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) YES NO YES N/A N/A YES YES Accept self-attestation unless individual is in the SNAP/TANF files and information within the integrated system (SNAP and TANF) conflicts with application. Reasonable explanation is then requested. For example, if a discrepancy such as a P.O. Box or hospital address is found, then they will use an EDS to investigate further. Electronic data sources may include SSA, SNAP, and/or TANF. If the information that comes back is still questionable, then they will ask for a reasonable explanation or paper documentation. For all other individuals, self-attestation is accepted. Social Security Number ** NO NO YES N/A N/A N/A YES SSA match via Data Services Hub. The agency will not deny or delay services pending issuance or verification of the individual's SSN by SSA or because the individual is not required to obtain a SSN because of ineligibility, eligibility only for non-work reasons or religious objection. Follow-up with applicant if a discrepancy is found. If not resolved through follow-up, paper documentation will be required. Other data sources that may be used at application include SNAP and/or TANF if the SSN on record for those programs has been verified with SSA. 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 SSA data match via Data Services Hub; if SSA cannot validate citizenship to the extent that an applicant has information that can be verified through DHS, DHS data match via Hub. If unable to validate citizenship through SSA or DHS, request and adjudicate other data sources or documentation in accordance with standard Medicaid and CHIP regulations. Follow-up with applicant if a discrepancy is found. If not resolved through follow- up, paper documentation will be required. Will follow the steps outlined in rule. Other data sources that may be used at application may include SNAP, TANF if citizenship has been verified in accordance with Medicaid and CHIP rules and/or State Department of Health - Vital Statistics. Immigration Status ** NO NO YES N/A N/A N/A YES DHS data match via Data Services Hub; if DHS cannot verify immigration status, request and adjudicate documentation in accordance with Medicaid and CHIP standards. Follow-up with applicant if a discrepancy is found. If not resolved through follow- up, paper documentation will be required. Will follow the steps outlined in rule. Other data sources that may be used at time of application include SNAP and/or TANF if immigration status has been verified in accordance with Medicaid and CHIP rules. 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 Accept self-attestation unless information within the integrated system (SNAP and TANF) conflicts with application. Reasonable explanation is then requested. Accept self-attestation unless individual is in the SNAP/TANF files and information within the integrated system (SNAP and TANF) conflicts with application. Reasonable explanation is then requested. For example, if a discrepancy such as a P.O. Box or hospital address is found, then they will use an EDS to investigate further. Electronic data sources may include SNAP, TANF and/or IRS If the information that comes back is still questionable, then they will ask for a reasonable explanation or paper documentation. For all other individuals, self-attestation is accepted. Accept self-attestation of number of unborns at time of application. Pregnancy *** YES NO NO N/A N/A NO NO Individual will be enrolled based on self-attestation of pregnancy and number of unborns with no further verification at the time of application. At post-eligibility , if records from the State's claims processing system indicates the individual is not pregnant, the state will follow-up with the individual and ask for an explanation or documentation. Post-eligibility electronic data sources may include MMIS/SDMED-X. 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 Caretaker Relative YES NO YES N/A N/A YES YES Accept self-attestation unless information within the integrated system (SNAP and TANF) conflicts with application. Reasonable explanation is then requested. Accept self-attestation unless individual is in the SNAP/TANF files and information within the integrated system (SNAP and TANF) conflicts with application. Reasonable explanation is then requested. For example, if a discrepancy such as a P.O. Box or hospital address is found, then they will use an EDS to investigate further. Electronic data sources may include SNAP and/or TANF If the information that comes back is still questionable, then they will ask for a reasonable explanation or paper documentation. For all other individuals, self-attestation is accepted. Medicare NO YES YES N/A N/A YES YES Would seek additional information if needed on a case by case basis. South Dakota will use SSA/CMS data source but will not use data sources from the HUB. Application for Other Benefits YES NO NO N/A N/A NO NO N/A Other: (Please describe any other eligibility factors in the space below) * 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 Both) Medicaid & CHIP State: South Dakota 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 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) YES YES YES YES YES YES NO YES YES NO Used at renewal if consent provided 2. Social Security Administration (SSA) (SSI, Title II) YES YES YES YES YES YES NO YES YES NO State plans on using SSA information provided through the Data Services Hub. The State receives information from SSA through its current agreements that it accesses on a case-by­ case basis but not a regular frequency. See additional comments. 