CMS-10877 Eligibility Results Toolkit - Phase 3

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

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

Phase 2 (different toolkit)

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

PRA DISCLOSURE: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938NEW, 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 3

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

Test Case Input Tabs (e.g., Test Case 3.A input, Test
Case 3.B input)

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

Auditors should use each tab to complete an eligibility application with the
answers detailed in the tab. Upon receiving an eligibility determination through
the EDE Pathway, the Auditor should confirm that the eligibility results from the
EDE Pathway are identical to the "Eligibility Results" included at the end of each
test case. The Auditor must take screenshots of the eligibility application process
while progressing through the test case, including a screenshot of the ERP, and
also store the EDN and provide the EDN to CMS (if applicable). The Auditor must
also submit the Get App API response (JSON) from each test case. The Auditor
should name the screenshot files sequentially and clearly identify them as
belonging to a specific test case (e.g., TestCase3A-1, TestCase3A-2). Similarly,
the Auditor should name the JSON files to clearly identify them as belonging to a
specific test case (e.g., TestCase3A-JSON). CMS strongly recommends that
Auditors sequentially aggregate the screenshots in a single document for each
test case (e.g., a Microsoft Word, PowerPoint, or PDF document with each
image labelled “TestCase3-A”) instead of submitting each screenshot as an
individually saved image (e.g., TestCase3A-1.jpg, TestCase3A-2.jpg). This may
help expedite CMS’s audit review.

Audit Requirements by Tab
Tab: Phase 3
In this tab, the Auditor must scroll to the right to complete the last six columns whose column headings are shaded in yellow or marked with "**."
Columns
Test Case ID

Description
Test Case ID that corresponds to each input tab.

State

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

Summary/Criteria
Expected Results/What's Tested

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

Test Scenario Description

Summary description of the test case.

How to Review
The Auditor must match the Test Case ID in the "Phase 3" tab to the
corresponding Test Case ID input tab, and use information from both tabs to
complete the audit.
The Auditor must use an approved state (i.e., the state or one of the states
provided for each test case) to complete each test case.
The Auditor may use this summary information to inform the audit.
As stated above, the Auditor must carefully examine the "Eligibility Results"
section of each "Test Case" input tab prior to confirming the EDE Entity's
compliance with each test case.
The Auditor may use this summary information to inform the audit.

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 use the test case eligibility details from the Test Case input tabs
to complete the EDE Entity's eligibility application. Upon completing the
eligibility application, the Auditor will verify that the eligibility results on the EDE
Entity's website match the eligibility results defined at the end of each Test Case
input tab. The Auditor will document each screen within the eligibility
application with screenshots and store the EDN and provide the EDN to CMS,
unless the test case ends after the screener questions, which is clearly marked in
each input tab. For each test case, the Auditor must provide the raw JSON from
the Get App API response for the application version used to complete the
scenario.
There are several required fields in each cell within this column:
- The first required field in each cell is, "Eligibility results compliance conclusion:
_____." If the test case is compliant, and matches the eligibility results expected
for the test case, the Auditor must indicate "Yes" in this column. If the row is not
compliant, the Auditor must indicate the noncompliance with a "No" in this
column.
- The subsequent required fields in each cell refer to the "Auditor Checklist"
column and include the item number from the Application UI Toolkit, and the
row number from the test case. For example, the first item in row 15 of the 3.A
Check List is "Check Item 32: Verify the answer format for the statement related
to not having a SSN is a checkbox format and conforms to the UI Q CG
requirements." After the Auditor verifies this checklist item, the Auditor must
document its compliance determination in the corresponding field in the
"Auditor Compliance Conclusion" column in the "Phase 3" tab, "Auditor checklist
item 32/row 15 compliance conclusion:_____"

Risks Identified**

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

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

Risk Level**

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 EDE Entity to ask, but optional for the consumer to answer). Lowrisk 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**

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

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

Estimated Resolution Date**

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

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

Auditor Comments**

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

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

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

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

Application Data

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

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

Application Input

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

Notes to Testers

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

Auditor Checklist

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

Application State & Coverage Year

This section provides the state and required ZIP Code Some test scenarios require the use of specific application states or ZIP Codes. In
(if any) and coverage year for each test case.
the event an EDE entity does not support an application state listed in the test
scenario, the Auditor may omit that test case.

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

Required Completion Rate (Reminder)
Auditors must conduct all possible test cases. However, depending on the
Entity's intended service areas, Auditors may not be able to conduct a test case
because the Entity does not intend to operate in the specific state(s) provided in
the test case. Auditors must conduct a minimum number of test cases from
each toolkit it completes. Auditors conducting Phase 1 audits must submit at
least 11 of 14 Phase 1 test cases. Auditors conducting Phase 2 audits must
submit at least 8 of 14 Phase 1 test cases AND 6 of 9 Phase 2 test cases. Auditors
conducting Phase 3 audits must submit at least 8 of 14 Phase 1 test cases AND 5
of 9 Phase 2 test cases AND 7 of 9 Phase 3 test cases. If an Auditor is not able to
conduct the minimum number of test cases for each toolkit because of the
Entity's planned service areas, it must email DE Support to request instructions
to modify test cases so that the Auditor is able to conduct and submit the
minimum number of test cases.
Household Member Input

Test data for each consumer in the test case.

Household Member Information

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

More About This Household

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

Tax Household

This section provides information for answering tax
filing status questions.

Medicaid Block

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

Income

This section provides each household member's
current income, deductions, annual income, and
income discrepancies, when applicable.

Program Questions

This section provides additional inputs for each test
case that are specific to APTC, Medicaid, CHIP, SEP,
and QHP eligibility.

Attestations

This section provides information for answering the
legal attestations.

Eligibility Results

This section shows the eligibility results that should
display for each consumer in the Eligibility Results
Page. The information displayed in the UI should
accurately reflect results found in the Eligibility
Determination Notice (EDN) and use specific
language where noted in the test cases.

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

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

Test Case ID

State

Summary/Criteria

Test Case 3.A

-Initial application, 2 member household
AL, FL, GA, KS, MS, -Not seeking financial assistance
NC, SC, SD, TN, or -Married, no dependents
WY
-One member has AI/AN status
-SEP

Test Case 3.A.2

Same application
state as 3.A

Test Case 3.C

Test Case 3.D

Test Case 3.E

Test Case 3.F

Test Case 3.G

Test Case 3.H

Test Case 3.I

-Change in circumstance (CiC) on application from test case 3.A,
2 member household
-Update 3.A to request financial assistance
-Married, no dependents
-One member has AI/AN status

Expected Results/What's Tested

Test Scenario Description

Auditor Compliance Conclusion**

-AI/AN status and federally recognized tribe questions
displayed
-CSR eligibility determined correctly with AI/AN household
members
-AI/AN consumer is QHP eligible with CSR; both spouses
are eligible to enroll in QHP through SEP

A young married couple applies for coverage together without seeking financial
assistance. One spouse is an American Indian/Alaska Native (AI/AN) and one is not,
which impacts the eligibility results: the AI/AN consumer receives CSR, even though
he is not applying for financial assistance. Both consumers are found eligible for the
marriage SEP, the AI/AN consumer qualifies for a tribal SEP.

Eligibility results compliance conclusion:
Auditor checklist Item 32/row 15 compliance conclusion:
Auditor checklist Items 211 and 270/row 22 compliance conclusion:
Auditor checklist item to verify display of eligibility results page/row 38
compliance conclusion:

-AI/AN status and federally recognized tribe questions
displayed
-Tribal income questions displayed
-CSR eligibility determined correctly with AI/AN household
member; spouse may be eligible for Medicaid

In this scenario, the couple from Test Case 3.A performs a change in circumstance
(CiC) to request financial assistance. Because of the husband's American
Indian/Alaska Native (AI/AN) status, special questions are asked related to tribal
income. The husband is now found eligible for a hardship exemption due to the
Medicaid coverage gap and having income below APTC range, and the wife is found
eligible for Medicaid because she was in foster care in the application state and aged
out in the application state.

Eligibility results compliance conclusion:
Auditor checklist Item 32/row 15 compliance conclusion:
Auditor checklist Items 149 or 269/row 24 compliance conclusion:
Auditor checklist Items 179 and 180/row 32 compliance conclusion:
Auditor checklist Item 285/row 35 compliance conclusion:
Auditor checklist Item 239/row 36 compliance conclusion:

In this scenario, a non-citizen parent and citizen child are both applying for coverage.
This scenario demonstrates a household where family members are found eligible for
different programs and where a child lives with someone who is not on the
application and whose information must be included in order to build the child's
Medicaid household. Although the household income is within CHIP range, the child
is subject to a CHIP waiting period and therefore becomes APTC eligible. This triggers
display of ESC coverage, and the applicant must provide information about a health
coverage offer from the mother's job that is available to the child, but is
unaffordable.

Eligibility results compliance conclusion:
Auditor checklist Item 30/row 10 compliance conclusion:
Auditor checklist Items 88, 282, and 104/row 12 compliance conclusion:
Auditor checklist Items 191 and 285/row 34 compliance conclusion:
Auditor checklist Items 243 and 244/row 36 compliance conclusion:
Auditor checklist Items 200 and 304/row 37 compliance conclusion:

Summary: In this scenario, a parent, her domestic partner, and her child apply for
coverage. This scenario demonstrates the UI can successfully build the household
when one of applicants (domestic partner) is not part of the tax return. The mother
has an offer of employer-sponsored coverage (ESC), and because the offer is
affordable, she is found QHP eligible without APTC. Because the daughter is enrolled
in COBRA, she is found QHP eligible without APTC. Because the domestic partner is
not filing a tax return, he is eligible for QHP without subsidy.

Eligibility results compliance conclusion:
Auditor checklist Items 88 and 104/row 13 compliance conclusion:
Auditor checklist Item 30/row 14 compliance conclusion:
Auditor checklist Item 116/row 15 compliance conclusion:
Auditor checklist Item 32/row 16 compliance conclusion:
Auditor checklist Items 200 and 208/row 36 compliance conclusion:
Auditor checklist Item 286/row 37 compliance conclusion:

This scenario demonstrates a multi-generation application where the application filer
is temporarily residing outside the application state and the other application
members reside at a different address within the application state. Because the
application filer intends to return to reside in the application state, he is found QHP
eligible with subsidy. This scenario also demonstrates the UI's ability to display
special Medicaid household composition questions to the grandchild.

Eligibility results compliance conclusion:
Auditor checklist Items 126, 127, and 279/row 13 compliance conclusion:
Auditor checklist Item 104/row 14 compliance conclusion:
Auditor checklist Item 117/row 15 compliance conclusion:
Auditor checklist Items 185, 186 and 187/row 33 compliance conclusion:
Auditor checklist Item 200/row 37 compliance conclusion:

In this application, a non-applicant non-custodial parent is applying for coverage for
her child. Because the child attests to a Medicaid/CHIP denial, the child is not found
eligible for Medicaid/CHIP regardless of income, and because the application filer has
a married filing separately tax status, the child is not eligible for APTC. Therefore, the
eligibility outcome is QHP only.

