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DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
Center for Consumer Information & Insurance Oversight 
200 Independence Avenue SW 
Washington, DC  20201 
   
  
Date:   June 18, 2013 
 
From:   Gary Cohen, CMS Deputy Administrator and Director  
Center for Consumer Information and Insurance Oversight  
 
Cindy Mann, CMS Deputy Administrator and Director 
Center for Medicaid and CHIP Services 
 
Subject:  Guidance on State Alternative Applications for Health Coverage  
 
Purpose and Scope of Guidance 
Beginning on October 1, 2013, the new Health Insurance Marketplace, also known as the 
Affordable Insurance Exchanges (Exchanges), and State Medicaid and Childrens Health 
Insurance Program (CHIP) agencies will use a single, streamlined application to determine 
eligibility for enrollment in Qualified Health Plans (QHPs) through the Marketplace, and for 
insurance affordability programs including advance payments of the premium tax credit 
(APTCs), cost-sharing reductions (CSRs), Medicaid, and CHIP.  
   
On April 30, 2013, CMS released the model single, streamlined application for coverage through 
the Marketplace and insurance affordability programs. The model single, streamlined application 
is available for review at http://www.cms.gov.  This application, in both its paper and online 
versions, will be the sole application used by the Federally-facilitated Marketplace to facilitate 
eligibility determinations and enrollment in health coverage.  State-based Marketplaces, as well 
as Medicaid and CHIP agencies, may choose to use the model single, streamlined application, or 
may develop an alternative single, streamlined application that is approved by CMS.  In States 
utilizing the Federally-facilitated Marketplace, the Medicaid and/or CHIP agency may develop 
an alternative application, but the Medicaid and/or CHIP agency must still be able to accept and 
process the paper version of the model single, streamlined application if an applicant for 
coverage submits it.  This guidance is intended to provide background on the development, 
review and approval of alternative applications.  
 
Designing an Alternative Application 
States may submit for approval an alternative application that can be tailored to accommodate 
state preferences and policies, while also reflecting the general principles of the model 
application and complying with the applicable provision of law, as described below.  This 
section outlines the parameters for creating an alternative application and also identifies areas 
where a formal approval of modifications to the model application is not needed. 
 
 
 
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General Principles 
States must adhere to regulations implementing the Affordable Care Act in the area of 
applications, eligibility standards, verifications, determinations, and coordination in developing 
alternative applications.  States should be guided by the model application and CMS expects 
State-based Marketplaces, Medicaid and CHIP agencies to collaborate in the development of 
alternative applications to the maximum extent possible (see specifically, 42 CFR 435.907, 
435.911, 435.945-435.956 and 435.1200, 457.330-457.380, and 45 CFR 155.300-155.320 and 
155.405).  Some examples of the aspects of the application that are minimally required for 
alternative application approval include: 
 
1.  An alternative application must request information necessary for determining eligibility for 
coverage in a Qualified Health Plan (QHP) and all insurance affordability programs. The 
law requires that one application be used for all programs under the Affordable Care Act to 
ensure a proper adjudication of eligibility, minimize burden on applicants who may not know 
which program they are eligible for and allow households with members eligible for different 
programs to apply using a single application. States must include all questions that will help 
the relevant entity or entities determine whether an applicant is potentially eligible for 
coverage through a QHP and any insurance affordability program, even if the agency making 
available the application will not be the entity processing certain portions of the application.  
For example, Medicaid and CHIP agencies must include questions about access to employer-
sponsored health coverage on their paper applications, though the responses may not affect 
eligibility for Medicaid or CHIP coverage.  On an online application, system logic should 
trigger these questions to appear only when an applicant does not appear eligible for 
Medicaid and CHIP based on their attestations.  It is important to note, too, that Medicaid 
and CHIP agencies do not need to ask questions related to QHP enrollment such as Special 
Enrollment Periods or tobacco use. 
 
Likewise, because an individual cannot be eligible for APTC if he or she is eligible for 
Medicaid or CHIP, a State-based Marketplace must ask applicants to provide answers to 
questions relating to Medicaid eligibility.  Additionally, states must include non-MAGI 
screening questions related to disability and long-term care needs, though states may seek to 
adjust these questions to more specifically fit the non-MAGI standards in that state. 
 
