CMS-10877 Eligibility Results Toolkit

OMB Control #: 0938-NEW
Expiration Date: XX/XX/20XX
Eligibility Results Toolkit - Phase 1
Purpose of This Toolkit
This document is designed to help Enhanced Direct Enrollment (EDE) Auditors ensure that the application returns accurate eligibility results for specific consumer scenarios. Each test case is
phase-specific, and describes a consumer scenario that must be supported by an EDE application. Auditors should complete each test case by using the information provided to complete an
application through the EDE Entity's user interface (UI). Some information collected by the UI (e.g., phone numbers, contact method preferences, language preferences) is not specified in the
test data. In these cases, Auditors may enter any value or skip optional inputs unless otherwise noted in the test case. The application must display all appropriate application questions to the
Auditor and provide the opportunity to enter the test case information into the application. After all of the information from the test case is entered into the application and the application is
submitted, the Auditor must verify that the eligibility results returned match the expected eligibility results provided in the test case, which is reflected in the Marketplace Eligibility
Determination Notice (EDN) and should be correctly conveyed in the entity's Eligibility Results Page (ERP).
Documentation Requirements
Phase 1 Entities must submit complete eligibility application UI screenshots, EDNs, and unparsed JSONs for all test cases it completes in the Phase 1 Eligibility Results Toolkit (ERT). In test cases
for which an EDN is not generated, but is expected, Auditors must repeat the test case. If the test case ends after the screening questions (i.e., if the consumer is not eligible to use a Phase 1 or
Phase 2 EDE pathway, the consumer must be guided to an alternate pathway), the Auditor will not provide a screenshot of the EDN, but must still provide screenshots showing the application
questions asked from the start of the application through the end of the test case (i.e., the redirect to the alternate pathway). Please review row 15 of this tab for more information about
naming files.
Required Completion Rate
Auditors must conduct all possible test cases. However, depending on the Entity's intended service areas, Auditors may not be able to conduct a test case because the Entity does not intend to
operate in the specific state(s) provided in the test case. Auditors must conduct a minimum number of test cases from each toolkit it completes. Auditors conducting Phase 1 audits must
submit at least 11 of 14 Phase 1 test cases. Auditors conducting Phase 2 audits must submit at least 8 of 14 Phase 1 test cases AND 6 of 9 Phase 2 test cases. Auditors conducting Phase 3 audits
must submit at least 8 of 14 Phase 1 test cases AND 5 of 9 Phase 2 test cases AND 7 of 9 Phase 3 test cases. If an Auditor is not able to conduct the minimum number of test cases for each
toolkit because of the Entity's planned service areas, it must email DE Support to request instructions to modify test cases so that the Auditor is able to conduct and submit the minimum
number of test cases.
Note:
Each phase-specific set of eligibility results test scenarios are contained within separate toolkits (e.g., there is a Eligibility Results Toolkit specific to Phase 3).
Note on Version
It is important to note that this document is subject to change.
Navigating Updates to the Toolkit
Different font colors are used to indicate when the content of a cell was last updated. Use the key below to navigate updates to the content of these tabs.
Black font: Original value
Tab
Phase 1

Tabs for Auditor Review
Description
How to Review
This tab displays an overview of the test scenarios for The Auditor will use this tab to track compliance with each eligibility result test
the Phase 1 eligibility application.
scenario defined in the subsequent tabs. The Auditor must carefully examine the
"Eligibility Results" section of each "Test Case" input tab prior to confirming the
EDE Entity's compliance with each test case.
Note: Auditors for Phase 1 EDE applications must complete all Phase 1 test case
scenarios, if possible. If an entity does not intend to operate in the specific
state(s) provided in the test case, Auditors must submit at least 11 of 14 Phase 1
test cases.

Phase 2 (different toolkit)

This tab displays an overview of the test scenarios for The Auditor will use this tab to track compliance with each eligibility result test
scenario defined in the subsequent tabs. The Auditor must carefully examine the
the Phase 2 eligibility application.
"Eligibility Results" section of each "Test Case" input tab prior to confirming the
EDE Entity's compliance with each test case.
Note: Auditors for Phase 2 EDE applications must complete all Phase 2 test case
scenarios, as well as the following test cases from Phase 1: 1.A, 1.B, 1.C, 1.D, 1.E,
1.F, 1.K, 1.L, 1.M, 1.N, 1.O (not 1.D.2, 1.H, 1.J which are Phase 1 only test cases), if
possible. If an entity does not intend to operate in the specific state(s) provided in
the test case, Auditors must submit at least 8 of 14 Phase 1 test cases AND 6 of 9
Phase 2 test cases. Note that because Phase 2 supports more consumer scenarios
than Phase 1, some information that is gathered via screening question for a
Phase 1 application is asked as an application question for a Phase 2 application.
For instance, pregnancy status is included in Phase 1 screening questions, but will
be included as an application question in Phase 2 applications.

PRA DISCLOSURE: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-NEW, expiration date is XX/XX/20XX. The time required to complete this information collection is
estimated to take up to 56,290 hours annually for all direct enrollment entities. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure****
Please do not send applications, claims, payments, medical records or any documents containing sensitive information to
the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection
burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or
retained. If you have questions or concerns regarding where to submit your documents, please contact Brittany Cain at
Brittany.Cain@cms.hhs.gov.

Phase 3 (different toolkit)

This tab displays an overview of the test scenarios for The Auditor will use this tab to track compliance with each eligibility result test
the Phase 3 eligibility application.
scenario defined in the subsequent tabs. The Auditor must carefully examine the
"Eligibility Results" section of each "Test Case" input tab prior to confirming the
EDE Entity's compliance with each test case.
Note: Auditors for Phase 3 EDE applications must complete all Phase 3 test case
scenarios, as well as the following test cases from Phase 1 and Phase 2: 1.A, 1.B,
1.C, 1.D, 1.E, 1.F, 1.K, 1.L, 1.M, 1.N, 1.O (not 1.D.2, 1.H, 1.J which are Phase 1 only
test cases) and 2.A, 2.B, 2.B.2, 2.D, 2.E, 2.E.2, 2.F and 2.G (not 2.H which is a Phase
2 only test case), if possible. If an entity does not intend to operate in the specific
state(s) provided in the test case, Auditors must submit at least 8 of 14 Phase 1
test cases AND 5 of 9 Phase 2 test cases AND 7 of 9 Phase 3 test cases. Note that
because Phase 3 supports all consumer scenarios, Phase 3 does not have
screening questions. Therefore, information that is gathered via screening
question for a Phase 1 or Phase 2 application is asked as an application question
for a Phase 3 application. For instance, American Indian or Alaska Native status is
included in Phase 1 and 2 screening questions, but will be included as an
application question in Phase 3 applications.

Test Case Input Tabs (e.g., Test Case 1.A input, Test
Case 1.B input)

Each test case input tab details the eligibility
application answers to test the eligibility
determination through the EDE pathway.

Auditors should use each tab to complete an eligibility application with the
answers detailed in the tab. Upon receiving an eligibility determination through
the EDE Pathway, the Auditor should confirm that the eligibility results from the
EDE Pathway are identical to the "Eligibility Result" included at the end of each
test case. The Auditor must take screenshots of the eligibility application process
while progressing through the test case, including a screenshot of the ERP, and
also store the EDN and provide the EDN to CMS (if applicable). The Auditor must
also submit the Get App API response (JSON) from each test case. The Auditor
should name the screenshot files sequentially and clearly identify them as
belonging to a specific test case (e.g., TestCase1A-1, TestCase1A-2). Similarly, the
Auditor should name the JSON files to clearly identify them as belonging to a
specific test case (e.g., TestCase1A-JSON). CMS strongly recommends that
Auditors sequentially aggregate the screenshots in a single document for each
test case (e.g., a Microsoft Word, PowerPoint, or PDF document with each image
labelled “TestCase1-A”) instead of submitting each screenshot as an individually
saved image (e.g., TestCase1A-1.jpg, TestCase1A-2.jpg). This may help expedite
CMS’s audit review.

Audit Requirements by Tab
Tab: Phase 1
In this tab, the Auditor must scroll to the right to complete the last six columns whose column headings are shaded in yellow or marked with "**."
Columns
Test Case ID

Description
Test Case ID that corresponds to each input tab.

State

List of state(s) for testing that corresponds to each
input tab.

Summary/Criteria
Expected Results/What's Tested

Summary of test data for each test case.
Summary of tested functionalities and expected
results for each test case.

Test Scenario Description

Summary description of the test case.

How to Review
The Auditor must match the Test Case ID in the "Phase 1" tab to the
corresponding Test Case ID input tab, and use information from both tabs to
complete the audit.
The Auditor must use an approved state (i.e., the state or one of the states
provided for each test case) to complete each test case.
The Auditor may use this summary information to inform the audit.
As stated above, the Auditor must carefully examine the "Eligibility Results"
section of each "Test Case" input tab prior to confirming the EDE Entity's
compliance with each test case.
The Auditor may use this summary information to inform the audit.

Auditor Compliance Conclusion**

The Auditor must provide a conclusion as to whether
the scenario or requirement defined in each row is
compliant with the CMS requirements. A compliance
conclusion should be indicated as "Yes" or "No."

The Auditor will use the test case eligibility details from the Test Case input tabs
to complete the EDE Entity's eligibility application. Upon completing the eligibility
application, the Auditor will verify that the eligibility results on the EDE Entity's
website match the eligibility results defined at the end of each Test Case input
tab. The Auditor will document each screen within the eligibility application with
screenshots and store the EDN and provide the EDN to CMS, unless the test case
ends after the screener questions, which is clearly marked in each input tab. For
each test case, the Auditor must provide the raw JSON from the Get App API
response for the application version used to complete the scenario.
There are several required fields in each cell within this column:
- The first required field in each cell is, "Eligibility results compliance conclusion:
_____." If the test case is compliant, and matches the eligibility results expected
for the test case, the Auditor must indicate "Yes" in this column. If the row is not
compliant, the Auditor must indicate the noncompliance with a "No" in this
column.
-The subsequent required fields in each cell refer to the "Auditor Checklist"
column and include the item number from the Application UI Toolkit, and the row
number from the test case. For example, the first item in row 33 of the 1.A Check
List is "Check Items 128-130: Verify that Race and Ethnicity questions are optional
to answer for all household members." After the Auditor verifies this checklist
item, the Auditor must document its compliance determination in the
corresponding field in the "Auditor Compliance Conclusion" column in the "Phase
1" tab, "Auditor checklist Items 128-130/row 33 compliance conclusion:_____"

As the Auditor reviews each test case in its entirety, the Auditor must indicate any
compliance risks identified in this column. This includes any compliance risks that
the EDE Entity has since resolved and come into compliance. One example finding
is the Auditor could not input all of the test data because UI questions were
missing. Another example is if the eligibility result was correct, but the Auditor
found that the Entity's UI did not seem to follow the test data inputs or display
correct questions.

Risks Identified**

The Auditor must detail any compliance risks
identified during the audit in this column for each
applicable row. Use this column if the Compliance
Conclusion was “No” or if the entity resolved a risk
prior to audit submission. There are two types of
risks: resolved and unresolved. Please document
them both here. Do not document a risk if the
requirement is compliant and there was no mitigation
required.

Risk Level**

Auditors must assign a risk level to each risk it
identifies.

Risk Mitigation Strategy**

Auditors must explain how a risk(s) was mitigated. For
example, if the entity had non-compliant question
text, the Auditor must identify that as a risk and list
the specific language used as well as how the issue
was resolved. This field is required for high-risk
findings. The Auditor can work with the EDE Entity to
decide on whether or not to include this for low-risk
findings.

Estimated Resolution Date**

Auditors must provide a timeframe for risk resolution CMS recommends Auditors work with the EDE Entity to provide a realistic
(required for unresolved high-risk findings).
timeframe of when a risk will be closed or mitigated given other dependencies
and their expertise.

Auditor Comments**

Auditors must use the Auditor comments column for
any additional notes or comments pertaining to each
item. The Auditor must use this column to include the
applicable screenshot file or folder names that show
proof of compliance (or non-compliance) for this
requirement.

The Auditor must assign a risk level of "high" or "low" to each risk. High-risk issues
may impact a consumer’s eligibility determination, enrollment disposition or
status, or legal attestation. High-risk issues may also greatly hinder the consumer
experience or impact data collection (e.g., skipping a question that is required for
CMS will take the risk level assigned by the Auditor
into consideration when reviewing the audit, but may a EDE Entity to ask, but optional for the consumer to answer).
Low-risk issues are unlikely to affect a consumer’s eligibility determination,
adjust it if necessary.
enrollment disposition or status, legal attestation, experience (i.e., in a negative or
confusing way), or data collection. Note: These risk determinations are applicable
for the business audit only and not the privacy and security audit.

As the Auditor identifies compliance risks, the Auditor and EDE Entity will identify
a mitigation strategy that will mitigate or eliminate the compliance risk. The
Auditor must document that mitigation strategy here. This includes documenting
the mitigation strategy for any identified risk that the EDE Entity has
resolved. One example is, if the initial test did not produce the expected eligibility
results (which would be an identified risk), the EDE Entity made a system or UI
change to correct the issue to produce the correct eligibility result.

For instructions on how to properly document supplemental documentation see
the Enhanced Direct Enrollment (EDE) Business Audit Instructions and Report
Template.
The Auditor can also use this column to provide any additional notes or
comments pertaining to each item. Business requirements audits should not
include comments that describe the Auditor’s process for verifying the
requirement unless there is a specific issue or concern regarding the requirement
that warrants raising a concern.

Tab: Test Case Input
Note: Not all columns are present in all test case tabs.
Columns & Sections
Summary
UI Question Companion Guide Reference

Description
A high-level summary of the test case.
Item numbers from the UI Question Companion
Guide so the Auditor can easily refer back to
requirements.

Testing Notes
The Auditor should note this column does not provide an exhaustive list of item
numbers for each test case and is not intended for audit purposes. It is a tool to
better understand question display requirements by providing an easily accessible
reference to detailed information in the UI Question Companion Guide.

