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 Age (Date of Birth) NO YES YES N/A N/A YES YES If data match comes back with an inconsistent age then Massachusetts does follow up through an outreach call to applicant to ask for paper documentation. This will not hold up eligibility determination or result in termination if the individual does not respond. For age, Massachusetts receives verification of a SSN from SSA via the FDSH. Part of the SSN verification includes confirmation of name and DOB. FDSH (SSA) will be used at application. Social Security Number ** NO NO YES N/A N/A N/A YES As authorized under Section 1902(e)(14)(A)of the Act, MA received approval from CMS on March 31, 2014 to extend the Provisional Eligibility period for applicants with verification inconsistencies an additional 90 days. This authority applies to provisional coverage for individuals who apply for coverage by June 30, 2014. Citizenship ** NO NO YES N/A N/A N/A YES Massachusetts will follow statute, regulations, and guidance for SSN, citizenship and immigration status including obtaining such information through the federal data hub services if available. As authorized under Section 1902(e)(14)(A)of the Act, MA received approval from CMS on March 31, 2014 to extend the Provisional Eligibility period for applicants with verification inconsistencies an additional 90 days. This authority applies to provisional coverage for individuals who apply for coverage by June 30, 2014. Immigration Status ** NO NO YES N/A N/A N/A YES Massachusetts will follow statute, regulations, and guidance for SSN, citizenship and immigration status including obtaining such information through the federal data hub services if available As authorized under Section 1902(e)(14)(A)of the Act, MA received approval from CMS on March 31, 2014 to extend the Provisional Eligibility period for applicants with verification inconsistencies an additional 90 days. This authority applies to provisional coverage for individuals who apply for coverage by June 30, 2014. Household Composition YES NO NO N/A N/A NO NO Pregnancy *** YES NO NO N/A N/A NO NO Caretaker Relative YES NO NO N/A N/A NO NO Medicare NO NO YES N/A N/A NO YES Application for Other Benefits YES NO NO N/A N/A NO NO Other: (Please describe any other eligibility factors in the space below) 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 Other (Identity) NO YES YES N/A N/A NO YES Using SSA to obtain both citizenship and identity. If information is incosistent with SSA and identity needs to be verified as part of citizenship, then identity would be verified separately through DMV (Mass RMV= registry of motor vehicles). Paper documentation will be requested only if those data sources are unavailable. As authorized under Section 1902(e)(14)(A)of the Act, MA received approval from CMS on March 31, 2014 to extend the Provisional Eligibility period for applicants with verification inconsistencies an additional 90 days. This authority applies to provisional coverage for individuals who apply for coverage by June 30, 2014. Other (Access to ESI) YES YES YES If applicant indicates working less than 32 hrs. per week, self attestation is accepted. If applicant indicates working 32 hours per week or more, an investigation is conducted regardless of applicant's response. N/A NO NO If state finds through electronic data sources that the individual has access to ESI and individual indicated that they don't have access, the agency will notify the individual. This applies to both Medicaid and CHIP. For Medicaid, it is to offer premium assistance if cost effective. For CHIP, it is to require enrollment in a qualified health plan. Other (Incarceration) NO NO YES N/A N/A YES NO Utilizing the HUB for incarceration status and also uses SVES Mass doesn't currently exercise option to suspend but only pay for services under certain circumstances. In the case where an applicant self attests they are not incarcerated but the HUB indicates they are incarcerated, Medicaid will ask the applicant for a paper verfication. As authorized under Section 1902(e)(14)(A)of the Act, MA received approval from CMS on March 31, 2014 to extend the Provisional Eligibility period for applicants with verification inconsistencies an additional 90 days. This authority applies to provisional coverage for individuals who apply for coverage by June 30, 2014. Other (Third Party Recovery) NO YES YES N/A N/A NO YES Data source matching occurs to identify individuals that haven't self-identified. Paper documentation is only required when an individual indicates that they've been injured. * 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: Massachusetts 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 Applicati on (Y/N) Data Source Used at Renewa l (Y/N) Data Source Used Post- Enrollmen t (Y/N) If Data Source Used for Post- Enrollment - Frequency Used (e.g. monthly, quarterly) Comments 1. Internal Revenue Service (IRS) YES YES YES YES YES YES NO YES YES NO Use at renewal if the person has provided consent. State to utilize FTI data match, then use SWICA & UI as secondary. All data matches are in real time. 2. Social Security Administration (SSA) (SSI, Title II) YES YES YES YES YES YES YES YES YES YES Monthly Massachusetts believes "other criteria used column" should be listed as "yes" as it is used to identify if an individual is receiving SSI benefits, and therefore exempt from a MAGI-determination. SSI data is obtained through our current match with SSA. 3. State Wage Information Collection Agency (SWICA) YES YES YES YES YES YES NO YES YES YES Quarterly 4. State Unemployment Compensation YES YES YES YES YES YES NO YES YES YES Monthly 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 Applicati on (Y/N) Data Source Used at Renewa l (Y/N) Data Source Used Post- Enrollmen t (Y/N) If Data Source Used for Post- Enrollment - Frequency Used (e.g. monthly, quarterly) Comments 5. State Administered Supplementary Payment Program NO YES YES YES YES YES NO NO NO NO Not used for MAGI. These individuals are considered referrred eligibles from Massachusetts state date exchange (excluded from MAGI calcuation) and are automatically eligible for MassHealth 6. State General Assistance Programs NO YES YES YES YES YES NO NO NO NO Not used for MAGI. These individuals are considered referrred eligibles from Massachusetts Department of Transitional Assistance (excluded from MAGI calcuation) and are automatically eligible for MassHealth. MA has received authority to establish eligiblity for these groups by referral, through our 1115 Demonstration amendment, approved on October 1, 2013. 7. Supplemental Nutrition Assistance Program (SNAP) YES YES YES YES YES YES YES NO YES NO Express Lane Renewals only 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 Applicati on (Y/N) Data Source Used at Renewa l (Y/N) Data Source Used Post- Enrollmen t (Y/N) If Data Source Used for Post- Enrollment - Frequency Used (e.g. monthly, quarterly) Comments 8. Temporary Assistance for Needy Families (TANF) NO YES YES YES YES YES NO NO NO NO Not used for MAGI. These individuals are considered referrred eligibles from Massachusetts Department of Transitional Assistance (excluded from MAGI calcuation) and are automatically eligible for MassHealth MA has received authority to establish eligiblity for these groups by referral, through our 1115 Demonstration amendment, approved on October 1, 2013. 9. Office of Child Support Enforcement (OCSE) NO NO NO NO NO NO NO NO NO NO Do not have access 10. State Income Tax NO NO NO NO NO NO NO NO NO NO Do not have access 11. Commercial database: (Pease describe any commercial databases in the space below) TALX / The Work Number NO NO NO NO NO NO NO NO NO NO At the time this federal service was introduced in the project it could not be included in the schedule for 10/1. This federal service will be included in future release. 12. Other: (Please describe any additional electronic data sources in the space below) 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: Massachusetts 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 Applicatio n (Y/N) Data Source Used at Renewal (Y/N) Data Source Used Post- Enrollme nt (Y/N) If Used for Post- Enrollment Frequency Used (i.e. monthly, quarterly) Comments 1. Social Security Administration (SSA) YES YES YES NO NO YES NO NO NO YES NO NO YES YES YES Monthly Post-enrollment, data source is checked monthly for any status changes related to Medicare 2. Department of Homeland Security (DHS) - SAVE YES NO NO YES NO NO NO NO NO NO NO NO YES YES NO We will data match for immigration status at the time of application, renewal, when a status is set to expire, and at least once every 12 months for members who have their MassHealth renewal date extended 3. Vital Statistics YES NO YES NO NO NO NO NO NO NO NO NO YES NO NO Mass can only check data source with permission. 