications, the question placement is flexible. For Wording must be similar.
the rest of the year. Follow-up questions for certain SEP types are critical for SEP FA applications, the question could be asked after preliminary eligibility
eligibility, such as questions about prior coverage for move and marriage. Some results so that it can be asked of QHP eligible applicants. The application
SEP questions only need to be asked for some people: the marriage SEP question may ask as a stand-alone question or may ask it as part of question asking
can be asked of married applicants only, and the immigration SEP question can about other life changes. The application may ask once per application or
be asked of non-citizen applicants only. This question flow will appear if
ask each QHP-eligible applicant separately.
applicants are potentially QHP eligible based on the Update App SES call.

Format of how consumers review their application data is flexible. It can be a
high level review as long as consumers have the option to click for more details.
A best practice is to make this section very clear, especially highlighting any
responses where typos might be common. Consumers must be able to save and
print their application summary. If the pre-application plan selection process
uses a zip code to provide plan options to the consumer, then once the
consumer has selected a plan it is allowed for the application not to provide an
option to edit the home address zip code within the application. Other aspects of
the address including the full mailing address should remain editable
The agreement related to a parent living outside the home must only be
displayed for an application filer who is Medicaid eligible, and there's a Medicaid
eligible child under age 18 on the application whose parent is living outside the
home. When applicants are Medicaid eligible, they must be presented with the
opportunity to agree with Medicaid related attestations, through a check box or
other means.

If the consumer is applying for financial assistance, the application must ask the
consumer if their income data can be used for future financial assistance
eligibility. If the consumer disagrees, a follow-up question must ask the
consumer to select the number of years their income data may be used.

Date: Flexible in the way the application collects the date. May collect date
through separate field for year, month, and day. May use a calendar widget to
assist the consumer with selecting a date. The UI must have a field level validation
to only allow the consumer to provide a date within the last 60 days to prevent
consumers from providing dates that would cause a SES error.

This must occur after the consumer has completed the application, but
prior to viewing the attestations in the Submit and Sign section of the
application. The consumer must be able to return to the application and
edit any components.

Flexible as long as the application review displays a summary of the
attestations on the application and explains to the consumer how they
can go back and adjust the attestations to correct anything that isn't
accurate.

N/A

This question should be asked with other attestations at the end of the
application prior to signing and submitting the application. The flow of
attestations is flexible, with the exception of the penalty of perjury
attestation. This may be grouped with other agreements for Medicaid
eligibility with a single answer format
This question should be asked with other attestations at the end of the
application prior to signing and submitting the application. The flow of
attestations is flexible, with the exception of the penalty of perjury
attestation.

Wording must be exact.

Answer format is flexible. If answer options display affirmative statements, it must
use the terms "agree" and "disagree."

Wording must be exact.

Answer format is flexible. If answer options display affirmative statements, it must
use the terms "agree" and "disagree."

This question should be asked with other attestations at the end of the
application prior to signing and submitting the application. The flow of
attestations is flexible, with the exception of the penalty of perjury
attestation.

Wording must be exact.

Answer format is flexible. If answer options display affirmative statements, it must
use the terms "agree" and "disagree."

This question should be asked with other attestations at the end of the
application prior to signing and submitting the application. It is a best
practice to ask this question after the use of income data attestation.

Wording must be similar.

Answer format is flexible. Consumers must only be able to choose between 0-5
years.

Select “I disagree” to change the period of time you’d like us to check your federal income tax return. You can select 0-4
years. If you select “0,” you’re not allowing us to check your tax data. Selecting this option may affect your ability to get
help paying for coverage at renewal or require you to provide more information.
Opting out of eligibility renewal now may impact your ability to get help paying for coverage at renewal later.

[Radio buttons]
1 year
2 years
3 years
4 years
5 years
Don't renew eligibility

Required

Required

Consumer is requesting financial assistance AND disagreed with attestation to reuse their income
data for future financial assistance eligibility

If consumer selects 1-5 years set:
1. renewalAgreementIndicator to true
2. renewEligibilityYearQuantity to the number selected

Help Drawer: You must report any changes that might affect your health coverage, like if you or a member of your
household move, have any income changes, get married, get divorced, become pregnant, or have a child. If a person is
enrolled in Medicaid or the Children’s Health Insurance Program (CHIP), you can report these changes by contacting
your state Medicaid or CHIP program.

[Checkbox]
I agree to this statement.

Required

Required

N/A

changeInformationAgreementIndicator

Application

boolean

Consumers must agree in order to be found eligible for any program.

A UI validation may be included to ensure that consumers agree to this before
submitting their application. Additional attestations must be displayed and
agreed to by all applicants prior to submission. The applicant must be able to
affirmatively sign their application through an electronic signature prior to
submission.

[Checkboxes, single-selection]
I agree to allow the Marketplace to end the Marketplace coverage of the people
on my application in this situation.

Required

Required

See item #34 in the "Backend Responses for UI" tab

terminateCoverageOtherMecFoundAgreementIndicator

Application

boolean

Consumers must be able to disagree with this attestation. This
attestation does not impact eligibility results if the consumer selects
"Agree" or "Disagree"

A UI validation cannot be included to ensure that consumers agree to this before This question should be asked with other attestations at the end of the
submitting their application. Consumers must be able to agree or disagree with
application prior to signing and submitting the application. The flow of
this attestation. Disagreeing with the attestation does not impact their eligibility. attestations is flexible, with the exception of the penalty of perjury
attestation.

A UI validation may be included to ensure that consumers agree to this before
submitting their application. Additional attestations must be displayed and
agreed to by all applicants prior to submission. The applicant must be able to
affirmatively sign their application through an electronic signature prior to
submission
A UI validation may be included with attestations to ensure that consumers
agree before submitting their application. This is optional, but encouraged to
include in the application
The applicant must be able to affirmatively sign their application through an
electronic signature prior to submission.

If you’re enrolled in a Marketplace health plan and need to report a change, log in to your Marketplace account on
HealthCare gov or call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325)
N/A

N/A

I don’t give the Marketplace permission to end Marketplace coverage in this
situation. I understand that the affected people on my application will no longer be
eligible for financial help and must pay full cost for their Marketplace plan
[Checkbox]
I agree to this statement.

If consumer selects "Don’t use tax data to renew my eligibility for help paying for health coverage" set:
1. renewalAgreementIndicator to false
2. renewEligibilityYearQuantity to 0

Required

Required

N/A

penaltyOfPerjuryAgreementIndicator

Application

boolean

Consumers must agree in order to be found eligible for any program.

Important: If you don't attest to this item, it may impact your eligibility.

N/A

Optional

Optional

Consumer disagrees with an attestation that may impact eligibility

None. This is not sent to SES.

Application

N/A

N/A

[Open text field]

Required

Required

N/A

1. applicationSignatureText

Application

1. string
2. string
3. enum

Consumers must agree to certain attestations prior to submitting the
application. This informational text is a reminder for consumers to
agree to the attestation statement
Consumers must electronically sign their application prior to submitting
their application.

When the signature is sent to SES, the (2.) applicationSignatureDate and (3.) applicationSignatureType
should also be sent from the backend.

This question should be asked with other attestations at the end of the
application prior to signing and submitting the application. The flow of
attestations is flexible, with the exception of the penalty of perjury
attestation.

Wording must be exact, except for references to the Marketplace
account and phone number.DE entities may reference their own
website for this purpose.

Answer format is flexible. If answer options display affirmative statements, it must
use the terms "agree" and "disagree."

Wording must be exact.

Answer format is flexible but must be a single-selection (checkbox, toggle button,
etc.) Answer options must be exact.

This attestation must accompany the electronic signature field at the end Wording must be exact.
of the application. All questions related to eligibility must occur prior to this
attestation.
This should appear after the consumer disagrees with an attestation in the Flexible.
Sign and Submit section. This should not appear for the use of income
data and incarceration attestation questions
Must be at the end of the application, prior to submitting the application Flexible. A signature is only needed from the application filer.
for an eligibility determination.

Answer format is flexible. If answer options display affirmative statements, it must
use the terms "agree" and "disagree."

N/A
Must be an open text field.

Notes

Auditor Compliance
Conclusion**

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor
Comments**

Document Type Enums
Item #
1

UI Question

Selection

Select the document type that corresponds Permanent Resident Card (Green Card) or
with [FN's] most current documentation Reentry Permit
and status

Sub-Selection
I-551 (Permanent Resident Card, "Green
Card")

SES Values
=
"PERMANENT_RESIDENT_CARD_I_551"

Immigration Status Input

SES Values

Help Text: Learn more about entering I-551 info
Alien Number
Card Number
Document expiration date
Does the name below match the name on the I-551?
One of these document types or statuses?

2

Temporary I-551 stamp (on passport or I-94) =
"TEMPORARY_I_551_STAMP_ON_PASSPORT_OR_I_94_I_94
A"

Help Text: Learn more about entering I-551 stamp info
Alien Number
Document expiration date
Passport number
Select the country that issued passport
One of these document types or statuses?

3

I-327 (Reentry permit)

= "REENTRY_PERMIT"

Help Text: Learn more about entering I-327 info
Alien Number
Document expiration date
One of these document types or statuses?

4

Machine Readable Immigrant Visa

=
"MACHINE_READABLE_IMMIGRANT_VISA_WITH_TEMPORA
RY_I_551_LANGUAGE"

Help Text: Learn more about entering machine readable visa info
Alien Number
Passport Number
Select the country that issued passport
Document expiration date
Does the name below match the name on the passport?
One of these document types or statuses?

5

Employment Authorization Card

=
"EMPLOYMENT_AUTHORIZATION_CARD_I_766"

Help Text: Learn more about entering employment authorization card info
Alien Number
Card Number
Document expiration date
Category code
Does the name below match the name on the card?
One of these document types or statuses?

6

Arrival/Departure Record

7

Arrival/Departure Record (I-94/I-94A)

=
Help Text: Learn more about entering I-94/I94A info
"ARRIVAL_DEPARTURE_RECORD_IN_FOREIGN_PASSPORT_I_ I-94 Number
Document expiration date
94"
SEVIS ID Number
One of these document types or statuses?

Arrival/Departure Record in foreign passport =
Help Text: Learn more about entering I-94/I94A info
(I-94)
"ARRIVAL_DEPARTURE_RECORD_IN_UNEXPIRED_FOREIGN_P I-94 Number
Passport Number
ASSPORT_I_94"
Document Expiration Date
Select the country that issued passport
SEVIS ID Number
Does the name below match the name on the passport?
One of these document types or statuses?

8

Refugee Travel Document

9

Nonimmigrant Student or Exchange Visitor Certificate of Eligibility for Nonimmigrant (F- =
Help Text: Learn more about entering I-20 info
Status
1) Student Status (I-20)
"CERTIFICATE_OF_ELIGIBILITY_FOR_NONIMMIGRANT_STUDE SEVIS ID Number
Passport number
NT_STATUS_I_20"
Document expiration date
Select the country that issued passport
I-94 number
One of these document types or statuses?

10

=
"REFUGEE_TRAVEL_DOCUMENT"

Help Text: Learn more about entering I-571 info
Alien Number
Document Expiration Date
One of these document types or statuses?

Certificate of Eligibility for Exchange Visitor (J- =
Help Text: Learn more about entering DS2019 info
1) Status
"CERTIFICATE_OF_ELIGIBILITY_FOR_EXCHANGE_VISITOR_STA SEVIS ID Number
TUS_DS_2019"
Passport number
Document expiration date
Select the country that issued passport
I-94 number
One of these document types or statuses?

Notes

If the consumer provides an Alien number of less than 9 digits, then
the requestor should prepend zero(s) so that the string submitted in
the JSON is 9 digits.

11

Notice of Action

=
"NOTICE_OF_ACTION_I_797"

Help Text: Learn more about entering I-797 info
Alien Number
I-94 number
One of these document types or statuses?

12

Unexpired foreign passport

= "FOREIGN_PASSPORT"

Help Text: Learn more about entering foreign passport info
Passport Number
Document Expiration Date
Select the country that issued passport
SEVIS ID Number
I-94 number
Does the name below match the name on the passport?
One of these document types or statuses?

13

Other document or status type

= null

One of these document types or statuses?

