Eligibility Factor Self- Attestation Accepted without Additional Verification (Y/N) Self- Attestation Accepted with Post-Eligibility Verification (Y/N) Electronic Data Source Used (Y/N) Reasonable Compatibility Standard Used Specify Reasonable Compatibility Standard for Income Ask for a Reasonable Explanation from the Individual (Y/N) Paper Documentation Required from the Individual (Y/N) Comments Social Security Number ** NO NO YES N/A N/A N/A YES Request documentation if the SSN cannot be verified through the Federal Hub. Citizenship ** NO NO YES N/A N/A N/A YES Request documentation if citizenship cannot be verified through the Federal or State Hub. Immigration Status ** NO NO YES N/A N/A N/A YES Request documentation if immigration status cannot be verified through the Federal or State Hub. The State will utilize the Federal Data Service Hub (FDSH) for SAVE steps 1 and 2, but will use the State's existing direct connection to SAVE for step 3. Household Composition YES NO YES N/A N/A NO YES Verify household composition when there is a discrepancy between the State's eligibility determination system and the attestation. State only uses internal data sources (previous records and not external data source). If not known to the internal data sources, will accept self-attestation. Pregnancy *** YES NO NO N/A N/A NO NO Request verification only if the state has information that is not consistent with the attestation. For example, medical records indicate that the woman was sterilized. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION A - Verification Procedures for Factors of Eligibility 2

Eligibility Factor Self- Attestation Accepted without Additional Verification (Y/N) Self- Attestation Accepted with Post-Eligibility Verification (Y/N) Electronic Data Source Used (Y/N) Reasonable Compatibility Standard Used Specify Reasonable Compatibility Standard for Income Ask for a Reasonable Explanation from the Individual (Y/N) Paper Documentation Required from the Individual (Y/N) Comments Caretaker Relative YES NO YES N/A N/A NO YES Verify only when there is a discrepancy between the State's Eligibility Determination System and the attestation. State only uses internal data sources (previous records and not external data source). If not known to the internal data sources, will accept self-attestation. Medicare NO NO YES N/A N/A NO YES Request documentation only if it cannot be verified electronically. Application for Other Benefits NO NO YES N/A N/A NO YES Other: (Please describe any other eligibility factors in the space below) * States must check electronic data sources determined useful to verify income in accordance with 42 CFR 435.948 but can be done post-enrollment. If the information obtained from electronic data sources and the information provided by or on behalf of the individual are both above, at or below the applicable income standard, the State must determine the applicant eligible or ineligible for Medicaid/CHIP. (NOTE: this option is prepopulated for the state and is not an option that can be changed). ** 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. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION A - Verification Procedures for Factors of Eligibility 3

MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Arizona Last updated 09/27/2016 Section B1. Use of Electronic Data Sources Financial: Electronic Data Source Determined Useful (Y/N)1 Accuracy Considered (Y/N) Timeliness Considered (Y/N) Ability to Access Considered (Y/N) Age of Data Considered (Y/N) Comprehensive Considered (Y/N) Other Criteria Used (Y/N) (Please Describe in Comments section) Data Source Used at Application (Y/N) Data Source Used at Renewal (Y/N) Data Source Used Post- Enrollment (Y/N) If Data Source Used for Post- Enrollment - Frequency Used (e.g. monthly, quarterly) Comments 1. Internal Revenue Service (IRS) NO NO NO YES YES YES NO NO NO NO IRS security requirements and safeguards are too stringent. In addition, FTI data will be at least a year to 18 months old. 2. Social Security Administration (SSA) (SSI, Title II) YES YES YES YES YES YES NO YES YES NO This information is retrieved through the Hub at application. Arizona is still testing the RRV service, and is using the existing SSA match at renewal. Arizona anticipates having the RRV service by August 31, 2016. 3. State Wage Information Collection Agency (SWICA) YES YES YES YES NO YES NO YES YES YES Other (specify in comments) This source will be considered only if more current data from The Work Number is not available. SWICA is functional and used in the hub checks at application, renewal and reported change events. Arizona is building functionality to be able to do a 6-month check for households who report no income. It will also be accessed when employment is reported. Once implemented and we have had a period of time to collect data, we will evaluate the effectiveness of the 6 month post-enrollment check to determine if a more frequent check is needed and may change the frequency. 4. State Unemployment Compensation YES YES YES YES YES YES NO YES YES YES Monthly This source will be accessed when loss of employment is reported. It will also be accessed monthly for those who have filed an application for unemployment benefits. 5. State Administered Supplementary Payment Program NO NO NO NO NO NO NO NO NO NO There is no SPP program in Arizona 6. State General Assistance Programs NO NO NO NO NO NO NO NO NO NO There is no GA program in Arizona MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B1 - Use of Electronic Data Sources, Financial 4