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 3. State Wage Information Collection Agency (SWICA) YES YES YES YES YES YES NO YES YES NO The State Wage Information Collection Agency (SWICA) (JOBS) identifies quarterly wage amounts reported to the State's Department of Labor. JOBS is updated on the 1st of each month and the IEVS target match is updated on the 9th of each month. State accesses these data matches on a case by case basis but not a regular frequency. 4. State Unemployment Compensation YES YES YES YES YES YES YES YES YES NO The State Unemployment Insurance Benefits (UNEM) identifies weekly unemployment insurance benefits paid from the South Dakota Department of Labor. UNEM is updated the 1st of each month and the IEVS target match is updated on the 9th of each month. State accesses these data matches on a case by case basis but not a regular frequency. 5. State Administered Supplementary Payment Program NO YES YES YES YES YES YES NO NO NO Eligibility information gathered for this group of indvidiuals is also gathered through other data sources. 6. State General Assistance Programs NO NO NO NO NO NO NO NO NO NO N/A - South Dakota does not have State General Assistance Programs 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 7. Supplemental Nutrition Assistance Program (SNAP) YES YES YES YES YES YES NO YES YES NO Information from the SNAP and TANF programs is located in the same system as Medical. Information from this system will be used at time of application and post-eligibility. State accesses these data matches on a case by case basis but not a regular frequency. Income data is raw data and not MAGI calculations. 8. Temporary Assistance for Needy Families (TANF) YES YES YES YES YES YES NO YES YES NO Information from the SNAP and TANF programs is located in the same system as Medical. Information from this system will be used at time of application and post-eligibility. State accesses these data matches on a case by case basis but not a regular frequency. Income data is raw data and not MAGI calculations. 9. Office of Child Support Enforcement (OCSE) NO NO NO NO NO NO NO NO NO NO N/A -The State Medicaid agency does not currently have access to financial information from the Division of Child Support. 10. State Income Tax NO NO NO NO NO NO NO NO NO NO N/A - South Dakota does not have a State Income Tax. 11. Commercial database: (Pease describe any commercial databases in the space below) TALX/The Work Number YES YES YES YES YES YES NO YES YES NO State plans on using TALX/The Work Number information provided through the Data Services Hub. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B1 - Use of Electronic Data Sources, Financial 8

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 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 9

MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: South Dakota 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 NO NO State plans on using SSA information provided through the Data Services Hub. The following information is available through the current State SSA agreement: 1) Beneficiary Earnings and Data Exchange (BENDEX) - identifies monthly Medicare premiums Part A/B, age/date of birth, and residency. BENDEX is updated every Monday through Friday and the IEVS targeting match is updated following each BENDX update. 2) State Data Exchange (SDX) identifies age/date of birth. SDX is updated every Monday through Friday and the IEVS target match is updated once a month (usually on the 19th). 3) SVES (State Verification and Exchange System). SVES allows staff to obtain information from SSA regarding Social Security Numbers, Medicare information, citizenship, 40 quarters, residency and age/date of birth. An online verification is received three (3) working days after the SVES request is submitted to SSA. The information received is a "snapshot" of the benefit information as it is the date the information is requires. The data is purged after 45 days of receipt. State accesses these data matches on a case by case basis post-enrollment for Medicare and residency but not a regular frequency 2. Department of Homeland Security (DHS) - SAVE YES NO NO YES NO NO NO NO NO NO NO NO YES NO NO State plans on using DHS information provided through the Data Services Hub. The following information is available through the current State DHS agreement: The Systematic Alien Verification for Entitlements (SAVE) system verifies immigration status of aliens requesting assistance. 3. Vital Statistics YES NO YES NO NO NO NO NO NO NO NO NO YES NO NO Query function in ACCESS to search SD Vital Statistics (Electronic Verification of Vital Events (EVVE) system). 4. Department of The State does not plan on using DMV as the State does not currently have access through DMV for Motor Vehicles NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO verification of applicable eligibility factors (e.g., residency, etc.). (DMV) 5. Temporary Assistance for Needy Families (TANF) YES YES YES YES YES YES NO YES YES NO NO NO YES YES NO Information from the SNAP and TANF programs is located in the same system as Medical. Information from this system will be used at time of application for individuals that are enrolled in these programs and post-eligibility for reported changes. 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 6. Supplemental Nutrition Assistance Program (SNAP) YES YES YES YES YES YES NO YES NO NO NO NO YES YES NO Information from the SNAP and TANF programs is located in the same system as Medical. Information from this system will be used at time of application for individuals that are enrolled in these programs and post-eligibility for reported changes. 7. Office of Child Support Enforcement NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO N/A - The Medicaid agency does not currently have access to non-financial information from the Division of Child Support. 