14

One of these document types or statuses?
>Another document or alien number / I-94 number

= "OTHER"

15

One of these document types or statuses?
>Document indicating member of a federally recognized Indian tribe or American Indian born in Canada/Members Of A Federally
Recognized Indian Tribe

=
NS1_MEMBERS_OF_A_FEDERALLY_RECOGNIZED_INDIAN_TRIBE

16

One of these document types or statuses?
>Certification from U.S. Department of Health and Human Services (HHS) Office of Refugee Resettlement (ORR)

=
"CERTIFICATION_FROM_HHS_ORR (OT1)"

17

One of these document types or statuses?
>Office of Refugee Resettlement (ORR) eligibility letter (if under 18)

= "ORR_ELIGIBILITY_LETTER"

18

One of these document types or statuses?
>Cuban/Haitian entrant

= "CUBAN_HAITAN_ENTRANT
(OT2)"

20

One of these document types or statuses?
>Resident of American Samoa/Non Citizen Who Is Lawfully Present In American Samoa

=
NS4_NON_CITIZEN_WHO_IS_LAWFULLY_PRESENT_IN_AMERICAN_
SAMOA

For i94 number, allow only numbers other than optionally a letter in
the 10th position

Item #

UI Question

Selection

Sub-Selection

SES Values

22

23

24

Is [FNLNS] a naturalized or derived citizen? Certificate of Citizenship

Certificate of Naturalization

=
"CERTIFICATE_OF_CITIZENSHIP"

=
"CERTIFICATE_OF_NATURALIZATION"

Immigration Status Input

SES Values

Battered spouse, child, or parent under VAWA
Help Text: As a battered spouse, child, or parent, you may have filed a petition based on the Violence Against Women Act (VAWA).

= "VAWA_SELF_PETITIONER"

Help Drawer: Learn where to find the document number.
Certificate of Citizenship number
Alien Number
"I don't have one"
Help Drawer: Learn where to find the document number.
Naturalization Certificate number
Alien Number
"I don't have one"

Obsolete:
OTHER.1
RESIDENT_OF_AMERICAN_SAMOA_CARD
NS2_NON_CITIZEN_WHO_IS_LAWFULLY_PRESENT_IN_AMERICAN_
SAMOA_UNDER_THE_IMMIGRATION_LAWS_OF_AMERICAN_SAM
OA
"DOCUMENT_INDICATING_A_MEMBER_OF_RECOGNIZED_INDIAN_
TRIBE_OR_INDIAN_BORN_IN_CANADA"

Notes
Addition for V37 - Needs to be added April 1 2019

Passport Issuing Countries
COUNTRY CODE**

COUNTRY DESCRIPTION**

ABW

Aruba

AFG

Afghanistan

AGO

Angola

AIA

Anguilla

ALA

Eland Islands

ALB

Albania

AND

Andorra

ANT

Netherlands Antilles

ARE

United Arab Emirates

ARG

Argentina

ARM

Armenia

ASM

American Samoa

ATA

Antarctica

ATF

French Southern Territories

ATG

Antigua And Barbuda

AUS

Australia

AUT

Austria

AZE

Azerbaijan

BDI

Burundi

BEL

Belgium

BEN

Benin

BFA

Burkina Faso

BGD

Bangladesh

BGR

Bulgaria

BHR

Bahrain

BHS

Bahamas

BIH

Bosnia And Herzegovina

BLM

Saint Barthelemy

BLR

Belarus

BLZ

Belize

BMU

Bermuda

BOL

Bolivia, Plurinational State Of

BRA

Brazil

BRB

Barbados

BRN

Brunei Darussalam

BTN

Bhutan

BVT

Bouvet Island

BWA

Botswana

CAF

Central African Republic

CAN

Canada

CCK

Cocos (Keeling) Islands

CHE

Switzerland

CHL

Chile

CHN

China

CIV

CÔTE D'IVOIRE

CMR

Cameroon

COUNTRY CODE**

COUNTRY DESCRIPTION**

COD

Congo, Democratic Republic Of The

COG

Congo

COK

Cook Islands

COL

Colombia

COM

Comoros

CPV

Cape Verde

CRI

Costa Rica

CUB

Cuba

CXR

Christmas Island

CYM

Cayman Islands

CYP

Cyprus

CZE

Czech Republic

DEU

Germany

DJI

Djibouti

DMA

Dominica

DNK

Denmark

DOM

Dominican Republic

DZA

Algeria

ECU

Ecuador

EGY

Egypt

ERI

Eritrea

ESH

Western Sahara

ESP

Spain

EST

Estonia

ETH

Ethiopia

FIN

Finland

FJI

Fiji

FLK

Falkland Islands (Malvinas)

FRA

France

FRO

Faroe Islands

FSM

Micronesia, Federated States Of

GAB

Gabon

GBR

United Kingdom

GEO

Georgia

GGY

Guernsey

GHA

Ghana

GIB

Gibraltar

GIN

Guinea

GLP

Guadeloupe

GMB

Gambia

GNB

Guinea-Bissau

GNQ

Equatorial Guinea

GRC

Greece

GRD

Grenada

GRL

Greenland

GTM

Guatemala

COUNTRY CODE**

COUNTRY DESCRIPTION**

GUF

French Guiana

GUM

Guam

GUY

Guyana

HKG

Hong Kong

HMD

Heard Island And McDonald Islands

HND

Honduras

HRV

Croatia

HTI

Haiti

HUN

Hungary

IDN

Indonesia

IMN

Isle Of Man

IND

India

IOT

British Indian Ocean Territory

IRL

Ireland

IRN

Iran, Islamic Republic Of

IRQ

Iraq

ISL

Iceland

ISR

Israel

ITA

Italy

JAM

Jamaica

JEY

Jersey

JOR

Jordan

JPN

Japan

KAZ

Kazakhstan

KEN

Kenya

KGZ

Kyrgyzstan

KHM

Cambodia

KIR

Kiribati

KNA

Saint Kitts And Nevis

KOR

Korea, Republic Of

KVO

Kosovo

KWT

Kuwait

LAO

Lao People's Democratic Republic

LBN

Lebanon

LBR

Liberia

LBY

Libyan Arab Jamahiriya

LCA

Saint Lucia

LIE

Liechtenstein

LKA

Sri Lanka

LSO

Lesotho

LTU

Lithuania

LUX

Luxembourg

LVA

Latvia

MAC

Macao

MAF

Saint Martin (French Part)

MAR

Morocco

COUNTRY CODE**

COUNTRY DESCRIPTION**

MCO

Monaco

MDA

Moldova, Republic Of

MDG

Madagascar

MDV

Maldives

MEX

Mexico

MHL

Marshall Islands

MKD

Macedonia, The Former Yugoslav Republic Of

MLI

Mali

MLT

Malta

MMR

Myanmar

MNE

Montenegro

MNG

Mongolia

MNP

Northern Mariana Islands

MOZ

Mozambique

MRT

Mauritania

MSR

Montserrat

MTQ

Martinique

MUS

Mauritius

MWI

Malawi

MYS

Malaysia

MYT

Mayotte

NAM

Namibia

NCL

New Caledonia

NER

Niger

NFK

Norfolk Island

NGA

Nigeria

NIC

Nicaragua

NIU

Niue

NLD

Netherlands

NOR

Norway

NPL

Nepal

NRU

Nauru

NZL

New Zealand

OMN

Oman

PAK

Pakistan

PAN

Panama

PCN

Pitcairn

PER

Peru

PHL

Philippines

PLW

Palau

PNG

Papua New Guinea

POL

Poland

PRI

Puerto Rico

PRK

Korea, Democratic People's Republic Of

PRT

Portugal

PRY

Paraguay

COUNTRY CODE**

COUNTRY DESCRIPTION**

PSE

Palestinian Territory, Occupied

PYF

French Polynesia

QAT

Qatar

REU

Reunion

ROU

Romania

RUS

Russian Federation

RWA

Rwanda

SAU

Saudi Arabia

SDN

Sudan

SEN

Senegal

SGP

Singapore

SGS

South Georgia And The South Sandwich Islands

SHN

Saint Helena, Ascension And Tristan Da Cunha

SJM

Svalbard And Jan Mayen

SLB

Solomon Islands

SLE

Sierra Leone

SLV

El Salvador

SMR

San Marino

SOM

Somalia

SPM

Saint Pierre And Miquelon

SRB

Serbia

SSD

South Sudan

STL

Stateless

STP

Sao Tome And Principe

SUR

Suriname

SVK

Slovakia

SVN

Slovenia

SWE

Sweden

SWZ

Swaziland

SYC

Seychelles

SYR

Syrian Arab Republic

TCA

Turks And Caicos Islands

TCD

Chad

TGO

Togo

THA

Thailand

TJK

Tajikistan

TKL

Tokelau

TKM

Turkmenistan

TLS

Timor-Leste

TON

Tonga

TTO

Trinidad And Tobago

TUN

Tunisia

TUR

Turkey

TUV

Tuvalu

TWN

TAIWAN

TZA

Tanzania, United Republic Of

COUNTRY CODE**

COUNTRY DESCRIPTION**

UGA

Uganda

UKR

Ukraine

UMI

United States Minor Outlying Islands

URY

Uruguay

USA

United States

UZB

Uzbekistan

VAT

Holy See (Vatican City State)

VCT

Saint Vincent And The Grenadines

VEN

Venezuela, Bolivarian Republic Of

VGB

Virgin Islands (British)

VIR

Virgin Islands (U.S.)

VNM

Viet Nam

VUT

Vanuatu

WLF

Wallis And Futuna

WSM

Samoa

YEM

Yemen

ZAF

South Africa

ZMB

Zambia

ZWE

Zimbabwe

Backend Responses for UI
Item #
1

Scenario

UI Question

Conditional Display Logic based on API Response

Update name, date of birth, SSN
information to verify SSN

We weren't able to verify [FNLNS]'s information. Please
confirm the information below is correct and try again.

ssnStatusReason = 634_ SSA_DATA_MISMATCH

Notes
(Where reason codes are listed, this is the full list of possible reason codes)
Return ssnStatus = Y and ssnStatusReason = 573 when the requestor exceeds the maximum limit to call SSA within 24 hours (3
times).

Section of Application

Card in Application

More about this household

Error SSN

Citizenship/immigration

Naturalized Citizen

Reason Codes:
- `187_DEATH_DATA_PRESENT` (string) - Death data present.
- `191_EDS_NOT_AVAILABLE` (string) - External data source not available.
- `227_NO_EDS_DATA_FOUND` (string) - No data found in external data source.
- `287_SSN_WAS_NOT_MATCHED_WITH_ATTESTED_INFORMATION` (string) - SSN was not matched with attested information.
- `288_SSN_NOT_VERIFIED` (string) - SSN was not verified.
- `341_HUB_DID_NOT_RESPOND` (string) - HUB did not respond.
- `352_NO_SSN_PROVIDED` (string) - Individual did not provide SSN.
- `432_DMI_RESOLVED_BY_ESW_ADJUDICATION` (string) - Inconsistency resolved by eligibility Worker adjudication.
- `456_DATA_SOURCE_NOT_CALLED_DUE_TO_FAILED_ID_PROOF` (string) - Data source not called due to failed ID proofing.
- `476_ESW_EXPIRED_DMI` (string) - Eligibility Worker expired inconsistency.
- `477_ESW_EXPIRED_ANOTHER_DMI_SO_INELGBLE` (string) - Expired when eligibility worker expired another inconsistency
resulting in ineligibility.
- `555_N_A_RULE_DOES_NOT_APPLY` (string) - Not applicable (rule does not apply).
- `573_SSA_HUB_CALL_HELD_CALL_COUNTER_3_OR_MORE` (string) - Social Security Administration (SSA) HUB call held due to call
counter being greater than or equal to 3.
- `634_SSA_DATA_MISMATCH` (string) - SSA data mismatch.
- `714_N_A_QHP_STOPPED_BY_OFFLINE_PROCESS` (string) - Qualified Health Plan terminated by an offline process.
- `999_N_A_RULE_INDICATOR_IS_Y` (string) - Not applicable.

4

Collect Naturalized Citizen status for
Medicaid LawfulpresenceStatus

Is [FNLNS] a naturalized or derived citizen?