Electronic Data Source Determined Useful (Y/N)1 Accuracy Considered (Y/N) Timeliness Considered (Y/N) Ability to Access Considered (Y/N) Age of Data Considered (Y/N) Comprehensive Considered (Y/N) Other Criteria Used (Y/N) (Please Describe in Comments section) Data Source Used at Application (Y/N) Data Source Used at Renewal (Y/N) Data Source Used Post- Enrollment (Y/N) If Data Source Used for Post- Enrollment - Frequency Used (e.g. monthly, quarterly) Comments 7. Supplemental Nutrition Assistance Program (SNAP) YES YES YES YES YES YES YES YES YES NO Arizona will have an integrated eligiblity system including Medicaid, CHIP, SNAP and TANF. The Yes in the Other column represents this. The implementation of the SNAP and TANF programs in the eligibility system is projected for July 2017. Can be used for raw income data (distinct from MAGI). 8. Temporary Assistance for Needy Families (TANF) 10. State Income Tax YES NO NO YES NO NO YES NO NO YES NO YES YES NO NO YES NO YES YES NO NO YES NO NO YES NO NO NO NO NO Arizona will have an integrated eligiblity system including Medicaid, CHIP, SNAP and TANF. The Yes in the Other column represents this. The implementation of the SNAP and TANF programs in the eligibility system is projected for July 2017. Can be used for raw income data (distinct from MAGI). Due to no change in the state statute, this source cannot be used at this time 11. Commercial database: (Pease describe any commercial databases in the space below) The Work Number YES YES YES YES YES YES NO YES YES YES Other (specify in comments) Because the data in The Work Number is more current than data from anyother source, it is considered primary to SWICA. This source will be accessed when employment is reported and every 6 months for households who report no income. Once implemented and we have had a period of time to collect data, we will evaluate the effectiveness of the 6 month post-enrollment check to determine if a more frequent check is needed and may change the frequency. State uses the FDSH, but the Work Number is also part of the State Hub. 12. Other: (Please describe any additional electronic data sources in the space below) State New Hire YES YES YES YES YES NO NO YES YES NO Used post-enrollment when new employment is reported but not at a regular frequency. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B1 - Use of Electronic Data Sources, Financial 5

Electronic Data Source Determined Useful (Y/N)1 Accuracy Considered (Y/N) Timeliness Considered (Y/N) Ability to Access Considered (Y/N) Age of Data Considered (Y/N) Comprehensive Considered (Y/N) Other Criteria Used (Y/N) (Please Describe in Comments section) Data Source Used at Application (Y/N) Data Source Used at Renewal (Y/N) Data Source Used Post- Enrollment (Y/N) If Data Source Used for Post- Enrollment - Frequency Used (e.g. monthly, quarterly) Comments Existing information in State Eligibility Determination Systems YES NO YES YES NO NO NO YES YES NO Data source containing previous application data. We will have data from previous applications, non-MAGI Medicaid eligibility such as ABD populations, Medicaid Buy-In program, Breast & Cervical Cancer Treatment Program, etc. If a case already exists and a new application is being made, we will compare the previous data to the new application for inconsistencies in income. Can be used for raw income data (distinct from MAGI). PARIS YES YES YES YES NO NO NO NO NO YES Quarterly AZ uses PARIS to identify benefits being received in another state and to verify VA income. 1. The state marked any criterion YES if they were considered in determining the usefulness of the electronic data source; however, the determination of whether the data source was useful/not useful did not rest solely on these criteria. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B1 - Use of Electronic Data Sources, Financial 6

MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Arizona Last update 09/27/2016 Section B2. Use of Electronic Data Sources Non-Financial: Electronic Data Source To Be Used (Y/N) Social Security Number Citizenship Immigration Status Residency Age/DOB Pregnancy Household Composition Caretaker Relative Medicare Application for other Benefits Other Data Source Used at Application (Y/N) Data Source Used at Renewal (Y/N) Data Source Used Post- Enrollment (Y/N) If Used for Post- Enrollment Frequency Used (i.e. monthly, quarterly) Comments 1. Social Security Arizona uses the Hub for SSN, Age/DOB, Administration and citizenship. Will only be used for (SSA) YES YES YES NO YES YES NO NO NO YES YES NO YES YES NO Medicare, Residency at Renewal. Will be used for application for potential benefits at application and renewal. 2. Department of Arizona uses steps 1 and 2 through the Hub. Homeland Security YES NO YES YES NO NO NO NO NO NO NO NO YES NO NO For step 3, AZ uses its direct connection to (DHS) - SAVE SAVE. 3. Vital Statistics Vital Statistics is used to verify citizenship YES NO YES NO NO YES NO NO NO NO NO NO YES NO NO and age/DOB if not verified through the Hub. 4. Department of Motor Vehicles YES NO NO NO YES NO NO NO NO NO NO NO YES YES NO (DMV) MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B2 - Use of Electronic Data Sources, Non-Financial 7

Electronic Data Source To Be Used (Y/N) Social Security Number Citizenship Immigration Status Residency Age/DOB Pregnancy Household Composition Caretaker Relative Medicare Application for other Benefits Other Data Source Used at Application (Y/N) Data Source Used at Renewal (Y/N) Data Source Used Post- Enrollment (Y/N) If Used for Post- Enrollment Frequency Used (i.e. monthly, quarterly) Comments 5. Temporary Assistance for Needy Families (TANF) YES YES YES YES YES YES NO YES YES NO NO NO YES YES NO Arizona will have an integrated eligiblity determination system in July 2017 which will include Medicaid, CHIP, SNAP and TANF. If the eligibility factor has been verified for SNAP or TANF, will not reverify. For citizenship and immigration status will only use the verification if it meets the same standards as Medicaid. Will only use for SSN if the SSN has been verified with SSA. 6. Supplemental Nutrition Assistance Program (SNAP) YES YES YES YES YES YES NO YES YES NO NO NO YES YES NO Arizona will have an integrated eligiblity determination system in July 2017 which will include Medicaid, CHIP, SNAP and TANF. If the eligibility factor has been verified for SNAP or TANF, will not reverify. For citizenship and immigration status will only use the verification if it meets the same standards as Medicaid. Will only use for SSN if the SSN has been verified with SSA. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B2 - Use of Electronic Data Sources, Non-Financial 8