2.  States must only ask questions that are necessary for determining eligibility for coverage in a 
Qualified Health Plan (QHP) and all insurance affordability programs, or for the 
administration of these programs.  Questions that are not essential to these purposes or 
programs cannot be required.  For example, in accordance with 42 CFR 435.907, states may 
not request citizenship and immigration information from non-applicants, or individuals 
who are identified on an application of an individual who is applying for coverage but who 
are themselves not applying for coverage.  Requests for Social Security Numbers of non-
applicants must be optional.  Please see page 5 for information on multi-benefit applications. 
 
3.  Requests for information from application filers should minimize the burden on the applying 
household.  For State-based Marketplaces, this includes providing two paths in the application 
such that individuals who opt to not receive financial assistance do not need to answer 
financial assistance questions.  For example, online applications must be structured in a 
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dynamic manner, so that questions that are specific to an insurance affordability program are 
only asked of individuals who appear eligible for that program.  These program-specific 
questions are outlined in sections XII and XIII of the online application questionnaire which 
can be found at https://calt.cms.gov/sf/go/doc28817?nav=1.  Also, a State-based Marketplace 
must provide an opportunity for individuals to opt to not receive financial assistance and 
apply for coverage in a QHP without requesting information on income or other criteria 
related only to insurance affordability programs.  In addition, when questions only apply to 
certain age groups or genders, states should ask them on online applications only when they 
are relevant. On paper applications, threshold questions which lead to appendices are one 
approach to streamline forms and minimize burden.  
  
4.  In accordance with the regulations on the use of the Federal Data Services Hub and other 
electronic data sources, states must first rely on available electronic data sources and should 
request paper documentation only when electronic data is insufficient or inconsistent. The 
state may only request paper documentation when an individuals attestation conflicts with 
electronic data, or when there is no electronic data available to verify an individuals 
attestation.  (See 42 CFR 435.945-435.956 and 457.330-457.380, and 45 CFR 155.315)  
 
Customizing the Model Application (No Approval Required)  
There are a number of ways that a state may adapt the model application without need for 
formal approval from CMS as an alternative application.  These include:   
 
1.  Adding the state Marketplace, Medicaid, and CHIP agency or program names and contact 
information to the application.  It is important that the states application provide the 
appropriate contact information for applicants to mail the paper application, contact the 
applicable call center, and access online help tools.   
 
2.  Changing the colors, logos, icons, and pictures on the model application to reflect branding 
appropriate for that state.  This includes removing CMS logos from the application.  
 
3.  Eliminating questions that are not relevant to the states eligibility rules.  The model online 
application includes some questions that are not relevant to all states.  For example, a state 
that does not take 40 work quarters into consideration for status as a qualified non-citizen 
does not need to include the associated question from the model application.  This same 
principle applies to the paper application. 
 
4.  If the state has additional income or other verification data sources outside of those received 
from the Federal Data Services Hub that can be used to pre-populate the current income 
section of the online application, those sources may be included as part of the application 
process without formal approval.  States may adjust the income section of the application to 
account for the data sources and verification criteria to be used by the state.  For example, if a 
state Medicaid or CHIP agency will not be using or storing federal tax information (FTI), 
then the state would not include the expedited income section as it exists in the model 
online application.  However, state Medicaid and CHIP agencies will still need to request 
attestations of annual income on the application in order to determine potential eligibility for 
APTC. 
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5.  Adding language to the privacy statement or rights and responsibilities section of the 
application, if required by state law or regulation. 
 
6.  Changing the placement and order of questions regarding contact information for the 
household, and removal of the question about text messaging if the state does not plan to 
send text messages to individuals. 
 
Modifications that Minimize Consumer Burden (No Approval Required) 
States may add or change the model application questions so that their application reflects the 
eligibility policies in place in the state.  Formal approval from CMS is not required for these 
changes if they do not add burden on the consumer.  Examples of these types of acceptable 
modifications include:  
 
1.  The removal of questions when a state elects to address an issue post-eligibility.  States may 
also tailor questions to make them more state-specific, such as including the state definition 
of temporary in the question regarding residency or the state definition of full-time 
student in the question about student status. 
 
2.  Changing the order of questions, as long as the change does not impede the online 
applications dynamic nature.   For example, a state could change the order of income 
questions within the income section, but must collect full income and household information 
early enough in the application so that only questions applicable to the relevant insurance 
affordability program or programs are asked (see item 3 in the General Principles section, 
above). 
 
