CMS-179 4.31, 4.32, 4.33, and 4.34

Form Approved CMS-179
OMB No. 0938-0193
Revision:
State/Territory: __________________________

4.31 Disclosure of Information by Providers and Fiscal Agents
Sections 1128 (b)(9) and 1902 (a)(38) of the Act,
P.L. 100-93 (sec. 8(f)) and
42 CFR 455.1033
The Medicaid agency has established procedures for the disclosure of
information by providers and fiscal agents as specified in 42 CFR 455.104
through 455. 106 and sections 1128 (b)(9) and 1902 (a)(38) of the Act.

Revision:
Citation(s)
Section 1137

State/Territory:

of the Act and 42 CFR
435.940 through 435.960

4.32 Income and Eligibility Verification System

The Medicaid agency has established a system for income and eligibility verification in
accordance with the requirements of 42 CFR 435.940 through 435.960.
(b) ATTACHMENT 4.32-A describes in accordance with 42 CFR 35.948(a)(6) the
information that will be requested in order to verify eligibility or the correct payment
amount and the agencies and the State(s) from which that information will be requested.

TN No.
Supersedes
TN No.

__________

_________

Approval Date ________

Effective Date _______

79a
Revision
State/Territory:

____________________________________________________________________________

Citation
Section 1902(a)(48) of the Act
4.33

Medicaid Eligibility Cards for Homeless Individuals

The Medicaid agency has a method for making cards evidencing eligibility for medical
assistance available to an individual eligible, under the State’s approved plan, who does
not reside in a permanent dwelling or does not have a fixed home or mailing address.

(b) ATTACHMENT 4.33-A specifies the method for issuance of Medicaid eligibility
cards to homeless individuals.

TN No.
Supersedes

_______

_

TN No.

Approval Date

_____________________

Effective Date

_________________

Revision:
State/Territory:

____________ __________________________________________________

Citation(s)
Section 1137 (d)(3) of the Act
4.34 Systematic Alien Verification for Entitlements
__________ The State Medicaid agency has established procedures for the verification of
alien status through the Department of Homeland Security’s designated system, System
Alien Verification for Entitlements (SAVE).
__________ The State Medicaid agency has received the following type(s) of waiver
from participation in SAVE.
__________ Total waiver
__________ Alternative System
__________Partial Implementation
Explain the nature of the waiver and the State Medicaid agency’s established procedures
for verification of alien status:
_________________________________________________________________

TN No. ______
Supersedes
TN No.

Approval Date _______

Effective Date _____________

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