(citizenshipStatus = YES and citizenshipStatusReason <> (999_N_A_RULE_INDICATOR_IS_Y OR If the applicant attests to being a US Citizen and their Citizenship Status is inconsistent after calling SSA, then display the
(432_DMI_RESOLVED_BY_ESW_ADJUDICATION)) OR (naturalizedCitizenIndicator = true and
Naturalized Citizenship question
requestingCoverageIndicator = true)
Reason Codes:
177_CITIZENSHIP_NOT_VERIFIED` (string) - Attested citizenship status was not verified.
- `187_DEATH_DATA_PRESENT` (string) - Death data present.
- `189_DHS_DATA_NOT_MATCH_ATTESTATION` (string) - DHS data does not match attested information.
- `191_EDS_NOT_AVAILABLE` (string) - EDS not available.
- `227_NO_EDS_DATA_FOUND` (string) - No data found in External Data Source.
- `288_SSN_NOT_VERIFIED` (string) - SSN was not verified.
- `341_HUB_DID_NOT_RESPOND` (string) - HUB did not respond.
- `352_NO_SSN_PROVIDED` (string) - Individual did not provide SSN.
- `395_DID_NOT_ATTEST_TO_NATURALIZED_CITIZENSHIP_OR_LP` (string) - Member did not attest to naturalized citizenship or
eligible immigration status.
- `397_DID_NOT_PROVIDE_SSN_WITH_CITIZENSHIP_ATTESTATION` (string) - Member did not provide SSN with attestation of US
Citizenship.
- `398_ATSTD_TO_SAVE_NON_VERIFIABLE_STATUS` (string) - Applicant attested to a SAVE non verifiable status.
- `399_NOT_ENOUGH_INFO_PROVIDED_TO_VERIFY_ELGBL_LP_STATUS` (string) - Applicant did not provide enough information to
verify eligible immigration status.
- `400_VERIFIED_STATUS_NOT_CITIZEN_OR_LAWFULLY_PRESENT_OR_QUALIFIED_NON_CITIZEN` (string) - Verified status is not
considered a citizen, lawfully present, or qualified non-citizen.
- `432_DMI_RESOLVED_BY_ESW_ADJUDICATION` (string) - Inconsistency resolved by Eligibility Worker adjudication.
- `456_DATA_SOURCE_NOT_CALLED_DUE_TO_FAILED_ID_PROOF` (string) - Data source not called due to failed ID proofing.
- `464_NOT_ENOUGH_INFO_TO_VERIFY_NATURALIZED_CITIZENSHIP` (string) - Applicant did not provide enough information to
verify naturalized citizenship status.
- `465_HUB_CALL_RETURNED_TRANSACTIONAL_ERROR` (string) - Hub call returned transactional error.
- `476_ESW_EXPIRED_DMI` (string) - Eligibility Worker expired inconsistency.
- `477_ESW_EXPIRED_ANOTHER_DMI_SO_INELGBLE` (string) - Expired when eligibility worker expired another inconsistency
resulting in ineligibility.
- `531_ATSTD_NON_CITIZEN` (string) - Attested non-citizen.
- `555_N_A_RULE_DOES_NOT_APPLY` (string) - Not applicable (rule does not apply).
- `559_NO_CITIZENSHIP_ATTESTATION` (string) - No citizenship attestation.
- `560_INDIVIDUAL_NOT_REQUESTING_COVERAGE` (string) - Individual is not requesting coverage.
- `568_NOT_VERIFIED_PENDING_PAPER_VERIFICATION` (string) - Not verified, pending paper verification.
- `573_SSA_HUB_CALL_HELD_CALL_COUNTER_3_OR_MORE` (string) - Social Security Administration (SSA) HUB call held due to call
counter being greater than or equal to 3.
- `634_SSA_DATA_MISMATCH` (string) - SSA data mismatch.
- `635_DHS_BIRTHDATE_MISMATCH`(string) - DHS data does not match attested birthdate.
- `636_DHS_DOCUMENT_NUMBER_MISMATCH`(string) - DHS data does not match attested document number.
- `684_APPLICATION_REQUIRES_STEP_3` (string) - Application requires step 3.
- `685_APPLICATION_PUSHED_TO_STEP_2_BUT_HUB_CALL_FAILED` (string) - Application pushed to step 2 but hub call failed.
- `714_N_A_QHP_STOPPED_BY_OFFLINE_PROCESS` (string) - Qualified Health Plan terminated by an offline process.
- `999_N_A_RULE_INDICATOR_IS_Y` (string) - Not applicable.

Item #

Scenario

UI Question

5

Collect Grant Date for
MedicaidLawfulPresenceStatus

When did [FNLNS] get their current immigration status?

7

Collect income discrepancy explanation
for job income

The income you entered for [Employer Name] is lower
than what our records show. Why?

9

Collect individual annual income
discrepancy explanation

[FNLN]'s income in [coverage year] seems like it will be
annualIncomeExplanationRequiredIndicator = True (If any member of a tax household has
lower than what our records from the past 2 years show. the following status: OR
Is there a reason why?
A Tax Household has the following status:
and
= INCOME_LOWER_THAN_SOURCE) and
taxReturnFilingStatusType <> MARRIED_FILING_JOINTLY

N/A

Income - Income discrepancies

10

Collect Joint annual income discrepancy
explanation

FNLN's or [Spouse] income in [coverage year] seems like
it will be lower than what our records from the past 2
years show. Is there a reason why?

annualIncomeExplanationRequiredIndicator = True (If any member of a tax household has
the following status: OR
A Tax Household has the following status:
and
= INCOME_LOWER_THAN_SOURCE) and
taxReturnFilingStatusType =MARRIED_FILING_JOINTLY

N/A

Income - Income discrepancies

Joint Annual Income
Discrepancy

11

Collect variable income discrepancy
explanation

Why is [FNLNS]’s income in other months during
[coverage year] different than this month’s income?

incomeLessExplainedIndicator = False (attestation from Items 9 & 10) and
(medicaidIncomeStatus= Y and medicaidChipIncomeStatusReason = 360) and
variableIncomeIndicator = true

This page is for Medicaid Gap Filling. Removed chipIncomeStatus from the logic because annual
incomeExplanationRequiredIndicator is only set for Medicaid.

Income - Income discrepancies

Variable Income
Discrepancy

13

Medicaid/CHIP:
Collect enrollment information to
determine Final M/C and

Are any of these people currently enrolled in health
coverage?

preliminaryChipStatus = YES or preliminaryMedicaidStatus = YES or preliminaryAptcStatus =
YES or preliminaryEmergencyMedicaidStatus = YES

App 3 will use the same the question to collect non-ESC MEC attestations for members that are prelim eligible for Medicaid/CHIP or Preliminary eligibility questions APTC
APTC/Medicaid/CHIP

Per Person Medicaid
and CHIP Specific
Questions

Has [FNLNS] ever gotten a health service from the Indian americanIndianAlaskanNativeIndicator = true and
Health Service, a tribal health program, or urban Indian (preliminaryCHIPStatus = YES or preliminaryMedicaidStatus = YES)
health program or through a referral from one of
these programs?

The answer to this question is not used to determine eligibility by the Marketplace, but is used by Medicaid and CHIP agencies to
determine cost-sharing

Preliminary eligibility questions Medicaid & CHIP Specific

Per Person Medicaid
and CHIP Specific
Questions

14

Non-ESC MEC:
Collect attested health coverage type to
determine whether to call the Hub for
Non-ESC and whether to collect ESC
information.
Collect Indian Health Service Information

Conditional Display Logic based on API Response

Notes
(Where reason codes are listed, this is the full list of possible reason codes)
qhpLawfulpresenceStatusReason =
Reason Codes:
682_FIVE_YEAR_BAR_PEND_NEED_GRANT_DATE_AND_LP_EXPIRE_AFTER_90_DAYS or
- `143_FIVE_YEAR_BAR_IN_EFFECT` (string) - Five year bar in effect.
`683_FIVE_YEAR_BAR_PEND_NEED_GRANT_DATE_AND_TEMP_LP_EXPIRE_WITHIN_90_DAYS` - `150_SAVE_VERIFICATION_PENDING` (string) - SAVE verification is pending.
- `191_EDS_NOT_AVAILABLE` (string) - EDS not available.
- `395_DID_NOT_ATTEST_TO_NATURALIZED_CITIZENSHIP_OR_LP` (string) - Member did not attest to naturalized citizenship or
eligible immigration status.
- `398_ATSTD_TO_SAVE_NON_VERIFIABLE_STATUS` (string) - Applicant attested to a SAVE non verifiable status.
- `399_NOT_ENOUGH_INFO_PROVIDED_TO_VERIFY_ELGBL_LP_STATUS` (string) - Applicant did not provide enough information to
verify eligible immigration status.
- `456_DATA_SOURCE_NOT_CALLED_DUE_TO_FAILED_ID_PROOF` (string) - Data source not called due to failed ID proofing.
- `465_HUB_CALL_RETURNED_TRANSACTIONAL_ERROR` (string) - Hub call returned transactional error.
- `473_FIVE_YEAR_BAR_IS_PENDING` (string) - Five Year Bar Met status is pending.
- `555_N_A_RULE_DOES_NOT_APPLY` (string) - Not applicable (rule does not apply).
- `569_APPLICANT_ATSTD_CITIZEN` (string) - Applicant is an attested citizen.
- `605_HUB_INDICATES_NOT_LPV_OR_QNC` (string) - Hub returned LPV and QNC = N.
- `606_HUB_CALL_SUCCESSFUL_NO_DATA_FOUND` (string) - Hub call successful, no data found. Note: to be replaced with 227
- `607_NOT_ATSTD_IMMIGRANT_OR_CITIZEN` (string) - Applicant is not an attested immigrant or an attested citizen. Note: to be
replaced with 395.
- `608_ELGBL_UNDER_CHIPRA` (string) - Applicant is eligible under Children's Health Insurance Program Reauthorization (CHIPRA).
- `609_HUB_QNC_INDICATOR_IS_PENDING` (string) - QNC hub indicator is still pending.
- `610_HUB_QNC_INDICATOR_IS_N` (string) - QNC hub indicator is N.
- `611_SUBJECT_TO_7_YEAR_LIMIT_RULE` (string) - Applicant is subject to the seven year limit rule.
- `626_ATSTD_VETERAN` (string) - Applicant is an attested veteran.
- `627_FIVE_YEAR_BAR_DOES_NOT_APPLY` (string) - Five year bar does not apply.
- `628_NO_ATSTD_GRANT_DATE_AND_NOT_AVAILABLE_FROM_HUB` (string) - Grant date not available from hub and no attested
grant date.
- `629_FIVE_YEAR_BAR_NOT_MET_WITH_ATSTD_GRANT_DATE` (string) - Five year bar not met based on attested grant date.
- `630_FIVE_YEAR_BAR_INCONSISTENT_WITH_ATSTD_GRANT_DATE` (string) - Five year bar inconsistent based on attested grant
date.
- `631_NOT_MDCAID_OR_CHIP_INCOME_ELGBL` (string) - Applicant is not Medicaid or CHIP income eligible.
- `999_N_A_RULE_INDICATOR_IS_Y` (string) - Not applicable.

Section of Application

Card in Application

Citizenship/immigration

Grant Date

jobIncomeExplanationRequiredIndicator = True OR jobIncomeExplanationAcceptance = YES N/A
or PENDING

Income - Income discrepancies

Decreased Hours
Discrepancy, Stop
Working Discrepancy
Individual Annual
Income Discrepancy

[combined with APTC prelim eligibility current coverage
question]

16

Collect attestation that is used for retro
active Medicaid Eligibility

Would any of these people like help paying for medical
bills from the last 3 months?

preliminaryMedicaidStatus = YES or preliminaryEmergencyMedicaidStatus = YES

You can only be prelim Medicaid or CHIP cannot be prelim eligible for both.

Preliminary eligibility questions Medicaid Specific

Per Person Medicaid
and CHIP Specific
Questions

17

Collect dependent child enrollment
information to determine Final M/C

Do any of these people currently have health coverage?

Option 1: (dependentChildCoveredStatusReason <> 555, 652, 655 AND
preliminaryMedicaidStatus = YES) or coveredDependentChildIndicator <> null for the
applicant parent

The list of on non-applicant children that appear as answer options should come from the list of children that make the adult
eligible for PCR parentCaretakerChildList.

Preliminary eligibility questions APTC/Medicaid/CHIP

Per Person Medicaid
and CHIP Specific
Questions

OR
Option 2: There exists at least 1 member (M1) who has preliminaryMedicaidStatus = YES
AND dependentChildCoveredStatus <> NOT_APPLICABLE, AND
There exists at least 1 member (M2) who has requestingCoverageIndicator = false (nonapplicant) and is in the parentCaretakerChildList of M1

Reason Codes:
- `128_DEPENDENT_CHILD_DOESNT_HAVE_MEC` (string) - Applicant’s dependent child does not have minimal coverage.
- `551_APPLICATION_NOT_REQUESTING_FA` (string) - Application is not requesting Financial Assistance.
- `555_N_A_RULE_DOES_NOT_APPLY` (string) - Not applicable (rule does not apply)
- `560_INDIVIDUAL_NOT_REQUESTING_COVERAGE` (string) - Individual is not requesting coverage.
- `652_NOT_PRELIM_MEDICAID_OR_PRELIM_CHIP_ELIGIBLE` (string) - Applicant is neither Prelim Medicaid or Prelim CHIP
- `655_NOT_PRELIM_MEDICAID_ELIGIBLE`- (string) - Applicant not Prelim Medicaid eligible
- `670_APTC_INELGBL_DID_NOT_AGREE_TO_MDCAID_CHIP_LEGAL_ATTESTATIONS` (string) - Applicant ineligible for APTC due to
disagreeing to one of the Medicaid/CHIP legal attestations.
- `999_N_A_RULE_INDICATOR_IS_Y` (string) - Not applicable.