3.  When needed to complete a MAGI-based eligibility determination, states may add questions 
relating to a state option that is not supported in the Federally-facilitated Marketplaces 
eligibility assessment or determination logic.  This may include questions relating to family 
planning, state-only funded eligibility groups, state premium assistance programs, and 
exceptions to waiting periods for CHIP coverage.   
 
4.  Making the application more dynamic to adapt to the states cascade of Medicaid eligibility 
categories.    
 
Development and Approval of Alternative Applications  Modifications that Require CMS 
Approval 
If your states application differs from the model application in ways other than those described 
in the previous sections (which do not require CMS approval), CMS will review these changes to 
ensure that the states application is consistent with the applicable statute and regulations, and 
maintains the principle of minimizing burden on the consumer.  Some examples of changes that 
would require approval include: 
 
1.  A different implementation of the option to consider reasonably predictable future changes in 
income. 
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2.  A different mechanism to determine whether dependents and children have federal income 
tax filing requirements. 
 
3.  Different reasonable explanation questions for addressing inconsistencies between income 
or household size information provided on the application and information from with 
electronic data sources used for verification. 
 
4.  A different approach to the timing of checking electronic data sources, e.g., at the end of the 
application after all questions have been asked, rather than verifying with electronic data 
sources as questions are asked at earlier points in the application process.  In this situation, a 
state may be considering eliminating questions that CMS has included based on data 
matching, including the questions soliciting reasonable explanations for discrepancies with 
income data and the expedited income section. 
 
5.  The addition of questions related to eligibility for Medicaid on a basis other than MAGI.  
Please see information further below on the use of a supplemental form for non-MAGI 
Medicaid questions.     
 
Special Considerations for Multi-benefit Applications  
Many states have expressed interest in using a multi-benefit human services application as the 
base for their alternative application.  This approach is acceptable if the application collects 
sufficient information to determine MAGI-based eligibility for all insurance affordability 
programs.  These applications include questions related to other benefit programs, such as the 
Supplemental Nutrition Assistance Program (SNAP).  These types of questions may be included 
on a single streamlined application, as long as the state clearly indicates the additional questions 
are optional, or not required for submission, and therefore do not serve as a barrier to the MAGI 
determination.  States may not deny or delay eligibility for an insurance affordability program 
due to missing or unverified information pertaining only to a non-health program.   States that 
elect to make available a multi-benefit application must also ensure the opportunity for an 
applicant to file a health coverage-only application. 
 
Non-MAGI Based Medicaid Applications  
For individuals seeking Medicaid eligibility on a basis other than MAGI, states may use a 
combination of the model single, streamlined application (or a CMS-approved single, 
streamlined application) and supplemental forms to collect the information needed to determine 
eligibility, or states may use a completely separate application designed specifically for this 
population.  If a state chooses to ask non-MAGI questions through a separate supplemental form, 
or through a completely separate application, these materials should be submitted to CMS in 
accordance with 42 CFR 435.907, but do not require CMS approval prior to use. 
 
Medicaid agencies seeking to incorporate non-MAGI related questions in their alternative 
application must ensure that these questions do not add burden on the consumer completing the 
application.  In an online application, these questions should only be asked of individuals who 
are potentially eligible for Medicaid on a basis other than MAGI, such as when the applicant 
answers affirmatively to one of the non-MAGI screening questions.  On a paper application, the 
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state must clearly indicate that these questions are optional and are posed to the applicant only if 
relevant.  Under both formats, the MAGI-based eligibility determination must not be delayed 
while information is collected to make the non-MAGI eligibility determination. 
 
Process for Submission and Approval of Alternative Applications  
Starting this year, for State-based Marketplaces, the states submission of its Marketplace 
Blueprint application will indicate the states intent to use either the model single, streamlined 
application or a CMS-approved alternative application.  As part of the Blueprint application, the 
State-based Marketplace should submit the material described below for CMS review and 
approval.  For State-based Marketplace states that develop an alternative application, decisions 
pertaining to the approval of the states application will be conferred by the Center for Consumer 
Information and Insurance Oversight (CCIIO).  CMS is committed to providing states with a 
coordinated, streamlined review process and CCIIO will conduct its review of State-based 
Marketplace alternative applications in close consultation with the Center for Medicaid and 
CHIP Services. 
 