Electronic Data Source To Be Used (Y/N) Social Security Number Citizenship Immigration Status Residency Age/DOB Pregnancy Household Composition Caretaker Relative Medicare Application for other Benefits Other Data Source Used at Application (Y/N) Data Source Used at Renewal (Y/N) Data Source Used Post- Enrollment (Y/N) If Used for Post- Enrollment Frequency Used (i.e. monthly, quarterly) Comments 7. Office of Child Support Enforcement NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO 8. State General Assistance Programs NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Arizona does not have a GA program 9. Women, Infants and Children Program (WIC) NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO 10. State Income Tax NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Due to no change in the state statute, this source cannot be used at this time (and not by Oct. 1). 11. Commercial database: (Please describe any commercial databases in the space below) MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B2 - Use of Electronic Data Sources, Non-Financial 9

Electronic Data Source To Be Used (Y/N) Social Security Number Citizenship Immigration Status Residency Age/DOB Pregnancy Household Composition Caretaker Relative Medicare Application for other Benefits Other Data Source Used at Application (Y/N) Data Source Used at Renewal (Y/N) Data Source Used Post- Enrollment (Y/N) If Used for Post- Enrollment Frequency Used (i.e. monthly, quarterly) Comments 13. Other: (Please describe additional electronic data sources in the space provided below) 12. PARIS* YES NO NO NO YES NO NO NO NO NO YES YES NO NO YES Quarterly When change in residency is reported by PARIS and for VA benefits Existing information in State Eligibility Determination Systems YES NO NO NO NO NO NO YES YES NO NO NO YES YES NO We will have data from previous applications, non-MAGI Medicaid eligibility such as ABD populations, Medicaid Buy-In program, Breast & Cervical Cancer Treatment Program, etc. If a case already exists and a new application is being made, we will compare the previous data to the new application for inconsistencies in household composition, relationships, etc. * 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 D. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B2 - Use of Electronic Data Sources, Non-Financial 10

MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Arizona Last updated 09/27/2015 Section C . Additional Factors of Eligibility for Separate CHIP Eligibility Factor Self- Attestation Accepted without Additional Verification Self- Attestation Accepted with Post- Enrollment Verification (Y/N) Electronic Data Source Used (Y/N) If Yes, please describe in comments Paper Documentation Required from the Individual (Y/N) Non-Applicable (N/A) Comments 1. Applicant does not have other coverage NO NO YES YES Must be Applied Arizona will use its TPL Contractor to verify health insurance enrollment. Paper documentation will be required only if needed and can't be verified by the TPL Contractor. The contractor will be called directly to resolve and only in rare instances paper documentation is needed. 2. Applicant does not have access to affordable ESI NO NO NO NO N/A 3. When child has had coverage (as applicable to states' waiting period) NO NO YES YES Arizona will use its TPL Contractor to verify health insurance termintion date. Paper documentation will be required only if needed and can't be verified by the TPL Contractor. The contractor will be called directly to resolve and only in rare instances paper documentation is needed. 4. Access to public employee coverage NO NO NO NO Request verification only if questionable such as state employment identified by The Work Number. 5a. Waiting period exception #1 (describe): NO NO YES YES Involuntary termination of employment. Arizona will verify this electronically through The Work Number, SWICA and UI. Non-electronic verification will be required only if electronic verification is not available; for example, lost employment in another state MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 11

Eligibility Factor Self- Attestation Accepted without Additional Verification Self- Attestation Accepted with Post- Enrollment Verification (Y/N) Electronic Data Source Used (Y/N) If Yes, please describe in comments Paper Documentation Required from the Individual (Y/N) Non-Applicable (N/A) Comments 5b. Waiting period exception Lost other government funded coverage. This will be verified electonically through the State's #2 (describe): NO NO YES YES eligibility determination system. Paper documentation will be required only when electronic data is not available (e.g. loss of coverage in another state). The government entity will be called directly to resolve and only in rare instances paper documentation is needed. 5c. Waiting period exception #3 (describe): YES NO NO NO Chronically or seriously ill 5d. Waiting period exception #4 (describe): N/A 5e. Waiting period exception #5 (describe): N/A 5f. Waiting period exception #6 (describe): N/A 5g. Waiting period exception #7 (describe): N/A 5h. Waiting period exception #8 (describe): N/A 5i. Waiting period exception #9 (describe): N/A 5j. Waiting period exception #10 (describe): N/A 6. Other eligibility factors or exceptions to eligibility factors: (Please describe in the space provided below) MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 12

Eligibility Factor Self- Attestation Accepted without Additional Verification Self- Attestation Accepted with Post- Enrollment Verification (Y/N) Electronic Data Source Used (Y/N) If Yes, please describe in comments Paper Documentation Required from the Individual (Y/N) Non-Applicable (N/A) Comments Resident of a Public Institution NO NO YES NO This would include both penal institutions and Institutions for Mental Disease.For Penal Institutions, Arizona will electronically match with the Arizona Department of Corrections and the County Jails. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 13

MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) State: Last update Section D. Additional Verification Questions Medicaid & CHIP Arizona 09/27/2016 Question Response 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): The state accepts self-attestation without additional verification for some factors of eligibility. For those that it doesn't the state uses all available electronic data sources, including Vital Statistics as a back-up for citizenship. For factors that can be verified with electronic data, non-electronic verification is requested only if questionable or not reasonably compatible. The state tries to resolve inconsistencies with follow-up questions and reasonable explanations prior to requesting paper documentation. 2 Please describe how the state uses PARIS? • Interstate residency check for leads on out-of-state moves • VA match for leads on VA income and benefits Arizona is also working on using PARIS to provide leads on federal pensions and benefits. 3 Please indicate (YES) or (NO) if the State intends to request 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). NO MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION D - Additional Verification Questions 14