Item #
18

Scenario

UI Question

Conditional Display Logic based on API Response

Collect absent parent information to
determine Final M/C

Does [Child name 1] have a parent living outside the
home?

The application filer (householdContactIndicator = true) has:
pregnancyIndicator = false
preliminaryMedicaidStatus = YES or preliminaryEmergencyMedicaidStatus = YES AND

N/A

Notes
(Where reason codes are listed, this is the full list of possible reason codes)

Section of Application

Card in Application

Preliminary eligibility questions Medicaid Specific

Per Person Medicaid
and CHIP Specific
Questions

Preliminary eligibility questions Medicaid Specific

Per Person Medicaid
and CHIP Specific
Questions

There exists an applicant child, under age 18, who:
preliminaryMedicaidStatus = YES or preliminaryEmergencyMedicaidStatus = YES AND
lives with 1 or no parents
19

Collect parent work hours to determine if How many hours per week do [Child’s name]’s parents
child is deprived parental support
work?

(preliminaryMedicaid = Y and parent1WeeklyWorkHourQuantity or
This should display regardless of whether they live parents or stepparents.
parent2WeeklyWorkHourQuantity <> null for children in the parentCaretakerChildList of the
applicant) OR
Display the question for the applicant: (requestingCoverageIndicator = true and
preliminaryMedicaidStatus = Y and parentCaretakerCategoryStatus = Temporary) and
Display the question for any child in the applicant's parentCaretakerChildList with:
childCaretakerDeprivedStatus = Temporary

20

Collect the attested coverage end date for Did any of these people have coverage through a job
states that require a CHIP Waiting Period. that ended in the last [waiting period] months?

preliminaryCHIPStatus = YES and chipWaitingPeriodStatusReason <> 555, 652, 657, 470, 551

Reason Codes:
- `139_CHIP_WAITING_PERIOD_IN_EFFECT` (string) - CHIP waiting period is still in effect.
- `470_RECENTLY_DENIED_MDCAID_CHIP_PREVENT_RETURN_TO_STATE` (string) - Applicant was recently denied Medicaid/CHIP;
prevent return to State.
- `551_APPLICATION_NOT_REQUESTING_FA` (string) - Application is not requesting financial assistance.
- `555_N_A_RULE_DOES_NOT_APPLY` (string) - Not applicable (rule does not apply)
- `560_INDIVIDUAL_NOT_REQUESTING_COVERAGE` (string) - Individual not requesting coverage.
- `652_NOT_PRELIM_MEDICAID_OR_PRELIM_CHIP_ELIGIBLE` (string) - Applicant is neither Prelim Medicaid or Prelim CHIP
- `656_ATTESTED_TO_CHIP_WAITING_PERIOD` (string) - Attested to a CHIP Waiting Period exception
- `657_APPLICANT_NOT_PRELIM_CHIP_ELIGIBLE` (string) - Applicant not Prelim CHIP eligible
- `670_APTC_INELGBL_DID_NOT_AGREE_TO_MDCAID_CHIP_LEGAL_ATTESTATIONS` (string) - Applicant ineligible for APTC due to
disagreeing to one of the Medicaid/CHIP legal attestations.
- `999_N_A_RULE_INDICATOR_IS_Y` (string) - Not applicable.

Preliminary eligibility questions - CHIP
Specific

Per Person Medicaid
and CHIP Specific
Questions

21

Collect attestations for State Health
Benefits to determine CHIP eligibility.

chipStateHealthBenefitStatusReason = 670, 654, 155, 138, 999

Reason Codes:
Preliminary eligibility questions - CHIP
- `138_INCOME_EXCEEDS_FPL_WHEN_APPLICANT_HAS_ACCESS_TO_STATE_EMPLOYEE_HEALTH_COVERAGE` (string) - Not applicable Specific
(rule does not apply)
- `155_STATE_PROVIDES_NO_CHIP_TO_APPLICANTS_ACCESS_TO_STATE_COVERAGE` (string) - State does not provide CHIP to
applicants with access to state health insurance.
- `551_APPLICATION_NOT_REQUESTING_FA` (string) - Application is not requesting financial asssistance.
- `560_INDIVIDUAL_NOT_REQUESTING_COVERAGE` (string) - Individual is not requesting coverage.
- `652_NOT_PRELIM_MEDICAID_OR_PRELIM_CHIP_ELIGIBLE` (string) - Applicant is neither Prelim Medicaid or Prelim CHIP
- `653_HEALTH_BENEFITS_QUESTION_NOT_DISPLAYED` (string) - Health benefits question not displayed
- `654_NO_STATE_HEALTH_BENEFITS_THROUGH_PUBLIC_EMPLOYEE` (string) - Applicant attest to not receiving State Health
Benefits through a public employee
- `657_APPLICANT_NOT_PRELIM_CHIP_ELIGIBLE` (string) - Applicant not Prelim CHIP eligible
- `670_APTC_INELGBL_DID_NOT_AGREE_TO_MDCAID_CHIP_LEGAL_ATTESTATIONS` (string) - Applicant ineligible for APTC due to
disagreeing to one of the Medicaid/CHIP legal attestations.
- `999_N_A_RULE_INDICATOR_IS_Y` (string) - Not applicable.

Per Person Medicaid
and CHIP Specific
Questions

23

Collect relationship between applicants to What is the relationship between [FNLNS] and [FNLNS]?
determine QHP eligible applicants

Is [FNLNS] offered the [tenantID] state employee health
benefit plan through a job or a family member’s job?

Ask only if relationship is not already collected or derived and both applicants are
preliminarily eligible for QHP, according to the following in the API response:
prelimQHP:
(citizenshipStatus= YES or qhpLawfulPresenceStatus= YES) and
qhpResidencyStatus = YES and
incarcerationStatus = NO and
(preliminaryCHIPStatus <> YES AND preliminaryMedicaidStatus <> YES)

Preliminary eligibility questions - QHP
Specific

QHP Applicant
Relationships

Item #
24

Scenario

UI Question

Conditional Display Logic based on API Response

Collect legal relationships for enrollment
groupings

You selected ["Other relative"/"Other unrelated"
(Selected Family Relationship)] for the relationship of
[Name 1-FNLNS] to [Name 2-FNLNS].

If person is prelimQHP eligible* & has one of following** relationships to a QHP eligible
member

You told us that [Name 1-FNLNS] is the [Selected Family
relationship - see rules ] of [Name 2-FNLNS].
Is the relationship between [FNLNS, applicant] and
[applicant FNLNS] also any of these?

Notes
(Where reason codes are listed, this is the full list of possible reason codes)

Section of Application

Card in Application

Preliminary eligibility questions - QHP
Specific

Legal Relationships

*prelimQHP:
(citizenshipStatus= YES or qhpLawfulPresenceStatus= YES) and
qhpResidencyStatus = YES and
incarcerationStatus = NO and (preliminaryCHIPStatus <> Y AND preliminaryMedicaidStatus <>
Y)
If person is QHP eligible & has one of those relationships or is a potential ward to a QHP
eligible member
subordinateMember has to be QHP eligible and the subordinate has to be QHP eligible and
the relationship between the subordinate and the subordinate has to be one of the
following
familyRelationshiptype exist between two prelimQHP eligible applicants
PARENTS_DOMESTIC_PARTNER
AUNT_UNCLE
GRANDPARENT
CHILD_OF_DOMESTIC_PARTNER
SIBLING
NEPHEW_NIECE
FIRST_COUSIN
GRANDCHILD
OTHER_RELATIVE
OTHER
DOMESTIC_PARTNER
or familyRelationshiptype exist (SON_DAUGHTER) or (STEPSON/_STEPDAUGHTER) and the
age of the subordinate has to be => 25 or
familyRelationshiptype exist (PARENT) or (STEP_PARENT) and the age of the subordinate has
to be => 25

25

Collect tribe information to determine
CSR and SEP eligibility

Which of these people are members of a federally
recognized tribe?

americanIndianAlaskanNativeIndicator = True AND
prelimQHP:
(citizenshipStatus = YES or qhpLawfulPresenceStatus = YES) and
qhpResidencyStatus = YES and
incarcerationStatus = NO and (preliminaryCHIPStatus <> Y AND preliminaryMedicaidStatus <>
Y)

Preliminary eligibility questions - QHP
Specific

Tribe Member

26

Collect change information to determine
SEP

All SEP Questions

prelimQHP:
(citizenshipStatus = YES or qhpLawfulPresenceStatus = YES) and
qhpResidencyStatus = YES and
incarcerationStatus = NO and (preliminaryCHIPStatus <> Y AND preliminaryMedicaidStatus <>
Y)

Preliminary eligibility questions - QHP
Specific

All SEP Questions

28

Application cannot be submitted due to
Data Source being down

You're almost finished with your application.

SES will set a unique HTTP status code and error code within the body. Currently this is a
response with an HTTP status reason of 200.
You have started an application for health coverage, but
our verification system is temporarily unavailable.
{
Without completing verification, you cannot submit your
"resultType": "ERROR",
application for an eligibility determination.
We will save your information and expect to resolve the
problem within 24 hours. When you return please
review your entire application from beginning to end in
order to receive your online eligibility results.

The Submit API will respond with a 200 OK and an “ERROR” status when DHS is unavailable. It will also respond with a 200 OK and a Review & Sign
“SUCCESS” status with a specific warn message when SSA, IRS, Equifax, etc. are unavailable.

Delayed Response
Shepherding

"error":{
"errorType": "DATA_SOURCE_ERROR",
"apiMessage": "The Data Services Hub has returned an error to SES",
"errors": [{
"errorCode": "EDS_OR_HUB_DELAYED ",
"apiMessage": "EDS_OR_HUB_DELAYED "
}]
}
}

29

Medicaid Agreement

If anyone on this application enrolls in Medicaid, I’m
preliminaryMedicaidStatus = YES or (preliminaryEmergencyMedicaidStatus = YES AND
giving the Medicaid agency our rights to pursue and get preliminaryMedicaidStatus = NO)
any money from other health insurance, legal
settlements, or other third parties. I’m also giving to the
Medicaid agency rights to pursue and get medical
support from a spouse or parent.

Agree/Sign/Submit - Attestations

Sign & Submit

30

Absent Parent Agreement

If a child on this application has a parent living outside
of the home, I know I’ll be asked to cooperate with the
agency that collects medical support from an absent
parent. If I think that cooperating to collect medical
support will harm me or my children, I can tell the
agency and I may not have to cooperate.

Agree/Sign/Submit - Attestations

Sign & Submit

The application filer (householdContactIndicator = true) has:
pregnancyIndicator = false
(preliminaryMedicaidStatus = YES and preliminaryMedicaidStatusReasonCode <> 670) or
preliminaryEmergencyMedicaidStatus = YES AND
There exists an applicant child, under 18, who:
(preliminaryMedicaidStatus = YES and preliminaryMedicaidStatusReasonCode <> 670) or
preliminaryEmergencyMedicaidStatus = YES AND
lives with 1 or no parents AND absentParentIndicator = true

Item #
31

Scenario

UI Question

Unable to Build Medicaid Household

This is a message to the UI to allow the application filer medicaidHouseholdStatusReason = 369 or 371
know that based on the attestations provided they could
be eligible for Medicaid if they file the application with
the applicable parent information:

Conditional Display Logic based on API Response

Section of Application

Card in Application

More about this household

Dependent

N/A

N/A

Include applicants (requestingCoverageIndicator = true) who meet ALL of the following
criteria:
medicaidStatus <> YES, AND
medicaidStatusReason <>
470_RECENTLY_DENIED_MDCAID_CHIP_PREVENT_RETURN_TO_STATE, AND
emergencyMedicaidStatus <> YES, AND
medicaidNonMagiReferralStatus <> YES OR
acceptMedicaidEligibilityIndicator <> Y

Eligibility results

N/A

prelimQHP for any applicant:
(citizenshipStatus = YES or qhpLawfulPresenceStatus= YES) and
qhpResidencyStatus = YES and
incarcerationStatus = NO and (preliminaryCHIPStatus <> Y AND preliminaryMedicaidStatus <>
Y)

Review & Sign

Sign & Submit

Message in UI: "[Dependent FNLNS] may be eligible for
Medicaid or the Children's Health Insurance Program
(CHIP) through the parent they live with. That parent can
file their own application. To do so, he or she can create
their own account on this website, call 1-800-318-2596,
or print a paper application at
www.healthcare.gov/paperapp to mail in. You can also
continue with this application now to see if [parent
FNLNS] can get a tax credit to pay for health insurance
for [dependent FNLNS] instead."

