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 Income* YES NO YES Percent Threshold 10% YES YES standard of 10% is used. - If the difference is less than 10%, the information is considered reasonably compatible and self-attested income is used. - If the difference is greater than 10%, reasonable explanation is requested. If reasonable explanation is provided, the self-attested income is used. If not reasonable, further verification is required. If an individual's attestation cannot be confirmed, due to no available data source or paper documenation, self-attestation will be accepted if the reported income is less than $600/month. Paper documentation is requested for self-employment income, when reasonable explanation is not provided, when data sources do not exist, or it is needed to resolve discrepancies. Individuals determined ineligible for Medicaid are referred for APTC through the marketplace. 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 Residency YES NO NO N/A N/A NO NO For most cases Maine will accept self-attestion without additional verification unless the state is made aware though electronic data that there is a discrepancy. Follow up will be done if a discrepancy is found post-eligibility with other programs (e.g. , SNAP/TANF) or if mail is returned. Source: Maine's eligibility system, SSA, The Work Number, Maine Department of Labor and PARIS. Will ask for an explanation and paper documentation if needed. Age (Date of Birth) NO YES YES N/A N/A YES YES Sources: Maine's eligibility system, SSA BENDEX and DHS SAVE. Social Security Number ** NO NO YES N/A N/A N/A YES Sources: SSA BENDEX and Maine's eligibility system. Maine will ask for documentation only when we have a mis-match with SSA. Citizenship ** NO NO YES N/A N/A N/A YES Source: Maine's eligibility system, BENDEX. Paper will only be requested when a mis-match with SSA BENDEX is identified. Immigration Status ** NO NO YES N/A N/A N/A YES Sources: SAVE. Maine will only request documentation when an individual's immigraton status cannot be verified through SAVE. 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 NO N/A N/A NO NO Source: Household composition in Maine's eligibility system. For most cases Maine will accept self-attestion without additional verification unless the state is made aware that there is a discrepancy. In such cases, will ask for an explanation and paper documentation only if necessary. Pregnancy *** YES NO NO N/A N/A NO NO Source: pregnancy information in Maine's eligibility system and other program records (e.g. SNAP, TANF, etc.) For most cases Maine will accept self-attestation without additional verification unless the state is made aware of a discrepancy. In such cases, will ask for an explanation and paper documentation only if necessary. Caretaker Relative YES NO NO N/A N/A NO NO Source: caretaker relative information in Maine's eligibility system and other program records (e.g. SNAP, TANF, etc). For most cases Maine will accept self-attestion without additional verification unless the state is made aware of a discrepancy. In such cases, will ask for an explanation and paper documentation only if necessary. Medicare NO YES YES N/A N/A YES YES Source: SSA BENDEX. Maine requests a copy of the individual's Medicare card when there is a discrepancy with the SSA match. Application for Other Benefits NO YES YES N/A N/A YES YES Sources: information in Maine's eligibility system and PARIS. Maine may follow up post eligibility in situations where the individual is awaiting a decision on other benefits such as VA. Paper documentation may be required if we cannot verifiy electronically. Other: (Please describe any other eligibility factors in the space below) 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 Incarceration YES NO NO N/A N/A NO NO Sources: Maine's eligibility system and the Maine Department of Corrections. Maine will take self-attestaion. However, if the state receives information that the person is incarcerated, Maine will ask for a reasonable explanation or paper documentation if necessary. If no source information is available, Maine will accept attestation. Maine limits services to inpatient hospital to those who are incarcerated. * 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

MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or BothMedicaid & CHIP State: Maine Date Submitted: (mm/dd/yyy 05/05/2020 Section B1. Use of Electronic Data Sources Financial: Electronic Data Source Determined Useful (Y/N) Accuracy Considered (Y/N) Timeliness Considered (Y/N) Ability to Access Consider ed (Y/N) Age of Data Considered (Y/N) Comprehensive Consider e d (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 YES YES YES NO NO NO NO NO Data is old and will not be useful for determinations; also security requirements are too onerous. 2. Social Security Administration (SSA) (SSI, Title II) YES YES YES YES YES YES NO YES YES YES Monthly If information received post eligibility indicates disrepancy, follow-up will occur to determine impact, if any, on eligibility. Post-eligibility data checks are based on state's current data match with SSA. Information for all applicable clients received on a monthly basis, received daily as requested for specific individuals. State will use existing SSA BENDEX data source. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B1 - Use of Electronic Data Sources, Financial 6

