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 Residency YES NO NO N/A N/A NO NO Additional verification is requested if there is a discrepancy with information received from electronic sources obtained for other purposed (as an integrated system) or returned mail is received. We do not use a specific data source for residency. Age (Date of Bi th) YES NO NO N/A N/A NO NO Social Security Number ** NO NO YES N/A N/A N/A YES For the legacy system we use batch interfaces with SSA and real time interfaces with state vital record. Georgia Gateway will be implemented 11/2016 and we will begin using the HUB to verify this information. Additional verification is requested if there is a discrepancy and we follow up post eligibility if there is a discrepancy. The state has an approved Hub waiver to use its current process for the legacy population. 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 Citizenship ** NO NO YES N/A N/A N/A YES Additional verification is requested if there is a discrepancy. For the legacy Medicaid/CHIP population we are using a real time interfaces with state vital records, and batch interfaces with SSA and DHS. Georgia Gateway will be implemented 11/16 and we will use the SSA Composite Service of the HUB. The last resort it to reach out to the individual for paper documentation. A 90 day reasonable opportunity period is also given for any applicant that needs to provide documentation. The application is approved while waiting on documentation if all other eligibility criteria are met. The state has an approved HUB Waiver to use its current process for the Legacy Medicaid/CHIP population. Immigration Status ** NO NO YES N/A N/A N/A YES Additional verification is requested if there is a discrepancy. For the legacy Medicaid/CHIP population, immigration status is verified via the web based SAVE application. The SAVE process requires the individual to be contacted and documentation requested if the individual's status cannot be verified at initial steps. We will begin using a direct interface with the UCIS SAVE web service with the implementation of Georgia Gateway 11/2016. A 90 day reasonable opportunity period is given for any applicant that needs to provide documentation. The state has an approved Hub waiver for the legacy Medicaid/CHIP population. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION A - Verification Procedures for Factors of Eligibility 3

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 Household Composition YES NO YES N/A N/A YES YES Current: Accept self-attestation unless information within the integrated system (SNAP and TANF) conflicts with application. Reasonable explanation is then requested. (80% of individuals are SNAP), and paper documentation if necessary. Georgia Gateway will be implement 11/2016 and self attestation will be accepted for Medicaid/CHIP unless the information within Georgia Gateway conflicts with the application. Reasonable explanation will be requested and paper documentation if necessary. Pregnancy *** YES NO NO N/A N/A NO NO If claiming multiple births, medical verification of multiple fetuses is required. Caretaker Relative YES NO YES N/A N/A NO YES Accept self-attestation unless information within the integrated system (SNAP and TANF) conflicts with application. Reasonable explanation is then requested, and paper documentation if necessary. Medicare NO YES YES N/A N/A NO YES We obtain data from Bendex for the legacy population and with the implementation of Georgia Gateway 11/16, we will use data from SOLQ. Paper documentation will be required if the data is not available through the electronic data sources or the information is inconsistent with the attestation. Application for Other Benefits NO YES YES N/A N/A NO YES Post-eligibility verification accepted for Medicaid only. Paper documentation requested after three months if electronic data source is unavailable or shows an inconsistency. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION A - Verification Procedures for Factors of Eligibility 4

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 Other: (Please describe any other eligibility factors in the * 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 5

Electronic Data Source

Determined Useful (Y/N)1 Accuracy Considere d (Y/N) Timeliness Considered (Y/N) y to Access Cons Abilit id

ered (Y/N) Ag dered e of Data Consi (Y/N) Comprehensive Consid

ered (Y/N) ( /N) Other Criteria Used Y e Describe in Co (Pleas

mments 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)

Georgia will not use IRS data as our current data sources are more

reliable and provide closer real time responses. NO YES YES YES YES YES NO NO NO NO

2. Social Security Administration Used post-enrollment when changes are reported.

We are using the (SSA) (SSI, Title II) state's current data match with SSA. YES YES YES YES YES YES NO YES YES YES

The state has an approved Hub waiver to use its current process until the new eligibility system is functional.

The Georgia will not use the RVV.

3. State Wage Information Collection Agency (SWICA) YES YES YES YES YES YES YES YES YES YES New Hire Alerts. Used post-enrollment when changes are reported.