Eligibility results compliance conclusion:
Auditor checklist Item 27/row 11 compliance conclusion:
Auditor checklist Items 104 and 105/row 13 compliance conclusion:
Auditor checklist Item 89/row 20 compliance conclusion:
Auditor checklist Items 133, 134, and 136/row 29 compliance conclusion:

-ESC questions display and collect required information
about Minimum Value (MV) and affordability
-Eligible immigration status questions display
-Information is collected for household members outside
IN
of the application, after child attests to living with a parent
outside the application
-Mother may be eligible for Medicaid due to pregnancy;
child is QHP eligible with APTC due to CHIP waiting period,
but cannot enroll due to lack of SEP
-Displays questions to build tax household when one
applicant is not part of tax return
-Initial application, 3 member household
-ESC questions display and collect required information
AZ, AR, DE, FL, MI,
-Seeking financial assistance
about Minimum Value (MV) and affordability
MS, NE, NC, ND,
-Single, 1 dependent, 1 domestic partner
-Application can support a domestic partner
OH, OK, SC, SD, TX,
-Applicant filer has access to an offer of employer-sponsored
-Mother, domestic partner and child are eligible for QHP
UT, VA, or WY
coverage (ESC), it is affordable
without subsidy
-All 3 members are eligible for a move SEP
-Initial application, 3 member household
-Application can support multi-generation application
-Home address in a state different from application state
-Seeking financial assistance
AL, DE, GA, MS,
and applicants with different addresses are supported
-Single, 1 child, 1 grandchild
MO, MT, NC, OK,
-Application filer temporarily resides outside of the application -Grandfather and son are determined QHP eligible with
OR, SC, TN, UT, VA,
state
APTC through a loss of coverage SEP, baby may be eligible
WV, or WI
-Dependents have address different from application filer and is for Medicaid based on income and referred for non-MAGI
factors
within application state
-Initial application, 3 member household
-Application supports married filing separately tax status
-Seeking financial assistance
and dependent living with a parent outside the tax
-Application filer is non-applicant
household
Any
-1 child, 1 non-applicant spouse
-Application supports non-applicant application filer
-Married filing separately tax status
-Child is QHP eligible without subsidy through a Medicaid
-Dependent attests to Medicaid denial and lives with a parent
denial SEP
outside the application
-Initial application, 3 member household
-Seeking financial assistance
-Single, 1 dependent applying for coverage, 1 domestic partner
not applying for coverage
-Application filer is a non-U.S. citizen and pregnant
-Applicant and their dependent have access to employersponsored coverage (ESC), but it is unaffordable
-Dependent also lives with a parent outside the application

SC or TX

-Initial application, 6 member household
-Seeking financial assistance
-Single, 3 children, 1 niece, 1 child's spouse
-Application filer is non-applicant
-One dependent is married, one dependent is filing separate tax
return
-Non-applicant added after start of application

-UI supports addition of non-applicants after start of
application and properly displays legal relationship
questions
-EDE Entity supports complex tax household scenario with
married dependents, non-applicant tax dependents, and
dependents filing their own return
-Application member may be eligible for Medicaid, and
application members are determined eligible for QHP with
APTC through a marriage SEP

This scenario presents an application within APTC income range that includes
married tax dependents, non-applicant tax dependents, and a tax dependent who is
also filing their own return. The scenario demonstrates the UI's ability to display
special Medicaid household composition questions as well as display legal
relationship questions, other individual market insurance coverage, and multiple SEP
types. This test case must be run in SC, zip code 29401 or TX, zip code 77001.

Eligibility results compliance conclusion:
Auditor checklist Item 104/row 13 compliance conclusion:
Auditor checklist Item 116/row 15 compliance conclusion:
Auditor checklist Item 41/row 18 compliance conclusion:
Auditor checklist Items 83 and 84/row 20 compliance conclusion:
Auditor checklist Item 138/row 29 compliance conclusion:
Auditor checklist Item 153/row 31 compliance conclusion:
Auditor checklist Items 226 and 234/row 39 compliance conclusion:

LA

-Initial application, 7 member household
-Seeking financial assistance
-Multiple marriages, other relative, parent/caretaker relative
question
-One married applicant who is not a tax dependent
-Application filer lives with unrelated other relative
-Non-applicants added after start of application

-UI supports addition of non-applicants after start of
application and properly displays parent caretaker
relatives and legal relationship questions
-EDE Entity supports complex tax households on
application
-Application members may be eligible for Medicaid and
application members are determined eligible for QHP with
and without APTC through a Medicaid denial SEP

This is another multi-generation household scenario that includes an applicant who is
not a dependent on the application filer's return. The scenario requires the UI to
display questions to collect information on a non-applicant dependent child for
purposes of parent/caretaker relative eligibility only; and collects information on
current health coverage for a dependent child non-applicant for Medicaid adult group
eligibility of the parent. This scenario also demonstrates results for a consumer who
does not file a tax return and is not claimed as a dependent. The scenario produces
eligibility results that include Medicaid and QHP with and without subsidy. This test
case should be run in LA, zip code 70802.

Eligibility results compliance conclusion:
Auditor checklist Item 30/row 9 compliance conclusion:
Auditor checklist Items 104/row 13 compliance conclusion:
Auditor checklist Items 117-119/row 15 compliance conclusion:
Auditor checklist Item 38/row 18 compliance conclusion:
Auditor checklist Item 136/row 29 compliance conclusion:
Auditor checklist Item 240/row 36 compliance conclusion:

FL, TX, WI

-Initial application, 2 member household
-Seeking financial assistance
-Married, no dependents
-Application filer and spouse attest to ICHRA offer from
application filer's job
-Spouse attests to QSEHRA offer

-UI supports collecting information about the application
filer's ICHRA and the spouse's QSEHRA offer for purposes
of a SEP
-Application members are determined for QHP with APTC
through a QSEHRA offer SEP

A married couple applying for financial assistance reports they were offered an
individual coverage HRA (ICHRA) they have not accepted yet. The scenario
demonstrates the UI's ability to collect information about the consumers' ICHRA
offer to determine whether it is considered "affordable" for purposes of determining
APTC eligibility. In addition, the UI must collect information about the application
Eligibility results compliance conclusion:
filer's ICHRA and the spouse's Qualified Small Employer HRA (QSEHRA) offer for
Auditor checklist Items 288, 291, and 292/row 36 compliance conclusion:
purposes of a special enrollment period (SEP) eligibility. Due to the unaffordable
Auditor checklist Items 296-299/row 37 compliance conclusion:
ICHRA offer, the couple is eligible for APTC/CSRs. The couple is also eligible for an SEP
due to being newly offered an ICHRA and being newly provided a QSEHRA, but the
eligibility results show the QSEHRA SEP. This test case should be run in FL (zip code
33305, Broward county), WI (zip code 53062, Calumet county), or TX (zip code
75001, Dallas county).

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor Comments**

Summary: A young married couple applies for coverage together without seeking financial assistance. One spouse is an American Indian/Alaska Native (AI/AN) and one is not, which impacts the eligibility results: the AI/AN
consumer receives CSR, even though he is not applying for financial assistance. Both consumers are found eligible for the marriage SEP, and the AI/AN consumer qualifies for a tribal SEP.
UI Question Companion Guide Reference

Item 1
Item 2

Tab: UI Questions

Item 21

Application Input

Application Data

State
Coverage Year
Seeking financial assistance?

Application State & Coverage Year
AL, FL, GA, KS, MS, NC, SC, SD, TN, or WY
Current year
Financial Assistance
No*

Notes to Testers

Auditor Checklist

*When asking consumers about financial assistance,
the entity's UI can provide a screener tool to help
consumers make their decisions on this question,
but the screener tool is not required (Items 22-26)
The UI must display answer options "Yes" and "No"
for Item 21. Entities are not required to display the
answer option "I'm not sure"
Items 22-26 may display if a consumer selects "I'm
not sure" for this question

Items 4, 30 Name
Items 5, 6, 123 Home address
Items 7, 8 Mailing address
Item 10 Language preferences

Household Member

Alex Burns*
Age: 26
Male

Household Member Information
Lynn Jones*
Age: 24
Female

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

Item 30

Application Filer/Relationship to
Application Filer and Other Family
Members

Application Filer

Spouse of Alex

Items 27, 30
Items 76, 77

Applicant/Non-Applicant
Marital Status

Applicant
Married

Applicant
Married

Items 5, 123, 276

Address and Living Situations

Item 117

Parent/Caretaker Relative Status

Item 32

SSN

Provide address in application state
Lives with spouse Lynn
N/A (should not display for this household
member)
Does not have SSN, continue without
providing SSN

Same address as application filer
Lives with spouse Alex
N/A (should not display for this household
member)
Does not have SSN, continue without
providing SSN

Item 36
Items 38, 40

Applying with same name as SSN
card?
Citizenship/immigration

Item 81

Tax Filing Status

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

N/A (should not display for this household
member)
Attests to U.S. citizenship;
not naturalized or derived citizen
Tax Household
N/A (should not display for this household N/A (should not display for this household
member)
member)
More About This Household

Not required to display if marital status is already
established in Item 30

Check Item 32: Verify that you can proceed without
entering an SSN and that wording and answer option
format conform to UI Q CG requirements

Items 131, 132

N/A (should not display)

N/A (should not display)

Member of a federally recognized
American Indian tribe: Seminole Tribe of
FL or Catawba of SC

Does not have AI/AN status

Item 147
Pregnancy Questions
Item 269 (depending on implementation)

N/A (should not display)

N/A (should not display)

Item 149
Foster Care Questions
Item 269 (depending on implementation)
Item 250
Incarceration Questions
Item 269 (depending on implementation)
Item 144
Full-Time Student Questions
Item 269 (depending on implementation)

N/A (should not display)

N/A (should not display)

Not incarcerated

Not incarcerated

N/A (should not display)

N/A (should not display)

Items 146, 210, 211, 270
Item 269 (depending on implementation)

Non-MAGI Medicaid Eligibility
Questions (physical disabilities,
assistance with daily living, nursing
home care)
American Indian/Alaska Native

Items 133, 138

Medicaid/CHIP Denial

Item 153
Item 174
Item 181

Current Month Income
Deductions
Annual Income

Items 213, 218, 224, 225, 226, 294

Recent Life Changes (SEPs)

Items 246, 254, 255, 256, 258

Application Review & Legal
Attestations

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

Medicaid Block
N/A (should not display)
Income
N/A (should not display)
N/A (should not display)
N/A (should not display)
N/A (should not display)
N/A (should not display)
N/A (should not display)
Program Questions
Got married
Got married
Provide date in last 60 days
Provide date in last 60 days
Attest "Yes" to prior coverage questions* Attest "Yes" to prior coverage questions*