Electronic Data Source Determined Useful (Y/N) 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 3. State Wage Information Collection Agency (SWICA) NO YES YES YES YES YES YES NO NO YES Quarterly Do not have a real-time data feed. Data is old and only available via reports that need to be worked manually. May be used for post-enrollment verification if other data sources or paper verification is not available. 4. State Unemployment Compensation YES YES YES YES YES YES NO YES YES YES Monthly Maine uses state unemployment compensation data at application, renewal and in post- enrollment. 5. State Administered Supplementary Payment Program YES YES YES YES YES YES NO YES YES YES Monthly Maine uses state supp payment data at application, renewal and in post-enrollment. Maine's eligibility system is integrated with state supplement benefits. 6. State General Assistance Programs NO NO NO YES NO NO NO NO NO NO This data is not available electronically. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B1 - Use of Electronic Data Sources, Financial 7

ed red dered red dered Y/N) n) If Data Source Electronic Data Source Determined Useful (Y/N) Accuracy Consider (Y/N) Timeliness Conside (Y/N) Ability to Access Consi (Y/N) Age de of Data Consi (Y/N) Comprehensive Consi (Y/N) Other Criteria Used ( (Please Describe in Comments sectio Data Source Used at Application (Y/N) Data Source Used at Renewal (Y/N) Data Source Used Post- Enrollment (Y/N) Used for Post- Enrollment - Frequency Used (e.g. monthly, Comments quarterly) 7. Supplemental Nutrition Assistance Program (SNAP) Maine's eligibility system is integrated with SNAP. Verified information contained in SNAP records will be used as a data source at intial YES YES YES YES YES YES NO YES YES YES Other (specify in comments) application and renewal. If information received post eligibility indicates disrepancy, follow-up will occur to determine impact, if any, on eligibility. Post-enrollment matches will occur whenever financial information is changed in Maine's eligibility system by another program (e.g., SNAP). 8. Temporary Assistance for Needy Families (TANF) Maine's eligibility system is integrated with the TANF program. Verified information contained in TANF records will be used as a data source at YES YES YES YES YES YES NO YES YES YES Other (specify in comments) intial application and renewal. If information received post eligibility indicates disrepancy, follow-up will occur to determine impact, if any, on eligibility. Post-enrollment matches will occur whenever financial information is changed in Maine's eligibility system by another program. 9. Office of Child Support Enforcement (OCSE) YES YES YES YES YES YES NO YES YES NO 10. State Income Tax NO NO NO YES NO NO NO NO NO NO Not available MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B1 - Use of Electronic Data Sources, Financial 8

Electronic Data Source Determined Useful (Y/N) 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 11. Commercial database: (Pease describe any commercial databases in the space below) The Work Number/Equifax YES YES YES YES YES YES NO YES YES NO Verify Advantage YES YES YES NO NO NO NO YES YES NO Similar to Work number - Maine uses this data source to verify employment/wage information. 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 9

MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Maine Date Submitted: (mm/dd/yyyy) 02/21/2019 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 Maine uses its direct connection to BENDEX to Security Administration verify citizenship, SSN, Age / DOB, Medicare and other benefits. Maine uses this connection (SSA) YES YES YES NO NO YES NO NO NO YES YES NO YES YES YES Monthly to resolve any residency inconsistencies as applicable. Maine uses SSA data at renewal and post-enrollment for Medicare and application for other benefits. 2. Department of Homeland Security (DHS) ­ SAVE YES NO YES YES NO YES NO NO NO NO NO NO YES YES YES Other (specify in comments) Maine uses its web-based connection to SAVE at renewal and post-enrollment for statuses that are subject to change or expire. 3. Vital Statistics YES NO YES NO NO YES NO NO NO NO NO NO YES YES 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 4. Department of Motor Vehicles (DMV) YES NO NO NO YES YES NO YES NO NO NO NO YES YES NO Maine uses DMV information to resolve inconsistencies with residency or household composition. 5. Temporary Assistance for Needy Families (TANF) YES YES YES YES YES YES YES YES YES NO YES NO YES YES YES Other (specify in comments) Maine will use TANF data for SSN verification only if there is an indication that the SSN had been previously verified with SSA. Maine will use TANF data to verify citizenship and/or immigration status if they had been recently verified in accordance with Medicaid/CHIP rules. Maine uses TANF data to resolve inconsistencies with residency, household composition, pregnancy, and caretaker relative, if applicable. Maine uses TANF data on an ad-hoc basis. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B2 - Use of Electronic Data Sources, Non-Financial 11

