MAGI-Based Eligibility Verification Plan Template

Status: Original and derived artifacts are available for this document.

Download: docx | pdf | html

(Insert Medicaid or CHIP or both) 	 MAGI-BASED ELIGIBILITY VERIFICATION PLAN
State:  	
Date Submitted: ______
In addition to the electronic data sources, the state uses the following procedures to complete the verification process:
A.  Verification Procedures for Factors of Eligibility




Eligibility Factor
Self-Attestation Accepted without Additional Verification (Y/N)
Self-attestation accepted with post-enrollment verification
(Y/N)

Electronic Data
Source Used
(Y/N)


Reasonable Compatibility
Standard Used

Ask for a Reasonable Explanation from the Individual 
      (Y/N)

Paper Documentation Required from the Individual
        (Y/N)



Comments




Income*





●

Both are below or at/above the applicable income standard







О

Percentage Threshold (Specific Threshold Percentage)  	%







О

Dollar Threshold (Specific Dollar Threshold) $ 	







О

Other (Specify)




Residency








Age (Date of Birth)








Social Security Number **








Citizenship **








Immigration Status **








Household Composition








Pregnancy
Y ***






    Caretaker Relative







    Medicare







    Application for Other  
    Benefits







    Other







*	States must check electronic data sources determined useful to verify income in accordance with 42 CFR 435.948 but can be done post-enrollment.
**   States must follow statute, regulations, and guidance for verification of SSN, citizenship and immigration status including obtaining such information through the federal data services hub if available. 
***States must accept self-attestation of pregnancy unless they have information that is not reasonably compatible with such attestation.

(Insert Medicaid or CHIP or both) 	 MAGI-BASED ELIGIBILITY VERIFICATION PLAN
State:  	
In accordance with 42 CFR 435.940-965, the state sets forth the following policies and procedures for verification:

B-1.	Use of Electronic Data Sources

Financial:



Criteria Used to Determine Useful or not Useful
(check all that apply for Y or N)

                          Data Source Usage







Comments



  Electronic Data Source

Determined
Useful

(Y/N)

Accuracy

Timeliness

Ability to Access

Age of Data

Comprehensive
Other
(Pleas Describe)


Used at
Application

(Y/N)


Used at
Renewal

(Y/N)


Used Post- Enrollment

(Y/N)

If Used for Post- Enrollment, Frequency Used (e.g. monthly, quarterly)


 1.  Internal Revenue Service (IRS)












 2. Social Security Administration (SSA)
(SSI, Title II)












 3. State Wage Information Collection
Agency (SWICA)













 4. State Unemployment Compensation












 5.  State Administered Supplementary
Payment Program













 6. State General Assistance Programs












 7. Supplemental Nutrition Assistance
Program (SNAP)












 8. Temporary Assistance for Needy
Families (TANF)












 9. Office of Child Support Enforcement
(OCSE)













 10. State Income Tax












 11. Commercial database:
(please describe)












 12. Other:
(please describe)













B-2. 	Use of Electronic Data Sources













			

































  *Under 42 CFR 435.945(d), all State Medicaid eligibility systems must conduct a match with PARIS for Interstate benefit information. If used for other purposes, please indicate in Section C.
 (Insert Medicaid or CHIP or both) 	 MAGI-BASED ELIGIBILITY VERIFICATION PLAN
State:  	
C. Additional Factors of Eligibility for Separate CHIP 


Eligibility Criteria
Self-Attestation Accepted without Additional Verification 
(Y/N)

Self-Attestation 
Accepted with 
Post-Enrollment Verification
(Y/N)

Electronic Data Source Used (Y/N)
If Yes, please describe

Paper Documentation Required from the Individual 
(Y/N)


Non-Applicable
                  (N/A)

    1. Applicant does not have other coverage






    2. Applicant does not have access to affordable ESI





    3. When child last had coverage (as applicable to states' waiting period)
 perperiod)





Waiting period exception #1 (describe):





Waiting period exception # 2 (describe):





Waiting period exception #3 (describe):





Waiting period exception #4 (describe):





Waiting period exception #5 (describe):





Waiting period exception #6 (describe):





Waiting period exception #7 (describe)





Waiting period exception #8 (describe):





 Waiting period exception #9 (describe):





 Waiting period exception #10 (describe):





    4. Access to public employee coverage





    5. Other Eligibility criteria or exceptions to eligibility criteria (please describe):







(Insert Medicaid or CHIP or both) _______________ MAGI-BASED ELIGIBILTIY VERIFICATION PLAN
State:  	

D.   Additional Verification Questions


1.  If paper documentation is required when a data source is not available or the information obtained from a data source is not reasonably compatible with the information provided by or on behalf of the individual, briefly describe how the state determined that establishing and using an electronic data source was not effective, considering such factors as cost and program integrity in accordance with 42 CFR 435.952(c):

2.  Please describe how the state uses PARIS?


3.   Please indicate if the state is requesting Secretarial approval to solely use alternative data sources for financial verification other than those listed in
42 CFR 435.948 (Numbers 1-8 in Section B-1), and if so, what sources:


	 Please describe how the State in using such alternative:

a.  Reduces administrative costs and burdens on both individuals and the state:


b.  Maximizes accuracy and minimizes delay:


c.  Meets the requirements related to confidentiality, disclosure, maintenance and use of information:


d.  Promotes coordination with other insurance affordability programs:


4.  Please indicate if the state is requesting Secretarial approval to use a mechanism other than the federal data services hub, and if so what mechanism:

	Please describe how the State in using such alternative:


a.  Reduces administrative costs and burdens on both individuals and the state:


b.  Maximizes accuracy and minimizes delay:


c.  Meets the requirements related to confidentiality, disclosure, maintenance and use of information:


d.  Promotes coordination with other insurance affordability programs:


5.  Describe any additional MAGI-based eligibility verification policies and procedures that have not been covered in this verification plan (optional):

PRA Disclosure Statement
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 voluntary information collection is 0938-1148 (Expires 03/31/2021).  The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. Your response is required to update CMS of changes to your verification plan. All responses are public and will be made available on the CMS web site.  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 Jessica Stephens at 410-786-3341.