Question Response If (YES), please submit a letter to CMS requesting such approval describing how the the state meets the following requirements: 1) Reduces administrative costs and burdens on both individuals and the State, 2) Maximizes accuracy and minimizes delay, 3) Meets the requirements related to confidentiality, disclosure, maintenance and use of information, and 4) Promotes coordination with other insurance affordability programs. 4 Please indicate (YES) or (NO) if the State intends to request Secretarial approval to use a mechanism other than the federal data services hub for information that is available through the hub. YES If (YES), please submit a letter to CMS requesting such approval describing how the the state meets the following requirements: 1) Reduces administrative costs and burdens on both individuals and the State, 2) Maximizes accuracy and minimizes delay, 3) Meets the requirements related to confidentiality, disclosure, maintenance and use of information, and 4) Promotes coordination with other insurance affordability programs. AZ has been granted a Hub waiver to use an existing SAVE match for step 3 rather than using the Hub VLP Service for this step. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION D - Additional Verification Questions 15

Question Response

Describe any additional MAGI-based eligibility verification policies

and procedures that have not been covered in this verification plan (optional): 5 MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION D - Additional Verification Questions 16

Section A. Additional Comments Eligibility Factor Source Reasonable Compatibility Plan State Flexibility Reference SSN SSA If unable to verify with electronic source, obtain verification of SSN or proof of application for SSN No state flexibility Medicaid Final Rule 42 CFR 435.956(d) 435.910(g) and (f) Citizenship Prior citizenship documentation in eligibility systems SSA Arizona Vital Stats (AVS) If unable to verify with electronic source, obtain hard copy verification No state flexibility Medicaid Final Rule 42 CFR 435.949 Non-citizenship Prior non-citizenship information in eligibility system Dept of Homeland Security (DHS) SAVE Use self-attestation for non-qualified immigrants If unable to verify with electronic source, obtain hard copy verification for others No state flexibility Medicaid Final Rule 42 CFR 435.949 Identity Prior identity documentation in eligibility systems SSA Motor Vehicle Division (MVD) If unable to verify with electronic source, obtain hard copy verification No state flexibility Medicaid Final Rule 42 CFR 435.949 Incarceration Arizona Department of Corrections (ADC) County jails SSA If attestation is inconsistent with source, obtain verification If no source available, accept attestation No state flexibility 42 CFR 457.310(c)(2) State residency Prior information in eligibility systems SSA TWork Number Unemployment Insurance (UI) New Hire MVD If unable to verify with electronic source, obtain verification. State flexibility to accept attestation of States define Medicaid Final Rule 42 CFR 435.956(c) MAGI-BASED ELIGIBILITY VERIFICATION PLAN Additional Comments 17

Eligibility Factor Source Reasonable Compatibility Plan State Flexibility Reference Marriage Prior household composition information in eligibility systems If attestation is inconsistent with source, obtain verification If no source available, accept attestation Agency MUST accept self- State defines “reasonably Medicaid Final Rule 42 CFR 435.956(f) Pregnancy Prior information in eligibility systems If attestation is inconsistent with source, obtain verification If no source available, accept attestation Agency MUST accept self- State defines “reasonably Medicaid Final Rule 42 CFR 435.956(e) Household members Prior household composition information in eligibility systems If attestation is inconsistent with source, obtain verification If no source available, accept attestation If electronic verification is not States may, but are State defines “reasonably Medicaid Final Rule 42 CFR 435.956(f) The relationships of household members Prior household composition information in eligibility systems If attestation is inconsistent with source, obtain verification If no source available, accept attestation If electronic verification is not States may, but are State defines “reasonably Medicaid Final Rule 42 CFR 435.956(f) Deprivation (18 Year Old Students) There is no reliable electronic method to verify deprivation Obtain verification If electronic verification is not States may, but are State defines “reasonably Medicaid Final Rule 435.956(f) American Indian Prior ethnicity (and tribe) information in eligibility systems Use self attestation if CHIP or FTW premiums are not affected. Obtain verification if CHIP or FTW premiums are affected. For CHIP and FTW, state flexibility to accept attestation or require hard 42 CFR 457.535 Age Prior information in eligibility systems SSA AVS Dept of Homeland Sec (DHS) SAVE If attestation is inconsistent with source, use source. Obtain verification (if age affects eligibility) If electronic verification is not available, the State State flexibility to Medicaid Final Rule 42 CFR 435.956(f) The Work Number Flexibility to rely exclusively on IRS Medicaid Final Rule 42 CFR 435.945 MAGI-BASED ELIGIBILITY VERIFICATION PLAN Additional Comments 18

Eligibility Factor Source Reasonable Compatibility Plan State Flexibility Reference Earned Income Base Wage New Hire Report SSA – SVES, SOLQI, SDX Arizona Department of Revenue Prior information in eligibility systems See “Health-e-Arizona Plus Application Questions to Clarify Income Inconsistencies” Table Flexibility to determine what Flexibility to Flexibility to Flexibility to determine the Flexibility to define the “reasonably Flexibility to determine how to Flexibility to Flexibility to establish Flexibility to determine what Flexibility to rely on alternate financial reduce maximize accuracy minimize delay meet applicable confidentiality, Medicaid Final Rule 42 CFR 435.948 Medicaid Final Rule 42 CFR 435.952 Unearned Income SSA Railroad Retirement Board Unemployment Insurance Arizona Department of Revenue Arizona Lottery PARIS (if real time) Prior information in eligibility systems If attestation is inconsistent with source, obtain verification If no source available, obtain verification Tax payer filing status Arizona Department of Revenue If attestation is inconsistent with source, ask clarifying questions. If no source available, accept attestation If electronic verification is not States may, but are State defines “reasonably Medicaid Final Rule 42 CFR 435.956(f) Dependents on tax return Arizona Department of Revenue If attestation is inconsistent with source, ask clarifying questions. If no source available, accept attestation State flexibility to accept attestation States define “reasonably Medicaid Final Rule 42 CFR 435.956(f) MAGI-BASED ELIGIBILITY VERIFICATION PLAN Additional Comments 19