For Medicaid and CHIP agencies, the review and approval of alternative applications will be 
through the State Plan Amendment (SPA) process.  CMS will soon be releasing SPA pages to 
assist states in indicating their decision to use the model single, streamlined application or an 
alternative application.  The approval of alternative applications will occur within the timeframes 
required by the SPA process, but CMS will make every effort to expedite technical assistance 
and requests for additional information so that states have time to implement changes and reach 
resolution.  For Medicaid/CHIP agencies that develop an alternative application, decisions 
pertaining to the approval of the states application will be conferred by the Center for Medicaid 
and CHIP Services (CMCS).  Likewise, CMCS will conduct its review of Medicaid and/or 
CHIP-developed alternative applications in close consultation with CCIIO. 
 
For the paper application, states should submit a full copy of the proposed alternative form and 
any accompanying supplements and instructions which relate to a MAGI-based determination.  
For the online application, the state may submit 1) a questionnaire document in a format similar 
to the model application online questionnaire; 2) a packet of screenshots depicting the screens a 
family completing the alternative application would see, and/or 3) a flow chart demonstrating the 
logic that takes applicants between sections and questions on the online application.  CMS may 
also request an interactive demonstration of the proposed online application.   
 
States should also provide an analysis document that identifies and describes key differences 
between the model application and the states alternative application, in terms of the 
modifications that require CMS approval.  Differences that do not require CMS approval do not 
need to be included in this document, but would be helpful to note and may expedite the review 
process.  States using a common IT vendor to develop their core application can submit one 
analysis document for the vendor-developed core application, along with a state-specific analysis 
describing only the state-specific modifications made, or proposed, to the core application that 
represents differences from the model application.  Upon receipt of a submission, CMS will 
contact the state to confirm receipt, and conduct its review. 
 
Approval of Alternative Applications for Coverage Year 2014 
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CMS recognizes that a unique set of circumstances exist for State-based Marketplaces, as well as 
Medicaid and CHIP agencies, who are implementing applications for coverage beginning on 
January 1, 2014.  Specifically, we are aware of the challenges posed by the amount of 
development work that states had completed on their applications and eligibility systems prior to 
the release of the model application and the release of this guidance. CMS may offer an 
expedited approval process, as necessary, for states and CMS will allow for conditional approval 
of an alternative application for 2014. 
 
In order to receive conditional approval of an alternative application, a state must: 1) attest that 
the application meets, or will meet by a certain date, all applicable regulatory requirements 
described in the General Principles section of this document; 2) attest that the design of the 
states application took into consideration, or aligns with, the proposed model single, streamlined 
application released on January 29, 2013; and 3) provide the material described in the section 
above, Process for Submissions of Alternative Applications, for CMS review.  A state must 
also submit a proposed timeline towards addressing any recommendations identified through 
CMS review. 
 
In order to receive full approval from CMS, a state must demonstrate that all applicable 
regulatory requirements are met by doing the following: 1) modifying its application based on 
recommendations identified by CMS review, or modifying its application to align with the 
model application.  This includes modifications to core application functionality that is shared 
across multiple states, through the use of a common IT vendor.  CMS will evaluate the States 
proposed timeline for such modifications and will arrive at an agreed-upon timeline between 
CMS and the state; 2) subsequently submitting evidence of the modifications, or submitting 
evidence indicating alignment with the model application, for CMS review.  This evidence can 
be submitted as part of regular or ad-hoc reviews conducted by CMS (e.g., Exchange Life Cycle 
Reviews, Gate Reviews, Design Reviews, and/or Implementation Reviews). 
 
States intending to implement alternative applications for coverage year 2014 may begin 
requesting CMS approval upon the release of this guidance, and will need to receive full 
approval of their applications in 2014.  CMS will make every effort to work with states in 
achieving conditional or full approval to states in as timely a manner as possible. 
 
Technical Assistance 
CMS is committed to providing states with a coordinated technical assistance process to states in 
their development of alternative applications.  CMS remains available to provide technical 
assistance to states to facilitate adoption of the model application, in their development of 
alternative applications.  CMS staff is available to review draft materials, participate in 
discussions and to join interactive demonstrations with states.  Questions from Medicaid and 
CHIP agencies regarding this guidance can be directed to Anne Marie Costello, Director of the 
Division of Eligibility, Enrollment and Outreach at CMCS at 410-786-5175.  Questions from 
State-based Marketplaces regarding this guidance can be directed to Hilary Dalin, Director of the 
State Technical Assistance Division, State Exchange Group at CCIIO at 301-492-4343, or Jenny 
Chen in the State Exchange Group at CCIIO at 301-492-5156.