Category

Activity / Exclusion

Verification Documentation Accepted

Qualifying Activity

Employment (including in-kind and/or unpaid work)

Appendix A, Page 2 - Medicaid Community Engagement Reporting Log with:

·         Applicable verification (e.g. pay stubs)

Qualifying Activity

Community Service

Appendix A, Page 3 - Community Service / Apprenticeship / Internship/ GED Verification Form

Qualifying Activity

Workforce Training

Appendix A, Page 4 - Work Programs Participation Department of Labor and Industry Form

Qualifying Activity

Education

Appendix A, Page 2 - Medicaid Community Engagement Reporting Log with:

·         Applicable verification (e.g. copy of school schedule or transcript)

Exclusion – Specified Excluded Individual

American Indians and Alaska Natives individuals

Appendix B, Page 2 - Community Engagement Exclusions Summary Form, with one of the options below:

·         Enrollment number

·         Letter from IHS, or

·         Appendix B, Page 3 - General Exclusion Self-Declaration Form*

Exclusion – Specified Excluded Individual

Former foster care children

Appendix B, Page 2 - Community Engagement Exclusions Summary Form and Appendix B, Page 3 - General Exclusion Self-Declaration Form* (DPHHS to verify with CFSD records)

Exclusion – Specified Excluded Individual

Inmate of a public institution

Appendix A, Page 2 - Medicaid Community Engagement Reporting Log with:

·         Facility documentation (e.g. jail or prison records)

Exclusion – Specified Excluded Individual

Medical condition or health needs that impact ability to work or do other community engagement activities (medically frail)

At Application: Appendix A, Page 2 - Medicaid Community Engagement Reporting Log, with one of the options below:

·         Provider documentation, or

·         Appendix B, Page 4 - Medical Condition or Health Needs that Impact Ability to Work or Do Other Community Engagement Activities – Self Declaration Form*

At Redetermination: Appendix A, Page 2 - Medicaid Community Engagement Reporting Log with:

·         Provider documentation (DPHHS to verify with future claims data)

Exclusion – Specified Excluded Individual

Individuals compliant with TANF work requirements and individuals in a SNAP household and subject to SNAP work requirements

N/A – DPHHS to verify using existing data

Exclusion – Specified Excluded Individual

Parent, guardian, caretaker relative, or family caregiver of a dependent child 13 years of age and under or an individual with a disability

Caregiver (dependent child under 14): Appendix B – Page 2 - Community Engagement Exclusions Summary Form and Appendix B, Pages 5-6 - Caregiver Declaration Form*

Caregiver (disabled individual): Appendix B – Page 2 - Community Engagement Exclusions Summary Form and Appendix B, Pages 5-6 - Caregiver Declaration Form* with:

·         Provider or facility documentation of the disability

Exclusion – Specified Excluded Individual

Participant in a drug or alcohol treatment or rehabilitation program

Appendix B – Page 2 - Community Engagement Exclusions Summary Form with:

·         Provider or facility documentation (e.g. enrollment or attendance letter)

Exclusion – Specified Excluded Individual

Pregnant or entitled to postpartum coverage

Appendix B, Page 2 - Community Engagement Exclusions Summary Form with one of the options below:

·         Provider documentation, or

·         Appendix B, Page 3 General Exclusion Self-Declaration Form*

Exclusion – Specified Excluded Individual

Veteran with a disability rated as total

Appendix B – Page 2 - Community Engagement Exclusions Summary Form with:

·         Statement from the VA showing disability rating of 100%

Exclusion – Mandatory Exception

Individual under the age of 19

N/A – Evaluated using existing data sources

Exclusion – Mandatory Exception

Individual entitled to or enrolled in Medicare benefits under Part A or Part B

Appendix B – Page 2 - Community Engagement Exclusions Summary Form with:

·         Letter from SSA or Medicare card

Exclusion – Mandatory Exception

Eligible for Medicaid for any other eligibility group

N/A – Evaluated using existing data sources

Exclusion – Mandatory Exception

Recently incarcerated in the last three months

Appendix B – Page 2 - Community Engagement Exclusions Summary Form with:

·         Facility documentation (e.g. jail or prison records)

Exclusion – Short-Term Hardship Mandatory Exception

Individual receiving inpatient or institutional services

Appendix B – Page 2 - Community Engagement Exclusions Summary Form with:

·         Provider or facility documentation

Exclusion – Short-Term Hardship Mandatory Exception

Living in a county with high unemployment and/or a disaster declaration

N/A – Evaluated using existing data sources

Exclusion – Short-Term Hardship Mandatory Exception

Applicable individual or dependent who must travel outside their community for an extended period to receive medical services necessary to treat a serious or complex medical condition

Appendix B – Page 2 - Community Engagement Exclusions Summary Form with:

·         Provider documentation