Check Items 211 and 270: Verify tribes in all states can
be selected and that all tribe names for selected state
appear in accordance with UI Q CG requirements

N/A (should not display)

Attestations
Answers affirmatively to all application attestations

Eligible to buy a Marketplace plan
Eligible for additional help with costs as a
member of a tribe*
Eligible for a Special Enrollment Period

Eligibility Results
Eligible to buy a Marketplace plan
Eligible for a Special Enrollment Period

*Questions regarding prior coverage may be omitted
for Alex and Lynn in this scenario because of Alex's
attested AI/AN status
Auditors should review the application review page
(Item 246) to ensure all information accurately
reflects the attestations inputted during the test
case
Auditors should review the Eligibility Results Page to Verify eligibility results page clearly indicates Alex (but
not Lynn) is eligible for additional help with costs as a
ensure it accurately reflects the eligibility results
found in the EDN and complies with ERP messaging member of a tribe
requirements outlined in the documentation listed
in Column A
*Eligible applicants who are members of a federallyrecognized tribe can enroll in Platinum, Gold, Silver,
or Bronze plans with cost-sharing reductions

Summary: In this scenario, the couple from Test Case 3.A performs a change in circumstance (CiC) to request financial assistance. Because of the husband's American Indian/Alaska Native (AI/AN) status, special questions
are asked related to tribal income. The husband is now found eligible for a hardship exemption due to the Medicaid coverage gap and having income below APTC range, and the wife is found eligible for Medicaid because
she was in foster care in the application state and aged out in the application state.
UI Question Companion Guide Reference
Tab: UI Questions

Application Input

Application Data

State

Same application state as 3.A

Item 2

Coverage Year

Same coverage year as 3.A

Item 21

Seeking financial assistance?

Yes*

Item 1

Application State & Coverage Year

Financial Assistance

Notes to Testers

Auditor Checklist

Because this is a CiC, the application coverage year
and state should remain the same and the
application from Test Case 3.A should be updated

*When asking consumers about financial assistance,
the entity's UI can provide a screener tool to help
consumers make their decisions on this question,
but the screener tool is not required (Items 22-26)
The UI must display answer options "Yes" and "No"
for Item 21. Entities are not required to display the
answer option "I'm not sure"
Items 22-26 may display if a consumer selects "I'm
not sure" for this question

Items 4, 30 Name
Items 5, 6, 123 Home address
Items 7, 8 Mailing address
Item 10 Language preferences

Household Member

Alex Burns*
Age: 26
Male

Household Member Information
Lynn Jones*
Age: 24
Female

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

Item 30

Items 27, 30
Items 76, 77
Items 5, 123, 276

Application Filer/Relationship to
Application Filer and Other Famiy
Members
Applicant/Non-Applicant
Marital Status
Address and Living Situations

Item 117

Parent/Caretaker Relative Status

Item 32

SSN

Item 36

Applying with same name as SSN
card?
Citizenship/immigration

Items 38, 40

Application Filer

Spouse of Alex

Applicant
Married
Provide address in application state
Lives with spouse Lynn
Not main person taking care of any
children age 18 or younger
Does not have SSN, continue without
providing SSN

Applicant
Married
Same address as application filer
Lives with spouse Alex
Not main person taking care of any
children age 18 or younger
Does not have SSN, continue without
providing SSN

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

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

Check Item 32: Verify that you can proceed without
entering an SSN and that wording and answer option
format conform to UI Q CG requirements

Items 81, 82

Tax Filing Status

Items 131, 132

Non-MAGI Medicaid Eligibility
Questions (physical disabilities,
assistance with daily living, nursing
home care)
American Indian/Alaska Native

Items 146, 210, 211, 270
Item 269 (depending on implementation)

Item 147
Pregnancy Questions
Item 269 (depending on implementation)
Items 149, 150, 151, 152
Foster Care Questions
Item 269 (depending on implementation)

Filing jointly with Lynn
Filing jointly with Alex
Does not attest to any dependents on
Does not attest to any dependents on
their tax return
their tax return
More About This Household
Do not answer affirmatively to any nonDo not answer affirmatively to any nonMAGI questions
MAGI questions

Member of a federally recognized
American Indian tribe: Seminole Tribe of
FL or Catawba of SC
N/A (should not display for this household
member)
N/A (should not display for this household
member)

Does not have AI/AN status

Not pregnant
Former Foster Care
State of application state;
Attests "Yes" to having Medicaid while in
foster care
Left foster care at age:
AL, FL, MS, or NC: 21
SC: 19
GA, KS, SD, TN, or WY: 18

Item 250
Incarceration Questions
Item 269 (depending on implementation)

Not incarcerated

Item 144
Full-Time Student Questions
Item 269 (depending on implementation)

N/A (should not display for this household N/A (should not display for this household
member)
member)
Medicaid Block
Does not have Medicaid/CHIP that
Does not have Medicaid/CHIP that
recently ended or will end soon; Not
recently ended or will end soon; Not
denied Medicaid/CHIP
denied Medicaid/CHIP
Income
Self-employment: $700 per month
No income

Items 133, 138

Medicaid/CHIP Denial

Items 153, 154, 159

Current Month Income
Deductions
Tribal Income

No deductions
No deductions
$100 of Alex's self-employment income is N/A (should not display for this household
member)
from a type of tribal income per month
(for selling items of tribal significance)

Items 181, 182, 183

Annual Income

Disagree with calculated annual income;
Income is not hard to predict;
Attest to $10,000 annual income

Items 191, 285

Current Coverage

Item 239

Help Paying Medical Bills

Items 213, 218, 224, 225, 226, 294

Recent Life Changes (SEPs)

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

Application Review & Legal
Attestations

Sample HealthCare.gov Eligibility Results
Messaging

Check Items 179 and 180: Verify these questions
display for Alex and question and answer option
language is exact

$0

Program Questions
N/A (should not display for this household None
member)
N/A (should not display for this household Do not answer affirmatively
member)
Recently married
Provide date in last 60 days
Attest "Yes" to prior coverage questions*

Check Item 149 or 269: Verify that Alex does not
appear as an answer option to the former foster care
question

Not incarcerated

Item 174
Items 179, 180

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

Testers must respond to the question regarding
when Lynn left foster care using the specified age
associated with the application state

N/A (should not display for this household *Questions regarding prior coverage may be omitted
member)
for Alex and Lynn in this scenario because of Alex's
attested AI/AN status
Attestations
Answers affirmatively to all application attestations
Auditors should review the application review page
(Item 246) to ensure all information accurately
reflects the attestations inputted during the test
case
Eligibility Results
May be eligible for Medicaid
Auditors should review the Eligibility Results Page to
Eligible to buy a Marketplace plan
ensure it accurately reflects the eligibility results
found in the EDN and complies with ERP messaging
Eligible for additional help with costs as a
requirements outlined in the documentation listed
member of a tribe*
in Column A
Eligible for a Special Enrollment Period
*Eligible applicants who are members of a federallyrecognized tribe can enroll in Platinum, Gold, Silver,
or Bronze plans with cost-sharing reductions

Check Item 285: Verify Item 285 does not display for
Lynn
Check Item 239: Verify Lynn is the only answer
option for "Would any of these people like help
paying for medical bills from the last 3 months?"

Summary: In this scenario, a non-citizen parent and citizen child are both applying for coverage. This scenario demonstrates a household where family members are found eligible for different programs and where a child lives with someone who is not on the application
and whose information must be included in order to build the child's Medicaid household. Although the household income is within CHIP range, the child is subject to a CHIP waiting period and therefore becomes APTC eligible. This triggers display of ESC coverage, and the
applicant must provide information about a health coverage offer from the mother's job that is available to the child, but is unaffordable.
UI Question Companion Guide Reference

Application Input

Application Data

Notes to Testers

Auditor Checklist

Application State & Coverage Year

Tab: UI Questions
Item 1
Item 2

State
Coverage Year

IN
Current year

Item 21

Seeking financial assistance?

Yes*

Financial Assistance
*When asking consumers about financial assistance,
the entity's UI can provide a screener tool to help
consumers make their decisions on this question, but
the screener tool is not required (Items 22-26)
The UI must display answer options "Yes" and "No"
for Item 21. Entities are not required to display the
answer option "I'm not sure"
Items 22-26 may display if a consumer selects "I'm
not sure" for this question
Items 4, 30 Name
Items 5, 6, 123 Home address
Items 7, 8 Mailing address
Item 10 Language preferences

Household Member

Laura Banfield*
Age: 35
Female

Household Member Information
Junior Banfield*
+ John Curtis
Age: 5
Age: 58
Male
Male

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

+ Add John when answering questions
Must provide a valid county and zip code for the
about Junior living with another parent. Do application state
not add him at the beginning of the
application
Use any date of birth that results in the correct age
for each household member
Other household contact and information fields (i.e.
email, phone, language preference, race/ethnicity,
etc.) may contain any value unless otherwise noted
Find additional information in the UI Question
Companion Guide:
- Items 4-9 Household Contact Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-Applicant
information - Race and Ethnicity

Item 30

Items 27, 30
Item 76

Items 123, 276
For Junior: Items 88, 282, 94, 104, 109

Application Filer/Relationship to
Application Filer and Other Family
Members
Applicant/Non-Applicant
Marital Status

Application Filer
Mother of Junior
Domestic partner to John
Applicant
Single

Address and Living Situations

Provide address in application state

Child of Laura
Child of John
Applicant
Single

Domestic partner to Laura
Father of Junior
Non-Applicant
Single

Same address as application filer
Lives with mother, Laura
Lives with parent/stepparent other than
Laura (father, John Curtis)
Junior does not live with any other family
members

Same address as application filer

Check Item 30: Verify UI collects John's relationship of "parent
(including adoptive parent)" to Junior

Entities have the flexibility to ask if all applicants are
married or to limit the question to applicants over the
age of 14. Depending on implementation, a UI may
not collect Junior's marital status
Must use valid zip code/county within application
state

Check Items 88 and 282: Verify Item 88 displays for Junior and
that the UI allows John Curtis' information to be entered
through Item 282 at that point
Check Item 104: Verify Item 104 displays for Junior

Item 116

Parent/Caretaker Relative Status

Main person taking care of son Junior

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

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

Items 32, 34

SSN

Item 36

Applying with same name as SSN
card?