32

Information Cannot Be Verified

Some systems are down. Save and return later, or
continue with the app without submitting.

SSA Not Available:
computed.members[*].ssnStatusReason =
"191_EDS_NOT_AVAILABLE"

Notes
(Where reason codes are listed, this is the full list of possible reason codes)
Reason Codes
- `369` (string) - No custodial parent in app
- `371` (string) - No family info in app
- `560` (string) - Not requesting coverage
- `662` (string) - Claiming tax filer not on application
- `663` (string) - Is a non-filer
- `664` (string) - Is a non-applicant and family of a non-filer
- `999` (string) - Successfully created medicaid household

HUB Not Availablefor SSA:
computed.members[*].ssnStatusReason =
"341_HUB_DID_NOT_RESPOND"
DHS Not Available:
computed.members[*].citizenshipStatusReason =
"191_EDS_NOT_AVAILABLE"
Hub Not Availablefor DHS:
computed.members[*].citizenshipStatusReason =
"341_HUB_DID_NOT_RESPOND"
33

Full Medicaid Determination

Full Medicaid Determination in a Determination State:
Do any of these people want to request a determination
for Medicaid as conducted [medicaidAgencyName] on
the basis of disability, blindness, or reoccurring medical
needs and bills?
Full Medicaid Determination in an Assessment State:
It looks like these people aren’t eligible for Medicaid.
They can still continue with a Medicaid application if we
send their information to the [State Medicaid Agency
name]. Do any of these people want us to send their
information to the [State Medicaid Agency name] so
they can check on Medicaid and The Children’s Health
Insurance Program (CHIP) eligibility, if applicable?

34

Terminate Coverage Agreement

If anyone on your application enrolls in coverage
through a Marketplace plan, but is later found to have
other qualifying health coverage (including Medicare,
Medicaid, and/or CHIP), you have the option to allow
the Marketplace to end their Marketplace coverage if
you select "I agree to this statement" below.
If you select "I disagree to this statement," anyone in
this situation will stay enrolled in Marketplace coverage
and will pay full cost for their Marketplace plan since
they'll no longer be eligible for advance payments of the
premium tax credit or extra savings.

Eligibility Results
Item # Applicable EDE Phase**

1

Phase 1, Phase 2, Phase 3

Required/Optional to
Display to Consumer**

Eligibility Results Section**

Information Included in Section**

View Your “Coverage Options at a Glance”

This section gives a quick snapshot of the consumer's eligibility Required
results. It contains high level information about program
eligibility for each applicant. In the FFE, this information is
displayed in a chart.

Wording**

Requirements**

Notes

HealthCare.gov uses the following messaging for the eligibility results page:

The application must display high level eligibility results and next steps and information
about each applicant's program eligibility, DMIs, and SVIs in a clear, comprehensive and
consumer-friendly way. DE entities have flexibility for how they display the high level results
to consumers. If a consumer is not eligible for any programs, the UI should indicate that they
are ineligible. If the consumer is eligible for Medicaid or CHIP, the UI does not need to say
that they are not eligible for QHPs. If the consumer is eligible for QHPs, the eligibility results
page does not need to say that they are not eligible for Medicaid/CHIP, APTC, or CSRs if they
are seeking financial assistance.

Partners should use the State Reference Data API to identify Assessment states and Determination states.

Ineligible for all programs: Not eligible for health plans, premium tax credits,
lower copayments, coinsurance, and deductibles (cost-sharing reductions),
or state health benefits.
QHP eligibility: Eligible to buy a Marketplace plan
Medicaid eligibility in Determination state: Eligible for Medicaid.
Medicaid eligibility in Determination state where the consumer also has
discrepancies in the data on their application and data from TDS (pending
Medicaid status): May be eligible for Medicaid. Your state Medicaid agency
will contact you if you need to provide more information.
CHIP eligibility in Determination state: Eligible for CHIP.
CHIP eligibility in Determination state where the consumer also has
discrepancies in the data on their application and data from TDS (pending CHIP
status): May be eligible for CHIP. Your state CHIP agency will contact you if you
need to provide more information.
Medicaid eligibility in Assessment state: May be eligible for Medicaid.
CHIP eligibility in Assessment state: May be eligible for CHIP.
DMIs: Your eligibility is temporary: By [date], you must submit documents to
confirm some information. See your eligibility notice for details and
deadlines.
SVIs: You're eligible for a Special Enrollment Period, but we need information.
Submit documents as soon as possible to confirm your marriage. You'll pick a
plan now, and your coverage will start once your documents are approved.
See your eligibility notice for details and deadlines.
APTC: use generic terms to describe eligibility for tax credits. Do not use
terms like "discount." HealthCare.gov uses the following messaging: "Eligible
for a premium tax credit of up to [amount] each month for your tax
household"
CSR for consumers who do not attest to being a member of a federally
recognized tribe: Eligible for lower copayments, coinsurance, and
deductibles (cost-sharing reductions) on Silver plans.
CSR for consumers who attest to being a member of a federally recognized
tribe: Eligible for additional help with costs as a member of a tribe
The following are two options for eligibility results wording for applicants
found both QHP and Medicaid eligible (applicants found Non-MAGI Medicaid
eligible) in either a Determination state or Assessment state:
QHP and Medicaid eligibility in Determination state:
1. Eligible to buy a Marketplace plan
2. Eligible to buy a Marketplace plan AND May be eligible for Medicaid
QHP and Medicaid eligibility in Assessment state:
1. Eligible to buy a Marketplace plan
2. Eligible to buy a Marketplace plan AND May be eligible for Medicaid

QHP and Medicaid eligible applicants
It may appear that an applicant is QHP eligible and Medicaid eligible in the Fetch Eligibility
response when in reality they are being referred to the state Medicaid agency for a
determination on the basis of age or disability. In this case, the eligibility results page should
not state that the applicant is Medicaid eligible. When it appears in the response that
consumers are eligible for both QHP and Medicaid, the eligibility results page can either say
that the applicant "May be eligible" for Medicaid, including in Determination states, or can
remove the Medicaid language altogether for the QHP eligible applicant. If partners provide
the "may be eligible" for Medicaid language on the eligibility results page, applicants found
MAGI or non-MAGI eligible in assessment states may be grouped together in the same line
item; however, applicants found MAGI or non-MAGI eligible in determination states must be
in separate line items. The detailed information about the referral will be available in the
EDN.
Wording Specifications
HealthCare.gov does not use the acronyms DMI, CSR, QHP, APTC, SEP, or SVI and EDE entity UIs
should not use these acronyms either. CMS uses specific language to describe each of these
components of eligibility. The eligibility results page should follow the guidelines below:
QHP eligibility: must use generic terms like "Marketplace health plans," "Marketplace plans,"
and "Marketplace coverage"
DMIs: language must indicate more information is needed from the consumer to confirm
their eligibility results.
Async pending (IRS): the UI must notify APTC-eligible consumers that their income information
is still being processed, and that they may get a separate message from the Marketplace/EDE
partner if more information is needed.
SVIs: The UI must notify the consumer they are required to provide more information to
confirm their eligibility for a Special Enrollment Period.
APTC/CSR: use generic terms to describe eligibility for financial assistance. Do not use
misleading terms like "discount." Each applicant is eligible for a specific amount of APTC as
determined by SES APTC and cannot be split between applicants. The APTC amount displayed
on the eligibility results page must be the determined APTC amount for each tax household.

Assessment states:
acceptCHIPEligibilityIndicator = N
acceptMedicaidEligibilityIndicator = N
Determination states:
acceptCHIPEligibilityIndicator = Y
acceptMedicaidEligibilityIndicator = Y
When consumers are found Medicaid or CHIP eligible in a Determination state and their eligibility status is pending, the eligibility
results page should state "May be eligible for Medicaid" or "May be eligible for CHIP" for that consumer.
To identify a pending status for consumers who are found Medicaid or CHIP eligible in a Determination state, partners should use
the Submit App and Get App response upon a successful application submission.
The following field names and reason codes will be returned in the Submit App or Get App response when consumers have a pending
Medicaid or CHIP eligibility status. Please note, both pending and inconsistencies will return a status of "Yes" for
result.computed.members.[MEMBER-ID].chipStatus or result.computed.members.[MEMBER-ID].medicaidStatus.
The result.computed.members.[MEMBER-ID].chipStatusReason or result.computed.members.[MEMBER-ID].medicaidStatusReason
will return the following codes:
150_SAVE_VERIFICATION_PENDING: SAVE verification is pending
177_ATTESTED_CITIZENSHIP_WAS_NOT_VERIFIED
189_DHS_DOES_NOT_MATCH_ATTESTATION
191_EDS_NOT_AVAILABLE: EDS not available
227_NO_EDS_DATA_FOUND: No data found in EDS
288_SSN_WAS_NOT_VALIDATED
302_RESIDENCY_INCOME_PENDING: Residency or Income information is pending
Inconsistent - chipStatusReason/medicaidStatusReason
341_HUB_DID_NOT_RESPOND
397_DID_NOT_PROVIDE_SSN_WITH_CITIZENSHIP_ATTESTATION
398_ATSTD_TO_SAVE_NON_VERIFIABLE_STATUS: Applicant attested to a SAVE non verifiable status
399_NOT_ENOUGH_INFO_PROVIDED_TO_VERIFY_ELGBL_LP_STATUS: Applicant did not provide enough information to verify eligible
immigration status
400_VERIFIED_STATUS_IS_NOT_CONSIDERED_A_CITIZEN_LAWFULLY_PRESENT_OR_QUALIFIED_NON_CITIZEN
456_DATA_SOURCE_NOT_CALLED_DUE_TO_FAILED_ID_PROOF: Data source not called due to failed ID Proofing
464_ATTESTED_NATURALIZED_CITIZEN_DID_NOT_PROVIDE_ENOUGH_INFORMATION
465_HUB_CALL_RETURNED_TRANSACTIONAL_ERROR: Hub call returned transactional error
473_FIVE_YEAR_BAR_IS_PENDING
573_SSA_HUB_CALL_HELD_DUE_TO_CALL_COUNTER_3
605_HUB_INDICATES_NOT_LPV_OR_QNC: Hub returned LPV and QNC = N
609_HUB_QNC_INDICATOR_IS_PENDING: QNC hub indicator is still pending
618_VOT_STATUS_REQUIRES_DOCUMENTATION: VOT Status always requires documentation
619_OLDER_THAN_18_DOCUMENTATION_REQ: Applicant older than 18, documentation required
620_GRANT_DATE_NOT_AVAILABLE_DOCUMENTATION_REQ: Grant date not available to calculate years with status, documentation
required
621_REQ_YEARS_WITH_STATUS_NOT_MET_DOCUMENTATION_REQ: Does not meet the required years with status, documentation
required
622_STATUS_START_DATE_NOT_AVAILABLE_TO_CALC_7_YR_LIMIT: Status start date is not available to calculate 7 year limit
626_ATSTD_VETERAN: Applicant is an attested veteran
628_NO_ATSTD_GRANT_DATE_AND_NOT_AVAILABLE_FROM_HUB: Grant date not available from hub and no attested grant date
630_FIVE_YEAR_BAR_INCONSISTENT_WITH_ATSTD_GRANT_DATE: Five year bar inconsistent based on attested grant date
634_SSA_DATA_MISMATCH
635_DHS_BIRTHDATE_MISMATCH
636_DHS_DOCUMENT_NUMBER_MISMATCH
645_APPLICANT_SPOUSE_PARENTS_PRESENT_MISSING_WORK_QUARTERS: Have applicant, spouse and parents but missing work
quarters
646_PARENT_OR_SPOUSE_NOT_ON_APPLICATION_FOR_WORK_QUARTERS: Spouse and/or parent(s) not on application for work
quarters
---------------------Async pending (IRS)
To identify when an application was submitted pending async response for income verification, partners can use the Submit App or
Get App response. Partners should display appropriate messaging for applications where:
1. at least one member qhpStatus=Yes AND aptcStatus=Yes AND Tax HH maxAPTCAmount > 0 AND
2. asyncSubmissionResult.asyncSubmissionStatus = PENDING, AND
3. taxHouseholds.[memberIdentifier].annualIncome.annualIncomeStatusReason= 753_PENDING_ASYNC AND
4. taxHouseholds.[memberIdentifier].annualIncome.asyncSubmissionIndicator= true

2

Phase 1, Phase 2, Phase 3

View Your “Eligibility Results”

This section gives the consumer a hyperlink or button to
download a PDF of their Eligibility Determination Notice (EDN).

