Page 7

REV. MAY 3, 2018 NEBRASKA DEPARTMENT OF MEDICAID ELIGIBILITY MANUAL LETTER #43-2018 HEALTH AND HUMAN SERVICES 477-000-004

Scenario 4: Sophie submitted an initial application for her two children, Scarlett (age 3) and Ben (age 7). The children have no creditable health insurance. Individual self-attestation of income is below the Medicaid MAGI eligibility level and the Data match shows that Sophie’s income is above the Medicaid MAGI eligibility level. o Eligibility level for Scarlett= $2,436 o Eligibility level for Ben= $2,234 o CHIP level= $3,578 o Self-attested current income= $3,400 o IRS data= $3,850 Determination: The reasonable compatibility standard is applied in Scarlett and Ben’s scenario. Paper documentation is required as the self-attested income is not within 10% of the electronic data source. Once verification is received the determination will be made. Scenario 5: James submitted an initial application for Medicaid. James is a single parent to four children. Individual self-attestation of income is above the Medicaid MAGI eligibility level and the data match shows that James’ income is below the Medicaid MAGI eligibility level. o Eligibility level= $1375 o Self-attested current income= $2,450 o IRS data= $1,000 Determination: James is determined ineligible for Medicaid based on his self-attested income and screened for APTC/CSR through the Federally Facilitated Marketplace (FFM). Scenario 6: Kimberly submitted an initial application for Medicaid. Kimberly is a single parent to one child. o Eligibility level= $774 o Self-attested current income= $1,500 o IRS data= $2,000 Determination: Kimberly is determined ineligible for Medicaid based on her self-attestation and the data match over the applicable income standard. Kimberly is screened for APTC/CSR through the FFM. Data Sources and Verifications The following is a listing of some of the most common verification sources. There may be other acceptable sources that are not listed here. A. Age Primary Source Federal Data Hub (Social Security data match), BDE, or SDX.