4. State Unemployment

UCB data is not stored. Information is displayed when a UCB request is Compensation YES YES YES YES YES YES YES YES YES NO

made by a worker as needed at renewal or when a change is reported. MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Bo Medicaid & CHIP State: Georgia Last updated 08/30/2016 Section B1. Use of Electronic Data Sources Financial: MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B1 - Use of Electronic Data Sources, Financial 6

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 5. State Administered Supplementary Payment Program NO NO NO NO NO NO NO NO NO NO The program does not exist in GA 6. State General Assistance Programs NO NO NO NO NO NO NO NO NO NO The program does not exist in GA 7. Supplemental Nutrition Assistance Program (SNAP) YES YES YES YES YES YES NO YES YES YES Used Post-enrollment when changes are reported. 8. Temporary Assistance for Needy Families (TANF) YES YES YES YES YES YES NO YES YES YES Used Post-enrollment when changes are reported. 9. Office of Child Support Enforcement (OCSE) YES YES YES YES YES YES NO YES YES NO Used Post-enrollment when changes are reported. 10. State Income Tax NO YES YES YES YES NO NO NO NO NO Does Not include specific income amounts. Limited access 11. Commercial database: (Pease describe any commercial databases in the space below) 12. Other: (Please describe any additional electronic data sources in the space below) MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B1 - Use of Electronic Data Sources, Financial 7

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 The Work Number (TALX) NO NO NO NO NO NO NO NO NO NO Other (specify in comments) Used post-enrollment when changes are reported. Information is coming through the state's current match with TALX. Medicaid worker can request information real time whenever needed. Electronic match for CHIP done daily. Will be used for the legacy population with the implementation of Georgia Gateway TALX will not be used. We will not connect to Equifax. Equifax will NOT be used through the HUB at this time in the new system. Georgia will continue its use of the Work Number outside the Hub. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B1 - Use of Electronic Data Sources, Financial 8

MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Georgia Last updated 08/30/2016 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 Administration (SSA) YES YES YES NO NO NO NO NO NO YES NO NO YES YES YES Other (specify in comments) For the legacy system we use batch interfaces with SSA and real time interfaces with state vital record. Georgia Gateway will be implemented 11/2016 and we will begin using the HUB to verify this information. Additional verification is requested if there is a discrepancy and we follow up post eligibility if there is a discrepancy. The state has an approved Hub waiver to use its current process for the legacy population. 2. Department of Homeland Security (DHS) - SAVE YES NO NO YES NO NO NO NO NO NO NO NO YES NO NO For the legacy population immigration status is verified by the SAVE application, which provides an immediate eligibility response. Georgia Gateway will be implemented 11/16 and will use a direct interface with UCIS SAVE web service. Legacy members converted to Georgia Gateway will not be re-verified unless a change in immigration status is reported. 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 3. Vital Statistics YES NO YES NO NO YES NO NO NO NO NO YES YES NO NO Also as needed for Death, Marriage, Birth, Divorce 4. Department of Motor Vehicles (DMV) NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO 5. Temporary Assistance for Needy Families (TANF) YES NO NO NO YES YES NO YES YES NO NO NO YES YES NO used post-enrollment as changes occur. Can be use for residency if necessary post-enrollment. 6. Supplemental Nutrition Assistance Program (SNAP) YES NO NO NO YES YES NO YES YES NO NO NO YES YES NO used post-enrollment as changes occur. Can be use for residency if necessary post-enrollment. 7. Office of Child Support Enforcement YES NO NO NO NO NO NO NO NO NO YES NO NO NO YES Other (specify in comments) used post-enrollment as changes occur. 8. State General Assistance Programs NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO 9. Women, Infants and Children Program (WIC) YES NO NO NO NO YES YES YES NO NO NO YES YES NO NO 10. State Income Tax NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B2 - Use of Electronic Data Sources, Non-Financial 10

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 11. Commercial database: (Please describe any commercial databases in the space below) 13. Other: (Please describe additional electronic data sources in the space provided below) 12. PARIS* Other (specify in The PARIS file is not used in the eligibility determination comments) process. The client's statement is accepted. The PARIS file YES NO NO NO NO NO NO NO NO NO NO YES NO NO YES is used post enrollment by the Office of Inspector General. We do not use this file for VA benefit, we will request verifciation or contact the VA office directly. * 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 11

MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Georgia Date Submitted: (mm/dd/yyyy) 08/30/2016 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 YES YES YES Must be Applied Electronic Data Sources - GA MMIS, State Health Benefit Plan and Board of Regents. Paper documentation only requested when applicant disagrees with electronic data source match In general, accept self-attestation but system does automatic matches with Medicaid (MMIS) and State Health Benefit (State Board of Regents) and post-enrollment with TPL vendor other health insurance. If a customer drops his or her insurance, a waiting period is imposed. 2. Applicant does not have access to affordable ESI NO NO NO YES We will verify access to ESI to determine member exemption from the waiting period when: 1. An applicant or enrollee reports any of the following in a written or verbal statement, or indicates on his or her application or renewal that the applicant or his or her spouse or parent: a. dropped health insurance from a current employer , or c. work for an employer that stopped offering health insurance. OR 2. An applicant or enrollee provides ESI information that is inconsistent with documentation or information on file and, 3. there are no electronic matches available to verify. 3. When child has had coverage (as applicable to states' waiting period) YES NO NO NO Documents are required to determine exemption from the waiting period. Documents are requested if parent reports that the cost of insurance listed below. (5a-5l) 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 4. Access to public employee coverage N/A 5a. Waiting period exception #1 (describe): NO NO NO YES Exception: Employer cancellation of entire group plan. Paper documentation only requested when applicant disagrees with electronic data source match or customer reports the information and there is no electronic data source match 5b. Waiting period exception #2 (describe): NO NO NO YES Exception: Loss of Eligibility due to parent’s layoff from employer: Paper documentation requested or verified with electronic data report or HMS Insurance associates. 5c. Waiting period exception #3 (describe): NO NO NO YES Exception: Employment Termination: Paper documentation requested. 5d. Waiting period exception #4 (describe): NO NO NO YES Exception: Leave of absence without pay or reduction of work hours: Paper documentation requested, electronic data report, HMS 5e. Waiting period exception #5 (describe): NO NO NO YES Exception: Cancellation of private health insurance due to cost share exceeding 5% of the annual income : Paper documentation requested 5f. Waiting period exception #6 (describe): NO NO NO YES Exception: Cancellation of individual policy to due meeting lifetime caps: Paper verification requested 5g. Waiting period exception #7 (describe): NO NO NO YES Exception: Cancellation of COBRA or individual policy: Paper documentation requested. 5h. Waiting period exception #8 (describe): NO NO NO YES Exception: Resignation of parent from employment : Paper documentation requested. 5i. Waiting period exception #9 (describe): NO NO NO YES Exception: A child born during the two month waiting period. 5j. Waiting period exception #10 NO NO NO YES Exception: Has special health care needs 5k. Waiting period exception #11 NO NO NO YES Exception: Lost coverage due to the death or divorce of a parent 5. Waiting period exception #12 (describe): NO NO NO YES Exception: The employer stopped offering coverage of dependents MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 13

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 For CHIP, if attestation of income puts premium (cost sharing) in a lower band than the data source, premium is assigned based on data source and the applicant will be given an opportunity to provide further verification in order to lower the premium. If verification is submitted, then we would redetermine the premium amount and eligibility. If ineligible for CHIP, refer to FFM or Medicaid program is applicable. 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 14

MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Georgia Date Submitted: (mm/dd/yyyy) 08/30/2016 Section D. Additional Verification Questions 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 many factors of eligibility. For those that we don't, the state uses all available electronic data sources and paper documentation is only required, due to the electronic database not storing real time data, if data is unavailable or if not passing the reasonable compatibility test and in some cases if a reasonable explanation is not provided. 2 Please describe how the state uses PARIS? We are currently working with the interstate and federal files. File is put in a dashboard and sorted by highest to lowest claim value and staff work to resolve the discrepancy. We are still working on setting up the VA file. The PARIS file is used as a fraud detection tool by Office of Inspector General not for eligibility. This is a post eligibility process and not a part of the enrollment process. OIG uses the file to verify benefits in another state. 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 15

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. NO 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. Georgia has been granted a full Hub waiver to forego using the Hub to verify citizenship, social security number, the amount and receipt of Title II cash benefits and to use SAVE through the Hub's VLP service for all three steps of SAVE. Georgia has continued authority to forego using the Hub for its legacy population. The Hub will be retired for the population transferred to the Georgia Gateway once the system goes live. 5 Describe any additional MAGI-based eligibility verification policies and procedures that have not been covered in this verification plan (optional): MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION D - Additional Verification Questions 16

Section A. Additional Comments MAGI-BASED ELIGIBILITY VERIFICATION PLAN Additional Comments 17

Section B1. Additional Comments MAGI-BASED ELIGIBILITY VERIFICATION PLAN Additional Comments 18

Section B2. Additional Comments MAGI-BASED ELIGIBILITY VERIFICATION PLAN Additional Comments 19

Section C. Additional Comments MAGI-BASED ELIGIBILITY VERIFICATION PLAN Additional Comments 20