Required

N/A

The eligibility results must provide the ability for the consumer to view and print the EDN,
which will display full information about each applicant's detailed eligibility results. The
consumer must download the EDN prior to finalizing the enrollment.

3

Phase 1, Phase 2, Phase 3

Full Medicaid Determination

This sections allows consumers who were found ineligible for
Medicaid to request a full Medicaid determination from their
state agency (and CHIP, if applicable).

Required

Full Medicaid Determination in an Assessment State:
It looks like these people aren’t eligible for Medicaid. They can still continue
with a Medicaid application if we send their information to the [State
Medicaid Agency name]. Do any of these people want us to send their
information to the [State Medicaid Agency name] so they can check on
Medicaid and The Children’s Health Insurance Program (CHIP) eligibility, if
applicable?
[Checkboxes, multi-selection]
Display names of all applicants who are ineligible for Medicaid
Full Medicaid Determination in a Determination State:
Do any of these people want to request a determination for Medicaid as
conducted by [state Medicaid Agency name] on the basis of disability,
blindness, or reoccurring medical needs and bills?
[Checkboxes, multi-selection]
Display names of all applicants who are ineligible for Medicaid

Under CMS regulations, the application must give consumers who are found ineligible for
Medicaid the opportunity to request a full determination by the state Medicaid agency.
Wording must be the exact same as provided in this document.

4

Phase 1, Phase 2, Phase 3

What should I do if I think my eligibility results
are wrong?

This section provides consumers with information on appealing Required
their eligibility results.

What should I do if I think my eligibility results are wrong?
The application must present full and clear appeal rights under the law for all consumers.
If you don’t agree with what you qualify for, you may be able to file an appeal. Wording must be the exact same as the appeals wording provided in this document.
You can appeal eligibility to buy Marketplace plans and also for enrollment
periods. If you're applying for help paying for coverage, you may also have the
r

Review your eligibility notice to find appeals instructions for each person in
your household, including the number of days you have to file an appeal.
Here's important information to consider when filing an appeal:
-You can have someone file and participate in your appeal. That person can
be a friend, relative, lawyer, or other person. Or, you can file and participate
in your appeal on your own.
-If you file an appeal, you may be able to keep your eligibility for coverage
while your appeal is pending.
-The outcome of an appeal could change the eligibility of other members of
your household.
-Depending on your state and your eligibility results, you may be able to file
an appeal through the Marketplace if you may have to file an appeal with
your state Medicaid or CHIP agency.
-Learn more about how to appeal your Marketplace eligibility results.
[Hyperlink to https://healthcare.gov/marketplace-appeals/] You can also
mail an appeal request form or your own letter filing an appeal to Health
Insurance Marketplace, 465 Industrial Blvd., London, KY, 40750-0001.

5

Phase 1, Phase 2, Phase 3

Voter Registration

This section guides applicants to the voter registration site.

Required

Would you like to register to vote? (Optional)
Click here to register to vote. (Hyperlink to
https://www.eac.gov/voters/national-mail-voter-registration-form/)

Under the National Voter Registration Act, the application must include a pathway to voter
registration. Wording is flexible, however, this must be clearly labeled as optional for all
applicants.

The SES data element for this request is requestMedicaidDeterminationMembers on Submit App. The application must be submitted
prior to requesting a full Medicaid determination. After the eligibility determination is complete, the requestor should call SES and
update this indicator. See item #33 on the "Backend Responses for UI" tab.

Auditor Compliance Conclusion**

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor Comments**

Error Handling
Item # Scenario
1

Verification systems down on
Update App call

Description

UI Messaging

Conditional Display Logic Based on API Response

Conditional Display Logic Based on Attestations in UI

Requirements

Notes

This may occur for any Update App call that can trigger
verifications with trusted data sources. This may occur for the
Social Security Administration (SSA) verification services,
Department of Homeland Security (DHS)verification services,
Internal Revenue Services (IRS) verification services, and
Federal Data Services Hub for SSA and/or DHS verification.
For example, after SSN is collected, SSN verification is
triggered. After income is collected, income verification is
triggered. After citizenship/immigration status is collected,
citizenship//immigration verification is triggered. This error
may be triggered when the SSA is down during SSN
verification, or DHS is down during citizenship/immigration
verification. This will result in SES returning a delay or error
response.

We can't verify your information right now. We’re working to
fix the issue. We verify your information using electronic
records and some of those records are temporarily unavailable.
We can't tell you what you are eligible for right now. You have
2 options:

SSA not available:
ssnStatusReason = 191_EDS_NOT_AVAILABLE

N/A

SES will only return errors when
verification systems are down and relevant
verifications are still required on the
application.

Save & return later: We'll save all of your information. We
expect to fix the issue within 24 hours. When you return, you
can complete your application and submit it to receive your
eligibility results.

DHS not available:
citizenshipStatusReason = 191_EDS_NOT_AVAILABLE

The UI must display user friendly error messaging when
verification services are down. The UI may choose to
implement a similar approach as outlined here where the
consumer is presented with an option to continue completing
their application or to save their information and return later.
If the UI does not implement options, it could follow login
described in item #2. The UI may use alternate messaging.

If the verification services are down on the Submit App call, a
message must be displayed in the UI that tells the user to
come back at a later time to submit their application for an
eligibility determination. The UI may use alternate messaging
and include the number to their own call center.

SES will only return errors when
verification systems are down and relevant
verifications are still required on the
application.

Continue & submit later: We'll save all of your information.
You can continue now, then return later to review, sign, and
submit your application to receive your eligibility results.

Hub not available for SSA:
ssnStatusReason = 341_HUB_DID_NOT_RESPOND

Hub not available for DHS:
citizenshipStatusReason = 341_HUB_DID_NOT_RESPOND

Display penalty of perjury attestation (row 257 of UI Questions N/A
tab) and the field for electronic signature (row 259 of UI. Call
Update App to manually save the signature date an
attestations.

Consumer selected to save and return later

Display all questions for the user to complete the application.
Display all necessary end of application attestations for the
consumer and collect signature.

N/A

Consumer selected to continue and submit later

SSA not available:
ssnStatusReason = 191_EDS_NOT_AVAILABLE

N/A

When the consumer opts to save and
return later, they will stop the application
where they are. When the consumer opts
to continue and return later, they will
complete the rest of the application and
return later to submit it. Both options
require the consumer to return to the
application, review their attestations, and
submit the application.

Note: At the end of the application, call SES Submit App and if
verification services are down for verifications that are still
needed, SES Update App should be called to manually save the
signature and attestations. The UI should then display similar
messaging for item #2 for verification systems down for
Submit App call or similar messaging used for the original
message displayed to the consumer in row 2.

2

Verification systems down on
Submit App call

If SSA or DHS is down and verifications that are still required Our verification system is temporarily unavailable. Please
for an eligibility determination, SES Submit App will return a come back in 24 hours. If you continue to get an error, call the
delay or error response for those verifications.
Marketplace Call Center at 1-800-318-2596 for assistance. TTY
users can use 1-855-889-4325. You will need your application
ID.

Hub not available for SSA:
ssnStatusReason = 341_HUB_DID_NOT_RESPOND
DHS not available:
citizenshipStatusReason = 191_EDS_NOT_AVAILABLE
Hub not available for DHS:
citizenshipStatusReason = 341_HUB_DID_NOT_RESPOND
SES will set a unique HTTP status code and error code
within the body of the response when an unidentified
trusted data source is unavailable. This is an example of a
response with an HTTP status reason of 200
"resultType": "ERROR",
"error": {
"errorType": "DATA_SOURCE_ERROR"
"apiMessage": "The Data Services Hub has returned an
error to SES"
"errors": [
{
"errorCode": "EDS_OR_HUB_DELAYED"
"apiMessage":"EDS_OR_HUB_DELAYED"

3

Blocking error in middle of
application

This occurs at any blocking error that happens when the
consumer is in the middle of the application. This could be
triggered by an issue with Update App, Add Member, or any
call prior to Submit App that is not related to a verification
system being down.

Note: After the error response is received, display the penalty SES will return an error with an http status of anywhere in N/A
of perjury attestation and the field for electronic signature if
the 4XX or 5XX. An example of the blocking response body:
the consumer has not completed these attestations. Call
Update App to manually save the signature date an
"resultType": "ERROR",
attestations.
"error": {
"errorType": "INTERNAL_ERROR"
Error Message in UI: Sorry, we're having a problem with our
"apiMessage": "System can't process your request, please
system. We don't have enough information to process your
try later"
application, but wee still have the date of your first signature
"errors": []
saved. If you complete your application and are determined
eligible for Medicaid or CHIP, your state may use this date to
determine when your coverage will begin. Please call the
Marketplace Call Center at 1-800-318-2596 for assistance. TTY
users can use 1-855-889-4325. You will need your application
ID.

If SES returns an error in the middle of the application, the UI
must display an error message that tells the consumer there is
an error but because they have provided a signature, the date
of their signature will be used for coverage dates for Medicaid
and CHIP. The UI may use alternate messaging and include the
number to their own call center.

Item # Scenario
4

5

6

Blocking error on application
submission

Validation errors in the middle
of the application

EDE entity system error

Description

UI Messaging

Conditional Display Logic Based on API Response

Conditional Display Logic Based on Attestations in UI

Requirements

This occurs at any blocking error that happens when the
consumer attempts to submit an application. This could
include flow level errors, which involved a 409 HTTP error
code from SES. Note that flow level validation blocking errors
earlier on the application are not treated as blocking errors
and will result in a 200 HTTP success code.

Note: After the error response is received, display the penalty
of perjury attestation and the field for electronic signature if
the consumer has not completed these attestations yet. Call
Update App to manually save the signature date an
attestations.

SES will set a unique HTTP status code and error code
within the body of the response. This is an example of a
response with an HTTP status reason of 200

N/A

If SES returns an error that blocks application submission, the
UI must display an error message that tells the consumer to
come back in 24 hours to reattempt application submission.
The UI may use alternate messaging and include the number
to their own call center.

N/A

If a data validation error occurs, the UI must prompt the user
to fix necessary data. Data validation errors from Update App
are unlikely if the UI displays all necessary questions and
requires all necessary fields. The UI does not need to display an
explicit error message and could instead highlight the field the
consumer needs to complete or fix.

N/A

EDE entities must have user friendly error messaging for errors
with their system. The UI may use alternate messaging and
include the number to their own call center.

"resultType": "ERROR",
"error": {
Error Message in UI: We've run into an unexpected error.
"errorType": "DATA_SOURCE_ERROR"
Don't worry, we still preserved the signature you provided
"apiMessage": "The Data Services Hub has returned an
before. Come back in 24 hours to see if you can complete the error to SES"
application. If you continue to get an error, call the
"errors": [
Marketplace Call Center at 1-800-318-2596 for assistance. TTY
{
users can use 1-855-889-4325. You will need your application
"errorCode": "EDS_OR_HUB_DELAYED"
ID.
"apiMessage":"EDS_OR_HUB_DELAYED"

This may occur when a data field is left blank by the
Display message in UI for consumer to fix the data in the
consumer and it is required for them to continue with the
application (or complete all required fields).
application. In such cases, error messaging should be
instructional for the consumer to fix the application data or
complete all necessary fields. This could be triggered by an
issue with Create App, Update App, Add Member, or any call
prior to Submit App.

SES will include a specific path in the error response where
the data validation issue may exist.

This may occur for any errors as a result of EDE entity system Please log out and log back in and try again. If the problem
errors. Some instances of this error may be a result of
persists, call the Marketplace Call Center at 1-800-318-2596
authentication issues with SES.
for assistance. TTY users can use 1-855-889-4325.