Eligibility Factor Source Reasonable Compatibility Plan State Flexibility Reference Current health insurance Prior information in eligibility systems Health Management Systems The Work Number If attestation is inconsistent with source, obtain verification If no source available, accept attestation State flexibility to accept attestation States define “reasonably Medicaid Final Rule 42 CFR 435.119(c) 42 CFR 457.310(c) Potential benefits UI/Base Wage Prior information in eligibility systems Use self-attestation State flexibility to States define “reasonably 42 CFR 435.608 Paid for Working ­ Payment of Social Security & Medicare Taxes (for Freedom to Work only) The Work Number Base Wage New Hire Arizona Department of Revenue If no source available, obtain verification No state flexibility 42 USC 1396a(a)(10)(A)(ii)(XVI) & (XVI) ARS 36-2928 & 2950 AAC R9-22-1918; R9-22­ 1919; R9-28-1320 Medicare SSA If attestation is inconsistent with source, obtain verification If no source available, obtain verification No State flexibility Medicaid Final Rule 42 CFR 435.119(b)(3) Medicaid Final Rule 42 CFR 435.603(j)(5) 42 USC 1396d(p) Disability Prior information in eligibility systems SSA Seriously Mentally Ill diagnosis from ADHS (SSI MAO) If needs to have eligibility determined under an optional disabled group (SSI MAO or FTW), refer to DDSA if there is no current information showing disability (receipt of SSDI, referred by ADHS as an SMI, etc.) No State flexibility Medicaid Final Rule 42 CFR 435.603(j)(3) 42 CFR 435.540 Breast or Cervical Cancer Diagnosis (for the Breast and Cervical Cancer None Obtain verification from one of Arizona’s programs of the National Breast and Cervical Cancer Early Detection Program (AZ-NBCCEDP) that is funded by the Centers for Disease Control and Prevention No State flexibility 42 USC 1396(a)(10)(A)(ii)(XVIII) MAGI-BASED ELIGIBILITY VERIFICATION PLAN Additional Comments 20

Eligibility Factor Source Reasonable Compatibility Plan State Flexibility Reference Treatment Program only) by the Centers for Disease Control and Prevention (CDC) ARS 36-2901.05 AAC R9-22-2003 Placement in an Institution for Mental Disease (IMD) – only a factor for CHIP Arizona Department of Health Services (potential) If attestation is inconsistent with source, obtain verification If no source available, accept attestation State flexibility to accept attestation or require hard copy. State defines reasonably 42 CFR 457.310(c)(2) MAGI-BASED ELIGIBILITY VERIFICATION PLAN Additional Comments 21

Health-e-Arizona Plus Application Questions to Clarify Income Inconsistencies Income information from the Federal and State hubs will be auto-populated into the Health-e-Arizona Plus online application as the applicant completes the application. If the applicant states that the information from the electronic source is incorrect, Health-e-Arizona Plus will present the applicant or recipient with a clarifying questions and drop down lists of answers that the applicant can select to explain why the income data from the hubs is inconsistent with their current income. Arizona has created rules that Health-e-Arizona Plus will use to determine if the information to which the applicant attests is reasonably compatible. When the information provided is reasonably compatible, this will eliminate the need for worker intervention and requests for additional non-electronic verification. However, if the information to which the applicant has attested is not reasonably compatible, non-electronic verification will be requested systematically and reviewed by a worker upon receipt. Arizona anticipates using multiple electronic sources to verify income such as SSA, State UI, Base Wage (SWICA) and The Work Number. Some of these sources provide current data but others provide less up to date information (such as from SWICA), so it is possible that Arizona will receive income data from multiple sources that will support an applicant’s attestation. For example, Arizona could receive current data from The Work Number that differs from the income reported through SWICA. Or a person could have earnings reported through SWICA but more current information from SSA shows that they are receiving Social Security Retirement of Disability benefits. Clarifying Questions and Answers Rule If the person attests that the earned income being received has ended, this dropdown list appears: Fired/laid off/employer out of o If UI shows claim, accept attestation o Otherwise, request non-electronic verification Quit Request non-electronic verification Changed employers Request non-electronic verification Retired o If hubs shows pension(s), accept attestation o If not, request non-electronic verification On leave without pay – obtain: o When did the leave begin? o If the data source shows income that is under the income limit, accept attestation.

Clarifying Questions and Answers Rule o When does [earner] expect to return to work? o Otherwise, request non-electronic verification Medical/disability leave – follow reasonably compatible rules o When did the leave begin? o When does [earner] expect to return to work? o If the data source shows income that is under the income limit, accept attestation. o Otherwise, request non-electronic verification Other Comments (provide free space for other). Will require State worker intervention If the person attests that the earned income amount has changed, this drop down list appears: Received a raise Accept attestation Reduction in pay o If the data source shows income that is under the income limit, accept attestation. o Otherwise, request non-electronic verification Increase in hours Accept attestation Decrease in hours o If the data source shows income that is under the income limit, accept attestation. o Otherwise, request non-electronic verification On leave without pay – obtain: o When did the leave begin? o If the data source shows income that is under the income limit, accept attestation.