Does not have SSN, continue without
providing SSN
N/A (should not display for this household
member)

Does not have SSN, continue without
providing SSN
N/A (should not display for this household
member)

Does not have SSN, continue without
providing SSN
N/A (should not display for this household
member)

This question is optional to appear for Laura (Item
116) because the backend logic can derive Laura lives
with her son Junior and set her parent/caretaker
relative status accordingly

Items 38, 39, 40, 44, 46, 48, 49, 71, 72

Citizenship/immigration

Not a U.S. citizen/national
Attests to eligible immigration status

Attests to U.S. citizenship; not naturalized
or derived citizen

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

Do not enter document numbers for Laura (Item 49)

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

*There is flexibility in the flow for collecting Junior's
tax filing information. If the UI first establishes that
he is claimed as a dependent by Laura, then it is
optional to ask him if he will also file his own return

Document type:
I-551 green card; does not have other
document types
Answer "Yes" to question: "Has Laura lived
in the U.S. since 1996?"
Tax Household
Items 80, 82, 83

Tax Filing Status

Filing taxes, claiming Junior

Claimed by Laura*

Items 131, 132

Non-MAGI Medicaid Eligibility
Questions (physical disabilities,
assistance with daily living, nursing
home care)
American Indian/Alaska Native

Do not answer affirmatively to any nonMAGI questions

More About This Household
Do not answer affirmatively to any nonN/A (should not display for this household
MAGI questions
member)

Does not have AI/AN status

Does not have AI/AN status

Does not have AI/AN status

Items 147, 148
Item 269 (depending on implementation)

Pregnancy Questions

Pregnant
Expecting 1 child

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

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

Item 149
Item 269 (depending on implementation)

Foster Care Questions

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

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

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

Item 250
Item 269 (depending on implementation)

Incarceration Questions

Not incarcerated

Not incarcerated

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

Item 144
Item 269 (depending on implementation)

Full-Time Student Questions

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

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

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

Items 133, 138, 141

Medicaid/CHIP Denial

Item 146
Item 269 (depending on implementation)

Medicaid Block
Does not have Medicaid/CHIP that recently Does not have Medicaid/CHIP that recently N/A (should not display for this household
ended or will end soon; Not denied
ended or will end soon; Not denied
member)
Medicaid/CHIP
Medicaid/CHIP
Was not found ineligible due to
immigration status
Income

Items 153, 154, 155, 156, 209

Current Month Income

Job: $20 an hour, 40 hours per week

No income

No income

Item 174
Items 181, 182, 183

Deductions
Annual Income

No deductions
Disagree with calculated annual income;
Income is not hard to predict;
Attest to $42,100 annual income

No deductions
$0

No deductions
$0

Items 191, 285

Current Coverage

None

Program Questions
None;
Does not already have an ICHRA

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

Item 239

Help Paying Medical Bills

Do not answer affirmatively

Items 243, 244

CHIP Waiting Period Questions

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

N/A (should not display for this household
member)
Answer "Yes" to CHIP waiting period
question "Did Junior have health coverage
through a job that ended in in the last
[number of months]?"

Offer of coverage through her own job

Answer "Other" or leave blank follow up
question of "why did that coverage end?"
Not offered [state]'s state employee health N/A (should not display for this household
member)
benefit plan through a job or a family
member's job

Employer name and phone number are required
fields, but any value may be entered (ex: "ABC Corp"
or "555-555-5555")

Check Items 191 and 285: Verify Item 285 displays separately
from Item 191 for Junior
Check Item 285: Verify Item 285 does not display for Laura

Items 200, 201, 203, 204, 207, 245, 284,
304

Offer of Coverage Through Job

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

Offer of coverage through Laura's job
Plan meets minimum value standard
Family premium for the plan is $800/month
Item 286
Items 213, 218, 224, 294

Offer of individual coverage HRA
(ICHRA)
Recent Life Changes (SEPs)

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

None

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

None of these changes
Attestations

The CHIP waiting period question will display the
value 3 months in IN

Check Items 243 and 244: Verify questions only display for
Junior and that the correct number of months value displays for
application state

Must include Laura's employer's name and phone
number

Check Item 200: Verify Laura is asked whether they have
coverage through their own job.*

Entities have flexibility about whether to ask
consumers age 13 or under if they are offered
coverage through their own job

*Please note, Junior may or may not be asked Item 200
depending on Entity implementation.
Check Item 304: Verify Laura is asked for the lowest-cost
premium amount that covers her and Junior.

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

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

Application Review & Legal
Attestations

Answers affirmatively to all application attestations

Eligibility Results Page

May be eligible for Medicaid

Eligibility Results
Eligible to buy a Marketplace plan
Eligible for a premium tax credit of up to
[amount] each month for your tax
household
Eligible for lower copayments, coinsurance,
and deductibles (cost-sharing reductions)
on Silver plans
Not eligible for a Special Enrollment
Period*

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

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

Summary: In this scenario, a parent, her domestic partner, and her child apply for coverage. This scenario demonstrates the UI can successfully build the household when one of applicants (domestic partner) is not part of the tax return. The mother has an offer of
employer-sponsored coverage (ESC), and because the offer is affordable, she is found QHP eligible without APTC. Because the daughter is enrolled in COBRA, she is found QHP eligible without APTC. Because the domestic partner is not filing a tax return, he is eligible for
QHP without subsidy.
UI Question Companion Guide Reference

Application Input

Application Data

Tab: UI Questions
Item 1
Item 2

State
Coverage Year

Item 21

Seeking financial assistance?

Notes to Testers

Application State & Coverage Year
AZ, AR, DE, FL, MI, MS, NE, NC, ND, OH, OK, SC, SD, TX, UT, VA, or WY
Current year
Financial Assistance
Yes*

Auditor Checklist

*When asking consumers about financial assistance,
the entity's UI can provide a screener tool to help
consumers make their decisions on this question, but
the screener tool is not required (Items 22-26)
The UI must display answer options "Yes" and "No"
for Item 21. Entities are not required to display the
answer option "I'm not sure"
Items 22-26 may display if a consumer selects "I'm
not sure" for this question

Items 4, 30 Name
Items 5, 6, 123 Home address
Items 7, 8 Mailing address
Item 10 Language preferences

Household Member

Jane Doe*
Age: 35
Female

Jim Doe*
Age: 35
Male

Household Member Information
Baby Doe*
Age: 5
Female

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

Item 30

Application Filer/Relationship to
Application Filer

Application Filer

Domestic Partner

Son/Daughter

Items 27, 30

Applicant/Non-Applicant

Applicant

Applicant

Applicant

Item 76

Marital Status

Single

Single

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

Entities have the flexibility to ask if all applicants are
married or to limit the question to applicants over the
age of 14. Depending on implementation, a UI may
not collect Baby's marital status

Item 276
For Baby: Item 88
For Jim: Item 104

Address and Living Situations

Provide address in application state
Lives with child (Baby) and domestic
partner (Jim)

Same address as application filer;
Jim does not live with any other family
members

Same address as application filer;
Baby does not live with another parent

Must use valid zip and county in application state

Items 30, 271

Relationships and Other Family
Members

Mother of Baby
Domestic partner to Jim
Does not attest to any legal relationship
with other household members

Domestic partner to Jane
Parent's domestic partner to Baby (Baby is
not Jim's child)
Does not attest to any legal relationship
with other household members

Child of Jane
Child of domestic partner to Jim (Jim is not
a parent of Baby)
Does not attest to any legal relationship
with other household members

Item 116

Parent/Caretaker Relative Status

Main person taking care of Baby

Main person taking care of Baby

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

Item 32

SSN

Does not have SSN, continue without
providing SSN

Does not have SSN, continue without
providing SSN

Does not have SSN, continue without
providing SSN

Item 36

Applying with same name as SSN
card?

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

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

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

Items 38, 40

Citizenship/immigration

Attests to U.S. citizenship; not naturalized
or derived citizen

Items 80, 82, 83, 90

Tax Filing Status

Filing a return, claiming Baby

Attests to U.S. citizenship; not naturalized Attests to U.S. citizenship; not naturalized
or derived citizen
or derived citizen
Tax Household
Not filing a return, not claimed as a
Tax dependent of Jane
dependent
More About This Household

Check Item 88: Verify Baby is asked about living with another
parent
Check Item 104: Verify Item 104 displays for Jim
Check Item 30: Verify UI collects Jim's relationship to both Jane
and Baby, and that relationships of "domestic partner" and
either "parent's domestic partner" or "child of domestic
partner" are accepted

This question is expected to appear for Jim (Item
116). It's optional to appear for Jane, as the backend
logic can derive Jane lives with her daughter and set
her parent/caretaker relative status accordingly

Check Item 116: Verify Jim is asked about children he lives with
and takes care of and is able to select "Baby" as an answer
option
Check Item 32: Verify that you can proceed without entering an
SSN and that wording and answer option format conform to UI
Q CG requirements

Items 131, 132

Non-MAGI Medicaid Eligibility
Questions (physical disabilities,
assistance with daily living, nursing
home care)
American Indian/Alaska Native

Do not answer affirmatively to any nonMAGI questions

Do not answer affirmatively to any nonMAGI questions

Do not answer affirmatively to any nonMAGI questions

Does not have AI/AN status

Does not have AI/AN status

Does not have AI/AN status

Item 147
Item 269 (depending on implementation)

Pregnancy Questions

Not pregnant

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

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

Item 149
Item 269 (depending on implementation)

Foster Care Questions

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

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

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

Item 250
Item 269 (depending on implementation)

Incarceration Questions

Not incarcerated

Not incarcerated

Not incarcerated

Item 144
Item 269 (depending on implementation)

Full-Time Student Questions

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

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

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

Items 133, 138

Medicaid/CHIP Denial

Items 153, 154, 155, 156, 209

Current Month Income

Medicaid Block
Does not have Medicaid/CHIP that recently Does not have Medicaid/CHIP that recently
ended or will end soon; Not denied
ended or will end soon; Not denied
Medicaid/CHIP
Medicaid/CHIP
Income
Job: $22 an hour, 40 hours per week
Job: $11 an hour, 40 hours per week

Item 174

Deductions

No deductions

No deductions

No deductions

Items 181, 182, 183

Annual Income

Disagree with calculated annual income;
Income is not hard to predict;
Attest to $48,720

$22,862.40

$0

Items 191, 285

Current Coverage

None;
Does not already have an ICHRA

Items 200, 201, 204, 207, 208

Offer of Coverage Through Job

Offer of coverage through her job
Coverage meets minimum value standard
Individual premium is $10/month

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

Offer of individual coverage HRA
(ICHRA)
Recent Life Changes (SEPs)

None

N/A (should not display for this household
member)
None of these changes

Application Review & Legal
Attestations

Answers affirmatively to all application attestations

Eligibility Results Page

Eligible to buy a Marketplace plan

Eligibility Results
Eligible to buy a Marketplace plan

Eligible to buy a Marketplace plan

Eligible for a Special Enrollment Period

Eligible for a Special Enrollment Period

Eligible for a Special Enrollment Period

Item 146
Item 269 (depending on implementation)