4. Department of Motor Vehicles (DMV) YES NO NO NO NO NO NO NO NO NO NO YES NO NO YES Other (specify in comments) Identity Verification if needed as part of citizenship during the reasonable opportunity period 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 Applicatio n (Y/N) Data Source Used at Renewal (Y/N) Data Source Used Post- Enrollme nt (Y/N) If Used for Post- Enrollment Frequency Used (i.e. monthly, quarterly) Comments 5. Temporary Assistance for Needy Families (TANF) YES NO YES YES NO NO NO NO NO NO NO YES YES YES YES Other (specify in comments) Daily Only used for citizenship and immigration status if they have been verified in accordance with Medicaid and CHIP rules. Back up to use when hub sources fail. Citizenship is a one-time verification and not reviewed at renewal or post- enrollment. Immigration status may be reviewed once every 12 months or if there is a change in immigration status. The "other" column indicates data that we receive that the individual is receiving TANF benefits and therefore automatically eligible for MassHealth. 6. Supplemental Nutrition Assistance Program (SNAP) YES NO NO NO NO NO NO NO NO NO NO YES NO YES NO The "Other" column indicates that we receive data from SNAP that is used for purposes of Express Lane Renewals. 7. Office of Child Support Enforcement 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 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 Applicatio n (Y/N) Data Source Used at Renewal (Y/N) Data Source Used Post- Enrollme nt (Y/N) If Used for Post- Enrollment Frequency Used (i.e. monthly, quarterly) Comments 8. State General Assistance Programs YES NO YES YES NO NO NO NO NO NO NO YES YES YES YES Other (specify in comments) Daily Only used for citizenship and immigration status if they have been verified in accordance with Medicaid and CHIP rules. Back up to use when hub sources fail. Citizenship is a one-time verification and not reviewed at renewal or post- enrollment. Immigration status may be reviewed once every 12 months or if there is a change in immigration status. The "other" column indicates data that we receive that the individual is receiving State General Assistance ( those referred eligibles from Massachusetts Department of Transitional Assistance, specifically Emergency Aid for Elderly, Disabled, and Children EAEDC) benefits and therefore automatically eligible for MassHealth. MA has received authority to establish eligiblity for these groups by referral, through our 1115 Demonstration amendment, approved on October 1, 2013. 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 Applicatio n (Y/N) Data Source Used at Renewal (Y/N) Data Source Used Post- Enrollme nt (Y/N) If Used for Post- Enrollment Frequency Used (i.e. monthly, quarterly) Comments 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 11. Commercial database: (Please describe any commercial databases in the space below) Third Party Liability Data Matching YES NO NO NO NO NO NO NO NO NO NO YES NO YES YES Monthly Other criteria considered is TPL, Current Vendor is HMS 13. Other: (Please describe additional electronic data sources in the space provided below) 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 Applicatio n (Y/N) Data Source Used at Renewal (Y/N) Data Source Used Post- Enrollme nt (Y/N) If Used for Post- Enrollment Frequency Used (i.e. monthly, quarterly) Comments 12. PARIS* YES NO NO NO NO NO NO NO NO NO YES YES NO YES YES Quarterly Uses PARIS to collect eligibility of individuals in other state Medicaid programs. Other (Experian/LexisNex is) YES NO NO NO YES NO NO NO NO NO NO NO YES YES YES Annually Performed once every 12 months if annual renewal date is extended * 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: Massachusetts 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 NO Must be Applied Column D:Periodic matching with Insurance carriers to identify coverage These verification policies and procedures (for questions 1 and 2) also apply to the state Medicaid Expansion program according to title XXI. Accept self-attestation but have backup ways to check to ensure that the application info is accurate. State will follow-up with periodic data match for those who have other insurance. Plan to file an amendment to program to eliminate waiting period for CHIP (to be effective 1/1/2014). Decision will impact whether questions 3-6 apply to them. 2. Applicant does not have access to affordable ESI YES YES YES NO Column B: Yes, if applicant indicates working less than 32 hours per week Column C: Yes, if applicant indicates working 32 hours per week or more Column C: Yes, when possible 3. When child has had coverage (as applicable to states' waiting period) YES NO NO NO 4. Access to public employee coverage YES YES YES NO Column B: Yes, if applicant indicates working less than 32 hrs. per week. Column C: Yes, if applicant indicates working 32 hours per week or more Column D: Yes, when possible. 5a. Waiting period exception #1 (describe): YES NO NO NO Description: A child in the family group has special or serious health-care needs. 