Application Data

The question, group of questions/application section,
or eligibility result.

Application Input

Test data for the consumer(s) in each test case (i.e.,
test data the EDE Entity and Auditor use to answer
questions in the eligibility application).

Notes to Testers

Additional notes to complete each test case and
provide additional information for the Auditor about
what should or should not appear in the UI.

Auditor Checklist

The Auditor is required to verify all checklist items and include it's compliance
Each case has 1-7 checklist items for the Auditor to
determination for each checklist item in the corresponding field in the "Auditor
use when going through the test case to ensure
correct implementation. The Auditor must review and Compliance Conclusion" column in the "Phase" tab.
verify each checklist item.

Application State & Coverage Year

This section provides the state and required ZIP Code Some test scenarios require the use of specific application states or ZIP Codes. In
(if any) and coverage year for each test case.
the event an EDE Entity does not support an application state listed in the test
scenario, the Auditor may omit that test case.
Required Completion Rate (Reminder)
Auditors must conduct all possible test cases. However, depending on the entity's
intended service areas, Auditors may not be able to conduct a test case because
the entity does not intend to operate in the specific state(s) provided in the test
case. Auditors must conduct a minimum number of test cases from each toolkit it
completes. Auditors conducting Phase 1 audits must submit at least 11 of 14
Phase 1 test cases. Auditors conducting Phase 2 audits must submit at least 8 of
14 Phase 1 test cases AND 6 of 9 Phase 2 test cases. Auditors conducting Phase 3
audits must submit at least 8 of 14 Phase 1 test cases AND 5 of 9 Phase 2 test
cases AND 7 of 9 Phase 3 test cases. If an Auditor is not able to conduct the
minimum number of test cases for each toolkit because of the entity's planned
service areas, it must email DE Support to request instructions to modify test
cases so that the Auditor is able to conduct and submit the minimum number of
test cases.

Screening Questions

This section provides the screener questions and
answers for each test case that determine if
consumer(s) can use a certain phase of EDE.

Screening Pass/Fail

This section describes and explains if the test
consumer(s) may continue the application or if the
test consumer must be guided to an alternate
pathway because the consumer is not eligible for this
phase of EDE.

Household Member Input

Test data for each consumer in the test case.

Household

This section provides the household composition
information such as relationships, whether household
members are applicants/non-applicants, Social
Security Numbers (SSNs), and citizenship/immigration
information.

More About This Household

This section provides information for answering the
Non-MAGI Medicaid eligibility questions (physical
disabilities, assistance with daily living, nursing home
care).

Medicaid Block

This section provides information for answering the
questions about Medicaid denial or Medicaid ending
due to a change in eligibility.

Income

This section provides each household member's
current income, deductions, annual income, and
income discrepancies, when applicable.

Program Questions

This section provides additional inputs for each test
case that are specific to APTC, Medicaid, CHIP, SEP,
and QHP eligibility.

Attestations

This section provides information for answering the
legal attestations.

All Phase 1 and some Phase 2 scenarios require the use of specific test SSNs
which are provided in the input table. Some Phase 2 and Phase 3 scenarios do not
include SSNs. In these instances, the Auditor should proceed in the application
without entering any values in the SSN field. Entering an invalid SSN will prevent
application submission. Please refer to phase-specific instructions.

Eligibility Results

This section shows the eligibility results that should
display for each consumer in the ERP. The
information displayed in the UI should accurately
reflect results found in the EDN and use specific
language where noted in the test cases.

Auditors should note that test cases do not include data matching issue (DMI)
status in the Eligibility Result section. If the test case results in a DMI, the ERP and
EDN will provide instruction that the consumer must submit documentation to
confirm information. DMIs can occur for citizenship status; immigration status;
household income; incarceration status; American Indian or Alaska Native status;
eligibility for minimum essential job-based coverage; and eligibility for coverage
through Medicaid or CHIP, TRICARE, Veterans Health Care Program, Medicare, or
Peace Corps.
Auditors should also note that the test cases do include information on Special
Enrollment Verification Issues (SVIs) in the Eligibility Results section, and that
messaging about SVIs is expected on both the ERP and EDN when noted in the
test case. However, SVIs will not be generated for applicants who are current
enrollees or for applications submitted during the annual open enrollment period.
Entities can help ensure they are generating the expected SVIs by always
randomizing demographic data as instructed by the test cases and completing the
toolkit outside of the open enrollment period.

Test Case ID

State

Summary/Criteria

Expected Results/What's Tested

Test Scenario Description

Auditor Compliance Conclusion**

Test Case 1.A

Any state except
AK

-Initial application, 2 member household
-Seeking financial assistance
-Married, no dependents
-Current coverage through Medicare

This is a simple test case with a two person household—a married couple filing a joint
tax return in any state. This test case allows the EDE Entity to demonstrate its ability to
handle non-applicants, as the application filer’s spouse must be included on the
-EDE Entity can handle non-applicants (spouse)
application, but is not seeking coverage herself. Because the application filer is over age
-EDE Entity accurately collects job-based income information (including both
65, the UI must display a message regarding impacts of Medicare and Marketplace
current monthly amount and annual amount)
coverage. This test case also demonstrates the collection of information about the
-Primary applicant is ineligible for APTC (due to Medicare enrollment)
consumer’s employer, because job-based income is reported, and about enrollment in
other non-employer-sponsored health coverage. In this case, the application filer has
Medicare which results in ineligibility for APTC.

Test Case 1.B

Any state

-Initial application, 1 member household
-Not seeking financial assistance
-Single, no dependents
-Loss of coverage SEP

-EDE Entity properly displays limited screener questions due to consumer
indicating they are not seeking financial assistance
-EDE Entity properly displays limited application questions due to consumer
indicating they are not seeking financial assistance
-Applicant is eligible for QHP and may enroll through SEP due to recent loss
of MEC

This is a scenario where the consumer is not requesting financial assistance. It can be
tested using any state's application. This allows the EDE Entity to demonstrate that only
limited screener questions and limited application questions appear based on the
consumer's choice not to be considered for insurance affordability programs. The
consumer attests to a recent loss of coverage and is therefore eligible to enroll through
a SEP.

Test Case 1.C

FL, NC, or SC

-Initial application, 2 member household
-Seeking financial assistance
-Single, 1 dependent

-EDE Entity properly displays prior coverage in the 60 days before the move
question
-EDE Entity UI successfully collects written language preference
-Child may be Medicaid eligible
-Parent is found QHP eligible and eligible for hardship exemption due to
income below 100% FPL and residency in non-expansion state

This scenario includes a single parent applying for herself and one young child. She
selects Spanish as her preferred written and spoken language, and the EDN will be
generated in Spanish as a result. In this scenario, the consumer reports a monthly
Eligibility results compliance conclusion:
deduction as well as weekly job income. Finally, the consumer in this scenario attests to
Auditor checklist item to verify Item 138/row 40 compliance conclusion:
a recent move. However, the consumer does not meet the prior coverage requirement
Auditor checklist item to verify "May be eligible for Medicaid" wording/row 52 compliance conclusion:
for the move SEP. In this scenario, the child is found Medicaid eligible while the parent is
found QHP eligible and eligible for a hardship exemption on the basis of living in a nonexpansion state with an income below 100% of the poverty line.

Test Case 1.D

AK, AZ, AR, DE,
HI, IL, IN, IA, LA,
MI, MO, MT, NE,
NH, ND, OH, OK,
OR, UT, VA, WV

-Initial application, 1 member household
-Seeking financial assistance
-Single, no dependents

-EDE Entity allows applicant to disagree with projected annual income and
input different amount
-Applicant may be eligible for Medicaid based on current monthly income

Test Case 1.D.2

State used in 1.D

-Change in circumstance (CiC) application for 1.D, 1
-EDE Entity demonstrates UI can support CiC
member household
-Applicant is routed to HealthCare.gov or alternate channel after attesting
-Seeking financial assistance
to pregnancy
-Single, no dependents
-Proper disclaimer regarding unsupported scenarios displayed
-Pregnant application filer

Test Case 1.E

Any state

-Initial application, 2 member household
-Not seeking financial assistance
-Married, no dependents
-Marriage SEP

-The EDE Entity properly displays prior coverage question after Marriage
SEP attestation
-Applicant and spouse are found eligible for QHP and SEP

Test Case 1.F

AZ, AR, DE, HI, IL,
IN, IA, LA, MI,
MT, NE, NH, ND,
OH, OK, OR, UT,
VA, WV

-Initial application, 1 member household
-Seeking financial assistance
-Single, no dependents
-Medicaid denial SEP

In this simple scenario, a single consumer applies for financial assistance in a Medicaid
Expansion state. He attests to job income and to a recent Medicaid denial. The
Eligibility results compliance conclusion:
-EDE Entity properly displays follow up questions to Medicaid denial question application should include follow-up questions about his Medicaid denial to determine
Auditor checklist Item 134 and Item 138/row 40 compliance conclusion:
-Applicant is found QHP, APTC, CSR and SEP eligible due to Medicaid denial whether he originally applied during Open Enrollment as well as the date of the denial.
Auditor checklist item to check Eligibility Results Tab, Item 4/row 52 compliance conclusion:
Despite income below the Medicaid limit in his state, the consumer is found QHP, APTC,
CSRs and SEP eligible due to the Medicaid denial attestation.

Test Case 1.H

Any state

-Initial application, 4 member household
-Seeking financial assistance
-Single, 3 dependents
-Dependent lives with parent not on the
application filer's tax return

-EDE Entity demonstrates UI properly screens out scenarios not supported
by Phase 1
-Applicant routed to HealthCare.gov or alternate channel after answering
screening questions
-Proper disclaimer regarding unsupported scenarios displayed

Test Case 1.J

Any state

-Initial application, 1 member household
-Not seeking financial assistance
-Single, no dependents
-Naturalized citizen

-EDE Entity displays naturalized citizenship questions properly in screener
-Applicant routed to HealthCare.gov or alternate channel after answering
screening questions
-Proper disclaimer regarding unsupported scenarios displayed

Test Case 1.K

NH

-Initial application, 3 member household
-Seeking financial assistance
-Married, 1 dependent
-Current coverage through TRICARE
-Move SEP

-EDE Entity UI handles multiple income and deduction types
-UI accounts for other coverage (TRICARE) and Move SEP
-One member is determined eligible for QHP with APTC, one member
determined eligible for QHP without subsidy, and the child is assessed as
eligible for Medicaid
-Correct APTC amount calculated

Test Case 1.L

SC

-Initial application, 5 member household
-Seeking financial assistance
-Married, 3 dependents
-1 non-applicant

-EDE Entity handles multiple member's income and properly calculates APTC
for a 5 member household
-EDE Entity supports non-applicants
-Four members are determined eligible for QHP with APTC; one member is
not seeking coverage and receives no eligibility results.
-Members are not eligible to enroll at this time due to lack of SEP

This test case verifies that the EDE Entity can support a five member household financial
assistance application, and successfully grants QHP eligibility with correct subsidy
amounts for Member 1, Member 3, Member 4, and Member 5, with Member 2 not
seeking health insurance coverage. This test case must be run in SC, zip code 29401.

Eligibility results compliance conclusion:
Auditor checklist Item 14/row 16 compliance conclusion:
Auditor checklist Item 131/row 38 compliance conclusion:
Auditor checklist Item 153-155/row 42 compliance conclusion:

Test Case 1.M

NH

-Initial application, 4 member household
-Seeking financial assistance
-Married, 2 dependents
-Current coverage through other non-MEC health
coverage

-EDE Entity UI handles multiple incomes and a deduction
-Correct APTC amount calculated
-UI accounts for other non-MEC coverage
-UI properly determines eligibility for mixed household - two members are
determined eligible for QHP with APTC and two may be eligible for Medicaid

This scenario includes a four member household financial assistance application with
multiple income and deduction types, where one member attests to having other nonMEC health coverage. The result is QHP with APTC for two (2) members and Medicaid
for two (2) members. This test case must be run in NH, zip code 03301.

Eligibility results compliance conclusion:
Auditor checklist Item 22/row 24 compliance conclusion:
Auditor checklist Item 175, column G/row 43 compliance conclusion:
Auditor checklist Item 192/row 46 compliance conclusion:
Auditor checklist Item 239/row 47 compliance conclusion:

TX

-EDE Entity handles multiple income and properly calculates APTC for a 5
member household
-EDE Entity properly displays marriage SEP and prior coverage questions
-Initial application, 5 member household
-UI accounts for CHIP waiting period and displays appropriate questions for
-Seeking financial assistance
minor children
-Married, 3 dependents
-UI accounts for Medicare and TRICARE coverage
-Current coverage through TRICARE and Medicare
-Parents are eligible for QHP without subsidy; two of the children are
-Marriage SEP
referred to Medicaid while one is granted APTC and CSR while in the CHIP
waiting period due to the answers to the CHIP waiting period exceptions
question

VA

-Initial application, 9 member household
-Seeking financial assistance
-Married, 7 dependents
-Affirmative answers to non-MAGI questions
-Medicaid/CHIP denial
-Medicaid denial SEP

Test Case 1.N

Test Case 1.O

-EDE Entity UI can handle complex large household with mixed eligibility
results
-UI correctly calculates multiple income and deduction types and correctly
calculates APTC
-UI can accommodate multiple SEP (move, loss of MEC, and Medicaid/CHIP
denial) and current coverage through the Peace Corps and return correct
eligibility results
-Members receive determinations of QHP without subsidy, QHP with APTC
and CSR, and CHIP eligibility for the family members

This is a simple scenario of a single individual with no dependents applying for financial
assistance in Medicaid Expansion states. This individual attests to weekly
unemployment income and disagrees with the calculated projected annual income and
inputs her own amount. She resides in a Medicaid Expansion state, and is found
Medicaid eligible based on current monthly income.
This test case tests the UI and functionality related to reporting a life change on an
existing application. For this test case, after completing test case 1.D, the tester must
report a change in circumstance (CiC) on the already-submitted 1.D application. The
household information for the individual would stay the same, except that on the CiC
application version, the consumer is now pregnant. Because pregnancy affects
Medicaid eligibility, the consumer should be routed to an alternative pathway after
accurately answering the screener questions.
In this scenario, a couple with no dependents in any state applies for coverage with no
financial assistance. The consumers attest to marriage in the last 60 days. The UI should
include a follow-up question asking if either spouse had coverage in the 60 days before
the marriage. Because at least one consumer answers "Yes", they are found both QHP
and SEP eligible.