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 6. Supplemental Nutrition Assistance Program (SNAP) YES YES YES YES YES YES NO YES YES NO YES NO YES YES YES Other (specify in comments) Maine will use SNAP data for SSN verification only if there is an indication that the SSN had been previously verified with SSA. Maine will use SNAP data to verify citizenship and/or immigration status if they had been verified in accordance with Medicaid/CHIP rules. Maine uses SNAP data to resolve inconsistencies with residency, household composition, pregnancy, and caretaker relative, if applicable. Maine uses SNAP data on an ad-hoc basis. 7. Office of Child Support NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Enforcement 8. State General Assistance NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Programs MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B2 - Use of Electronic Data Sources, Non-Financial 12

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 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) 12. PARIS* YES NO NO NO YES NO NO NO NO NO NO YES NO NO YES Quarterly Maine uses PARIS to identify benefits in another state. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B2 - Use of Electronic Data Sources, Non-Financial 13

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) Maine Department of Corrections YES NO NO NO YES NO NO YES NO NO NO YES NO NO YES Other (specify in comments) Maine uses the state's Dept. of Corrections to resolve inconsistencies with residency and household composition. DOC information may also be used to determine incarceration and suspend Medicaid benefits for payments as well. * 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 14

MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Maine Date Submitted: (mm/dd/yyyy) 05/05/2020 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 Source: Maine's eligibility system, HMS. If attestation is inconsistent with source, obtain other coverage verification. NO YES YES YES Must be Applied 2. Applicant does not have access to affordable ESI YES NO NO NO N/A 3. When child has had coverage (as applicable to YES NO NO NO states' waiting period) 4. Access to public employee coverage YES NO NO NO Maine has elected to cover children of state employees. 5a. Waiting period exception #1 (describe): NO YES YES YES Exception reason: Individual who dropped coverage does not reside with the child. Source: Maine's eligibility system. 5b. Waiting period exception #2 (describe): NO NO NO YES Exception reason: Family (employee) pays 50% or more of the cost of the child's coverage. Will try and call the employer first before asking for paper. No electronic data source to obtain this information. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 15

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): NO NO YES NO Exception reason: Family pays over 9.5% of all family income for family coverage (including the child dropped from coverage). Source: Maine's eligibility system. 5d. Waiting period exception #4 (describe): NO NO YES YES Exception reason: The individual had good cause for terminating the insurance coverage. Source: Maine's eligibility system. 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) Child residing in a public institution or in-patient psychiatric facility YES NO NO NO MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibility for Separate CHIP 16

MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: Maine Date Submitted: (mm/dd/yyyy) 05/05/2020 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 and the state plans to use all electronic sources of data currently available. At this time the most cost-effective process is to request paper documentation only when needed to resolve identified discrepancies or in those cases where an electronic source for data does not exist. 2 Please describe how the state uses PARIS? Maine uploads to the PARIS system data files that include information for all persons open to any program within ACES, Maine's eligibility system. Maine receives from PARIS Interstate Match files that include a data match of all records open in Maine and another state. Maine also receives Federal Match files that contains a data match between all records open in Maine and the Federal Defense Payroll. Maine also receives VA Match file that contain a data match of all records open in Maine with records from the Veteran's Administration. 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 17

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. 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 18

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

Section B1. Additional Comments MAGI-BASED ELIGIBILITY VERIFICATION PLAN Additional Comments 20

Section B2. Additional Comments MAGI-BASED ELIGIBILITY VERIFICATION PLAN Additional Comments 21

Section C. Additional Comments MAGI-BASED ELIGIBILITY VERIFICATION PLAN Additional Comments 22