Item 286
Items 213, 218, 224, 231, 232, 233, 234,
294

Recently moved
Provide zip code in a different county than
zip code provided in home address;
Provide date within 60 days of present;
Attest "Yes" to prior coverage question

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

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

Employer name and phone number are required
fields, but any value may be entered (ex: "ABC Corp"
or "555-555-5555")

Enrolled in COBRA through Jane's
employer;
Does not already have an ICHRA
N/A (should not display for this household
member)

Any values can be entered for employer contact
Entities have flexibility about whether to ask
consumers age 13 or under if they are offered
coverage through their own job

None
Recently moved
Provide zip code in a different county than
zip code provided in home address;
Provide date within 60 days of present;
Attest "Yes" to prior coverage question

If a date outside of the last 60 days is entered, then
an error message will appear

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

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

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

Check Item 200: Verify that Jim is not asked whether he has
coverage through his own job
Check Item 208: Verify Jane is asked for the lowest cost
premium for just herself
Check Item 286: Verify that Jim is not asked about an ICHRA
offer

Summary: This scenario demonstrates a multi-generation application where the application filer is temporarily residing outside the application state and the other application members reside at a different address within the application state. Because the application
filer intends to return to reside in the application state, he is found QHP eligible with subsidy. This scenario also demonstrates the UI's ability to display special Medicaid household composition questions to the grandchild.
UI Question Companion Guide
Reference

Application Data

Notes to Testers

Application Input

Tab: UI Questions

Auditor Checklist

Application State & Coverage Year

Item 1

State

AL, DE, GA, MS, MO, MT, NC, OK, OR, SC, TN, UT, VA, WV, or WI

Item 2

Coverage Year

Current year
Financial Assistance

Item 21

Seeking financial assistance?

*When asking consumers about financial
assistance, the entity's UI can provide a screener
tool to help consumers make their decisions on this
question, but the screener tool is not required
(Items 22-26)

Yes*

The UI must display answer options "Yes" and "No"
for Item 21. Entities are not required to display the
answer option "I'm not sure"
Items 22-26 may display if a consumer selects "I'm
not sure" for this question
Household Member Information
Items 4, 30 Name
Items 5, 6, 123 Home address
Items 7, 8 Mailing address
Item 10 Language preferences

Household Member

Grandpa Ee*
Age: 64
Male

Sonny Ee*
Age: 25
Male

Baby Ee*
Age: 6
Female

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

Item 30

Application Filer/Relationship to
Application Filer

Application Filer

Son/Daughter

Grandchild

Items 27, 30

Applicant/Non-Applicant

Applicant

Applicant

Applicant

Item 76

Marital Status

Single

Single

Single

Provide a home address that is in a state
outside of application state

Enter address in application state, separate Same address as Sonny
from Grandpa. Any zip code

Item 280
Address and Living Situations
For Grandpa: Items 5, 7, 126, 127,
276, 279
For Sonny and Baby: Items 124, 276,
277, 278

Attest "Yes" to "Is Grandpa living outside
[state of application] temporarily?"
Provide mailing address in application state
For question "Where will Grandpa live in
[state of application]?" provide city and zip
code in application state

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

Entities have the flexibility to ask if all applicants
are married or to limit the question to applicants
over the age of 14. Depending on implementation,
a UI may not collect Baby's marital status
Check Items 126, 127, and 279: Verify these
Sonny must provide a valid county and zip code for items display for Grandpa after he enters a
the application state
home address outside of the application state

Item 30
For Baby: Items 104
For Sonny and Baby: Item 271

Relationships and Other Family
Members

Parent to Sonny; Grandparent to Baby

For Sonny: Item 116 (depending on
implementation)
For Grandpa: Item 117

Parent/Caretaker Relative Status

Not main person taking care of any children Main person taking care of daughter
age 18 or younger
(Baby)

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

Item 32

SSN

Does not have SSN, continue without
providing SSN

Does not have SSN, continue without
providing SSN

Does not have SSN, continue without providing
SSN

Item 36

Applying with same name as SSN
card?
Citizenship/immigration

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

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

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

Items 80, 82, 83
Item 275 (depending on
implementation)

Tax Filing Status

Tax filer, files own return, claims child
(Sonny) and grandchild (Baby) as
dependents

Not filing a return, claimed as a dependent
by Grandpa

Items 131, 132

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

Do not answer affirmatively to any nonMAGI questions

Do not answer affirmatively to any nonMAGI questions

Attests to physical disability; attests to
needing help with daily activities

Item 146
Item 269 (depending on
implementation)
Item 147
Item 269 (depending on
implementation)

American Indian/Alaska Native

Does not have AI/AN status

Does not have AI/AN status

Does not have AI/AN status

Pregnancy Questions

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

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

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

Item 149
Item 269 (depending on
implementation)

Foster Care Questions

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

Not former foster care

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

Item 250
Item 269 (depending on
implementation)

Incarceration Questions

Not incarcerated

Not incarcerated

Not incarcerated

Item 144
Item 269 (depending on
implementation)

Full-Time Student Questions

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

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

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

Items 133, 138

Medicaid/CHIP Denial

Does not have Medicaid/CHIP that recently Does not have Medicaid/CHIP that recently
ended or will end soon; Not denied
ended or will end soon; Not denied
Medicaid/CHIP
Medicaid/CHIP
Income
Social Security income: $1,000 per month Self-employment income: $1,100 per
Retirement: $1,000 per month
month

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

Items 38, 40

Son of Grandpa; Parent to Baby
Does not attest to any legal relationship
with other household members

Check Item 104: Verify Item 104 displays for
Baby

Child of Sonny; Grandchild to Grandpa
Does not attest to any legal relationship with
other household members
Baby does not live with any other family
members
This question (Item 116) is optional to appear for
Sonny, as the backend logic can derive Sonny lives
with his son and set his parent/caretaker relative
status accordingly

Check Item 117: Verify Grandpa is asked if he
lives with and takes care of any children under
19

Tax Household
Not filing a return, claimed as a dependent by
Grandpa

Sonny and Baby do not need to be asked if they are
filing taxes after Grandpa attests to claiming them
as dependents

More About This Household

Medicaid Block

Items 153, 154, 157, 159, 162, 209 Current Month Income

No income

Item 174

Deductions

No deductions

No deductions

No deductions

Item 181

Annual Income

$24,000

$13,200

$0

All household members should be asked of their
current income and deductions regardless of age.
The UI should display expected annual income for
each household member
Household members should attest to agreeing with Check Items 185, 186, and 187: Verify income
the expected income calculated
discrepancy questions do not display

Program Questions
Items 191, 285

Current coverage

Item 239

Help paying for medical bills

Item 200

Offer of coverage through job

None;
Does not already have an ICHRA
N/A (should not display for this household
member)
Does not have an offer of coverage through
their own employer

None;
Does not already have an ICHRA
N/A (should not display for this household
member)
Does not have an offer of coverage through
their own employer

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

Entities have flexibility about whether to ask
consumers age 13 or under if they are offered
coverage through their own job

Check Item 200: Verify Grandpa and Sonny,
depending on implementation are asked
whether they have coverage through their
owns jobs.*
*Please note, Baby may or may not be asked
Item 200 depending on Entity

Item 286

Offer of individual coverage HRA
(ICHRA)

None

None

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

Items 213, 214, 215, 218, 224, 294 Recent Life Changes (SEPs)

None of these changes

Recent loss of minimum essential
coverage (MEC);
Provide date in last 60 days;
Do not provide the name of the plan

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

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

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

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

Answers affirmatively to all application attestations

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

Eligible for a Special Enrollment Period

Auditors should review the Eligibility Results Page
to ensure it accurately reflects the eligibility results
found in the EDN and complies with ERP messaging
requirements outlined in the documentation listed
in Column A

Summary: In this application, a non-applicant non-custodial parent is applying for coverage for her child. Because the child attests to a Medicaid/CHIP denial, the child is not found eligible for Medicaid/CHIP regardless of income, and because the
application filer has a married filing separately tax status, the child is not eligible for APTC. Therefore, the eligibility outcome is QHP only.
UI Question Companion Guide Reference

Application Input

Application Data

Notes to Testers

Auditor Checklist

Application State & Coverage Year

Tab: UI Questions
Item 1
Item 2

State
Coverage Year

Any state
Current year

Item 21

Seeking financial assistance?

Yes*

Financial Assistance
*When asking consumers about financial assistance,
the entity's UI can provide a screener tool to help
consumers make their decisions on this question, but
the screener tool is not required (Items 22-26)
The UI must display answer options "Yes" and "No"
for Item 21. Entities are not required to display the
answer option "I'm not sure"
Items 22-26 may display if a consumer selects "I'm
not sure" for this question
Household Member Information
Items 4, 30 Name
Items 5, 6, 123 Home address
Items 7, 8 Mailing address
Item 10 Language preferences

Household Member

Francis F*
Age: 35
Female

Kid F*
Age: 5
Female

*Do not use F. as the last name. Use a different last
name that is unique (it can be a random string of
letters). Do not change the first name
+ Frank F *
Age: 35
Male

+ Add Frank when asked about Francis'
marital status. Do not add him at the
beginning of the application

Item 30

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

Application Filer

Son/Daughter

Spouse

Non-Applicant

Applicant

Non-Applicant

Item 76
For Francis: Items 77, 78

Marital Status

Married

Single

Married

Items 276, 277, 280
For Francis: Item 5
For Kid and Frank: Items 278, 124
For Kid: Items 104, 105 (Items 94 and 95
depending on implementation)

Address and Living Situations

Enter address in application state
Lives alone

For Kid: Item 30
For Frank: Item 78
Item 117

Relationships and Other Family
Members
Parent/Caretaker Relative Status

Parent of Kid; Spouse of Frank

Enter address in application state, separate Same address as Kid
Lives with Kid
from Francis
Any zip code
Does not live with claiming parent Francis
Lives with parent Frank
Kid does not live with any other family
members
Child of Francis and Frank
Spouse of Francis; Parent of Kid

Items 32, 34

SSN

Item 36

Applying with same name as SSN
card?
Citizenship/immigration

Items 27, 30

Items 38, 40

Items 80, 82, 83, 89, 90, 91
Items 275, 281 (depending on
implementation)

Tax Filing Status

N/A (should not display for this household
member)
Does not have SSN, continue without
providing SSN
N/A (should not display for this household
member)
N/A (should not display for this household
member)
Married, filing separately
Claiming Kid
Attest "No" to Head of Household question

N/A (should not display for this household
member)
Does not have SSN, continue without
providing SSN
N/A (should not display for this household
member)
Attests to U.S. citizenship; not naturalized
or derived citizen
Tax Household
Not filing a return, claimed as a dependent
by Francis