This scenario demonstrates proper functionality of the screener tool for an unmarried
parent seeking coverage and financial assistance for three tax dependents in any state.
The application filer also lives with a domestic partner, which requires use of an
alternative pathway only because that domestic partner is the parent of one or more of
the application filer’s tax dependents. Therefore the application filer should answer
“Yes” to the screener question which asks whether their dependents live with a parent
who’s not on his/her tax return. Upon doing so, they should be directed to an
alternative pathway.
This test case demonstrates the screener tool UI and functionality for a consumer not
applying for financial assistance. In this scenario, an unmarried consumer in any state
with no dependents completes the screener on the EDE entity site. Although this
consumer is a U.S. citizen, they were not born in the U.S. and became naturalized as a
U.S. citizen in the 1990s. On the screener tool, when the consumer answers the
question about naturalized citizenship accurately, they should be redirected to an
alternative pathway.
This test case demonstrates functionality for a mixed eligibility household with multiple
income and deduction types, other health coverage, and a Move SEP. In a three
member household financial assistance application, one member is determined eligible
for QHP with a Move SEP, APTC, and CSRs, one member determined eligible for QHP
with a Move SEP and without subsidy, and the child is assessed as eligible for Medicaid.
This test case must be run in NH, zip code 03301.

Eligibility results compliance conclusion:
Auditor checklist Item 27/row 21 compliance conclusion:
Auditor checklist Items 128-130/row 33 compliance conclusion:
Auditor checklist Item 34/row 36 compliance conclusion:
Auditor checklist Item 194/row 47 compliance conclusion:

Eligibility results compliance conclusion:
Auditor checklist Item 9/row 33 compliance conclusion:
Auditor checklist Item 215/row 46 compliance conclusion:
Auditor checklist Item 246 to verify that income does not display on the review application page/row 48
compliance conclusion:
Auditor checklist item to verify display of eligibility results page/row 50 compliance conclusion:

Eligibility results compliance conclusion:
Auditor checklist Item 9/row 12 compliance conclusion:
Auditor checklist Item 4/row 33 compliance conclusion:
Auditor checklist item to check Eligibility Results Tab, Item 3/row 51 compliance conclusion:

Eligibility results compliance conclusion:
Auditor checklist Item 9/row 12 compliance conclusion:
Auditor checklist Item 19/row 20 compliance conclusion:

Eligibility results compliance conclusion:
Auditor checklist Item 32/row 36 compliance conclusion:
Auditor checklist Item 246 to verify that income does not display on the review application page/row 48
compliance conclusion:

Eligibility results compliance conclusion:
Auditor checklist Item 12/row 15 compliance conclusion:
Auditor checklist Item 20/row 22 compliance conclusion:

Eligibility results compliance conclusion:
Auditor checklist item to verify consumer is guided to an alternate pathway with consumer friendly
language/row 28 compliance conclusion:

Eligibility results compliance conclusion:
Auditor checklist Item 195/row 46 compliance conclusion:
Auditor checklist Item 239/row 47 compliance conclusion:
Auditor checklist item to check Eligibility Results Tab, Item 5/row 52 compliance conclusion:

This scenario includes a five member household financial assistance application, where
Eligibility results compliance conclusion:
the household's income places a child within CHIP range in a state with a CHIP waiting
Auditor checklist Item 154, Column G/row 42 compliance conclusion:
period. Two of the children are referred to Medicaid while one is granted APTC and CSR
Auditor checklist Items 243 and 244/row 48 compliance conclusion:
while in the CHIP waiting period due to the answers to the CHIP waiting period
Auditor checklist Item 246 to verify the application review page/row 51 compliance conclusion:
exceptions question. This test case must be run in TX, zip code 77001.

This test case verifies the ability for the EDE Entity UI to handle a complex scenario in
which a nine (9) member household is applying for financial assistance in Virginia. The
application contains multiple income and deduction types, current coverage, multiple
SEPs, and attestations to physical disabilities and assistance with daily living that result
in determinations of QHP without subsidy, QHP with APTC and CSR, and CHIP eligibility
for the family members. The test case must be run in VA with zip code 22032 (Fairfax
County).

Eligibility results compliance conclusion:
Auditor checklist Item 23/row 25 compliance conclusion:
Auditor checklist Item 32/row 36 compliance conclusion:
Auditor checklist Item 234/row 47 compliance conclusion:
Auditor checklist item to verify display of Eligibility Results Page/row 51 compliance conclusion:

Risks Identified**

Risk Level**

Risk Mitigation Strategy**

Estimated Resolution Date**

Auditor Comments**

Summary: This is a simple test case with a two person household—a married couple filing a joint tax return in any state. This test case allows the EDE Entity to demonstrate its
ability to handle non-applicants, as the application filer’s spouse must be included on the application, but is not seeking coverage herself. Because the application filer is over age
65, the UI must display a message regarding impacts of Medicare and Marketplace coverage. This test case also demonstrates the collection of information about the consumer’s
employer, because job-based income is reported, and about enrollment in other non-employer-sponsored health coverage. In this case, the application filer has Medicare which
results in ineligibility for APTC.
UI Question Companion Guide
Application Data
Reference
Tab: UI Questions
Item 1
State
Item 2
Coverage Year
Tab: Phase 1 Screening Question
Item 1
Marital Status
Item 2
Number of tax dependents
Item 3
Who is applying for coverage?

Application Input

Any state except AK
Current year

Notes to Testers

Application State & Coverage Year

Married
0
Application filer

Screening Questions

Item 5
Items 4, 6, 7 (depending on
implementation)
Item 8

Seeking financial assistance?

Yes

Resides in application state

Yes, all household members live at same address in Must provide a valid zip code for the application state
application state

Item 9
Item 10

Tax filing status
Responsible for a child 18 or
younger not on tax return

Item 11
Item 12
Items 14, 17
Item 15
Item 16
Item 18
Item 19
Item 27

Item 20
Item 21
Item 22
Items 23, 25

Item 26

Filing jointly
No one in household is responsible for a child 18 or
younger who they live with but isn't on their tax
return
Full-time student
No one in household is a full-time student
Pregnant
No one in household is pregnant
Citizenship
Application filer is a U.S. citizen, not naturalized or
Can provide SSN
All applicants can provide SSN
Applying with same name as name All applicants are applying with name same as the
on SSN card
name on their SSN card
Incarceration
No applicants are incarcerated
American Indian/Alaska Native
No one in household has AI/AN status
Offer of individual coverage HRA No applicants have an ICHRA or QSEHRA offer
(ICHRA) or a qualified small
employer Health Reimbursement
Arrangement (QSEHRA)

Offer of coverage through job or
COBRA
Former foster care
Claiming all dependents on tax
return
Dependent is child, single (not
married), 25 or younger, not step
child or grandchild
Dependents live with parent not
on tax return
Pass screener?

Auditor Checklist

No applicants have access to coverage through a job
or COBRA
No applicants are former foster care
N/A (should not display)
N/A (should not display)

N/A (should not display)
Screening Pass/Fail
Yes, continue with application

Item 27: Verify "Are either of you offered an
individual coverage Health Reimbursement
Arrangement (HRA) or a qualified small employer
Health Reimbursement Arrangement (QSEHRA)
through your job, or through the job of another
person, like a spouse or parent?" displays as a
screening question

UI Question Companion Guide
Application Data
Reference
Tab: UI Questions
Household member
Items 4, 28 Name
Item 5 Home address
Items 7, 8 Mailing address
Item 10 Preferred language

Household Member Input

Dwayne Curtis *
Male
Age: 72

Household Member
Input
Household
Betty Curtis *
Female
Age: 58

Notes to Testers

Auditor Checklist

*Do not use Curtis as the last name. Use a different last Check Items 128-130: Verify that Race and Ethnicity
name that is unique (it can be a random string of letters). questions are optional to answer for all household
Do not change the first name
members
Must provide a valid county and zip code for the
application state
Use any date of birth that results in the correct age for
each household member
Other household contact and information fields (i.e.
email, phone, language preference, race/ethnicity, etc.)
may contain any value unless otherwise noted
Find additional information in the UI Question
Companion Guide:
- Items 4, 5, 7, 8, 9 Household Contact Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-applicant information Race and Ethnicity

Item 28
Items 27, 29
Items 32, 34

Items 131, 132

Items 133, 138

Items 153, 154, 155, 209

Item 174
Item 181

Application Filer/Relationship to
Application Filer
Applicant/Non-Applicant
SSN

Application Filer

Spouse

Applicant
317-20-1410

Non-applicant
317-20-1411

SSN must be entered exactly for test case to function

More About This Household
Non-MAGI Medicaid Eligibility
Do not answer affirmatively N/A (should not display
Questions (physical disabilities,
to any non-MAGI questions for this household
assistance with daily living, nursing
member)
home care)
Medicaid Block
Medicaid/CHIP Denial
Does not have
N/A (should not display
Medicaid/CHIP that
for this household
recently ended or will end member)
soon;
Not denied Medicaid/CHIP
Income
Current Month Income
Job: $2,798.08 per month No income
Employer name (and phone number, where Item 209 is
included) fields are required but any value may be
entered (ex: ABC corp; 555-555-5555)
Deductions
No deductions
No deductions
Annual Income
$33,576.96
$0
All household members should be asked of their current
income and deductions regardless of age. The UI should
display expected annual income for each household
member

Check Item 34: Verify that SSN is clearly optional for
Betty since she is a non-applicant

Item 186

Income Discrepancies

Items 191, 192, 194

Current coverage

Items 213, 218, 223

Recent Life Changes (SEPs)

Items 246, 252, 254, 255, 256,
258

Application Review & Legal
Attestations

Reference Materials
UI Q CG Eligibility Results Tab:
Items 1, 3, 4, 5

Eligibility Results Page (ERP)

Sample HealthCare.gov
Eligibility Results Messaging

Answer "Household
N/A (should not display
members have changed" to for this household
"Dwayne and Betty's
member)
income in [coverage year]
seems like it will be lower
than what our records
from the past 2 years show.
Program Questions
Medicare
N/A (should not display
Check Item 194: Verify "Medicare Number" is
for this household
optional to answer
member)
None of these changes
N/A (should not display
for this household
Attestations
Answers affirmatively to all application attestations Auditors should review the application review page
(Item 246) to ensure all information accurately reflects
the attestations inputted during the test case
Eligibility Results
Eligible to buy a
N/A
Auditors should review the Eligibility Results Page to
Marketplace plan
ensure it accurately reflects the eligibility results found in
the EDN and complies with ERP messaging requirements
Not eligible for a Special
outlined in the documentation listed in Column A
Enrollment Period
*Optional to display for QHP applicant who is also being
May be eligible for
referred to the state Medicaid agency based on
Medicaid*
age/disability (non-MAGI)

Summary: This is a scenario where the consumer is not requesting financial assistance. It can be tested using any state's application. This allows the EDE Entity to demonstrate that only limited
screener questions and limited application questions appear based on the consumer's choice not to be considered for insurance affordability programs. The consumer attests to a recent loss of
coverage and is therefore eligible to enroll through a SEP.
UI Question Companion Guide
Reference
Tab: UI Questions
Item 1
Item 2
Tab: Phase 1 Screening Question
Item 1
Item 2
Item 3
Item 5
Items 4, 6, 7 (depending on
implementation)
Item 8
Item 9
Item 10
Item 11
Item 12
Items 14, 17
Item 15
Item 16
Item 18
Item 19
Item 27

Item 20
Item 21
Item 22
Items 23, 25
Item 26

Application Data

Any state
Current year

Marital Status
Number of tax dependents
Who is applying for coverage?
Seeking financial assistance?

Single
0
Application filer
No

Resides in application state

Yes, application filer lives in application state
N/A (should not display)
N/A (should not display)

Application Data

Auditor Checklist

Screening Questions

Tax filing status
Responsible for a child 18 or younger not on
tax return
Full-time student
Pregnant
Citizenship
Can provide SSN
Applying with same name as name on SSN
card
Incarceration
American Indian/Alaska Native
Offer of individual coverage HRA (ICHRA) or a
qualified small employer Health
Reimbursement Arrangement (QSEHRA)
Offer of coverage through job or COBRA
Former foster care
Claiming all dependents on tax return
Dependent is child, single (not married), 25 or
younger, not step child or grandchild
Dependents live with parent not on tax return

Notes to Testers

Application State & Coverage Year

State
Coverage Year

Pass screener?

