DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
 
 
CMCS Informational Bulletin 
 
DATE:   February 21, 2013  
 
FROM:   Cindy Mann, Director 
    Center for Medicaid and CHIP Services  
 
SUBJECT:   MAGI-Based Eligibility Verification Plans  
 
The purpose of this Informational Bulletin is to provide information to state Medicaid and CHIP 
agencies on the verification plans required for both Medicaid and Childrens Health Insurance Program 
(CHIP) eligibility, the MAGI-based (Modified Adjusted Gross Income) Eligibility Verification Plan 
Template, and a review of the final verification regulations.  
 
Verification Plans 
 
Regulations at 42 CFR 435.945(j) and 457.380(j), require state Medicaid and CHIP agencies to develop 
and update as modified, a verification plan describing the verification policies and procedures adopted 
by the agency in accordance with section 435.940-435.965, and section 457.380.  The plan must be 
submitted to the Secretary upon request.   
 
We are approaching the development of the verification plans in two phases.  In Phase I in the spring of 
2013, states will describe their verification policies and procedures only for individuals whose eligibility 
is based on MAGI. In Phase II, CMS will develop a separate verification plan template for states to 
describe the verification policies and procedures for MAGI-excepted populations, including the aged, 
blind and disabled, and individuals needing long-term services and supports, and will include the criteria 
unique to these populations, such as disability status and assets.   
 
At this time, CMS is requesting that state Medicaid and CHIP agencies submit their MAGI-based 
eligibility verification plan by March 20, 2013.  States are at a critical juncture in developing their 
online single streamlined applications, and building or modernizing their eligibility systems to 
implement MAGI rules and facilitate coordination among insurance affordability programs, all of which 
need to incorporate electronic data sources and verification procedures. Therefore, this is an important 
time for states to develop and CMS to review states verification policies and procedures to ensure they 
are in accordance with the regulation. CMS will be available to provide technical assistance to states as 
they develop their verification policies and in completing the verification plan prior to submission to 
CMS and throughout the review process. 
 
MAGI-Based Eligibility Verification Plan Template 
 
To assist states in developing effective verification policies that align with the Affordable Care Act 
goals for a seamless and streamlined system of eligibility determinations, CMS developed a Verification 
Plan Template for MAGI-based eligibility for use by state Medicaid and CHIP agencies. Included are  CMCS Informational Bulletin  Page 2 
instructions for completing the template, and examples of how a reasonable compatibility standard could 
be applied.   
 
States can download a fillable Excel version of the template on the Collaborative Application Lifecycle 
Tool (CALT) at 
https://calt.cms.gov/sf/docman/do/listDocuments/projects.medicaid_state_collaborative_com/docman.ro
ot.verification_plan.template\.  Additionally, a PDF version of the template, the template instructions, 
and examples of reasonable compatibility scenarios can be found at http://www.medicaid.gov/Medicaid-
CHIP-Program-Information/By-Topics/Eligibility/Eligibility.html. 
 
States should use this fillable Excel version to complete and to submit their plan to CMS. The 
instructions tab on the template includes information about how and where to submit the verification 
plan on the CALT.   
 
States may use one template for both Medicaid and separate CHIPs if the verification policies and 
procedures are the same across programs.  The template includes a separate section related to factors of 
eligibility that are specific to separate CHIP programs, but if the verification policies for CHIP are 
substantially different, states should submit a separate verification plan. 
 
Upon completion of the review of the verification plan, CMS will send a letter to states acknowledging 
receipt and providing assessment of states verification plan in accordance with the regulations. 
 
Overview of the Verification Regulations 
 
The verification rules at 435.940-435.965, and 457.380 include requirements to which all state 
verification plans must conform and areas of flexibility in which states may select among different 
options. The March 2012 final rule can be found at http://www.gpo.gov/fdsys/pkg/FR-2012-03-
23/pdf/2012-6560.pdf and the January 2013 proposed rule, which contains rules related to verification 
of citizenship and immigration and for special circumstances, can be found at 
https://s3.amazonaws.com/public-inspection.federalregister.gov/2013-00659.pdf. An April 2012 
webinar providing an overview of the verification rules can be found at http://www.medicaid.gov/State-
Resource-Center/Downloads/4-19-12-Application-Verification-Renewals-Slides.pdf. The regulations at 
435.940-435.965 apply to all Medicaid populations (MAGI and MAGI-excepted):  
 
Self-attestation (435.945, 457.380) 
States can choose to accept self-attestation of the individuals information for all factors of eligibility 
except where otherwise required by law (e.g. citizenship and immigration status).  Self-attestation can 
be accepted from the individual applying, an adult who is in the applicants household, an authorized 
representative, or if the individual is a minor or incapacitated, someone acting responsibly for the 
individual.  States must accept self-attestation of pregnancy unless the state has information that is not 
reasonably compatible with such attestation.  
 