More About This Household

Must provide a valid county and zip code for the
application state
Use any date of birth that results in the correct age
for each household member
Other household contact and information fields (i.e.
email, phone, language preference, race/ethnicity,
etc.) may contain any value unless otherwise noted.
Find additional information in the UI Question
Companion Guide:
- Items 4-9 Household Contact Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-Applicant
information - Race and Ethnicity

Check Item 27: Verify user is able to proceed after
indicating the application filer (Francis) is not applying for
coverage
Entities have the flexibility to ask if all applicants are
married or to limit the question to applicants over the
age of 14. Depending on implementation, a UI may
not collect Kid's marital status
Check Items 104 and 105: Verify applicant is asked to
provide additional information about Kid's other parent,
Frank

N/A (should not display for this household
member)
Does not have SSN, continue without
providing SSN
N/A (should not display for this household
member)
N/A (should not display for this household
member)
N/A (should not display for this household
member)

Check Item 89: Verify the Head of Household question
displays for Francis only after the UI has established that 1)
she is married filing separately, 2) that she does not live
with her spouse, and 3) that she is claiming a dependent

Items 131, 132

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

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

Do not answer affirmatively to any nonMAGI questions

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

Item 146
Item 269 (depending on implementation)

American Indian/Alaska Native

Does not have AI/AN status

Does not have AI/AN status

Does not have AI/AN status

Item 147
Item 269 (depending on implementation)

Pregnancy Questions

Not pregnant

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

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

Item 149
Item 269 (depending on implementation)

Foster Care Questions

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

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

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

Item 250
Item 269 (depending on implementation)

Incarceration Questions

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

Not incarcerated

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

Item 144
Item 269 (depending on implementation)

Full-Time Student Questions

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

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

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

Items 133, 134, 136

Medicaid/CHIP Denial

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

Items 153, 154, 155, 156, 209

Current Month Income

Job: $11 an hour, 40 hours per week

Item 174
Items 181, 182, 183

Deductions
Annual Income

No deductions
Disagree with calculated annual income;
Income is not hard to predict;
Attest to $23,000

Items 213, 218, 224, 294

Recent Life Changes (SEPs)

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

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

Application Review & Legal
Attestations

Answers affirmatively to all application attestations

Eligibility Results Page

N/A

Medicaid Block
Does not have Medicaid/CHIP that recently N/A (should not display for this household
ended or will end soon
member)
Denied Medicaid in the last 90 days;
Provide date in last 60 days;
Attest to applying during last Open
Enrollment [most recent OE start date] –
[most recent end date]
Income
No income
No income

No deductions
$0

The date provided should be within the last 60 days

Employer name and phone number are required
fields, but any value may be entered (ex: "ABC Corp"
or "555-555-5555")

No deductions
$0

Program Questions
None of these changes

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

Attestations

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

Eligibility Results
Eligible to buy a Marketplace plan
Eligible for a Special Enrollment Period

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

Auditors should review the Eligibility Results Page to
ensure it accurately reflects the eligibility results
found in the EDN and complies with ERP messaging
requirements outlined in the documentation listed in
Column A

Check Items 133, 134, and 136: Verify that attesting to past
Medicaid denial displays follow-up questions regarding
date of denial (Item 134) and whether the applicant applied
during the last Open Enrollment (Item 136)

Summary: This scenario presents an application within APTC income range that includes married tax dependents, non-applicant tax dependents, and a tax dependent who is also filing their own return. The scenario demonstrates the UI's ability to display special Medicaid household composition questions as well as display legal
relationship questions, other individual market insurance coverage, and multiple SEP types. This test case must be run in SC, zip code 29401 or TX, zip code 77001.
UI Question Companion Guide
Reference
Tab: UI Questions

Application Input

Application Data

Item 1

State

SC, zip code 29401
TX, zip code 77001

Item 2

Coverage Year

Current Year

Item 21

Seeking financial assistance?

Yes*

Notes to Testers

Auditor Checklist

Application State & Coverage Year

Financial Assistance

*When asking consumers about financial
assistance, the entity's UI can provide a screener
tool to help consumers make their decisions on
this question, but the screener tool is not required
(Items 22-26)
The UI must display answer options "Yes" and "No"
for Item 21. Entities are not required to display the
answer option "I'm not sure"
Items 22-26 may display if a consumer selects "I'm
not sure" for this question

Items 4, 30 Name
Items 5, 6, 123 Home address
Items 7, 8 Mailing address
Item 10 Language preferences

Item 30

Household Member

Aubrey Gee*
Age: 51
Female

Tony Gee*
Age: 21
Male

Gabriella Gee*
Age: 18
Female

Household Member Information
Will Gee*
Age: 18
Male

+ Robert Gee*
Age: 14
Male

+ Sandra Gee*
Age: 18
Female

+ Add Robert when Aubrey is asked
about additional dependents on her tax
return. Do not add him at the beginning
of the application

+ Add Sandra when Will is asked about
his marital status. Do not add her at the
beginning of the application

Application Filer

Son/Daughter

Niece

Son/Daughter

Son/Daughter

Daughter-in-law

Non-Applicant

Applicant

Applicant

Applicant

Non-Applicant

Non-Applicant

For Aubrey, Tony, Gabriella, Will: Item
76
For Will: Items 77, 78

Marital Status

Single

Single

Single

Married

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

Married

Items 276, 277
For Sandra: Items 278, 124
For Will: Item 88
For Gabriella: Item 104

Address and Living Situations

Provide address in application state

Same address as application filer

Same address as application filer

Same address as application filer

Same address as application filer

Different address than application filer

Lives with children Tony, Will, and
Robert; and niece Gabriella

Lives with parent Aubrey,
brother Will and Robert, and first cousin
Gabriella

Lives with aunt Aubrey, and first cousins
Will, Tony, and Robert;

Lives with parent Aubrey, brothers Tony
and Robert, and first cousin Gabriella;

Lives with parent Aubrey, brothers Will
and Tony, and first cousin Gabriella

Gabriella does not live with any other
family members

Does not live with spouse (Sandra); does
not live with another parent at this
address

Parent of Tony, Will, and Robert; Aunt of Son of Aubrey;
Gabriella
Brother of Will and Robert;
First cousin to Gabriella
Does not attest to any legal relationship
with other household members

Niece of Aubrey;
First cousin to Will, Tony, and Robert;
Does not attest to any legal relationship
with other household members

Son of Aubrey;
Brother of Tony and Robert
First cousin to Gabriella
Does not attest to any legal relationship
with other household members

For Will, Gabriella, Tony: Item 30
For Robert: Item 84
For Sandra: Item 78
For Gabriella: Item 271

Relationships and Other Family
Members

Son of Aubrey;
Brother of Will and Tony;
First cousin to Gabriella;
Brother-in-law to Sandra

Item 116

Parent/Caretaker Relative Status

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

Not main person taking care of any
children age 18 or younger

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

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

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

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

SSN

Does not have SSN, continue without
providing SSN
N/A (should not display for this
household member)

Does not have SSN, continue without
providing SSN
N/A (should not display for this
household member)

Does not have SSN, continue without
providing SSN
N/A (should not display for this
household member)

Does not have SSN, continue without
providing SSN
N/A (should not display for this
household member)

Does not have SSN, continue without
providing SSN
N/A (should not display for this
household member)

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

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

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

Applying with same name as SSN
card?
Citizenship/immigration

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

Attests to U.S. citizenship;
not naturalized or derived citizen

Attests to U.S. citizenship;
Attests to U.S. citizenship;
not naturalized or derived citizen
Attests to naturalized or derived
citizenship;
Does not have a Naturalization Certificate
or Certificate of Citizenship

Items 80, 81, 82, 83, 84, 90, 91

Tax Filing Status

Filing return, claiming
Tony, Gabriella, Will, Robert as
dependents

Not filing a return
Claimed as dependent by Aubrey

Not filing a return
Claimed as dependent by Aubrey

Tax Household
Filing a return (not jointly with spouse)** Not filing a return
Claimed as dependent by Aubrey
Claimed as dependent by Aubrey*

Use any date of birth that results in the correct age
for each household member

Provide zip code 29401 in SC or 77001 for TX

Not filing, not claimed as a dependent

Check Item 116: Verify this question displays for Tony

Check Item 41: Verify that the questions that request
documentation after Gabriella attests to naturalized
citizenship are optional

*This is the point at which the application should
collect information about any other dependents
Aubrey will claim on her return. At this point,
testers should add Robert as an additional
dependent. Note Robert is not applying for
coverage
**There is flexibility in the flow for collecting Will's
tax filing information. If the UI first establishes that
he is claimed as a dependent by Aubrey, then it is
optional to ask him if he will also file his own
return

Items 131, 132

Item 146
Item 269 (depending on
implementation)
Item 147
Item 269 (depending on
implementation)
Item 149
Item 269 (depending on
implementation)
Item 250
Item 269 (depending on
implementation)
Item 144
Item 269 (depending on
implementation)

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

Do not answer affirmatively to any nonMAGI questions

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

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

Check Item 104: Verify this question displays for Gabriella

Audrey's daughter-in-law;
Will's spouse

Items 32
For Aubrey, Robert: Item 34
Item 36
Items 38, 40
For Gabriella: Item 41

Provide zip code 29401 in SC or 77001 for TX

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

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

Items 27, 30

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

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

American Indian/Alaska Native

Does not have AI/AN status

Does not have AI/AN status

Does not have AI/AN status

Does not have AI/AN status

Does not have AI/AN status

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

Pregnancy Questions

Not pregnant

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

Not pregnant

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

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

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

Foster Care Questions

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

Not former foster care

Not former foster care

Not former foster care

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

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

Incarceration Questions

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

Not incarcerated

Not incarcerated

Not incarcerated

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

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

Full-Time Student Questions

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

Not a full-time student

Not a full-time student

Not a full-time student

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

Not a full-time student

Check Items 83 and 84: Verify Aubrey is able to select known
applicants (Tony, Will, Gabriella) as dependents and able to
add Robert as a non-applicant dependent through Item 84

Items 153, 154, 155, 209

Current Month Income

Job: $7,250 per month

Job: $91.17 per month

Job: $139.25 per month

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

Job: $88.42 per month

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

Items 174, 175, 176

Deductions

No deductions

No deductions

No deductions

Alimony: $400 per month

No deductions

Item 181

Annual Income

$87,000

$1,094.04

$1,671

$5,199.96

$1,061.04

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

Items 133, 138

Medicaid/CHIP Denial

Items 191, 192, 285

Current Coverage

Item 239

Help Paying Medical Bills

Item 200

Offer of Coverage Through Job

Item 286

Offer of individual coverage HRA
(ICHRA)

Items 213, 218, 224, 225, 226, 231,
232, 233, 234, 294

Recent Life Changes (SEPs)

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

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

Eligibility Results Page

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

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

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

N/A (should not display for this
household member)
N/A (should not display for this
household member)
Does not have an offer of coverage
through their own employer
N/A (should not display for this
household member)