UI Question Companion Guide
Reference
Tab: UI Questions

Application Input

Must provide a valid zip code for the application state

N/A (should not display)
N/A (should not display)
Application filer is a U.S. citizen, not naturalized or
Yes
Yes
Not incarcerated
No one in household has AI/AN status
Does not have an ICHRA or QSEHRA offer

N/A (should not display)
N/A (should not display)
N/A (should not display)
N/A (should not display)
N/A (should not display)
Screening Pass/Fail
Yes, continue with application

Household Member Input
Household

Notes to Testers

Auditor Checklist

Items 4, 28 Name
Item 5 Home address
Items 7, 8 Mailing address
Item 10 Preferred language

Household member

Michael Ewing *
Male
Age: 31

*Do not use Ewing as the last name. Use a different last
Check Item 9: Verify that phone number
name that is unique (it can be a random string of letters). Do is a required field to answer
not change the first name
Must provide a valid county and zip code for the application
state
Use any date of birth that results in the correct age for each
household member
Other household contact and information fields (i.e. email,
phone, language preference, race/ethnicity, etc.) may
contain any value unless otherwise noted
Find additional information in the UI Question Companion
Guide:
- Items 4, 5, 7, 8, 9 Household Contact Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-applicant information Race and Ethnicity

Item 28
Items 27, 29
Item 32

Application Filer/Relationship to Application
Filer
Applicant/Non-Applicant
SSN

Application Filer
Applicant
317-20-1400

More About This Household
N/A (should not display)

Items 131, 132

Non-MAGI Medicaid Eligibility Questions
(physical disabilities, assistance with daily
living, nursing home care)

Items 133, 138

Medicaid/CHIP Denial

N/A (should not display)

Item 153
Item 174
Item 181

Current Month Income
Deductions
Annual Income

N/A (should not display)
N/A (should not display)
N/A (should not display)

Items 213, 214, 215, 218, 223

Recent Life Changes (SEPs)

Items 246, 254, 255, 256, 258

Application Review & Legal Attestations

Program Questions
Recent loss of minimum essential coverage (MEC);
Provide date in last 60 days;
Do not provide the name of the plan
Attestations
Answers affirmatively to all application attestations

Reference Materials
UI Q CG Eligibility Results Tab:
Items 1, 4, 5

Eligibility Results Page (ERP)

Eligibility Results
Eligible to buy a Marketplace plan

Sample HealthCare.gov

SSN must be entered exactly for test case to function

Medicaid Block
Income

Eligible for a Special Enrollment Period

Check Item 215: Verify that the field to
enter plan name is optional

Auditors should review the application review page (Item
246) to ensure all information accurately reflects the
attestations inputted during the test case

Verify that income does not display on
the review application page since this is
a non-financial assistance application

Auditors should review the Eligibility Results Page to ensure it
accurately reflects the eligibility results found in the EDN and
complies with ERP messaging requirements outlined in the
documentation listed in Column A

Verify eligibility results page displays
that Michael is "eligible to buy a
Marketplace plan," "eligible for a Special
Enrollment Period"

Summary: This scenario includes a single parent applying for herself and one young child. She selects Spanish as her preferred written and spoken language, and the EDN will be generated in Spanish as a result. In this scenario, the
consumer reports a monthly deduction as well as weekly job income. Finally, the consumer in this scenario attests to a recent move. However, the consumer does not meet the prior coverage requirement for the move SEP. In this
scenario, the child is found Medicaid eligible while the parent is found QHP eligible and eligible for a hardship exemption on the basis of living in a non-expansion state with an income below 100% of the poverty line.
UI Question Companion Guide
Reference
Tab: UI Questions
Item 1
Item 2
Tab: Phase 1 Screening Questions
Item 1
Item 2
Item 3
Item 5
Items 4, 6, 7 (depending on
implementation)
Item 8
Item 9
Item 10

Application Input

Application Data

Notes to testers

Application State & Coverage Year
State
Coverage Year

FL, NC, or SC
Current year

Marital Status
Number of tax dependents
Who is applying for coverage?
Seeking financial assistance?

Single
1
Application filer, dependent
Yes

Item 11
Item 12

Resides in application state
Tax filing status
Responsible for a child 18 or younger not on tax
return
Full-time student
Pregnant

Must provide a valid zip code for the application state
Yes, all household members live at same address in application state
Filing taxes
No one in household is responsible for a child 18 or younger who they live with
but isn't on their tax return tax return
No one in household is a full-time student
No one in household is pregnant

Items 14, 17
Item 15
Item 16

Citizenship
Can provide SSN
Applying with same name as name on SSN card

All applicants are U.S. citizens, not naturalized or derived
All applicants can provide SSN
All applicants are applying with name same as the name on their SSN card

Item 18
Item 19
Item 27

Incarceration
American Indian/Alaska Native
Offer of individual coverage HRA (ICHRA) or a
qualified small employer Health Reimbursement
Arrangement (QSEHRA)
Offer of coverage through job or COBRA
Former foster care
Claiming all dependents on tax return
Dependent is child, single (not married), 25 or
younger, not step child or grandchild
Dependents live with parent not on tax return

No applicants are incarcerated
No one in household has AI/AN status
No applicants have an ICHRA or QSEHRA offer

Pass screener?

Yes, continue with application

Item 20
Item 21
Item 22
Items 23, 25
Item 26

Auditor Checklist

Screening Questions

No applicants have access to coverage through a job or COBRA
No applicants are former foster care
Yes
Yes
No
Screening Pass/Fail

UI Question Companion Guide
Reference
Tab: UI Questions

Application Data

Household Member Input

Household Member Input
Household

Notes to Testers

Auditor Checklist

Items 4, 28 Name
Item 5 Home address
Items 7, 8 Mailing address
Item 10 Preferred language

Household member
Becky Eleanor Oliver *
Female
Age: 38

Bill Oliver *
Male
Age: 3

*Do not use Oliver as the last name. Use a different last name
that is unique (it can be a random string of letters). Do not
change the first name
Must provide a valid county and zip code for the application
state

Preferred written/spoken language Spanish

Use any date of birth that results in the correct age for each
household member
Other household contact and information fields (i.e. email,
phone, language preference, race/ethnicity, etc.) may contain
any value unless otherwise noted
Find additional information in the UI Question Companion
Guide:
- Items 4, 5, 7, 8, 9 Household Contact Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-applicant information - Race
and Ethnicity

Item 28

Application Filer/Relationship to Application Filer Application Filer
Parent of Bill

Items 27, 29
Item 32

Applicant/Non-Applicant
SSN

Child of Becky

Items 153, 154, 155, 209

Applicant
766-42-4551
More About This Household
Non-MAGI Medicaid Eligibility Questions (physical Do not answer affirmatively to any non- Do not answer affirmatively to any
disabilities, assistance with daily living, nursing
non-MAGI questions
MAGI questions
home care)
Medicaid Block
Medicaid/CHIP Denial
Does not have Medicaid/CHIP that
Does not have Medicaid/CHIP that
recently ended or will end soon; Not
recently ended or will end soon; Not
denied Medicaid/CHIP
denied Medicaid/CHIP
Income
Current Month Income
Job: $325 per week
No income

Items 174, 175, 177
Item 181

Deductions
Annual Income

Student Loans: $100 per month
$15,687

Item 191

Current coverage

Item 239

Help paying for medical bills

N/A (should not display for this
household member)
N/A (should not display for this
household member)

Items 213, 218, 223, 231, 232,
233, 234

Recent Life Changes (SEPs)

Items 246, 247, 252, 254, 255,
256, 258

Application Review & Legal Attestations

Items 131, 132

Items 133, 138

Reference Materials

Applicant
766-42-2490

No deductions
$0

SSN must be entered exactly for test case to function

Check Item 138: Verify Medicaid
recently ended or ending soon is asked
before Medicaid denial
Employer name (and phone number, where Item 209 is
included) fields are required but any value may be entered (ex:
ABC corp; 555-555-5555)
All household members should be asked of their current
income and deductions regardless of age. The UI should display
expected annual income for each household member

Program Questions
None
Do not answer affirmatively

Recently Moved
N/A (should not display for this
Provide zip code in a different county
household member)
than zip code provided in home address
Provide date within last 60 days
Attest "No" to prior coverage question

Attestations
Answers affirmatively to all application attestations

Eligibility Results

If a date outside of the last 60 days is entered, then an error
message will appear

Auditors should review the application review page (Item
246) to ensure all information accurately reflects the
attestations inputted during the test case

UI Q CG Eligibility Results Tab:
Items 1, 3, 4, 5
Sample HealthCare.gov Eligibility
Results Messaging

Eligibility Results Page (ERP)

Eligible to buy a Marketplace plan

May be eligible for Medicaid

Auditors should review the Eligibility Results Page to ensure it
accurately reflects the eligibility results found in the EDN and
complies with ERP messaging requirements outlined in the
documentation listed in Column A

Verify "May be eligible for Medicaid"
wording is used for Bill on the
Eligibility Results Page because FL, NC,
and SC are Assessment states

Summary: This is a simple scenario of a single individual with no dependents applying for financial assistance in Medicaid Expansion states. This individual attests to weekly unemployment
income and disagrees with the calculated projected annual income and inputs her own amount. She resides in a Medicaid Expansion state, and is found Medicaid eligible based on current
monthly income.
UI Question Companion Guide
Reference
Tab: UI Questions
Item 1
State
Item 2
Tab: Phase 1 Screening
Item 1
Item 2
Item 3
Item 5
Items 4, 6, 7 (depending on
implementation)
Item 8
Item 9

Application Data

Marital Status
Number of tax dependents
Who is applying for coverage?
Seeking financial assistance?

Application State & Coverage Year
AK, AZ, AR, DE, HI, IL, IN, IA, LA, MI, MO, MT, NE,
NH, ND, OH, OK, OR, UT, VA, WV
Current year
Screening Questions
Single
0
Application filer
Yes

Resides in application state
Tax filing status

Yes, application filer lives in application state
Filing taxes

Coverage Year

Item 10

Responsible for a child 18 or younger not Not responsible for a child 18 or younger who they
live with but isn't on their tax return
on tax return

Item 11
Item 12
Items 14, 17

Full-time student
Pregnant
Citizenship

Item 15
Item 16

Can provide SSN
Applying with same name as name on
SSN card
Incarceration
Not incarcerated
American Indian/Alaska Native
No one in household has AI/AN status
Offer of individual coverage HRA (ICHRA) Does not have an ICHRA or QSEHRA offer
or a qualified small employer Health
Reimbursement Arrangement (QSEHRA)

Item 18
Item 19
Item 27

Item 20

Offer of coverage through job or COBRA Does not have coverage through a job or COBRA
Former foster care
Claiming all dependents on tax return
Dependent is child, single (not married),
25 or younger, not step child or
grandchild
Dependents live with parent not on tax
return
Pass Screener?

UI Question Companion Guide
Reference
Tab: UI Questions

Application Data

Auditor Checklist

Must provide a valid zip code for the application state
Check Item 9: Verify question text
displays relevant coverage year

Not a full-time student
No one in household is pregnant
Application filer is a U.S. citizen, not naturalized or
derived
Yes
Yes

Item 21
Item 22
Items 23, 25

Item 26

Notes to Testers

Application Input

Not former foster care
N/A (should not display)
N/A (should not display)

N/A (should not display)
Screening Pass/Fail
Yes, continue with application

Household Member Input
Household

Notes to Testers

Auditor Checklist

Items 4, 28 Name
Item 5 Home address
Items 7, 8 Mailing address
Item 10 Preferred language

Household member

Aisha Modell *
Age: 31
Female

*Do not use Modell as the last name. Use a different last name
that is unique (it can be a random string of letters). Do not
change the first name
Must provide a valid county and zip code for the application
state
Use any date of birth that results in the correct age for each
household member

Item 28
Items 27, 29
Item 32
Items 131, 132

Items 133, 138

Application Filer/Relationship to
Application Filer
Applicant/Non-Applicant
SSN

Other household contact and information fields (i.e. email,
phone, language preference, race/ethnicity, etc.) may contain
any value unless otherwise noted
Find additional information in the UI Question Companion
Guide:
- Items 4, 5, 7, 8, 9 Household Contact Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-applicant information - Race
and Ethnicity

Application Filer
Applicant
317-20-1400

SSN must be entered exactly for test case to function

More About This Household
Non-MAGI Medicaid Eligibility Questions Do not answer affirmatively to any non-MAGI
(physical disabilities, assistance with daily questions
living, nursing home care)
Medicaid Block
Medicaid/CHIP Denial
Does not have Medicaid/CHIP that recently ended
or will end soon; Not denied Medicaid/CHIP
Income

Items 153, 154, 165, 209

Current Month Income

Unemployment: $288 per week

Item 174
Items 181, 182, 183

Deductions
Annual Income

Item 191
Item 239

Current coverage
Help paying for medical bills

Items 246, 247, 252, 254, 256,
258

Application Review & Legal Attestations

No deductions
Disagree with calculated annual income;
Income is not hard to predict;
Attests to $16,093
Program Questions
None
Do not answer affirmatively
Attestations
Answers affirmatively to all other application
attestations

Reference Materials

Eligibility Results

Employer name (and phone number, where Item 209 is
included) fields are required but any value may be entered (ex:
ABC corp; 555-555-5555)

Auditors should review the application review page (Item 246)
to ensure all information accurately reflects the attestations
inputted during the test case

Check Item 4: Verify answer fields for
Middle Name and Suffix are optional

UI Q CG Eligibility Results Tab:
Items 1, 4, 5
Sample HealthCare.gov
Eligibility Results Messaging

Eligibility Results Page (ERP)

May be eligible for Medicaid

Auditors should review the Eligibility Results Page to ensure it
accurately reflects the eligibility results found in the EDN and
complies with ERP messaging requirements outlined in the
documentation listed in Column A

Check Eligibility Results Tab, Item 3:
Verify UI does not display Full Medicaid
Determination

Summary: This test case tests the UI and functionality related to reporting a life change on an existing application. For this test case, after completing test case 1.D, the
tester must report a change in circumstance (CiC) on the already-submitted 1.D application. The household information for the individual would stay the same, except
that on the CiC application version, the consumer is now pregnant. Because pregnancy affects Medicaid eligibility, the consumer should be routed to an alternative
pathway after accurately answering the screener questions.
UI Question Companion
Guide Reference
Tab: UI Questions
Item 1

Item 2
Tab: Phase 1 Screening
Item 1
Item 2
Item 3
Item 5
Items 4, 6, 7 (depending
on implementation)
Item 8

Application Data

State

Application State & Coverage Year
State used in 1.D

Marital Status
Number of tax dependents
Who is applying for coverage?
Seeking financial assistance?