Clarifying Questions and Answers Rule o When does [earner] expect to return to work? o Otherwise, request non-electronic verification Medical/disability leave – follow reasonably compatible rules o When did the leave begin? o When does [earner] expect to return to work? o If the data source shows income that is under the income limit, accept attestation. o Otherwise, request non-electronic verification If the person attests that the person never worked there, ask the following question: Does this income belong to a different household member? o If it does not belong to a different household member, accept attestation. (Arizona is exploring on line report of Identity Theft to the SOS.) o If it belongs to a different household member, attribute the income to the correct household member If the person attests the unearned income amount has changed, this drop down list appears: Benefits ran out/exhausted o If the data source shows income that is under the income limit, accept attestation. o Otherwise, request non-electronic verification No longer qualify (i.e. Unemployment benefits ran out; no longer disabled; aged out) o If the data source shows income that is under the income limit, accept attestation. o Otherwise, request non-electronic verification

Clarifying Questions and Answers Rule Payer stopped paying (Child support; alimony; foster care) Accept Attestation Not accounting for deductions Count gross amount Overpayment Refer to State worker Garnishment Count gross amount Cost of Living Adjustment change Accept attestation [Earner] started working Request non-electronic verification of recent pay Income fluctuates/changes regularly o If the data source shows income that is under the income limit, accept attestation. o Otherwise, request non-electronic verification Never received this Income Refer to a State worker If the person attests to having no income, ask how the person is meeting their living expenses Living with family/friends Accept attestation and, for households with no income, perform post-eligibility match with The Work Number and Base Wage every six months. Note: Once implemented and we have had a period of time to collect data, we will evaluate the effectiveness of the 6 month post-enrollment check to determine if a more frequent check is needed and may change the frequency. Using money from my savings/checking account Accept attestation and, for households with no income, perform post-eligibility match with The Work Number and Base Wage every six months. Note: Once implemented and we have had a period of time to collect data, we will evaluate the effectiveness of the 6 month post-enrollment check to determine if a more frequent check is needed and may change the frequency. Accept attestation and, for households with no income, perform post-eligibility match with The Work Number and Base Wage every six months.

Clarifying Questions and Answers Rule Living on credit cards Note: Once implemented and we have had a period of time to collect data, we will evaluate the effectiveness of the 6 month post-enrollment check to determine if a more frequent check is needed and may change the frequency. Borrowing money Accept attestation and, for households with no income, perform post-eligibility match with The Work Number and Base Wage every six months. If this is selected, obtain: Note: Once implemented and we have had a period of time to collect data, we will evaluate the effectiveness of the 6 month post-enrollment check to determine if a more frequent check is needed and may change the frequency. o Name and contact info of person who loaned you the money o Expected repayment date ο Amount of loan Someone is giving me money as a gift Accept attestation and disregard (since gifts are not taxable). For households with no income, perform post-eligibility match with The Work Number and Base Wage every six months. Note: Once implemented and we have had a period of time to collect data, we will evaluate the effectiveness of the 6 month post-enrollment check to determine if a more frequent check is needed and may change the frequency. Someone is paying my bills. If this is selected, obtain: o Name and contact info of person who is paying your bills o Which bills paid? Accept attestation and, for households with no income, perform post-eligibility match with The Work Number and Base Wage every six months. Note: Once implemented and we have had a period of time to collect data, we will evaluate the effectiveness of the 6 month post-enrollment check to determine if a more frequent check is needed and may change the frequency.

Clarifying Questions and Answers Rule Rent/Mortgage Telephone Utilities Other ο How long do you expect this person to continue to pay your bills? Less than three months Three months or more Working in exchange for rent Accept attestation and, for households with no income, perform post-eligibility match with The Work Number and Base Wage every six months. Note: Once implemented and we have had a period of time to collect data, we will evaluate the effectiveness of the 6 month post-enrollment check to determine if a more frequent check is needed and may change the frequency. Working odd jobs Accept attestation count the income amount reported. Other Provide free form explanation field. Requires State worker intervention.

Clarifying Questions and Answers Rule If the person attests that the earned income being received has ended, this dropdown list appears: Fired/laid off/employer out of business o If UI shows claim, accept attestation o Otherwise, request non-electronic verification Quit Request non-electronic verification Changed employers Request non-electronic verification Retired o If hubs shows pension(s), accept attestation o If not, request non-electronic verification On leave without pay – obtain: o When did the leave begin? o When does [earner] expect to return to work? o If the data source shows income that is under the income limit, accept attestation. o Otherwise, request non-electronic verification Medical/disability leave – follow reasonably compatible rules o When did the leave begin? o When does [earner] expect to return to work? o If the data source shows income that is under the income limit, accept attestation. o Otherwise, request non-electronic verification Other Comments (provide free space for other). Will require State worker intervention If the person attests that the earned income amount has changed, this drop down list appears: Received a raise Accept attestation Reduction in pay o If the data source shows income that is under the income limit, accept attestation. o Otherwise, request non-electronic verification Increase in hours Accept attestation

Clarifying Questions and Answers Rule Decrease in hours o If the data source shows income that is under the income limit, accept attestation. o Otherwise, request non-electronic verification On leave without pay – obtain: o When did the leave begin? o When does [earner] expect to return to work? o If the data source shows income that is under the income limit, accept attestation. o Otherwise, request non-electronic verification Medical/disability leave – follow reasonably compatible rules o When did the leave begin? o When does [earner] expect to return to work? o If the data source shows income that is under the income limit, accept attestation. o Otherwise, request non-electronic verification If the person attests that the person never worked there, ask the following question: Does this income belong to a different household member? o If it does not belong to a different household member, accept attestation. (Arizona is exploring on line report of Identity Theft to the SOS.) o If it belongs to a different household member, attribute the income to the correct household member If the person attests the unearned income amount has changed, this drop down list appears: o If the data source shows income that is under the income limit, accept attestation. o Otherwise, request non-electronic verification Benefits ran out/exhausted