None;
Does not already have an ICHRA
N/A (should not display for this
household member)
Does not have an offer of coverage
through their own employer
None

None

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

Recently moved;
N/A (should not display for this
Provide zip code in a different county
household member)
than zip code provided in home address;
Provide date in last 60 days;
Attest "No" to prior coverage question

Does not answer affirmatively
Does not have an offer of coverage
through their own employer
N/A (should not display for this
household member)

Answers affirmatively to all application attestations

N/A

Eligible to buy a Marketplace plan with a May be eligible for Medicaid
premium tax credit of up to
[SC - $339; TX - $333] each month for
your tax household
Eligible for a Special Enrollment Period

Program Questions
Marketplace Coverage;
Does not already have an ICHRA
N/A (should not display for this
household member)
Does not have an offer of coverage
through their own employer
None
Recently married;
Provide date in last 60 days;
Attest "Yes" to prior coverage question

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

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

N/A (should not display for this
household member)
N/A (should not display for this
household member)
Does not have an offer of coverage
through their own employer
N/A (should not display for this
household member)

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

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

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

Check Item 138: Verify Medicaid/CHIP recently ended or
ending soon is asked before Medicaid/CHIP denial

Employer name and phone number are required
fields, but any value may be entered (ex: "ABC
Corp" or "555-555-5555")

Household members should attest to agreeing
with the expected income calculated

If a date outside of the last 60 days is entered, then Check Items 226 and 234: Verify question about prior
an error message will appear
coverage displays for both move and marriage SEP
attestations

Recently moved;
Provide zip code in a different county
than zip code provided in home address;
Provide date in last 60 days;
Attest "No" to prior coverage question

Attestations

Eligibility Results
Eligible to buy a Marketplace plan with a N/A
premium tax credit of up to
[SC - $339; TX - $333] each month for
your tax household
Eligible for a Special Enrollment Period

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

N/A

Check Item 153: Verify income information is not requested
of Sandra

Auditors should review the Eligibility Results Page
to ensure it accurately reflects the eligibility results
found in the EDN and complies with ERP messaging
requirements outlined in the documentation listed
in Column A

Summary: This is another multi-generation household scenario that includes an applicant who is not a dependent on the application filer's return. The scenario requires the UI to display questions to collect information on a non-applicant dependent child for purposes of parent/caretaker relative eligibility only; and collects information on current health coverage for a dependent child non-applicant for Medicaid adult group eligibility of the parent. This scenario also demonstrates results for a
consumer who does not file a tax return and is not claimed as a dependent. The scenario produces eligibility results that include Medicaid and QHP with and without subsidy. This test case should be run in LA, zip code 70802.
UI Question Companion Guide
Reference
Tab: UI Questions

Application Input

Application Data

Item 1
Item 2

State
Coverage Year

LA, zip code 70802
Current year

Item 21

Seeking financial assistance?

Yes*

Notes to Testers

Auditor Checklist

Application State & Coverage Year

Financial Assistance

*When asking consumers about financial
assistance, the entity's UI can provide a screener
tool to help consumers make their decisions on
this question, but the screener tool is not required
(Items 22-26)
The UI must display answer options "Yes" and "No"
for Item 21. Entities are not required to display the
answer option "I'm not sure"
Items 22-26 may display if a consumer selects "I'm
not sure" for this question

Items 4, 30 Name
Items 5, 6, 123 Home address
Items 7, 8 Mailing address
Item 10 Language preferences

Household Member

Farrah H *
Age: 48
Female

Henry H *
Age: 48
Male

Rina H *
Age: 18
Female

Household Member Information
Mama H *
Age: 66
+ Mark H *
Female
Age: 16
Male
+ Add Mark when asked about additional
dependents on Farrah's tax return. Do
not add him at the beginning of the
application

Items 30

+ Husband H*
Age: 66
Male

+ Anastasia H*
Age: 8
Female

Provide zip code 70802
+ Add Husband when asked about Mama + Add Anastasia when Mama H is asked if
H's marital status. Do not add him at the she is the main caretaker for a child
Use any date of birth that results in the correct age
beginning of the application
under age 18. Do not add her at the
for each household member
beginning of the application
Other household contact and information fields
(i.e. email, phone, language preference,
race/ethnicity, etc.) may contain any value unless
otherwise noted. Find additional information in the
UI Question Companion Guide:
- Items 4-9 Household Contact Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-Applicant
information - Race and Ethnicity

Application Filer/Relationship to
Application Filer
Applicant/non-applicant
Marital Status

Application Filer

Spouse

Son/Daughter

Son/Daughter

Mother

Other relative

Other relative

Applicant
Married

Applicant
Married

Applicant
Single

Non-Applicant
Single*

Applicant
Married

Non-Applicant
Married

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

Items 276, 277
For Husband: Items 124, 278
For Mama: Item 104

Address and Living Situations

Provide address in application state

Same address as application filer

Same address as application filer

Different address in application state

Same address as application filer

Items 30, 271
For Farrah, Henry, Rina, Mother: Item
30
For Mark: Item 84
For Husband: Item 78
For Anastasia: Item 119
Item 116 (depending on
implementation)
For Mama: Items 117, 118, 119

Items 27, 30
For Farrah, Henry, Rina, Mark, Mama,
Husband: Item 76
For Farrah, Mama: Item 77

Check Item 30: Verify that Medicare messaging displays for
*Do not use H. as the last name. Use a different
last name that is unique (it can be a random string Mama
of letters). Do not change the first name

Same address as application filer

Same address as application filer

Lives with spouse Henry, children Rina
Lives with spouse Farrah, children Rina,
Lives with parents Farrah and Henry,
and Mark; parent Mama H, other relative Mark, mother-in-law Mama H, and other brother Mark, grandmother Mama, and
Anastasia
relative Anastasia
other relative Anastasia

Lives with parents Farrah and Henry,
sister Rina, grandmother Mama, and
other relative Anastasia

Lives with daughter Farrah, son-in-law
Lives alone
Henry, grandchildren Anastasia, Rina, and
Mark (does not live with spouse)

Relationships and Other Family
Members

Spouse of Henry, parent of Rina and
Spouse to Farrah, parent of Rina and
Mark; child to Mama H, other relative to Mark, son-in-law to Mama H, and other
Anastasia
relative to Anastasia

Daughter to Farrah and Henry, sibling of
Mark, grandchild of Mama H., other
relative to Anastasia
Does not attest to any legal relationship
with other household members

Son to Farrah and Henry, sibling of Rina, Mother to Farrah, mother-in-law to
grandchild of Mama H. and Husband H.*, Henry, grandmother to Anastasia, Rina,
other relative to Anastasia
and Mark;
Does not attest to any legal relationship
with other household members

Parent/Caretaker Relative Status

Main person taking care of Rina and
Mark*

Main person taking care of Rina and
Mark*

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

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

SSN

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

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

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

Does not have SSN, continue without
providing SSN
N/A (should not display for this
household member)
N/A (should not display for this
household member)

*Depending on application implementation, if
marital status is collected before tax filing status,
the application may not collect Mark's marital
Provide zip code 70802

Check Item 104: Verify this question displays for Mama

Lives with grandmother Mama and other
relatives Farrah, Henry, Rina, and Mark

Does not live with any other family
members

Items 32
For Mark: Item 34
Item 36
Items 38, 40

Applying with same name as SSN
card?
Citizenship/immigration

Items 80, 81, 82, 83, 84, 90

Tax Filing Status

Items 131, 132

Item 146
Item 269 (depending on
implementation)
Items 147
Item 269 (depending on
implementation)
Item 149
Item 269 (depending on
implementation)
Item 250
Item 269 (depending on
implementation)
Item 144
Item 269 (depending on
implementation)

Married filing jointly
Claims Rina and Mark as dependents

Spouse of Mama

Granddaughter to Mama and Husband

*The entity's UI is not required to collect the
relationship between Mark and Husband

Main person taking care of
granddaughter Anastasia*

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

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

*Farrah and Henry do not need to be asked the
parent/caretaker relative question if the
application has already established they live with
and claim their children, Rina and Mark, as tax
dependents. If the application has not
implemented this logic, it is compliant for it to
collect that Farrah and Henry are taking care of
their children Rina and Mark. However, this
question must appear for Mama, and testers
should respond "Yes" and should be prompted to
enter information about Anastasia for the first
time at that point

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

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

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

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

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

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

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

Tax Household

Married filing jointly
Claims Rina and Mark as dependents

Not filing a return
Not filing a return
Dependent (claimed by Farrah and Henry) Dependent (claimed by Farrah and Henry) Not filing a return
Not claimed as a dependent

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

Do not answer affirmatively to any nonMAGI questions

Attests to physical disability; attests to
needing help with daily activities

American Indian/Alaska Native

Does not have AI/AN status

Does not have AI/AN status

Does not have AI/AN status

Does not have AI/AN status

Does not have AI/AN status

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

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

Pregnancy Questions

Not pregnant

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

Not pregnant

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

Not pregnant

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

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

Foster Care Questions

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

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

Not former foster care

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

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

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

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

More About This Household
N/A (should not display for this
Do not answer affirmatively to any nonhousehold member)
MAGI questions

Incarceration Questions

Not incarcerated

Not incarcerated

Not incarcerated

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

Not incarcerated

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

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

Full-Time Student Questions

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

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

Not a full-time student

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

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

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

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

Medicaid Block

Check Items 117, 118, and 119: Verify Mama is able to
attest to living with and taking care of a child not on the
application, and can add Anastasia's information at this
point

Check Item 38: Verify citizenship questions are only asked
for applicants Farrah, Henry, Rina, and Mama
This is the point at which the application should
collect information about any other dependents
Farrah will claim on her return. At this point,
testers should add Mark as an additional
dependent. Note: Mark is not applying for
coverage

Items 133, 134, 135, 136, 138

Medicaid/CHIP Denial

Does not have Medicaid/CHIP that
Does not have Medicaid/CHIP that
recently ended or will end soon
recently ended or will end soon; Not
Denied Medicaid in the last 90 days
denied Medicaid/CHIP
Provide date in last 60 days;
Attest to applying during last Open
Enrollment [most recent OE start date] –
[most recent OE end date] or during
qualifying life event

Does not have Mediciad/CHIP that
N/A (should not display for this
recently ended or will end soon
household member)
Denied Medicaid in the last 90 days
Provide date in last 60 days;
Attest to applying during last Open
Enrollment [most recent OE start date] –
[most recent OE end date] or during
qualifying life event