Coverage year used in 1.D
Screening Questions
Single
0
Application filer
Yes

Resides in application state

Yes, application filer lives in application state

Item 9

Tax filing status

Filing taxes

Item 10
Item 11
Item 12

Responsible for a child 18 or younger not
on tax return
Full-time student
Pregnant

Not responsible for a child 18 or younger who
they live with but isn't on their tax return
Not a full-time student
Application filer is pregnant

Items 14, 17

Citizenship

Item 15
Item 16
Item 18
Item 19

Item 27

Coverage Year

Application Input

Application filer is a U.S. citizen, not naturalized
or derived
Can provide SSN
Yes
Applying with same name as name on SSN Yes
card
Incarceration
Not incarcerated
American Indian/Alaska Native
No one in household has AI/AN status

Offer of individual coverage HRA (ICHRA)
or a qualified small employer Health
Reimbursement Arrangement (QSEHRA)

Does not have an ICHRA or QSEHRA offer

Notes to Testers

Auditor Checklist

Because this is a CiC, the application coverage
year and state should remain the same and the
application from Test Case 1.D should be

Must provide a valid zip code for the application
state
Check Item 9: Verify the question is written as or
similarly to "Do you plan to file a federal tax
return for [insert coverage year]? You don't have
to file taxes to apply for coverage, but you'll
need to file next year if you want to get a
premium tax credit to help pay for coverage
now."

The pathway for consumers to report this life
change may vary by UI, but the tester should see
similar screening questions that will allow them
to report the pregnancy CiC. Pregnancy is not
supported by Phase 1 applications, so this
answer/input will result in the consumer being
redirected to an alternate pathway

Check Item 19: The question should be written
as or similarly to "Are you an American Indian or
Alaska Native?"

Item 20
Item 21
Item 22
Items 23, 25
Item 26

Offer of coverage through job or COBRA
Former foster care
Claiming all dependents on tax return
Dependent is child, single (not married), 25
or younger, not step child or grandchild
Dependents live with parent not on tax
return
Pass Screener?

No coverage through job or COBRA
Not former foster care
N/A (should not display)
N/A (should not display)
N/A (should not display)
Screening Pass/Fail
No, consumer should be guided to alternate
pathway and should not complete the
application

When a consumer fails the screening questions,
the UI should redirect the consumer to
HealthCare.gov or a Direct Enrollment pathway
and display consumer friendly language as to why
they cannot continue the application on the
entity site

Summary: In this scenario, a couple with no dependents in any state applies for coverage with no financial assistance. The consumers attest to marriage in the last 60 days. The UI should
include a follow-up question asking if either spouse had coverage in the 60 days before the marriage. Because at least one consumer answers "Yes", they are found both QHP and SEP
eligible.
UI Question Companion
Guide Reference
Tab: UI Questions
Item 1
Item 2
Tab: Phase 1 Screening

Application Input

Application Data

Any state
Current year

Item 1
Item 2
Item 3
Item 5
Items 4, 6, 7 (depending on
implementation)
Item 8

Marital Status
Number of tax dependents
Who is applying for coverage?
Seeking financial assistance?

Married
0
Application filer, spouse
No

Resides in application state

Yes, all household members live at same address in application state

Item 9
Item 10

Tax filing status
Responsible for a child 18 or
younger not on tax return
Full-time student
Pregnant
Citizenship
Can provide SSN
Applying with same name as
name on SSN card
Incarceration
American Indian/Alaska Native

N/A (should not display)
N/A (should not display)

Item 18
Item 19
Item 27

Item 20
Item 21
Item 22
Items 23, 25

Item 26

Auditor Checklist

Application State & Coverage Year
State
Coverage Year

Item 11
Item 12
Items 14, 17
Item 15
Item 16

Notes to Testers

Screening Questions

Must provide a valid zip code for the application
state

N/A (should not display)
N/A (should not display)
All applicants are U.S. citizens, not naturalized or derived
All applicants can provide SSN
All applicants are applying with name same as the name on their SSN
card
No applicants are incarcerated
No one in household has AI/AN status

Offer of individual coverage HRA
(ICHRA) or a qualified small
employer Health
Reimbursement Arrangement
(QSEHRA)
Offer of coverage through job or
COBRA
Former foster care
Claiming all dependents on tax
return
Dependent is child, single (not
married), 25 or younger, not
step child or grandchild
Dependents live with parent not
on tax return

No applicants have an ICHRA or QSEHRA offer

Pass Screener?

Yes, continue with application

N/A (should not display)
N/A (should not display)
N/A (should not display)
N/A (should not display)

N/A (should not display)
Screening Pass/Fail

UI Question Companion
Guide Reference
Tab: UI Questions

Application Data

Household Member Input

Household Member Input
Household

Notes to Testers

Auditor Checklist

Items 4, 28 Name
Household member
Item 5 Home address
Items 7, 8 Mailing address
Item 10 Preferred language

Jose Bandas *
Age: 59
Male

Benita Bandas *
Age: 61
Female

*Do not use Bandas as the last name. Use a
different last name that is unique (it can be a
random string of letters). Do not change the first
name
Must provide a valid county and zip code for the
application state
Use any date of birth that results in the correct age
for each household member
Other household contact and information fields
(i.e. email, phone, language preference,
race/ethnicity, etc.) may contain any value unless
otherwise noted.
Find additional information in the UI Question
Companion Guide:
- Items 4, 5, 7, 8, 9 Household Contact Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-applicant
information - Race and Ethnicity

Item 28

Application Filer/Relationship to
Application Filer
Applicant/Non-Applicant
SSN

Application Filer
Spouse of Benita
Applicant
317-20-1410

Items 131, 132

Non-MAGI Medicaid Eligibility
Questions (physical disabilities,
assistance with daily living,
nursing home care)

N/A (should not display)

Items 133, 138

Medicaid/CHIP Denial

Item 153
Item 174
Item 181

Current Month Income
Deductions
Annual Income

Items 213, 218, 223, 225,
226

Recent Life Changes (SEPs)

Items 246, 254, 255, 256,
258

Application Review & Legal
Attestations

Items 27, 29
Item 32

Reference Materials

Spouse of Jose
Applicant
317-20-1411

SSN must be entered exactly for test case to
function

Check Item 32: Verify this question is
accompanied by the required help text
about use of SSN (found in Column F)

Auditors should review the application review
page (Item 246) to ensure all information
accurately reflects the attestations inputted
during the test case

Verify that income does not display on
the review application page since this is a
non-financial assistance application

More About This Household
N/A (should not display)

Medicaid Block
N/A (should not display)
Income
N/A (should not display)
N/A (should not display)
N/A (should not display)
N/A (should not display)
N/A (should not display)
N/A (should not display)
Program Questions
Got Married
Got Married
Provide date in last 60 days
Provide date in last 60 days
Attest "Yes" to prior coverage
Attest "Yes" to prior coverage
question
question
Attestations
Answers affirmatively to all application attestations
N/A (should not display)

Eligibility Results

UI Q CG Eligibility Results
Tab: Items 1, 4, 5
Sample HealthCare.gov
Eligibility Results Messaging

Eligibility Results Page (ERP)

Eligible to buy a Marketplace plan
Eligible for a Special Enrollment
Period

Eligible to buy a Marketplace
plan
Eligible for a Special Enrollment
Period

Auditors should review the Eligibility Results Page
to ensure it accurately reflects the eligibility results
found in the EDN and complies with ERP
messaging requirements outlined in the
documentation listed in Column A

Summary: In this simple scenario, a single consumer applies for financial assistance in a Medicaid Expansion state. He attests to job income and to a recent Medicaid denial. The application
should include follow-up questions about his Medicaid denial to determine whether he originally applied during Open Enrollment as well as the date of the denial. Despite income below the
Medicaid limit in his state, the consumer is found QHP, APTC, CSRs and SEP eligible due to the Medicaid denial attestation.
UI Question Companion Guide
Reference
Tab: UI Questions
Item 1
State
Item 2
Tab: Phase 1 Screening
Item 1
Item 2
Item 3
Item 5
Items 4, 6, 7 (depending on
implementation)
Item 8
Item 9
Item 10
Item 11
Item 12
Items 14, 17
Item 15
Item 16
Item 18
Item 19
Item 27

Item 20
Item 21

Application Data

Coverage Year
Marital Status
Number of tax dependents
Who is applying for coverage?
Seeking financial assistance?

Resides in application state
Tax filing status
Responsible for a child 18 or younger not
on tax return
Full-time student
Pregnant
Citizenship
Can provide SSN
Applying with same name as name on SSN
card
Incarceration
American Indian/Alaska Native
Offer of individual coverage HRA (ICHRA) or
a qualified small employer Health
Reimbursement Arrangement (QSEHRA)
Offer of coverage through job or COBRA
Former foster care

Application Input

Auditor Checklist

Not incarcerated
No one in household has AI/AN status
Does not have an ICHRA or QSEHRA offer

Does not have coverage through a job or COBRA
Not former foster care

Claiming all dependents on tax return

Dependent is child, single (not married), 25 N/A (should not display)
or younger, not step child or grandchild

Item 26

Dependents live with parent not on tax
return

Application Input

Notes to Testers

Yes, application filer lives in application state
Filing taxes
Not responsible for a child 18 or younger who they live
with but isn't on their tax return
Not a full-time student
No one in household is pregnant
Application filer is a U.S. citizen, not naturalized or
Yes
Yes

Item 22

UI Question Companion Guide
Reference
Tab: UI Questions

Auditor Checklist

Application State & Coverage Year
AZ, AR, DE, HI, IL, IN, IA, LA, MI, MT, NE, NH, ND, OH, OK,
OR, UT, VA, WV
Current year
Screening Questions
Single
0
Application filer
Yes

Items 23, 25

Pass Screener?

Notes to testers

N/A (should not display)

N/A (should not display)
Screening Pass/Fail
Yes, continue with application

Household Member Input
Household

Items 4, 28 Name
Item 5 Home address
Items 7, 8 Mailing address
Item 10 Preferred language

Household member

*Do not use Rivers as the last name. Use a different
last name that is unique (it can be a random string of
letters). Do not change the first name

Gerald Rivers *
Age: 20
Male

Must provide a valid county and zip code for the
application state
Use any date of birth that results in the correct age
for each household member
Other household contact and information fields (i.e.
email, phone, language preference, race/ethnicity,
etc.) may contain any value unless otherwise noted.
Find additional information in the UI Question
Companion Guide:
- Items 4, 5, 7, 8, 9 Household Contact Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-applicant
information - Race and Ethnicity

Item 28
Items 27, 29
Item 32

Application Filer/Relationship to
Application Filer
Applicant/Non-Applicant
SSN

Items 131, 132

Non-MAGI Medicaid Eligibility Questions
(physical disabilities, assistance with daily
living, nursing home care)

Items 133, 134, 136, 138

Medicaid/CHIP Denial

Application Filer
Applicant
317-20-1405

SSN must be entered exactly for test case to function

More About This Household
Do not answer affirmatively to any non-MAGI questions

Medicaid Block
Does not have Medicaid that recently ended or will end
soon

The date provided should be within the last 60 days

Denied Medicaid/CHIP in the last 90 days
Provide date within the last 60 days;
Answer "Yes" to question: "Did you apply for coverage
during November 1, 2022 to January 15, 2023?"
Income

Items 153, 154, 155, 209

Current Month Income

Job: $1,417 per month

Item 174
Items 181, 182, 183

Deductions
Annual Income

Item 186

Income Discrepancy

Item 191
Items 213, 218, 223

Current coverage
Recent Life Changes (SEPs)

No deductions
Disagree with calculated annual income;
Income is not hard to predict;
Attest to $15,750
Answer "Household members have changed" to question
"Gerald's household income in [coverage year] seems like
it will be lower than what our records from the past 2
years show. Is there a reason why?"
Program Questions
None
None of these changes
Attestations

Check Item 138: Verify Medicaid recently
ended or ending soon is asked before
Medicaid denial
Check Item 134: Verify that a date greater
than 90 days in the past is not allowed as an
answer

Employer name (and phone number, where Item 209
is included) fields are required but any value may be
entered (ex: ABC corp; 555-555-5555)

Items 246, 252, 254, 255, 256,
258

Reference Materials
UI Q CG Eligibility Results Tab:
Items 1, 4, 5
Sample HealthCare.gov Eligibility
Results Messaging

Application Review & Legal Attestations

Eligibility Results Page (ERP)

Answers affirmatively to all application attestations

Eligibility Results
Eligible to buy a Marketplace plan with a premium tax
credit of up to [amount] each month for your tax
household
Eligible for lower copayments, coinsurance, and
deductibles (cost-sharing reductions) on Silver plans
Eligible for a Special Enrollment Period

Auditors should review the application review page
(Item 246) to ensure all information accurately
reflects the attestations inputted during the test
case
Auditors should review the Eligibility Results Page to Check Eligibility Results Tab, Item 4: Verify UI
displays exact language "What should I do if I
ensure it accurately reflects the eligibility results
think my eligibility results are wrong?"
found in the EDN and complies with ERP messaging
requirements outlined in the documentation listed in
Column A

Summary: This scenario demonstrates proper functionality of the screener tool for an unmarried parent seeking coverage and financial assistance for three tax dependents in any state. The
application filer also lives with a domestic partner, which requires use of an alternative pathway only because that domestic partner is the parent of one or more of the application filer’s tax
dependents. Therefore the application filer should answer “Yes” to the screener question which asks whether their dependents live with a parent who’s not on his/her tax return. Upon doing
so, they should be directed to an alternative pathway.
UI Question Companion
Guide Reference
Tab: UI Questions
Item 1
Item 2
Tab: Phase 1 Screening
Item 1
Item 2
Item 3
Item 5
Items 4, 6, 7 (depending on
implementation)
Item 8

Application Data

Application Input

Any state
Current year

Marital Status
Number of tax dependents
Who is applying for coverage?
Seeking financial assistance?