Clarifying Questions and Answers Rule No longer qualify (i.e. Unemployment benefits ran out; no longer disabled; aged out) o If the data source shows income that is under the income limit, accept attestation. o Otherwise, request non-electronic verification Payer stopped paying (Child support; alimony; foster care) Accept Attestation Not accounting for deductions Count gross amount Overpayment Refer to State worker Garnishment Count gross amount Cost of Living Adjustment change Accept attestation [Earner] started working Request non-electronic verification of recent pay Income fluctuates/changes regularly o If the data source shows income that is under the income limit, accept attestation. o Otherwise, request non-electronic verification Never received this Income Refer to a State worker If the person attests to having no income, ask how the person is meeting their living expenses Living with family/friends Accept attestation and, for households with no income, perform post-eligibility match with The Work Number and Base Wage every six months. Note: Once implemented and we have had a period of time to collect data, we will evaluate the effectiveness of the 6 month post-enrollment check to determine if a more frequent check is needed and may change the frequency. Using money from my savings/checking account Accept attestation and, for households with no income, perform post-eligibility match with The Work Number and Base Wage every six months. Note: Once implemented and we have had a period of time to collect data, we will evaluate the effectiveness of the 6 month post-enrollment check to determine if a more frequent check is needed and may change the frequency.

Clarifying Questions and Answers Rule Living on credit cards Accept attestation and, for households with no income, perform post-eligibility match with The Work Number and Base Wage every six months. Note: Once implemented and we have had a period of time to collect data, we will evaluate the effectiveness of the 6 month post-enrollment check to determine if a more frequent check is needed and may change the frequency. Borrowing money If this is selected, obtain: o Name and contact info of person who loaned you the money o Expected repayment date ο Amount of loan Accept attestation and, for households with no income, perform post-eligibility match with The Work Number and Base Wage every six months. Note: Once implemented and we have had a period of time to collect data, we will evaluate the effectiveness of the 6 month post-enrollment check to determine if a more frequent check is needed and may change the frequency. Someone is giving me money as a gift Accept attestation and disregard (since gifts are not taxable). For households with no income, perform post-eligibility match with The Work Number and Base Wage every six months. Note: Once implemented and we have had a period of time to collect data, we will evaluate the effectiveness of the 6 month post-enrollment check to determine if a more frequent check is needed and may change the frequency. Someone is paying my bills. Accept attestation and, for households with no income, perform post-eligibility match with The Work Number and Base Wage every six months. Note: Once implemented and we have had a period of time to collect data, we If this is selected, obtain: will evaluate the effectiveness of the 6 month post-enrollment check to determine if a more frequent check is needed and may change the frequency.

Clarifying Questions and Answers Rule o Name and contact info of person who is paying your bills o Which bills paid? Rent/Mortgage Telephone Utilities Other ο How long do you expect this person to continue to pay your bills? Less than three months Three months or more Working in exchange for rent Accept attestation and, for households with no income, perform post-eligibility match with The Work Number and Base Wage every six months. Note: Once implemented and we have had a period of time to collect data, we will evaluate the effectiveness of the 6 month post-enrollment check to determine if a more frequent check is needed and may change the frequency. Working odd jobs Accept attestation count the income amount reported. Other Provide free form explanation field. Requires State worker intervention.

Health-e-Arizona Plus Application Questions to Clarify Income Inconsistencies Income information from the Federal and State hubs will be auto-populated into the Health-e-Arizona Plus online application as the applicant completes the application. If the applicant states that the information from the electronic source is incorrect, Health-e-Arizona Plus will present the applicant or recipient with a clarifying questions and drop down lists of answers that the applicant can select to explain why the income data from the hubs is inconsistent with their current income. Arizona has created rules that Health-e-Arizona Plus will use to determine if the information to which the applicant attests is reasonably compatible. When the information provided is reasonably compatible, this will eliminate the need for worker intervention and requests for additional non-electronic verification. However, if the information to which the applicant has attested is not reasonably compatible, non-electronic verification will be requested systematically and reviewed by a worker upon receipt. Arizona anticipates using multiple electronic sources to verify income such as SSA, State UI, Base Wage (SWICA) and The Work Number. Some of these sources provide current data but others provide less up to date information (such as from SWICA), so it is possible that Arizona will receive income data from multiple sources that will support an applicant’s attestation. For example, Arizona could receive current data from The Work Number that differs from the income reported through SWICA. Or a person could have earnings reported through SWICA but more current information from SSA shows that they are receiving Social Security Retirement of Disability benefits. Eligibility Factor Source Reasonable Compatibility Plan State Flexibility Reference SSN SSA If unable to verify with electronic source, obtain verification of SSN or proof of application for SSN No state flexibility Medicaid Final Rule 42 CFR 435.956(d) 435.910(g) and (f) Citizenshi p Prior citizenship documentation in eligibility systems If unable to verify with electronic source, obtain hard copy verification No state flexibility Medicaid Final Rule 42 CFR 435.949

Eligibility Factor Source Reasonable Compatibility Plan State Flexibility Reference SSA Arizona Vital Stats (AVS) Non- citizenship Prior non- citizenship information in eligibility system Dept of Homeland Security (DHS) SAVE Use self-attestation for non- qualified immigrants If unable to verify with electronic source, obtain hard copy verification for others No state flexibility Medicaid Final Rule 42 CFR 435.949 Identity Prior identity documentation in eligibility systems SSA Motor Vehicle Division (MVD) If unable to verify with electronic source, obtain hard copy verification No state flexibility Medicaid Final Rule 42 CFR 435.949