Items 153, 154, 155, 162, 209

Current Month Income

Job: $2,791.67 per month

No income

No income

No income

Item 174

Deductions

No deductions

No deductions

No deductions

No deductions

Item 181

Annual Income

$33,500.04

$0

$0

$0

$2,000.04

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

Income

Items 191, 192, 194, 285

Current Coverage

None;
Does not already have an ICHRA

None

Medicare;
Does not already have an ICHRA

Item 240

Covered Dependent Question

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

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

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

Attests to having health coverage now

N/A (should not display for this
household member)
Does not have an offer of coverage
through their own employer
None

Do not answer affirmatively

N/A (should not display for this
household member)
Does not have an offer of coverage
through their own employer
None

N/A (should not display for this
household member)
Does not have an offer of coverage
through their own employer
N/A (should not display for this
household member)
N/A (should not display for this
household member)
Attestations

Item 239

Help Paying Medical Bills

Item 200

Offer of Coverage Through Job

Item 286

Offer of individual coverage HRA
(ICHRA)
Recent Life Changes (SEPs)

Items 213, 218, 224, 294

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

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

Eligibility Results Page

None of these changes

Does not have an offer of coverage
through their own employer
N/A (should not display for this
household member)
N/A (should not display for this
household member)

None of these changes

Answers affirmatively to all application attestations

Eligible to buy a Marketplace plan with a May be eligible for Medicaid
premium tax credit of up to $707 each
month for your tax household
Eligible for lower copayments,
coinsurance, and deductibles (costsharing reductions) on Silver plans
Eligible for a Special Enrollment Period

Eligible to buy a Marketplace plan
Eligible for a Special Enrollment Period

N/A

Eligibility Results

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

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

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

Social Security benefits: $166.67 per
month

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

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

No deductions

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

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

None

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

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

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

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

None

Do not answer affirmatively

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

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

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

The date provided should be within the last 60
days

Household members should attest to agreeing
with the expected income calculated

The UI must collect information on the nonCheck Item 240: Verify Item 240 displays in the UI for Mark
applicant dependent's (Mark's) health coverage for
purposes of determining Medicaid eligibility for his
parent

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

May be eligible for Medicaid

N/A

N/A

Check Item 136: Verify that this question only displays for
Farrah and Rina

Auditors should review the Eligibility Results Page
to ensure it accurately reflects the eligibility results
found in the EDN and complies with ERP messaging
requirements outlined in the documentation listed
in Column A

Summary: A married couple applying for financial assistance reports they were offered an individual coverage HRA (ICHRA) they have not accepted yet. The scenario demonstrates the UI's ability to collect information about the consumers' ICHRA offer to determine whether it is considered "affordable"
for purposes of determining APTC eligibility. In addition, the UI must collect information about the application filer's ICHRA and the spouse's Qualified Small Employer HRA (QSEHRA) offer for purposes of a special enrollment period (SEP) eligibility. Due to the unaffordable ICHRA offer, the couple is
eligible for APTC/CSRs. The couple is also eligible for an SEP due to being newly offered an ICHRA and being newly provided a QSEHRA, but the eligibility results show the QSEHRA SEP. This test case should be run in FL (zip code 33305, Broward county), WI (zip code 53062, Calumet county), or TX (zip
code 75001, Dallas county).
UI Question Companion Guide Reference

Item 1

Tab: UI Questions

Application Input

Application Data

State

FL, zip code 33305, county Broward
WI, zip code 53062, county Calumet
TX, zip code 75001, county Dallas

Item 2

Coverage Year

Current year

Item 21

Seeking financial assistance?

Yes*

Notes to Testers

Application State & Coverage Year

Financial Assistance

*When asking consumers about financial assistance,
the entity's UI can provide a screener tool to help
consumers make their decisions on this question, but
the screener tool is not required (Items 22-26)
The UI must display answer options "Yes" and "No"
for Item 21. Entities are not required to display the
answer option "I'm not sure"
Items 22-26 may display if a consumer selects "I'm
not sure" for this question

Items 4, 30 Name
Items 5, 6, 123 Home address
Items 7, 8 Mailing address
Item 10 Language preferences

Household Member

Ned Roseman*
Age: 25
Male

Household Member Information
Marietta Roseman*
Age: 25
Female

*Do not use Roseman as the last name. Use a
different last name that is unique (it can be a random
string of letters). Do not change the first name
Provide zip code 33305 in FL, 53062 in WI, or 75001 in
TX
Use any date of birth that results in the correct age
for each household member
Other household contact and information fields (i.e.
email, phone, language preference, race/ethnicity,
etc.) may contain any value unless otherwise noted.
Find additional information in the UI Question
Companion Guide:
- Items 4-9 Household Contact Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-applicant
information - Race and Ethnicity

Item 30

Application Filer/Relationship to
Application Filer
Applicant/Non-Applicant
Marital Status

Application Filer
Spouse of Marietta
Applicant
Married

Items 276
For Ned: Item 5
Item 117

Address and Living Situations

Item 32

SSN

Item 36
Items 38, 40

Applying with same name as SSN
card?
Citizenship/immigration

Provide address in application state
Lives with spouse, Marietta
Not main person taking care of any children age
18 or younger
Does not have SSN, continue without providing
SSN
N/A (should not display for this household
member)
Attests to U.S. citizenship;
not naturalized or derived citizen

Items 81 and 82

Tax Filing Status

Items 27, 30
Items 76, 77

Parent/Caretaker Relative Status

Spouse of Ned
Applicant
Married

Same address as application filer
Lives with spouse, Ned
Not main person taking care of any children age
18 or younger
Does not have SSN, continue without providing
SSN
N/A (should not display for this household
member)
Attests to U.S. citizenship;
not naturalized or derived citizen
Tax Household
Married filing jointly;
Married filing jointly;
Does not attest to any dependents on their tax
Does not attest to any dependents on their tax
return
return
More About This Household

Not required to display if marital status is already
established in Item 30
Provide zip code 33305 in FL, 53062 in WI, or 75001 in
TX

Auditor Checklist

Items 131, 132

Do not answer affirmatively to any non-MAGI
questions

Do not answer affirmatively to any non-MAGI
questions

Does not have AI/AN status

Does not have AI/AN status

Item 147
Pregnancy Questions
Item 269 (depending on implementation)

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

Not pregnant

Item 149
Foster Care Questions
Item 269 (depending on implementation)

Not former foster care

Not former foster care

Item 250
Incarceration Questions
Item 269 (depending on implementation)

Not incarcerated

Not incarcerated

Item 144
Full-Time Student Questions
Item 269 (depending on implementation)

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

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

Items 133, 138

Medicaid/CHIP Denial

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

Items 153, 154, 155, 209

Current Month Income

Job A: $1,666.67 per month

Income
Job B: $833.33 per month

Item 174
Item 181

Deductions
Annual Income

No deductions
$20,000.04

No deductions
$9,999.96

Items 191, 285

Current coverage

Item 200

Offer of coverage through job

Item 146
Item 269 (depending on implementation)

Non-MAGI Medicaid Eligibility
Questions (physical disabilities,
assistance with daily living, nursing
home care)
American Indian/Alaska Native

Items 286, 288, 291, 292, 293
Offer of individual coverage HRA
Item 287 (depending on implementation) (ICHRA)

Items 213, 218, 224, 294, 295, 296, 297,
298, 299

Recent Life Changes (SEPs)

Program Questions
None;
None;
Does not already have an ICHRA
Does not already have an ICHRA
Does not have an offer of coverage through their Does not have an offer of coverage through their
own employer
own employer
ICHRA offer from Job A (Ned's job)
ICHRA offer from Job A
Can use offer 60 days from today's date*
Can use offer 60 days from today's date*
Start date: 5 days before today's date
End date: 75 days after today's date
Maximum self-only premium: $50/month

Employer name and phone number are required
fields, but any value may be entered (ex: "ABC Corp"
or "555-555-5555")
Household members should attest to agreeing with
the expected income calculated

*The UI can either 1) display Item 287, or 2) not
display Item 287 and include help text in Item 286
that instructs applicants to only attest "yes" to having
an ICHRA offer for ICHRAs they'll be able to use 60
days from now

Check Items 291 and 292: Verify that start date, end date, and
maximum self-only premium are collected only once for the
**It's important to carefully follow the instructions ICHRA offer from Job A
for inputting dates for the test case to function

Offered an ICHRA
Notice date: 95 days before today's date
Start date: 5 days before today's date
Not currently enrolled in an ICHRA through this
employer

Offered an ICHRA
Notice date: 95 days before today's date
Start date: 5 days before today's date
Not currently enrolled in an ICHRA through this
employer

Check Items 296-299: Verify that questions about the ICHRA
offer clearly indicate "individual coverage HRA" while questions
about the QSEHRA offer clearly indicate "Qualified Small
Employer HRA"

Offered a QSEHRA
Notice date: 30 days before today's date
Start date: first day of the next month
Currently enrolled in a QSEHRA through Job B
Will not stay enrolled in the current QSEHRA until
the new one begins on [attested start date]

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

Reference Materials

Application Review & Legal
Attestations

Answers affirmatively to all application attestations

Attestations

Eligibility Results

Check Item 288: When asked which employer offers the
individual coverage HRA, verify that both Ned and Marietta can
choose Job A, Job B, or another employer not listed

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

UI Q CG Eligibility Results Tab: Items 1, 3,
4, 5
Sample HealthCare.gov Eligibility Results
Messaging
HRA Messaging Resource

Eligibility Results Page

Eligible to buy a Marketplace plan with a premium Eligible to buy a Marketplace plan with a premium
tax credit of up to [FL - $678; WI - $622; TX tax credit of up to [FL - $678; WI - $622; TX $682] each month for your tax household
$682] each month for your tax household, but
since you told us you have a QSEHRA from an
Eligible for lower copayments, coinsurance, and employer, you'll have to manually adjust the
amount you use based on the QSEHRA amount*
deductibles (cost-sharing reductions) on Silver
Plans
Eligible for lower copayments, coinsurance, and
deductibles (cost-sharing reductions) on Silver
Eligible for an individual coverage HRA. An
Plans
employer offers an individual coverage HRA, so
be sure to opt out of this employer's offer if you
plan to use the premium tax credit that you're
Eligible for an individual coverage HRA. An
employer offers an individual coverage HRA, so
eligible for from the Marketplace*
be sure to opt out of this employer's offer if you
plan to use the premium tax credit that you're
eligible for from the Marketplace*
Eligible for a Special Enrollment Period

Eligible for a Special Enrollment Period

Auditors should review the Eligibility Results Page to
ensure it accurately reflects the eligibility results
found in the EDN and complies with ERP messaging
requirements outlined in the documentation listed in
Column A
*Entities have flexibility in messaging HRA in their UI
and are encouraged to include it on the Eligibility
Results Page. However, entities can choose to display
required messaging in their plan selection UI instead
or in addition to the messaging on the Eligibility
Results Page. Please see HRA messaging requirements
outlined in CR#47 and the DE API Specs Version 9.1,
Appendix F. In addition, please see the "HRA
Messaging Resource" on zONE