Example of SES authentication issue:

"resultType": "ERROR",
"error": {
"errorType": "CLIENT_ERROR",
"errorCode": "VALIDATION_ERROR",
"apiMessage": "Data Validation issue, please correct the
data and try again",
"errors": [
{
"errorCode": "cannot.be.null",
"path":
"$.attestation.member[\\\"879602660483081269\\\"].me
mber.attestation.name.first"
}

"resultType": "ERROR",
"error": {
"errorType": "CLIENT_ERROR",
"errorCode": "UNABLE_TO_AUTHENTICATE",
"apiMessage": "Source system header did not match API
Key.",
"errors": []

Notes

High-Level Requirements
Item #

High-Level Requirement**

1

Within the application UI, applicants can only be asked questions that are
necessary for determining eligibility for coverage in a Qualified Health Plan
(QHP) and all insurance affordability programs, or for the administration of
these programs. DE Entities must not ask questions that are not essential to
these purposes or programs as part of the application UI.

2

DE entities should not require consumers to enter the same information
multiple times; however, if a DE entity prepopulates the response to an
application question based on previously collected information, the DE
entity must display the application question and provide the consumer the
ability to edit that answer.
Certain requests for information must also be optional—as designated in
the Application UI Companion Guide— and all optional fields must be
clearly marked as such.
The UI must accommodate applications that are requesting financial
assistance and those that opt not to request financial assistance.
For an application that is not requesting financial assistance, a DE entity
must not ask tax filing status questions or income questions. An application
not requesting financial assistance does not have a branch, so programspecific questions are not asked.
If the consumer changes attestations (e.g., through backward navigation)
the client system must clear the answers to any question provided on a
path that is not the final path by submitting the value ‘null’ in the Update
Application API for those attestations.
The UI must perform a preliminary eligibility determination within the
application and only display QHP, APTC, Medicad and CHIP program specific
questions to applicants with relevant prelimiary eligibility for those
programs after that point. The preliminary eligibilty for each applicant is
determined by calling the Update App API after collecting all relevant
household composition and income information for each applicant.

3

4
5

6

7

Auditor Compliance Conclusion**

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor Comments**

Requirements
Item #

1

Requirement Grouping

Requirement

Question(s) Reference

Consent from App filer

The application must collect consent from the application filer that
all application members agree to have their information used and
retrieved from data sources.

1. I agree to have my information used and retrieved from data sources for this
application. I have consent for all people I'll list on the application for their information
to be retrieved and used from data sources.

UI Questions Question content or
display rules vary by
tab Item #
state
3

Applicable EDE Phases

Phases 1, 2, 3

2. I understand that I’m required to provide true answers and that I may be asked to
provide additional information, including proof of my eligibility for a Special Enrollment
Period, if I qualify. If I don’t, I may face penalties, including the risk of losing my
eligibility for coverage.
2

HH contact info

The application must collect at least first name, last name, and date
of birth from the application filer in order to create an application.

firstName
middleName
lastName
suffix
birthDate

3

Home address

The application must request a home address for each applicant,
What's your home address?
but also must allow for a consumer to continue with the application No home address
and indicate their residency without attesting that they live in a
particular home address. If no home address, the UI must collect the
applicant's mailing address which SES will use as their residency
address.

4

Mailing Address

The application must collect a mailing address for at least the
application filer in order to receive communications by mail.

What is your mailing address?

7, 8

Phases 1, 2, 3

5

Communication Preferences

How would you like to get notices about your application?

11

Phases 1, 2, 3

6

Phone Number

The application must provide the consumer an option to receive
their notices by mail. Notices will always also be available through
the online account.
The application must collect at least one phone number for the
application, to use for communications from the FEE and State
Medicaid/CHIP agencies if the application is transferred.

What's your contact information?
1. Email address
2. Phone number
3. Phone type

9

Phases 1, 2, 3

7

SSN

The application must adhere to security protocols for protection of
SSN information and must provide notice to the application member
about how SSN will be used. SSNs must be optional for nonapplicants and the application must allow an applicant to proceed
and submit their application if they do not have an SSN.

What is [FNLNS]'s Social Security Number (SSN)?
Do you want to provide [FNLNS]'s Social Security Number?
Entering this person’s SSN is optional, but it could speed up the process for household
members who want help paying for coverage. SSNs won’t be used for immigration
enforcement.
Are you sure? It's important to enter the SSN for everyone on your application, if they
have them…..
Providing your Social Security number (SSN) can be helpful if you don’t want health
coverage because it can speed up the application process. We use SSNs to check
income and other information to see who is eligible for help paying for health
coverage. If [FNLNS] needs help getting an SSN, visit socialsecurity.gov, or call 1-800722-1213. TTY users should call 1-800-325-0778.

8

US Citizen/US National

The application must ask whether an applicant is a US citizen or US
national (but need not differentiate between these two statuses).

Is [FNLNS] a U.S citizen or U.S. national?

38

Phases 1, 2, 3 (though Phase 1 collects this
attestation through the screener question)

9

Eligible immigration status

Does [FNLNS] have eligible immigration status?
1. Yes, [FNLNS] has eligible immigration status
2. I would like to continue the application without answering this question. I
understand that if I don't answer it, [FNLNS] won't be eligible for full Medicaid or
Marketplace coverage and will be considered only for coverage of emergency services,
including labor and delivery services.

44

Phases 2, 3

10

Naturalized Citizen

For applicants who attest that they are not US citizens, the
application must provide an opportunity to attest to eligible
immigration status, but may not provide a "no" option. The
application could implement this by using a checkbox answer format
and only providing an answer to let the consumer indicate they have
eligible immigration status. If this answer format is used, the
consumer must be able to leave this question blank. If the
application uses an answer format like radio buttons, answer option
wording must be exact.
For applicants who attest that they are US citizens, and whose
citizenship is not verified through SSA, the application must ask
about naturalized or derived citizenship (but need not differentiate
between the two statuses)

Is [FNLNS] a naturalized or derived citizen?

40

Phases 1, 2, 3 (though Phase 1 collects this
attestation through the screener question)

11

Immigration Document Type

46

Phases 2, 3

For applicants who attest that they have eligible immigration status, Select the document type that corresponds with [FNLNS]'s most current
the application must provide an opportunity to input relevant
documentation and status. Optional
information from all SAVE-verifiable document types

4

Phases 1, 2, 3

5

Phases 1, 2, 3 must request home address. Phases 1
and 2 would screen out consumers with no home
address, whereas Phase 3 applications must include
an option for homeless consumers to indicate no
home address.

32-35

Phases 1, 2, 3 must request SSNs. Phase 1 would
screen out consumers who cannot or prefer not to
provide SSNs, whereas Phase 2 and 3 applications
must allow consumers to continue without providing
SSNs, and must include clear notice that SSNs are
optional for non-applicants.

Item #

Requirement Grouping

Requirement

Question(s) Reference

12

FA/Non-FA

The application must provide a pathway for consumers to complete Do you want to find out if you can get help paying for health coverage?
a non-financial assistance application without having to answer any
questions relevant only for financial assistance determinations
including questions about their income or tax return

13

Applying for Coverage

On financial assistance applications, the application must allow
Who are you applying for health coverage for?
consumers to designate whether or not they are applying for
coverage for themselves, and must provide an opportunity for other
family members to be either applicants or non-applicants

14

Tax Filing Status

On financial assistance applications, the application must ask
whether the application member plans to file a federal income tax
return for the coverage year and if so, whether the applicant will be
a tax filer, tax dependent, and/or will claim a tax dependent on the
federal tax return that will be filed for the coverage year. If married,
the consumer must attest whether or not they will file jointly.

15

Relationships

On financial assistance applications, the application must collect
How is this person related to [Dependent FNLNS]? [FNLNS] is the (Display relationship
sufficient information to determine whether an exception to the tax dropdown menu) of their claiming tax filer.
household applies for Medicaid/CHIP household composition
Does [Dependent FNLNS] live with any other parent or stepparent?

16

Parent/Caretaker Relative

It is necessary to gather sufficient information to determine
Does [FNLNS] live with and take care of any children age 18 or younger?
parent/caretaker relative status. For applicants over the age of 18
Is [FNLNS] the main person taking care of this child (or children)?
who live with a child the application must request information about
whether the applicant is the main person taking care of the child
under age 19. The application need not include this question for a
parent living with their child or for a tax filer claiming a child they live
with as a tax dependent, for whom SES can determine this status
without an additional question.

117, 118

17

Race/Ethnicity

The application must include optional race and ethnicity questions
in accordance with the standards in ACA Section 4302.

Is [FNLNS] of Hispanic, Latino, or Spanish origin? (optional)
What is [FLNLS]'s race? (Check all that apply) (optional)

128, 130

Phases 1, 2, 3

18

Non-MAGI questions

The application must ask for information regarding disabilities and
whether applicants need assistance with daily living because the FFE
uses this information in order to determine whether and applicant
may be eligible for Medicaid on a non-MAGI basis, and should
therefore send the consumer's information to the state Medicaid
agency for further review.

Do any of these people below have a physical disability or mental health condition that
limits their ability to work, attend school, or take care of their daily needs? (optional)
Do any of these people need help with activities of daily living (like bathing, dressing,
and using the bathroom), or live in a nursing home or other medical facility? (optional)

131, 132

Phases 1, 2, 3

19

AI/AN

The application must ask about American Indian or Alaska Native
status because American Indians and Alaska natives may qualify for
special benefits (SEP, CSR, Medicaid/CHIP cost-sharing rules).
Medicaid and CHIP have different rules for who gets benefits related
to AI/AN status than the Exchange.

Are any of these people American Indian or Alaska Native?
146, 176, 237,
238, 210, 211,
Is any of this income from these sources?
• Per capita payments from the tribe that come from natural resources, usage rights,
270
leases or royalties.
• Payments from natural resources, farming, ranching, fishing, leases, or royalties from
land designated as Indian land by the Development of Interior (including reservations
On financial assistance applications, it is important that AI/AN
and former reservations).
household members, including non-applicants, have the
• Money from selling things that have cultural significance.
opportunity to flag whether any of their attested income falls into
Has [FNLNS] ever gotten a health service from the Indian Health Service, a tribal health
the tribal income categories. In addition, for applicants who are
program, or urban Indian health program or through a referral from one of these
potentially Medicaid/CHIP eligible, the application must ask about
programs?
eligibility and receipt of Indian Health Services using the FFE
Is [FNLNS] eligible to get health services from the Indian Health Service, a tribal health
language.
program, or an urban Indian health program or through referral from one of these
programs?
For applicants who are potentially QHP eligible, the application must Are any of these people a member of a federally recognized tribe?
Where's [Name selected in item 210] tribe located?
ask whether the consumer is a member of a federally recognized
Which federally recognized tribe does [Name selected in item 211] belong to?
tribe, and if so, for the name of the tribe.

Phase 3

20

Pregnancy

Phases 2, 3

21

Former foster care

The application must ask females for pregnancy status because
pregnancy/number of babies due affects household size and
income limits for Medicaid and CHIP.
The application must ask for former foster care status because it can
help someone aged 18-25 become Medicaid eligible with no income
test. However, there are rules around state and Medicaid receipt
and age the consumer left foster care.

Does [FNLNS] plan to file a joint federal income tax return with [his/her] spouse for
[coverage year]?
Will [FNLNS] [and spouse name (if married and filing jointly)] claim any dependents on
[his/her/their joint] federal income tax return for [coverage year]?
Will [FNLNS] be claimed as a dependent on someone else's tax return for [coverage
year]?

UI Questions Question content or
display rules vary by
tab Item #
state
21

27, 29

Applicable EDE Phases

Phases 1, 2, 3

Phases 1, 2, 3

81, 82, 90

Phases 1, 2, 3 (though Phase 1 and 2 applications
collect this attestation through the screener
question)

92, 95

Phases 1, 2, 3 (though Phase 1 and 2 applications
collect this attestation through the screener
question)

Are any of these people pregnant?
How many babies is [Name selected in item #147] expecting during this pregnancy?

147, 148

Were any of these people ever in foster care?
In what state was [Name selected in item #149] in the foster care system?
Was [Name selected in item #150] getting health care through [Name of state Medicaid
program](Medicaid)?
How old was [Name selected in item #151] when [he/she] left the foster care system?