Screening Questions
Single
3
Application filer, 3 dependents
Yes

Item 11
Item 12

Tax filing status
Responsible for a child 18 or younger not on
tax return
Full-time student
Pregnant

Items 14, 17

Citizenship

All applicants are U.S. citizens, not naturalized or derived

Item 15
Item 16

Can provide SSN
All applicants can provide SSN
Applying with same name as name on SSN card All applicants are applying with name same as the name
on their SSN card
Incarceration
No applicants are incarcerated
American Indian/Alaska Native
No one in household has AI/AN status
Offer of individual coverage HRA (ICHRA) or a No applicants have an ICHRA or QSEHRA offer
qualified small employer Health
Reimbursement Arrangement (QSEHRA)
Offer of coverage through job or COBRA
No applicants have access to coverage through a job or
COBRA

Item 18
Item 19
Item 27

Item 20

Item 21
Item 22
Items 23, 25
Item 26

Auditor Checklist

Application State & Coverage Year
State
Coverage Year

Yes, all household members live at same address in
application state
Filing taxes
No one in household is responsible for a child 18 or
younger who they live with but isn't on their tax return
No one in household is a full-time student
No one in household is pregnant

Item 9
Item 10

Notes to Testers

Resides in application state

Former foster care
Claiming all dependents on tax return
Dependent is child, single (not married), 25 or
younger, not step child or grandchild
Dependents live with parent not on tax return

Must provide a valid zip code for the application state

Check Item 12: The question should be written as
or similarly to "Is anyone pregnant?" since there is
more than one household member on the
application

Check Item 20: The question should be written as
or similarly to "Are any of you offered health
coverage through your job, someone else's job, or
COBRA?" since there are more than two
applicants on the application

No applicants are former foster care
Yes
Yes
Yes

This scenario is not supported by Phase 1
applications. This answer will result in the consumer
being redirected to an alternate pathway
Screening Pass/Fail

Pass Screener?

No, consumer should be guided to alternate pathway and When a consumer fails the screening questions, the
should not complete the application
UI should redirect the consumer to HealthCare.gov or
a Direct Enrollment pathway and display consumer
friendly language as to why they cannot continue the
application on the entity site

Summary: This test case demonstrates the screener tool UI and functionality for a consumer not applying for financial assistance. In this scenario, an unmarried consumer in any state
with no dependents completes the screener on the EDE entity site. Although this consumer is a U.S. citizen, they were not born in the U.S. and became naturalized as a U.S. citizen in the
1990s. On the screener tool, when the consumer answers the question about naturalized citizenship accurately, they should be redirected to an alternative pathway.
UI Question Companion
Guide Reference
Tab: UI Questions
Item 1
Item 2
Tab: Phase 1 Screening
Item 1
Item 2
Item 3
Item 5
Items 4, 6, 7 (depending on
implementation)
Item 8
Item 9
Item 10
Item 11
Item 12
Items 14, 17

Item 15
Item 16
Item 18
Item 19
Item 27

Item 20
Item 21
Item 22
Items 23, 25
Item 26

Application Data

Application Input

Marital Status
Number of tax dependents
Who is applying for coverage?
Seeking financial assistance?

Application State & Coverage Year
Any state
Current Year
Screening Questions
Single
0
Application filer
No

Resides in application state

Application filer lives in application state

Tax filing status
Responsible for a child 18 or younger not on tax
return
Full-time student
Pregnant
Citizenship

N/A (should not display)
N/A (should not display)

Can provide SSN
Applying with same name as name on SSN card
Incarceration
American Indian/Alaska Native
Offer of individual coverage HRA (ICHRA) or a
qualified small employer Health Reimbursement
Arrangement (QSEHRA)
Offer of coverage through job or COBRA
Former foster care
Claiming all dependents on tax return
Dependent is child, single (not married), 25 or
younger, not step child or grandchild
Dependents live with parent not on tax return

Yes
Yes
Not incarcerated
No one in household has AI/AN status
Does not have an ICHRA or QSEHRA offer

State
Coverage Year

Pass Screener?

N/A (should not display)
N/A (should not display)
Application filer was born outside of the U.S.
and is a naturalized citizen

Notes to Testers

Auditor Checklist

Must provide a valid zip code for the application
state

This scenario is not supported by Phase 1
applications. This answer will result in the consumer
being redirected to an alternate pathway

N/A (should not display)
N/A (should not display)
N/A (should not display)
N/A (should not display)
N/A (should not display)
Screening Pass/Fail
No, consumer should be guided to alternate
pathway and should not complete the
application

When a consumer fails the screening questions, the Verify consumer is guided to an alternate
UI should redirect the consumer to HealthCare.gov pathway with consumer friendly language
or a Direct Enrollment pathway and display
consumer friendly language as to why they cannot
continue the application on the entity site

Summary: This test case demonstrates functionality for a mixed eligibility household with multiple income and deduction types, other health coverage, and a Move SEP. In a three member household financial assistance
application, one member is determined eligible for QHP with a Move SEP, APTC, and CSRs, one member determined eligible for QHP with a Move SEP and without subsidy, and the child is assessed as eligible for Medicaid. This
test case must be run in NH, zip code 03301.
UI Question Companion
Guide Reference
Tab: UI Questions
Item 1
Item 2
Tab: Phase 1 Screening
Item 1
Item 2
Item 3
Item 5
Items 4, 6, 7 (depending on
implementation)

Application Data

Notes to Testers

Application Input
Application State & Coverage Year

State
Coverage Year

NH, zip code 03301
Current year

Marital Status
Number of tax dependents
Who is applying for coverage?
Seeking financial assistance?

Married
1
Application filer, spouse, dependent
Yes

Item 8

Resides in application state

Yes, all household members live at same address in application state, 03301

Item 9
Item 10

Tax filing status
Responsible for a child 18 or younger
not on tax return
Full-time student
Pregnant
Citizenship
Can provide SSN
Applying with same name as name on
SSN card
Incarceration
American Indian/Alaska Native
Offer of individual coverage HRA
(ICHRA) or a qualified small employer
Health Reimbursement Arrangement
(QSEHRA)
Offer of coverage through job or
COBRA
Former foster care
Claiming all dependents on tax return

Filing jointly
No one in household is responsible for a child 18 or younger who they live with but isn't on their tax return

Dependent is child, single (not
married), 25 or younger, not step
child or grandchild
Dependents live with parent not on
tax return

Yes

Pass screener?

Yes, continue with application

Item 11
Item 12
Items 14, 17
Item 15
Item 16
Item 18
Item 19
Item 27

Item 20
Item 21
Item 22
Items 23, 25

Item 26

Auditor Checklist

Screening Questions

This test case requires use of zip code 03301 in
state of NH

No one in household is a full-time student
No one in household is pregnant
All applicants are U.S. citizens, not naturalized or derived
All applicants can provide SSN
All applicants are applying with name same as the name on their SSN card
No applicants are incarcerated
No one in household has AI/AN status
No applicants have an ICHRA or QSEHRA offer

No applicants have access to coverage through a job or COBRA
No applicants are former foster care
Yes

No
Screening Pass/Fail

UI Question Companion
Guide Reference
Tab: UI Questions

Application Data

Household Member Input

Household Member Input
Household

Household Member Input

Notes to Testers

Auditor Checklist

Items 4, 28 Name
Item 5 Home address
Items 7, 8 Mailing address
Item 10 Preferred language

Household member

Bobby Alva Jones *
Age: 55
Male

Roxy Verna Jones *
Age: 51
Female

Amber Amy Jones *
Age: 10
Female

*Do not use Jones as the last name. Use a
different last name that is unique (it can be a
random string of letters). Do not change the first
name
Provide zip code 03301
Use any date of birth that results in the correct
age for each household member
Other household contact and information fields
(i.e. email, phone, language preference,
race/ethnicity, etc.) may contain any value unless
otherwise noted. Find additional information in
the UI Question Companion Guide:
- Items 4, 5, 7, 8, 9 Household Contact
Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-applicant
information - Race and Ethnicity

Item 28
Items 27, 29
Item 32

Application Filer/Relationship to
Application Filer
Applicant/Non-Applicant
SSN

Application Filer

Spouse

Son/Daughter

Applicant
276-72-8793

Applicant
276-72-9990

Applicant
276-74-0252

Do not answer affirmatively to
any non-MAGI questions

More About This Household
Do not answer affirmatively to
Do not answer affirmatively to any
any non-MAGI questions
non-MAGI questions

Items 131, 132

Non-MAGI Medicaid Eligibility
Questions (physical disabilities,
assistance with daily living, nursing
home care)

Items 133, 138

Medicaid/CHIP Denial

Items 153, 154, 155, 209

Current Month Income

Job: $1,550.07 per month
Job: $429.93 per month
Job: $99.37 per week

Items 174, 175, 176
Item 181

Deductions
Annual Income

Alimony: $197.77 per month
$26,550.03

Items 191, 192, 195

Current coverage

None

No deductions
No deductions
$26,546.04
$0
Program Questions
TRICARE
None

Item 239

Help paying for medical bills

N/A (should not display for this
household member)

N/A (should not display for this
household member)

Do not answer affirmatively

Recently moved;
Provide zip code in a different
county than zip code provided in
home address;
Provide date within last 60 days;
Attest "Yes" to prior coverage
question

None of these changes

N/A (should not display for this
household member)

Items 213, 218, 223, 231, 232, Recent Life Changes (SEPs)
233, 234

Medicaid Block
Does not have Medicaid/CHIP
Does not have Medicaid/CHIP
that recently ended or will end
that recently ended or will end
soon; Not denied Medicaid/CHIP soon; Not denied Medicaid/CHIP
Income
Job: $2,212.17 per month

Attestations

SSN must be entered exactly for test case to
function

Does not have Medicaid/CHIP that
recently ended or will end soon; Not
denied Medicaid/CHIP
No income

Employer name (and phone number, where Item
209 is included) fields are required but any value
may be entered (ex: ABC corp; 555-555-5555)

Check Item 195: Verify policy number and
Member ID are optional
Check Item 239: Verify "Would any of these
people like help paying for medical bills
from the last 3 months?" only displays for
Amber because she is prelim Medicaid
eligible
If a date outside of the last 60 days is entered,
then an error message will appear

Items 246, 247, 252, 254, 255, Application Review & Legal
256, 258
Attestations

Answers affirmatively to all other application attestations

Reference Materials
UI Q CG Eligibility Results Tab: Eligibility Results Page (ERP)
Items 1, 3, 4, 5

Eligibility Results
Eligible to buy a Marketplace plan Eligible to buy a Marketplace plan May be eligible for Medicaid
with a premium tax credit of up to
$421 each month for your tax
Eligible for a Special Enrollment
household
Period

Sample HealthCare.gov
Eligibility Results Messaging

Eligible for lower copayments,
coinsurance, and deductibles
(cost-sharing reductions) on Silver
plans
Eligible for a Special Enrollment
Period

Auditors should review the application review
page (Item 246) to ensure all information
accurately reflects the attestations inputted
during the test case
Auditors should review the Eligibility Results Page Check Eligibility Results Tab, Item 5: Verify
to ensure it accurately reflects the eligibility
UI displays link to voter registration
results found in the EDN and complies with ERP
messaging requirements outlined in the
documentation listed in Column A

Summary: This test case verifies that the EDE Entity can support a five member household financial assistance application, and successfully grants QHP eligibility with correct subsidy amounts for Member 1, Member 3, Member 4, and Member 5, with Member 2 not seeking health
insurance coverage. This test case must be run in SC, zip code 29401.
UI Question Companion Guide
Reference
Tab: UI Questions
Item 1
Item 2
Tab: Phase 1 Screening
Item 1
Item 2
Item 3
Item 5
Items 4, 6, 7 (depending on
implementation)
Item 8
Item 9
Item 10
Item 11
Item 12
Items 14, 17

Item 15
Item 16
Item 18
Item 19
Item 27

Item 20
Item 21
Item 22
Items 23, 25

Item 26

Application Data

Notes to Testers

Application Input

State
Coverage Year

SC, zip code 29401
Current year

Marital Status
Number of tax dependents
Who is applying for coverage?
Seeking financial assistance?

Married
3 dependents
Application filer, 3 dependents
Yes

Resides in application state

Yes, all household members live at same address in application state, 29401

Tax filing status
Responsible for a child 18 or
younger not on tax return
Full-time student
Pregnant
Citizenship

Filing jointly
No one in household is responsible for a child 18 or younger who they live with but isn't on their tax return

Can provide SSN
Applying with same name as name
on SSN card
Incarceration
American Indian/Alaska Native
Offer of individual coverage HRA
(ICHRA) or a qualified small
employer Health Reimbursement
Arrangement (QSEHRA)
Offer of coverage through job or
COBRA
Former foster care
Claiming all dependents on tax
return
Dependent is child, single (not
married), 25 or younger, not step
child or grandchild
Dependents live with parent not on
tax return

All applicants can provide SSN
All applicants are applying with name same as the name on their SSN card

Pass screener?