8. State General Assistance Programs NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO N/A - The State of South Dakota does not have State General Assistance Programs. 9. Women, Infants and Children Program (WIC) NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO N/A - The Medicaid agency does not have access to non-financial information from WIC 10. State Income Tax NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO N/A - South Dakota does not have a state income tax. 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 To identify dual state participation and eligibility for federal health insurance benefits. 13. Other: (Please describe additional electronic data sources in the space provided below) HMS (ORFI) YES NO NO NO NO NO NO NO NO NO NO YES NO NO YES Monthly HMS is used to identify enrollment in private health insurance for Targeted Low Income Children. 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 * 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 12

MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) Medicaid & CHIP State: South Dakota 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 South Dakota does not have electronic data sources available at time of application but will use data sources post-enrollment (e.g., HMS and South Dakota Division of Child Support). Follow-up if a discrepancy is found. If not resolved through follow-up, paper documentation will be required. These verification policies and procedures (for questions 1 and 2) also apply to the state Medicaid Expansion program according to title XXI. Questions 3-6 do not apply to the Medicaid Expansion program. No waiting periods would apply to the Medicaid expansion programs. 2. Applicant does not have access to affordable ESI N/A N/A - South Dakota does not use "access to" as an eligibility requirement. 3. When child has had Accept self-attestation but if the application or records from other human services program(s) coverage (as applicable to NO YES YES YES shows a conflict, the state will follow-up with the individual and ask for an explanation or states' waiting period) paper documentation. Data sources may include HMS and SSA Medicare for children with renal. 4. Access to public employee coverage YES NO NO NO 5a. Waiting period exception #1 (describe): NO YES NO YES Cost of the discontinued coverage for the child exceeded 5% of the household income 5b. Waiting period exception #2 (describe): NO YES NO YES Cost of family coverage that includes the child exceeds 9.5% of the household income 5c. Waiting period exception #3 (describe): YES NO NO NO The employer stopped offering coverage of dependents MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibilty 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 5d. Waiting period exception #4 (describe): YES NO NO NO A change in employment, including involuntary separation, resulted in loss of access to employer-sponsored insurance (ESI) (other than through payment of the full premium by the parent under COBRA) 5e. Waiting period exception #5 (describe): YES NO NO NO The child has special health care needs 5f. Waiting period exception #6 (describe): YES NO NO NO The child lost coverage due to the death or divorce of a parent 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) MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION C - Additional Factors of Eligibilty for Separate CHIP 14

MAGI-BASED ELIGIBILITY VERIFICATION PLAN (Insert Medicaid, CHIP, or Both) State: Section D. Additional Verification Questions Medicaid & CHIP South Dakota 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 verfication for many factors of eligibility. State will also utilize SNAP/TANF data when available. For eligibility factors that we do not accept self attestation, we utilize all available electronic data sources, including vital statistics as a back-up for citizenship. If self-attestation is not reasonably compatible with electronic information, staff will first attempt to contact the individual or another person who can verify information for an explanation. If the explanation is not reasonable or staff are not able to contact the individual, paper documentation will be requested. 2 Please describe how the state uses PARIS? To identify dual state participation and eligibility for federal health insurance benefits. PARIS is used quarterly. 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. 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 Section B1. Additional Comments The following information is available through the current State SSA agreement: 1) Beneficiary Earnings and Data Exchange (BENDEX) - identifies monthly Social Security Title II Benefits (OASI, disabled, etc.) and/or Medicare premiums Part A/B. BENDEX is updated every Monday through Friday and the IEVS targeting match is updated following each BNDX update. 2) SDX is updated every Monday through Friday and the IEVS target match is updated once a month (usually on the 19th). 3) SVES (State Verification and Exchange System). SVES is a computerized verification system to request information from the Social Security Administration (SSA). SVES allows staff to obtain information from SSA regarding Social Security Income. An online verification is received three (3) working days after the SVES request is submitted to SSA. The information received is a "snapshot" of the benefit information as it is the date the information is requested. The data is purged after 45 days of receipt. State accesses these data matches on a case by case basis but not a regular frequency. Section B2. Additional Comments Section C. Additional Comments MAGI-BASED ELIGIBILITY VERIFICATION PLAN Additional Comments 17