56.11 Acceptance of attestation52

Notwithstanding any other requirement described in this section to the contrary, when AHS requests tax return data regarding income and family size from the Secretary of the Treasury as described in paragraph 56.01(a) of this section but no such data is returned for an individual, AHS will accept that individual’s attestation of income and family size without further verification for purposes of APTC and CSR eligibility, Inconsistencies (01/01/2026, GCR 25-055) Reasonable compatibility53 For purposes of QHP, information obtained through electronic data sources, other information provided by the individual, or other information in AHS’s records will be considered reasonably compatible with an individual’s attestation when the difference or discrepancy does not impact the eligibility of the individual or the benefits to which the individual may be entitled, including the APTC amount and CSR category. For purposes of Medicaid, income and resource information obtained through an electronic data match shall be considered reasonably compatible with income and resource information provided by or on behalf of an individual if both are either above or at or below the applicable standard or other relevant 52 45 CFR § 155.320(c)(5). 53 42 CFR § 435.952(c); 45 CFR § 155.300(d). Eligibility-and-Enrollment Procedures Part 7 – Page 25 (Sec.57.00, Sub.0) threshold. For eligibility criteria other than income and resources, an individual’s attestation will be considered reasonably compatible with information obtained through electronic data sources, other information provided by the individual, or other information in AHS’s records if the discrepancy does not affect eligibility for a specific Medicaid category. (b) Applicability of reasonable-compatibility procedures. Except as otherwise specified in this rule, the procedures outlined in this section will be used when: Information needed in accordance with §§ 53.00 through 56.00 is not available electronically and establishing a data match would not be effective, considering such factors as the administrative costs associated with establishing and using the data match, compared with the administrative costs associated with relying on paper documentation, and the impact on program integrity in terms of the potential for ineligible individuals to be approved as well as for eligible individuals to be denied coverage; AHS cannot verify information required to determine eligibility for health benefits, including when: (i) Electronic data sources are required but data for individuals relevant to the eligibility determination are not included in such data sources; or (ii) Electronic data from IRS, DHS and SSA are required but it is not reasonably expected that data sources will be available within one day of the initial request to the data source, except that an individual’s attestation of residency or, for purposes of QHP, eligibility for MEC, may be accepted, and the procedures outlined in this section will not be used, when verification of those criteria would otherwise be required and the electronic data to support the attestation are not reasonably expected to be available within one day of the initial request to the data source; or Attested information that would not otherwise be verified is not reasonably compatible with other information that is provided by the application filer or that is otherwise available to AHS. (c) Procedures for determining reasonable compatibility. In circumstances described in paragraph (b) of this section, AHS will: Make a reasonable effort to identify and address the causes of such inconsistency, including through typographical or other clerical errors, such as by contacting the application filer to confirm the accuracy of the information submitted by the application filer, and by allowing the individual, or the application filer on the individual’s behalf, the opportunity to provide AHS with a statement that reasonably explains the discrepancy. If unable to resolve the inconsistency as provided in paragraph (c)(1) of this section: (i) Provide notice to the individual regarding the inconsistency; and (ii) Provide the individual with an opportunity period, as described in this paragraph (c)(2)(ii), from the date on which such notice is sent to the individual to either present satisfactory documentary evidence via the channels available for the submission of an application, (except for by telephone Eligibility-and-Enrollment Procedures Part 7 – Page 26 (Sec.57.00, Sub.0) through a call center), or otherwise resolve the inconsistency.54 If, because of evidence submitted by the individual, one or more requests for additional evidence is necessary, such additional evidence must be submitted by the individual within the same opportunity period that begins with the first verification request. For purposes of QHP, the individual’s opportunity period is 90 days. For purposes of Medicaid, the individual’s opportunity period is as follows: (I) If the individual is a new Medicaid applicant, the opportunity period is 20 days. (II) If the individual is a Medicaid enrollee, the opportunity period is 10 days. Extend the opportunity period