Federal Data Services Hub (435.949, 457.380)  
To the extent that information related to Medicaid or CHIP eligibility is available through the electronic 
data services hub established by the Secretary, states must obtain the information through this data 
services hub. Subject to Secretarial approval and the conditions described in 435.945(k) and 
457.380(i), states can obtain information through a mechanism other than the data services hub.  
 
 
  CMCS Informational Bulletin  Page 3 
Use of Electronic Data Sources (435.940, 435.948, 435.952, 457.380)  
States have some flexibility to decide what data sources they use to verify an individuals information to 
determine eligibility. For verification of financial information, states must verify income information 
with the data sources listed in 435.948. States have the discretion to determine which data sources 
listed in 435.948 are useful for making an eligibility determination, and states may elect to use only 
some of those sources. States may use data sources in addition to those listed 435.948; however, if a 
state does not intend to use any of the data sources listed in 435.948 and wishes to only use data 
sources other than those listed in 435.948, it must receive approval from the Secretary to do so 
(435.948, 435.945(k) and 457.380(i)). 
 
Reasonable Compatibility Standard (435.952, 457.380) 
For all factors of eligibility, states can determine the reasonable compatibility standard they will apply 
when information obtained from a data source is inconsistent with the information provided by or on 
behalf of the individual. Specifically for income, information obtained through an electronic data match 
must be considered reasonably compatible with income information provided by or on behalf of the 
individual if both are either above, at, or below the applicable income standard or other relevant income 
threshold (such as a premium band). In each case, the state must determine eligibility based on that 
information.    
 
Documentation (435.952, 457.380) 
Individuals must not be required to provide additional information or documentation unless information 
cannot be obtained electronically or the information obtained electronically is not reasonably compatible 
with self-attested information (435.952(c)/457.380(f)).  Documentation from individuals is permitted 
only to the extent that establishing a data match would not be effective, considering such factors as: 
 
  Administrative costs related to establishing and using the data match compared to administrative 
costs related to relying on paper documentation. 
  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. 
 
For example, if the state does not accept self-attestation of residency, before requiring the individual to 
provide documentation, the state would need to consider the effectiveness of conducting a match with a 
state database such as the Department of Motor Vehicles, Temporary Assistance for Needy Families 
(TANF) or Supplemental Nutrition Assistance Program (SNAP.) We would not expect a state to utilize 
a data match that requires data elements that cannot be obtained from the information provided on the 
application.  
 
States have the option to first request and accept an explanation from the individual as to why the 
information might not be reasonably compatible, such as a reduction in the number of hours worked, 
before requesting paper documentation.  
 
Citizenship and Immigration Status (435.406, 435.407 435.956, 457.320 and 457.380) 
Effective January 1, 2014, sections 435.949 and 435.956 of the January 2013 proposed rule require 
states to obtain information for verification of citizenship and immigration status through the hub if 
available. Sections 435.406, 435.407 435.956, 457.320 and 457.380 of the January 2013 proposed rule 
outlines a new set of parameters that states must follow when data is not available from the hub or there 
is an inconsistency with the data match. 
  CMCS Informational Bulletin  Page 4 
Social Security Number (435.910, 435.956) 
States must require, as a condition of eligibility, that all individuals (including children) seeking 
Medicaid or CHIP coverage furnish their social security number (SSN).  This requirement does not 
apply to individuals who are not eligible to receive an SSN, individuals who do not have an SSN and 
may only be issued an SSN for a valid non-work reason, or individuals who refuse to obtain an SSN 
because of well-established religious objections. States are required to verify SSNs with the Social 
Security Administration (SSA) through the data services hub. 
 
Social Security Number for non-applicants (435.907) 
Individuals who are not applying for Medicaid or CHIP coverage are not required to provide their SSN.  
An SSN can be requested of a non-applicant if it is clear that providing the SSN is voluntary, that it will 
only be used to determine eligibility or for a purpose directly connected to the State plan and that clear 
notice is provided to individual. 
  
Post-enrollment verification (435.945) 
States have the option to conduct post-enrollment data matches to verify an individuals self-attested 
information or explanations. If a state accepts self-attestation of income, it must conduct post-enrollment 
verification with the electronic data sources it determines useful.  
 
We hope that this information will be helpful. Questions regarding the verification plans may directed to 
Jesse Havens at 410-786-6566 or Jesse.Havens@cms.hhs.gov. States are also encouraged to use their 
monthly Sate Operations and Technical Assistance (SOTA) calls to discuss these issues.