Page 20

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