Yes, continue with application

Screening Questions

UI Question Companion Guide
Application Data
Reference
Tab: UI Questions
Items 4, 28 Name
Household member
Item 5 Home address
Items 7, 8 Mailing address
Item 10 Preferred language

Test case requires use of zip code 29401 in state
of SC

No one in household is a full-time student
No one in household is pregnant
All applicants are U.S. citizens, not naturalized or derived

Check Item 14: The question should be written
as or similarly to "Are all of you U.S. citizens?"
because there are more than two household
members on the application

No applicants are incarcerated
No one in household has AI/AN status
No applicants have an ICHRA or QSEHRA offer

No applicants have access to coverage through a job or COBRA
No applicants are former foster care
Yes
Yes

No

Household Member Input

Laila Simon *
Age: 38
Female

Screening Pass/Fail

Household Member Input

William Simon *
Age: 38
Male

Household Member Input

Finley Simon *
Age: 16
Male

Household

Household Member Input

Princeton Simon *
Age: 10
Male

Household Member Input

Alexzander Carl Simon * IV
Age: 11
Male

Notes to Testers

*Do not use Simon as the last name. Use a
different last name that is unique (it can be a
random string of letters). Do not change the first
name
Provide zip code 29401
Use any date of birth that results in the correct
age for each household member
Other household contact and information fields
(i.e. email, phone, language preference,
race/ethnicity, etc.) may contain any value
unless otherwise noted.
Find additional information in the UI Question
Companion Guide:
- Items 4, 5, 7, 8, 9 Household Contact
Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-applicant
information - Race and Ethnicity

Item 28

Auditor Checklist

Application State & Coverage Year

Application Filer/Relationship to
Application Filer

Application Filer

Spouse

Son/Daughter

Son/Daughter

Son/Daughter

Auditor Checklist

Items 27, 29
Items 32, 34

Applicant/Non-Applicant
SSN

Applicant
292-62-0994

Non-Applicant
292-62-1254

Items 131, 132

Non-MAGI Medicaid Eligibility
Do not answer affirmatively to N/A (should not display for
Questions (physical disabilities,
any non-MAGI questions
this household member)
assistance with daily living, nursing
home care)

Items 133, 138

Medicaid/CHIP Denial

Items 153, 154, 155, 209

Current Month Income

Item 174
Item 181

Deductions
Annual Income

No deductions
$57,560.04

No deductions
$57,559.92

Item 191

Current coverage

None

N/A (should not display for
this household member)

Items 213, 218, 223

Recent Life Changes (SEPs)

None of these changes

N/A (should not display for
this household member)

Does not have Medicaid/CHIP N/A (should not display for
that recently ended or will end this household member)
soon; Not denied
Medicaid/CHIP

Job: $4,796.67 per month

Job: $4,796.66 per month

Applicant
292-62-7192

Applicant
292-66-0653

More About This Household
Do not answer affirmatively to Do not answer affirmatively to
any non-MAGI questions
any non-MAGI questions

Medicaid Block
Does not have Medicaid/CHIP
Does not have Medicaid/CHIP
that recently ended or will end that recently ended or will end
soon; Not denied Medicaid/CHIP soon; Not denied
Medicaid/CHIP
Income
No income
No income

Applicant
292-66-1450

Do not answer affirmatively to
any non-MAGI questions

No income

None

None of these changes

None of these changes

Employer name (and phone number, where Item Check Items 153, 154, and 155: Verify that
209 is included) fields are required but any value William (non-applicant) is an answer option and
may be entered (ex: ABC corp; 555-555-5555)
allowed to attest to income

No deductions
$0

Attestations

Auditors should review the application review
page (Item 246) to ensure all information
accurately reflects the attestations inputted
during the test case

Items 246, 252, 254, 255, 256,
258

Application Review & Legal
Attestations

Answers affirmatively to all application attestations

Reference Materials
UI Q CG Eligibility Results Tab:
Items 1, 3, 4, 5

Eligibility Results Page (ERP)

Eligible to buy a Marketplace
N/A
plan with a premium tax credit
of up to $605 each month for
your tax household

Eligibility Results
Eligible to buy a Marketplace
plan with a premium tax credit
of up to $605 each month for
your tax household

Eligible to buy a Marketplace
plan with a premium tax credit
of up to $605 each month for
your tax household

Eligible to buy a Marketplace
plan with a premium tax credit
of up to $605 each month for
your tax household

Not eligible for a Special
Enrollment Period*

Not eligible for a Special
Enrollment Period*

Not eligible for a Special
Enrollment Period*

Not eligible for a Special
Enrollment Period*

Sample HealthCare.gov
Eligibility Results Messaging

Check Item 131: Verify that William (nonapplicant) does not display as answer option

Does not have Medicaid/CHIP
that recently ended or will end
soon; Not denied
Medicaid/CHIP

No deductions
No deductions
$0
$0
Program Questions
None
None
None of these changes

SSN must be entered exactly for test case to
function

Auditors should review the Eligibility Results
Page to ensure it accurately reflects the
eligibility results found in the EDN and complies
with ERP messaging requirements outlined in
the documentation listed in Column A
*Optional to display if consumer is not eligible
for Special Enrollment Period

Summary: This scenario includes a four member household financial assistance application with multiple income and deduction types, where one member attests to having other non-MEC health coverage. The result is QHP with APTC for two (2) members and
Medicaid for two (2) members. This test case must be run in NH, zip code 03301.
UI Question Companion Guide
Application Data
Reference
Tab: UI Questions
Item 1
State
Item 2
Coverage Year
Tab: Phase 1 Screening

Application Input

NH, zip code 03301
Current Year

Screening Questions

Marital Status
Number of tax dependents

Item 3
Item 5
Items 4, 6, 7 (depending on
implementation)
Item 8

Who is applying for coverage? Application filer, spouse, 2 dependents
Yes
Seeking financial assistance?

Resides in application state

Yes, all household members live at same address in application state, 03301

Item 9
Item 10

Tax filing status
Responsible for a child 18 or
younger not on tax return
Full-time student
Pregnant
Citizenship
Can provide SSN
Applying with same name as
name on SSN card
Incarceration
American Indian/Alaska Native

Filing jointly
No one in household is responsible for a child 18 or younger who they live with but isn't on their tax return

Offer of individual coverage
HRA (ICHRA) or a qualified small
employer Health
Reimbursement Arrangement
(QSEHRA)
Offer of coverage through job
or COBRA
Former foster care
Claiming all dependents on tax
return

No applicants have an ICHRA or QSEHRA offer

Item 18
Item 19
Item 27

Item 20
Item 21
Item 22

Items 23, 25

Item 26

This test case requires use of zip code 03301 in state of
NH

No one in household is a full-time student
No one in household is pregnant
All applicants are U.S. citizens, not naturalized or derived
All applicants can provide SSN
All applicants are applying with name same as the name on their SSN card
No applicants are incarcerated
No one in household has AI/AN status

No applicants have access to coverage through a job or COBRA
No applicants are former foster care
Yes

Check Item 22: This question should
be worded as or similarly to "Will you
claim all of them as dependents on
your federal income tax return for
[coverage year]?" because there is
more than one dependent on the
application

Dependent is child, single (not Yes
married), 25 or younger, not
step child or grandchild
No
Dependents live with parent
not on tax return
Pass screener?

UI Question Companion Guide
Reference
Tab: UI Questions

Auditor Checklist

Married
2

Item 1
Item 2

Item 11
Item 12
Items 14, 17
Item 15
Item 16

Notes to Testers

Application State & Coverage Year

Application Data

Screening Pass/Fail

Yes, continue with application

Household Member Input

Household Member Input

Household Member Input
Household

Household Member Input

Notes to Testers

Auditor Checklist

Items 4, 28 Name
Item 5 Home address
Items 7, 8 Mailing address
Item 10 Preferred language

Household member

Soren M Sharp *
Age: 31
Male

Mia Sharp *
Age: 31
Female

Christian Matthew Sharp *
Age: 9
Male

Monika Leila Sharp *
Age: 6
Female

*Do not use Sharp as the last name. Use a different last
name that is unique (it can be a random string of
letters). Do not change the first name
Provide zip code 03301
Use any date of birth that results in the correct age for
each household member
Other household contact and information fields (i.e.
email, phone, language preference, race/ethnicity, etc.)
may contain any value unless otherwise noted. Find
additional information in the UI Question Companion
Guide:
- Items 4, 5, 7, 8, 9 Household Contact Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-applicant
information - Race and Ethnicity

Item 28
Items 27, 29
Item 32

Application Filer/Relationship
to Application Filer
Applicant/Non-Applicant
SSN

Application Filer

Spouse

Applicant
276-98-1152

Applicant
276-98-1693

Items 131, 132

Non-MAGI Medicaid Eligibility Do not answer affirmatively to
Questions (physical disabilities, any non-MAGI questions
assistance with daily living,
nursing home care)

Items 133, 138

Medicaid/CHIP Denial

Items 153, 154, 155, 209

Current Month Income

Job: $2,982.39 per month

Items 174, 175, 177

Deductions

Item 181

Son/Daughter

Applicant
276-98-1793
More About This Household
Do not answer affirmatively to
Do not answer affirmatively to
any non-MAGI questions
any non-MAGI questions

Son/Daughter
Applicant
276-98-4751

SSN must be entered exactly for test case to function

Do not answer affirmatively to
any non-MAGI questions

Medicaid Block
Does not have Medicaid/CHIP
Does not have Medicaid/CHIP
Does not have Medicaid/CHIP
Does not have Medicaid/CHIP
that recently ended or will end
that recently ended or will end
that recently ended or will end that recently ended or will end
soon; Not denied Medicaid/CHIP soon; Not denied Medicaid/CHIP soon; Not denied Medicaid/CHIP soon; Not denied Medicaid/CHIP
Income
No income

No income

Student Loan: $214.88 per month No deductions

No deductions

No deductions

Annual Income

$33,210.12

$36,165.00

$0

Items 191, 192, 197

Current Coverage

None

None

Check Item 192: Verify all coverage
options display

Item 239

Help Paying For Medical Bills

Other full benefit coverage;
Name of health plan: ABC plan;
Policy number: #12345678
N/A (should not display for this
household member)

$0
Program Questions
None

N/A (should not display for this
household member)

Do not answer affirmatively

Do not answer affirmatively

Check Item 239: Verify Soren and Mia
are not answer options because they
are preliminary QHP eligible

Items 213, 218, 223

Recent Life Changes (SEPs)

None of these changes

None of these changes

N/A (should not display for this
household member)

N/A (should not display for this
household member)

Items 246, 247, 252, 254, 255,
256, 258

Application Review & Legal
Attestations

Answers affirmatively to all application attestations

Reference Materials
UI Q CG Eligibility Results Tab:
Items 1, 3, 4, 5

Eligibility Results Page (ERP)

Eligible to buy a Marketplace plan
with a premium tax credit of up to
$355 each month for your tax
household

Eligibility Results
Eligible to buy a Marketplace plan May be eligible for Medicaid
with a premium tax credit of up to
$355 each month for your tax
household

Eligible for lower copayments,
coinsurance, and deductibles
(cost-sharing reductions) on Silver
plans

Eligible for lower copayments,
coinsurance, and deductibles
(cost-sharing reductions) on Silver
plans

Not eligible for a Special

Not eligible for a Special

Sample HealthCare.gov Eligibility
Results Messaging

Job: $3,013.75 per month

Attestations

Employer name (and phone number, where Item 209 is
included) fields are required but any value may be
entered (ex: ABC corp; 555-555-5555)
Check Item 175, column G: Verify all
expenses are listed as answer options

Auditors should review the application review page
(Item 246) to ensure all information accurately reflects
the attestations inputted during the test case
May be eligible for Medicaid

Auditors should review the Eligibility Results Page to
ensure it accurately reflects the eligibility results found
in the EDN and complies with ERP messaging
requirements outlined in the documentation listed in
Column A
*Optional to display if consumer is not eligible for
Special Enrollment Period

Summary: This scenario includes a five member household financial assistance application, where the household's income places a child within CHIP range in a state with a CHIP waiting period. Two of the children are referred to Medicaid while one is granted APTC and CSR while in the CHIP waiting period due to the answers to
the CHIP waiting period exceptions question. This test case must be run in TX, zip code 77001.
UI Question Companion Guide
Reference

Application Input

Application Data

Item 1
State
Item 2
Coverage Year
Tab: Phase 1 Screening Questions

TX, zip code 77001
Current year

Item 1
Item 2
Item 3
Item 5
Items 4, 6, 7 (depending on
implementation)
Item 8

Marital Status
Number of tax dependents
Who is applying for coverage?
Seeking financial assistance?

Married
3
Application filer, spouse, 3 dependents
Yes

Resides in application state

Yes, all household members live at same address in application state, 77001

Item 9
Item 10

Tax filing status
Responsible for a child 18 or
younger not on tax return
Full-time student
Pregnant
Citizenship
Can provide SSN
Applying with same name as name
on SSN card
Incarceration
American Indian/Alaska Native

Filing jointly
No one in household is responsible for a child 18 or younger who they live with but isn't on their tax return

Item 27

Offer of individual coverage HRA
(ICHRA) or a qualified small
employer Health Reimbursement
Arrangement (QSEHRA)

No applicants have an ICHRA or QSEHRA offer

Item 20

Offer of coverage through job or
COBRA
Former foster care
Claiming all dependents on tax
return
Dependent is child, single (not
married), 25 or younger, not step
child or grandchild
Dependents live with parent not on
tax return

No applicants have access to coverage through a job or COBRA

Pass screener?