149-152

Y

Y

Phase 3 (sufficient information is collected for this
eligibility category through Phase 1 and Phase 2
screener answers instead)

Phases 2, 3

Item #

Requirement Grouping

Requirement

Question(s) Reference

UI Questions Question content or
display rules vary by
tab Item #
state
144, 259, 283 Y

Applicable EDE Phases

22

Full time student

In some situations, information on full time student status is
required for 18-22 year-olds. The application may use the state
reference data available through the SES API to limit the situations
further in which to ask this question. If so, the application would ask
if applicants aged 18-22 are full time students in states with special
residency rules in Medicaid/CHIP for full-time students. If not, fulltime student status should still be asked for 18 year old household
members if the state elects to consider an 18 year-old student as a
dependent child for purposes of Medicaid parent/caretaker relative
rules, and for 19-20 year old household members if the state counts
19-20 year old students as children for Medicaid and CHIP
household composition rules.

Are any of these people full time students?
Does one or more of [Applicant name selected above]'s parents or guardians live in
[State of application]?
Does [Applicant name selected in item #144] go to school in [Application state]?

23

Incarceration

The application must ask whether applicants are incarcerated, as a
factor of eligibility for QHP and CHIP. For individuals who are
incarcerated, the application must ask whether they are
incarcerated pending disposition of charges.

Which of these people are incarcerated?
Is [FNLNS] only incarcerated pending disposition of charges?

250, 251

Phases 2, 3

24

Medicaid block* Note: CMS is
considering adjustments to the
wording of questions that will
satisfy this requirement.

The application must ask whether any applicants were recently
found not eligible for Medicaid or CHIP by the state so that
consumers who have recently been denied Medicaid and CHIP by
the state are prevented from being again found eligible for Medicaid
or CHIP by the FFE and sent back to the state. For non-citizen
applicants, the application must ask whether the denial was due to
immigration status.
The application must ask if any applicants applied for coverage
during Open Enrollment or after a qualifying life event in order to
determine eligibility for an SEP.

Were any of these people found not eligible for [state Medicaid program name] or
[state CHIP name] by [state] since [date of 90 days ago]?
When was [FNLNS] denied Medicaid or CHIP coverage?
Did any of these people apply for health coverage between [most recent OE start date]
– [most recent end date]?
Did [FNLNS] apply through the Health Insurance Marketplace after a qualifying life
event?

133-143

Phases 1, 2, 3

Phases 2, 3

Did [FNLNS] have [state Medicaid program name] or [state CHIP program name] that
will end soon or that recently ended because of a change in eligibility?
Has the household income or household size changed since [FNLNS] was told [his/her]
coverage was ending?
What's the last day of [FNLNS]'s Medicaid or CHIP coverage?
Were any of these people found not eligible for [state Medicaid program name] or
[state CHIP program name] based on their immigration status since [current year
minus 5 years]?
Has [FNLNS] had their current immigration status since [current year minus 5 years]?
Has [FNLNS] had a change in their immigration status since they were not found
eligible for [state Medicaid program name] or [state CHIP program name]?

25

Current and annual income

The application must request information about current month
income from each relevant household member (as indicated by SES
Update App call) because it will be used to calculate Medicaid and
CHIP eligibility. The application must request current month income
information separately for every applicant and relevant nonapplicant. The application needs to provide an opportunity to add
information about adjustments to income the consumer will take on
the front page of their 1040 tax return as well. In addition, each
applicant must have the opportunity to attest to an annual income
amount for the coverage year.

Will any of these people have income this month? (Display list of current income types 153, 154, 174,
175, 181, 182,
below question.)
Select a type of income [FNLNS] currently gets this month.
183-184
Do any of these people pay student loan interest, alimony, educator expenses, or
contribute to an IRA in [coverage year]?
Select [FNLNS]'s current expense. (Display list of expense types below question.)
We calculated this expected yearly income amount based on what you entered for
[FNLNS]'s monthly income and expenses. Is this correct?
Is [FNLNS]'s income for [coverage year] hard to predict?
Enter your best estimate of [FNLNS] expected yearly income for [coverage year].

26

Current coverage questions

The application must ask whether applicants are currently enrolled Are any of these people currently enrolled in health coverage?
in health care coverage, and if so, what type. For consumers
What type of coverage does [FNLNS] have? (Display list of current coverage options).
potentially eligible for CHIP, the options for insurance coverage
Tell us about [FNLNS]'s [selected coverage]
must include "limited benefit coverage". For consumers who are
potentially eligible for APTC (based on SES Update App call), the
options for current coverage must include all government minimum
essential coverage types including: Medicare, Veterans Health
Program, Tricare, Medicaid, CHIP, and Peace Corps coverage.

191-199

Phases 1, 2, 3

Phases 1, 2, 3

Item #

Requirement Grouping

Requirement

Question(s) Reference

27

Employer Sponsored Coverage
(ESC) questions

The application must ask whether applicants who are potentially
eligible for APTC (based on SES Update App call) have an offer of
employer sponsored coverage for the coverage year. For those who
are offered coverage, the application must ask whether the
consumer is enrolled. If not (and it is not COBRA or retiree health
plans, which have no affordability test) then the application must
ask whether the coverage meets the minimum value standard and
what the premium amount is, so that SES can determine whether
the coverage offer is affordable. For each APTC eligible applicant
with job income, the application must also request information
regarding the employer's contact information (and require
employer name and phone number) so that the FFE can collect
more information about coverage offered to the employee.

Will any of these people be offered health coverage through a job (including another
person's job, like a spouse or parent)? Tell us about coverage offers that apply to them
starting [January 1st, 2019 if during OE or first day of following month outside of OE].
Which employer offers [FNLNS] this health coverage? Select all that apply.
Enter the name of the employer who offers this insurance.
Who can we contact about [employer name]'s health coverage?
Which of these people works for [Employer Name]?
Does [Employer name] offer a health plan that meets the minimum value standard?
Enter the regular amount [FNLNS] would have to pay for coverage (the premium).
Tell us more about [FNLNS]'s employer.

28

CHIP waiting period and state
employee questions

The application must ask applicants who are potentially eligible for
CHIP in states with CHIP waiting periods (see state configuration data
API information) whether they lost coverage in the last few months-populating the time period in the question (the number of months)
depending on the length of the waiting period in that state. If the
applicant answers yes, then the application must ask whether the
applicant qualifies for one of the exceptions to the waiting period,
which would enable the child to get CHIP right away.
In some states, the application must ask also preliminarily CHIP
eligible applicants whether they have access to state employee
health benefits.

Did [FNLNS] have health coverage through a job that ended in the last [number of
months of waiting period] months?
Why did that coverage end?
Is [FNLNS] offered the [state of application] state employee health benefit plan
through a job or a family member’s job?
Is [FNLNS] enrolled in the [state of application] state employee health benefit plan
through a job or family member's job (like a parent)?

29

Dependent child covered questions If an adult applicant is preliminarily Medicaid eligible for the adult
Some people may qualify to get help even if they already have health coverage. Do any
group (based on Update App SES call) and lives with a non-applicant of these people have health coverage now?
and deprivation questions
son or daughter under the Medicaid child age, then the application
must ask whether the non-applicant child is enrolled in other
How many hours per week do [Child’s name]’s parents work?
coverage, as a factor of eligibility for the applicant parent.

UI Questions Question content or
display rules vary by
tab Item #
state
200-209

Applicable EDE Phases

243-245, 284 Y

Phases 1, 2, 3 for CHIP waiting period questions;
Phase 3 only for state employee health benefit
question

240, 242

Y (Hours worked)

Phases 3

Phases 1, 2, 3

The application must collect the number of hours worked by a
child's parents when an adult on the application may qualify as a
parent/caretaker relative, the dependent child lives with two
parents, and the state Medicaid agency has a deprivation
requirement for the parent/caretaker relative category. If the
parent(s) are on the application, and hours per week were collected
as part of the income section, then it should not be asked again.

30

SEP questions

The application must ask SEP questions during Open Enrollment as
well as during the rest of the year. Follow-up questions for certain
SEP types are critical for SEP eligibility, such as questions about prior
coverage for move and marriage. Some SEP questions only need to
be asked for some people: the marriage SEP question can be asked
of married applicants only, and the immigration SEP question can be
asked of non-citizen applicants only

Did any of these people lose qualifying health coverage between [60 days prior to
current date] - [current date]? Learn more about qualifying health coverage
Will any of these people lose qualifying health coverage between [current date] - [60
days after current date]?
Did any of these people recently get married?
Did any of these people recently get adopted, get placed in foster care, or become a
dependent through a child support or other court order?
Did any of these people recently gain eligible immigration status?
Did any of these people move in the past 60 days?
Did any of these people recently get released from incarceration (detention or jail)?

31

Full application review

The applicant must have the opportunity to review a summary of
Summary of key information regarding contact information, applicants, citizenship, tax
the attestations on their application and be able to make changes
filing, income, current coverage, offers of coverage and SEPs, as applicable
before continuing to sign and submit. The consumer should be able
to save and print this summary for their records.

213, 218, 223224

246

Phases 1, 2, 3 (noting that the eligible immigration
status question in particular is Phases 2 and 3 only)

Phases 1, 2, 3

Item #

Requirement Grouping

Requirement

Question(s) Reference

32

Medicaid Agreements

When applicants are Medicaid eligible, they must be presented with
the opportunity to agree with Medicaid related attestations,
through a check box or other means. The agreement related to a
parent living outside the home should only be displayed for a parent
who is Medicaid eligible, and whose Medicaid eligible child has a
parent living outside the home.

33

Agreements for all programs, sign
and submit

Additional attestations must be displayed and agreed to by all
applicants prior to submission. The applicant must be able to
affirmatively sign their application through an electronic signature
prior to submission.

If anyone on this application enrolls in Medicaid, I’m giving the Medicaid agency our
rights to pursue and get any money from other health insurance, legal settlements, or
other third parties. I’m also giving to the Medicaid agency rights to pursue and get
medical support from a spouse or parent.
If a child on this application has a parent living outside of the home, I know I’ll be asked
to cooperate with the agency that collects medical support from an absent parent. If I
think that cooperating to collect medical support will harm me or my children, I can tell
the agency and I may not have to cooperate.
To make it easier to determine my eligibility for help paying for health coverage in
future years, I agree to allow the Marketplace to use income data, including
information from tax returns, for the next 5 years (the maximum number of years
allowed). The Marketplace will send me a notice, let me make any changes, and I can
opt out at any time.
I know that I must tell the program I’ll be enrolled in if information I listed on this
application changes. I know I can make changes in my Marketplace account or by
calling 1-800-318-2596. TTY users should call 1-855-889-4325. I understand that a
change in my information could affect my eligibility for member(s) of my household.
If anyone on your application is enrolled in Marketplace coverage and is later found to
have other qualifying health coverage (like Medicare, Medicaid, or CHIP), the
Marketplace will automatically end their Marketplace plan coverage. This will help
make sure that anyone who’s found to have other qualifying coverage won’t stay
enrolled in Marketplace coverage and have to pay full cost.
I’m signing this application under penalty of perjury, which means I’ve provided true
answers to all of the questions to the best of my knowledge. I know that I may be
subject to penalties under federal law if I intentionally provide false or untrue
information.
Electronic Signature

34

Clear eligibility results

35

UI Questions Question content or
display rules vary by
tab Item #
state
247-248

Applicable EDE Phases

Phases 1, 2, 3

252-256

Phases 1, 2, 3

The application must display high level eligibility results and next
Step 1: View Your “Coverage Options at a Glance”
steps and information about each applicant's program eligibility,
Step 2: View Your “Eligibility Results”
DMIs, and SVIs in a clear, comprehensive and consumer-friendly
way. The eligibility results must provide the ability for the consumer
to view and print the Eligibility Determination Notice.

N/A

Phases 1, 2, 3

Full Medicaid determination

Under CMS regulations, the application must give consumers who
are found ineligible for Medicaid the opportunity to request a full
determination by the state Medicaid agency.

(Reveals for determination state) Do any of these people want to request a
determination for Medicaid as conducted by [State Medicaid Agency Name] on the
basis of disability, blindness, or recurring medical needs and bills?
(Reveals for assessment state) It looks like these people aren’t eligible for Medicaid.
They can still continue with a Medicaid application if we sent their information to the
[State Medicaid Agency Name]. Do any of these people want us to send their
information to the [State Medicaid Agency Name] so they can check on Medicaid and
The Children’s Health Insurance Program (CHIP) eligibility, if applicable?

N/A

36

Appeal Rights

The application must present full and clear appeal rights under the
law for all consumers.

What should I do if I think my eligibility results are wrong?

N/A

Phases 1, 2, 3

37

Voter Registration

Under the National Voter Registration Act, the application must
include a pathway to voter registration

Would you like to register to vote? (Optional)

N/A

Phases 1, 2, 3

Y

Phases 1, 2, 3