5b. Waiting period exception #2 (describe): YES NO NO NO Description: The prior coverage was involuntarily terminated 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 5c. Waiting period exception #3 (describe): YES NO NO NO Description: A parent in the family group died in the previous six months 5d. Waiting period exception #4 (describe): YES NO NO NO Description: The prior coverage was lost due to domestic violence 5e. Waiting period exception #5 (describe): YES NO NO NO Description: The prior coverage was lost due to becoming self-employed 5f. Waiting period exception #6 (describe): YES NO NO NO Description: The existing coverage's lifetime benefits were reduced substantially within the previous six months or prior employer-sponsored health insurance was cancelled for this reason. 5g. Waiting period exception #7 (describe): YES NO NO NO Placeholder any additional exceptions pending publication of CMS Final Rule 5h. Waiting period exception #8 (describe): 5i. Waiting period exception #9 (describe): 5j. Waiting period exception #10 (describe): 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 13

MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Massachusetts 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 is accepting self-attesation without additional verification for some factors of eligibility. For those that it doesn't, the state utilizes all available data sources, including back up sources for citizenship. We only request paper documenation when electtonic data is not available or is inconsistent with the attestation and does not meet the reasonable compatibitlity standard when relevant. We believe this strikes the appropriate balance of ensuring program integrity while promoting a streamlined process that minimizes the use of paper verifications. HIV Status and Breast and Cervical Cancer Treatment Program Eligibility: There are no reliable electronic data sources for medical diagnosis. Therefore MA will require paper verification post eligiblity for individuals whose eligibility for the state's 1115 Demonstration programs, HIV-Family Assistance and Breast and Cervical Cancer Treatment Program, depends in part on these factors. 2 Please describe how the state uses PARIS? Massachusetts uses PARIS to compare eligibility with other state Medicaid programs. 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. 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. 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 15

Section A. Additional Comments If data matches fail, are not reasonably compatible, or are not available, then Massachusetts will require post-enrollment paper verificatons within 90 days. An individual may only receive benefits during a post-enrollment verification period once per year, except if the individual has a change in circumstance resulting in a change of eligibility from QHP to Medicaid/CHIP, or if the individual becomes pregnant. This process was authorized through MassHealth's 1115 waiver on October 1 2013. Additional Other Categories: HIV+ Status (applies to ACA expansion adult group for richer benefit and to applicable 1115 waiver program for HIV+ individuals) - NO to self-attestation accepted without additional verification, YES to self-attestation accepted with post-enrollment verification, NO to electronic data sources used, NO to ask for explanation from the individual, YES to paper documentation required from the individual. Breast or Cervical Cancer Certification Status (applies to ACA expansion adult group for richer benefit and to 1115 waiver BCCTP Program for those with income between 133 and 250% FPL) - NO to self- attestation accepted without additional verification, YES to self-attestation accepted with post-enrollment verification, NO to electronic data sources used, NO to ask for explanation from the individual, YES to paper documentation required from the individual. As authorized under Section 1902(e)(14)(A)of the Act, MA received approval from CMS on March 31, 2014 to extend the Provisional Eligiblity period for applicants with verification inconsistencies (for eligibility factors noted in Section A) an additional 90 days. This authority applies to provisional coverage for individuals who apply for coverage by June 30, 2014. Section B1. Additional Comments Section B2. Additional Comments Section C. Additional Comments Medicaid and CHIP are part of one program called MassHealth. With regards to waiting periods and the associated exceptions, MA plans to file a state plan amendment to eliminate waiting periods for CHIP (consitent with CMS final eligibility rule released in July). MA intends to submit SPA before end of 2013. MAGI-BASED ELIGIBILITY VERIFICATION PLAN Additional Comments 16