Yes, continue with application

Item 11
Item 12
Items 14, 17
Item 15
Item 16
Item 18
Item 19

Item 21
Item 22
Items 23, 25

Item 26

Notes to Testers

Auditor Checklist

Application State & Coverage Year

Tab: UI Questions

Screening Questions

This test case requires use of zip code 77001 in state
of TX

No one in household is a full-time student
No one in household is pregnant
All applicants are U.S. citizens, not naturalized or derived
All applicants can provide SSN
All applicants are applying with name same as the name on their SSN card
No applicants are incarcerated
No one in household has AI/AN status

No applicants are former foster care
Yes
Yes

No
Screening Pass/Fail

UI Question Companion Guide
Reference
Tab: UI Questions
Items 4, 28 Name
Item 5 Home address
Items 7, 8 Mailing address
Item 10 Preferred language

Application Data

Household Member Input

Household Member Input

Household Member Input

Household Member Input

Household Member Input

Notes to Testers

Household
Household member

Kylan Isaac Dickson *
Age: 34
Male

Kathryn Elizabeth Dickson *
Age: 34
Female

Phoenix Dickson *
Age: 2
Female

Keira Dickson *
Age: 4
Female

Zaara Leona Dickson *
Age: 6
Female

*Do not use Dickson as the last name. Use a different
last name that is unique (it can be a random string of
letters). Do not change the first name
Provide zip code 77001
Use any date of birth that results in the correct age
for each household member
Other household contact and information fields (i.e.
email, phone, language preference, race/ethnicity,
etc.) may contain any value unless otherwise noted.
Find additional information in the UI Question
Companion Guide:
- Items 4, 5, 7, 8, 9 Contact Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-applicant
information - Race and Ethnicity

Item 28
Items 27, 29
Item 32

Items 131, 132

Application Filer/Relationship to
Application Filer
Applicant/Non-Applicant
SSN

Application Filer

Spouse

Son/Daughter

Son/Daughter

Son/Daughter

Applicant
278-03-1454

Applicant
278-03-4151

Applicant
278-03-8550

Applicant
278-04-0190

Applicant
278-04-4990

More About This Household
Do not answer affirmatively to any non- Do not answer affirmatively to any non- Do not answer affirmatively to any non- Do not answer affirmatively to any non- Do not answer affirmatively to any
Non-MAGI Medicaid Eligibility
MAGI questions
MAGI questions
MAGI questions
MAGI questions
non-MAGI questions
Questions (physical disabilities,
assistance with daily living, nursing
home care)

SSN must be entered exactly for test case to function

Auditor Checklist

Does not have Medicaid/CHIP that
recently ended or will end soon; Not
denied Medicaid/CHIP

Items 133, 138

Medicaid/CHIP Denial

Does not have Medicaid/CHIP that
recently ended or will end soon; Not
denied Medicaid/CHIP

Items 153, 154, 155, 159, 209

Current Month Income

Items 174, 175, 178
Items 181

Deductions
Annual Income

Job: $742.04 per month
Job: $2,744.38 per month
Self-employment: $859.31, profit, per
month
Other: $128.90 per month
No deductions
$41,697.48
$8,904.48

Medicaid Block
Does not have Medicaid/CHIP that
recently ended or will end soon; Not
denied Medicaid/CHIP
Income
No income

No deductions
$0

Does not have Medicaid/CHIP that
recently ended or will end soon; Not
denied Medicaid/CHIP

Does not have Medicaid/CHIP that
recently ended or will end soon; Not
denied Medicaid/CHIP

No income

No income

No deductions
$0

No deductions
$0
None
N/A (should not display for this
household member)
Answer "Yes" to "Did Zaara have
coverage through a job that ended in
the last three months?";
Reason for coverage ending: "Other"

Employer name (and phone number, where Item 209 Check Item 154, Column G: Verify all
is included) fields are required but any value may be income types are listed as answer
entered (ex: ABC corp; 555-555-5555)
options

Program Questions
TRICARE
N/A (should not display for this
household member)
N/A (should not display for this
household member)

Medicare
N/A (should not display for this
household member)
N/A (should not display for this
household member)

None
Do not answer affirmatively

None
Do not answer affirmatively

N/A (should not display for this
household member)

N/A (should not display for this
household member)

Recent Life Changes (SEPs)

Got Married
Provide a date within the last 60 days;
Answer "Yes" to prior coverage
question

Got Married
Provide a date within the last 60 days;
Answer "Yes" to prior coverage
question

N/A (should not display for this
household member)

N/A (should not display for this
household member)

Items 246, 247, 252, 254, 255,
256, 258

Application Review & Legal
Attestations

Answers affirmatively to all application attestations

Reference Materials
UI Q CG Eligibility Results Tab:
Items 1, 3, 4, 5

Eligibility Results Page (ERP)

Eligible to buy a Marketplace plan

Items 191, 192, 194, 195
Item 239

Current coverage
Help paying for medical bills

Items 243, 244

CHIP waiting period questions

Items 213, 218, 223, 225, 226

Check Items 243 and 244: Verify only
Zaara is listed as an answer option for
Item 243, and that all reasons for
coverage ending in Item 244, column
G are displayed

None of these changes

Attestations

Sample HealthCare.gov Eligibility
Results Messaging

Eligible to buy a Marketplace plan

Eligible for a Special Enrollment Period Eligible for a Special Enrollment Period

Auditors should review the application review page
(Item 246) to ensure all information accurately
reflects the attestations inputted during the test
case
Eligibility Results
May be eligible for Medicaid

May be eligible for Medicaid

Eligible to buy a Marketplace plan
with a premium tax credit of up to
$267 each month for your tax
household
Eligible for lower copayments,
coinsurance, and deductibles (costsharing reductions) on Silver plans

Auditors should review the Eligibility Results Page to
ensure it accurately reflects the eligibility results
found in the EDN and complies with ERP messaging
requirements outlined in the documentation listed in
Column A

Verify all the information on the
application review page accurately
reflects the attestations inputted
during the test case

Summary: This test case verifies the ability for the EDE Entity UI to handle a complex scenario in which a nine (9) member household is applying for financial assistance in Virginia. The application contains multiple income and deduction types, current coverage, multiple SEPs, and attestations to physical disabilities and assistance with daily living that result in determinations of QHP without subsidy, QHP with APTC and CSR, and
CHIP eligibility for the family members. The test case must be run in VA with zip code 22032 (Fairfax County).
UI Question Companion Guide
Reference
Tab: UI Questions
Item 1

Application Data

State

VA, zip code 22032, county Fairfax

Coverage Year

Current year

Marital Status
Number of tax dependents

Married
7

Item 3

Who is applying for coverage?

Application filer, spouse, 7 dependents

Item 5
Items 4, 6, 7 (depending on
implementation)
Item 8

Seeking financial assistance?

Yes

Resides in application state

Yes, all household members live at same address in application state, 22032

Item 9
Item 10

Tax filing status
Responsible for a child 18 or
younger not on tax return
Full-time student
Pregnant
Citizenship
Can provide SSN
Applying with same name as
name on SSN card
Incarceration
American Indian/Alaska Native

Filing jointly
No one in household is responsible for a child 18 or younger who they live with but isn't on their tax return

Item 18
Item 19
Item 27

Item 20

Offer of individual coverage
HRA (ICHRA) or a qualified
small employer Health
Reimbursement Arrangement
(QSEHRA)
Offer of coverage through job
or COBRA

No applicants have an ICHRA or QSEHRA offer

No applicants have access to coverage through a job or COBRA
No applicants are former foster care

Item 22

Claiming all dependents on tax Yes
return
Dependent is child, single (not Yes
married), 25 or younger, not
step child or grandchild

UI Question Companion Guide
Reference
Tab: UI Questions
Items 4, 28 Name
Item 5 Home address
Items 7, 8 Mailing address
Item 10 Preferred language

Dependents live with parent
not on tax return

No

Pass screener?

Yes, continue with application

Application Data

Household member

This test case requires use of zip code 22032 (Fairfax
County) in state of VA

No applicants are incarcerated
No one in household has AI/AN status

Former foster care

Item 26

Screening Questions

No one in household is a full-time student
No one in household is pregnant
All applicants are U.S. citizens, not naturalized or derived
All applicants can provide SSN
All applicants are applying with name same as the name on their SSN card

Item 21

Items 23, 25

Auditor Checklist

Application State & Coverage Year

Item 2
Tab: Phase 1 Screening
Item 1
Item 2

Item 11
Item 12
Items 14, 17
Item 15
Item 16

Notes to Testers

Application Input

Household Member Input

Clayton Morgan *
Age: 38
Male

Check Item 23: The question should be written as
or similarly to "Are all of them your children who
are single (not married) and 25 or younger?" since
there is more than one dependent on the
application

Screening Pass/Fail

Household Member Input

Alba Morgan *
Age: 38
Female

Household Member Input

Ayva Morgan *
Age: 6
Female

Household Member Input

Safiyah Nina Morgan *
Age: 8
Female

Household Member Input

Daphne Morgan *
Age: 10
Female

Household Member Input

Household
Hareem Christina Morgan *
Age: 12
Female

Household Member Input

Theodore Clarence Morgan *
Age: 14
Male

Household Member Input

Michael Morgan *
Age: 16
Male

Household Member Input

Hugh Morgan *
Age: 18
Male

Notes to Testers

Auditor Checklist

*Do not use Morgan as the last name. Use a different last
name that is unique (it can be a random string of letters).
Do not change the first name.
Provide zip code 22032 (Fairfax County)
Use any date of birth that results in the correct age for
each household member.
Other household contact and information fields (i.e.
email, phone, language preference, race/ethnicity, etc.)
may contain any value unless otherwise noted.
Find additional information in the UI Question
Companion Guide:
- Items 4, 5, 7, 8, 9 Household Contact Information
- Items 10-14 Communication Preferences
- Items 15-20 Help Applying for Coverage
- Items 128-130 Applicant and non-applicant information
- Race and Ethnicity

Item 28

Application Filer/Relationship
to Application Filer

Application Filer
Spouse of Alba

Spouse of Clayton

Child of Clayton
Child of Alba

Child of Clayton
Child of Alba

Child of Clayton
Child of Alba

Child of Clayton
Child of Alba

Child of Clayton
Child of Alba

Child of Clayton
Child of Alba

Child of Clayton
Child of Alba

Items 27, 29
Item 32

Applicant/Non-Applicant
SSN

Applicant
278-24-3790

Applicant
278-24-6594

Applicant
278-24-9494

Applicant
278-26-4192

Applicant
278-26-6153

Applicant
278-26-7351

Applicant
278-28-3690

Applicant
278-28-5191

Applicant
278-30-5192

Items 131, 132

Non-MAGI Medicaid Eligibility Do not answer affirmatively to
Questions (physical disabilities, any non-MAGI questions
assistance with daily living,
nursing home care)

Do not answer affirmatively to
any non-MAGI questions

Attests to physical disability or
mental health condition

Do not answer affirmatively to
any non-MAGI questions

More About This Household
Attest to needing help with
Do not answer affirmatively to
activities of daily living
any non-MAGI questions

Do not answer affirmatively to
any non-MAGI questions

Do not answer affirmatively to
any non-MAGI questions

Do not answer affirmatively to
any non-MAGI questions

Items 133, 134, 136, 137, 138,
139, 140

Medicaid/CHIP Denial

Does not have Medicaid/CHIP
Does not have Medicaid/CHIP
Does not have Medicaid/CHIP
that recently ended or will end that recently ended or will end that recently ended or will end
soon; Not denied Medicaid/CHIP soon; Not denied Medicaid/CHIP soon

Items 153, 154, 155, 159, 209

Current Month Income

Job: $1,804 every two weeks

SSN must be entered exactly for test case to function

Medicaid Block
Does not have Medicaid/CHIP
Does not have Medicaid/CHIP
Had Medicaid coverage that
Does not have Medicaid/CHIP
Does not have Medicaid/CHIP
Does not have Medicaid/CHIP
The date provided should be within the last 60 days
that recently ended or will end that recently ended or will end ended recently due to a change that recently ended or will end that recently ended or will end that recently ended or will end
soon; Not denied Medicaid/CHIP soon; Not denied Medicaid/CHIP in eligibility;
soon; Not denied Medicaid/CHIP soon; Not denied Medicaid/CHIP soon; Not denied Medicaid/CHIP
Income and household size have
Denied Medicaid in last 90 days;
not changed since applicant was
Provide a date within the last 60
told their coverage was ending;
days;
Provide a date in the last 60
Attest to applying after a
days
qualifying life event

Job: $3,755.25 per month

No income

No income

No income

Income

No income

Self-employment: $50 per
month

No income

No deductions

No income

Items 174, 175, 176, 177

Deductions

Alimony: $100 every two weeks Student loans: $300 per month

No deductions

No deductions

No deductions

No deductions

No deductions

Items 181, 182, 183, 184

Annual Income

Disagree with calculated annual $41,463
income;
Income is hard to predict; Attest
to $44,315

$0

$0

$0

$0

Disagree with calculated annual $0
income;
Income is not hard to predict;
Attest to $300

$0

Items 191, 192

Current Coverage

None

None

None

None

None

None

Peace Corps

Program Questions
None

None

No deductions

Employer name (and phone number, where Item 209 is
included) fields are required but any value may be
entered (ex: ABC corp; 555-555-5555)

Check Item 32, Column F: Verify this question is
accompanied by the required help text about use
of SSN

Items 213, 214, 215, 218, 223,
231, 232, 233, 234

Recent Life Changes (SEPs)

None of these changes
Loss of coverage;
Moved;
Provide date within last 60 days Provide date within last 60 days;
Provide zip code in a different
county than zip code provided in
home address;
Answer "Yes" to prior coverage
question

Items 246, 252, 254, 255, 256,
258

Application Review & Legal
Attestations

Answers affirmatively to all application attestations

Reference Materials
UI Q CG Eligibility Results Tab:
Items 1, 3, 4, 5

Eligibility Results Page (ERP)

Eligible to buy a Marketplace
plan with a premium tax credit
of up to $732 each month for
your tax household

Sample HealthCare.gov Eligibility
Results Messaging

Eligible for lower copayments,
coinsurance, and deductibles
(cost-sharing reductions) on
Silver plans
Eligible for a Special Enrollment
Period

Eligible to buy a Marketplace
plan
Eligible for a Special Enrollment
Period

N/A (should not display for this
household member)

N/A (should not display for this
household member)

Loss of coverage;
N/A (should not display for this
Provide date within last 60 days household member)
(same date as when Hareem's
Medicaid ended above)

N/A (should not display for this
household member)

N/A (should not display for this
household member)

Attestations

Eligible to buy a Marketplace
plan with a premium tax credit
of up to $732 each month for
your tax household

Eligible for CHIP

Eligible for CHIP

Eligibility Results
Eligible to buy a Marketplace
plan with a premium tax credit
of up to $732 each month for
your tax household

Eligible for lower copayments,
coinsurance, and deductibles
(cost-sharing reductions) on
Silver plans

Eligible for lower copayments,
coinsurance, and deductibles
(cost-sharing reductions) on
Silver plans

Eligible for a Special Enrollment
Period

Eligible for a Special Enrollment
Period

The loss of coverage date for Hareem may be
prepopulated by the UI

Check Item 234: Verify Alba is required to answer
question about prior coverage after attesting to a
recent move

Auditors should review the application review page
(Item 246) to ensure all information accurately reflects
the attestations inputted during the test case
Eligible for CHIP

Eligible for CHIP

Eligible for CHIP

Auditors should review the Eligibility Results Page to
Verify the Eligibility Results Page displays correct
ensure it accurately reflects the eligibility results found in eligibility and APTC amount for each household
the EDN and complies with ERP messaging requirements member
outlined in the documentation listed in Column A