Eligibility Factor Source Reasonable Compatibility Plan State Flexibility Reference Incarcerati on Arizona Department of Corrections (ADC) County jails SSA If attestation is inconsistent with source, obtain verification If no source available, accept attestation No state flexibility 42 CFR 457.310(c)(2) State residency Prior information in eligibility systems SSA TWork Number Unemploymen t Insurance (UI) New Hire MVD If unable to verify with electronic source, obtain verification. State flexibility to accept attestation of residency or to require database matching for verification States define “reasonably compatible” standard Medicaid Final Rule 42 CFR 435.956(c) Marriage Prior household composition information in eligibility If attestation is inconsistent with source, obtain verification If no source available, accept attestation Agency MUST accept self- attestation unless not reasonably compatible State defines “reasonably compatible” Medicaid Final Rule 42 CFR 435.956(f)

Eligibility Factor Source Reasonable Compatibility Plan State Flexibility Reference Pregnancy Prior information in eligibility systems If attestation is inconsistent with source, obtain verification If no source available, accept attestation Agency MUST accept self- attestation unless not reasonably compatible State defines “reasonably compatible” Medicaid Final Rule 42 CFR 435.956(e) Househol d members Prior household composition information in eligibility systems If attestation is inconsistent with source, obtain verification If no source available, accept attestation If electronic verification is not available, the State may request other documents and/or use a reasonable compatibility process. States may, but are not required to use self- attestation State defines “reasonably compatible” Medicaid Final Rule 42 CFR 435.956(f) The relationshi ps of household members Prior household composition information in eligibility systems If attestation is inconsistent with source, obtain verification If no source available, accept attestation If electronic verification is not available, the State may request other documents and/or use a reasonable compatibility process. States may, but are not required to use self- attestation State defines “reasonably compatible” Medicaid Final Rule 42 CFR 435.956(f)

Eligibility Factor Source Reasonable Compatibility Plan State Flexibility Reference Deprivatio n (18 Year Old Students) There is no reliable electronic method to verify deprivation Obtain verification If electronic verification is not available, the State may request other documents and/or use a reasonable compatibility process. States may, but are not required to use self- attestation State defines “reasonably compatible” Medicaid Final Rule 435.956(f) American Indian Prior ethnicity (and tribe) information in eligibility systems Use self attestation if CHIP or FTW premiums are not affected. Obtain verification if CHIP or FTW premiums are affected. For CHIP and FTW, state flexibility to accept attestation or require hard copy verification 42 CFR 457.535 Age Prior information in eligibility systems SSA AVS If attestation is inconsistent with source, use source. Obtain verification (if age affects eligibility) If electronic verification is not available, the State may request other documents and/or use a reasonable compatibility process. State flexibility to define “reasonably compatible” standard Medicaid Final Rule 42 CFR 435.956(f)

Eligibility Factor Source Reasonable Compatibility Plan State Flexibility Reference Dept of Homeland Sec (DHS) SAVE Flexibility to rely exclusively on IRS data or combination The Work Number of IRS and state and federal data sources, or non-IRS state and federal data sources showing current monthly income. Flexibility to determine Medicaid Final Rule 42 CFR 435.945 Base Wage what data sources are “useful” , with certain exceptions (e.g. PARIS) Flexibility to determine Medicaid Final Rule 42 CFR 435.948 Earned Income New Hire Report See “Health-e-Arizona Plus Application Questions to Clarify Income Inconsistencies” Table current income by using available annual income and divide it by 12. Flexibility to employ Medicaid Final Rule 42 CFR 435.952 SSA – SVES, SOLQI, SDX reasonably predictable income and projected annual income methodologies

Eligibility Factor Source Reasonable Compatibility Plan State Flexibility Reference Arizona Department of Revenue Prior information in eligibility systems Flexibility to determine the hierarchy of verification through data base matching and Attestation Flexibility to define the “reasonably compatible” standard. SSA If attestation is inconsistent with source, obtain verification Railroad Retirement Board If no source available, obtain verification Flexibility to determine how to assist individuals in constructing MAGI household income. Flexibility to determine Unemploymen whether, how and how t Insurance often to conduct post eligibility data matching. Flexibility to establish Arizona operational infrastructure Department of (scan capacity, in-person Revenue kiosks, email) to accept paper documentation.

Eligibility Factor Source Reasonable Compatibility Plan State Flexibility Reference Unearned Income Arizona Lottery PARIS (if real time) Flexibility to determine what data sources to rely on for re-determining eligibility. Flexibility to rely on alternate financial eligibility data sources subject to HHS approval and provided Prior information in eligibility systems they: reduce administrative costs and burdens on individuals and States maximize accuracy minimize delay meet applicable confidentiality, disclosure and maintenance requirements promote coordination with other insurance affordability programs

Eligibility Factor Source Reasonable Compatibility Plan State Flexibility Reference Tax payer filing status Arizona Department of Revenue If attestation is inconsistent with source, ask clarifying questions. If no source available, accept attestation If electronic verification is not available, the State may request other documents and/or use a reasonable compatibility process. States may, but are not required to use self- attestation State defines “reasonably compatible” Medicaid Final Rule 42 CFR 435.956(f) Dependen ts on tax return Arizona Department of Revenue If attestation is inconsistent with source, ask clarifying questions. If no source available, accept attestation State flexibility to accept attestation or require hard copy verification States define “reasonably compatible” standard Medicaid Final Rule 42 CFR 435.956(f) Current Prior information in eligibility systems If attestation is inconsistent with source, obtain verification State flexibility to accept attestation or require hard copy verification Medicaid Final Rule 42 CFR 435.119(c) health insurance Health Management Systems The Work Number If no source available, accept attestation States define “reasonably compatible” standard 42 CFR 457.310(c)

Eligibility Factor Source Reasonable Compatibility Plan State Flexibility Reference Potential benefits UI/Base Wage Prior information in eligibility systems Use self-attestation State flexibility to accept attestation or require hard copy verification States define “reasonably compatible” standard 42 CFR 435.608