described in paragraph (c)(2)(ii) of this section if the individual demonstrates that a good-faith effort has been made to obtain the required documentation during the period. In connection with the verification of an attestation for QHP eligibility: (i) During the opportunity period described in paragraph (c)(2)(ii) of this section: Proceed with all other elements of eligibility determination using the individual’s attestation, and provide eligibility for enrollment in a QHP to the extent that an individual is otherwise qualified; and Ensure that APTC, the Vermont Premium Reduction, and federal and state CSR are provided on behalf of an individual within this period who is otherwise qualified for such payments and reductions, if the tax filer attests that they understand that any APTC paid on their behalf is subject to reconciliation. (ii) After the period described in paragraph (c)(2)(ii) of this section, determine whether the individual is eligible to enroll in a QHP using the information available from the data sources specified above, if any, if AHS remains unable to verify the attestation. AHS will notify the individual of such determination, including notice that AHS is unable to verify the attestation. For an individual determined eligible for enrollment in a QHP who is seeking financial assistance (APTC/CSR): If AHS can determine the individual is not eligible for Medicaid based on available information, determine whether the individual is eligible for APTC, the Vermont Premium Reduction, and federal and state CSR based on the information available from the data sources specified above, and notify the individual of such determination, including notice that AHS is unable to verify the attestation. If AHS cannot determine, based on available information, that the individual is ineligible for Medicaid, deny the application for or terminate the individual’s APTC, Vermont Premium Reduction and federal and state CSR on the basis that there is insufficient information to 54 The opportunity period described in this paragraph (c)(2)(ii) does not apply to an inconsistency related to citizenship or immigration status. For the opportunity period for citizenship and immigration status, see § 54.05(a)(1). Eligibility-and-Enrollment Procedures Part 7 – Page 27 (Sec.57.00, Sub.0) determine the individual’s eligibility for Medicaid.55 If an individual is determined ineligible for financial assistance, the individual would still be eligible for enrollment in a QHP without financial assistance. In connection with the verification of an attestation for Medicaid eligibility: (i) If, after the opportunity period described in paragraph (c)(2)(ii) of this section, the individual has not responded to a request for additional information or has not provided information sufficient to resolve the inconsistency, or AHS otherwise remains unable to verify the attestation, deny the application or disenroll the individual on the basis that there is insufficient information to determine the individual’s eligibility for Medicaid. Medicaid coverage cannot begin for a new Medicaid applicant until verification of the attestation is received, unless the verification is for purposes of establishing citizenship or immigration status as described in § 54.05(b). (ii) If the individual is a new Medicaid applicant and subsequently submits the additional information within 90 days after the date of denial, treat the additional information as a new application and reconsider eligibility without requiring a new application.56 (d) Exception for special circumstances57 Except for an inconsistency related to citizenship or immigration status, AHS will provide an exception, on a case-by-case basis, to accept an individual’s attestation as to the information which cannot otherwise be verified, because such documentation: (i) Does not exist; or (ii) Is not reasonably available. To receive such an exception: (i) The inconsistency must not be able to be otherwise resolved; and (ii) The individual must provide an adequate explanation of the circumstances as to why they cannot obtain the documentation needed to resolve the inconsistency. (e) Pursuit of additional information in cases where verification data are not reasonably compatible with information provided for or on behalf of an individual.58 Eligibility will not be denied or terminated nor benefits 55 It is a condition of eligibility for APTC and CSR that the individual is not eligible for government-sponsored MEC; 26 CFR § 1.36B-2(a)(2). In this case, the individual’s failure to respond to the verification request precludes the determination of this condition of eligibility. 56 42 CFR § 435.907(d)(1)(iii). 57 42 CFR § 435.952(c)(3); 45 CFR § 155.315(g). 58 42 CFR § 435.952(d). Eligibility-and-Enrollment Procedures Part 7 – Page 28 (Sec.58.00, Sub.58.01) reduced for any individual on the basis of verification information received in accordance with this part Seven unless additional information from the individual has been sought in accordance with this section, and proper notice and hearing rights have been provided to the individual. Determination of eligibility for health-benefits programs59 (01/01/2026, GCR 25-055)