7. Verifying Status as a Specified Excluded Individual

Specified excluded individuals, defined in Section 1902(xx)(9)(A)(ii) of the Act and implemented at § 435.554, are carved out from the definition of an applicable individual, as defined in section 1902(xx)(9)(A)(i) of the Act and implemented at § 435.551. As such, specified excluded individuals are not ( printed page 33402) subject to the requirement to demonstrate community engagement. Consistent with section 1902(xx)(5) of the Act, States must establish processes and use reliable information available to the State without requiring, where possible, additional information to verify that an individual meets the definition of a specified excluded individual at application and renewal. We note that, because specified excluded individuals are not applicable individuals, the requirement in section 1902(xx)(1) of the Act to verify an applicable individual met the requirement in the 1 or more months prior to the month of application, or 1 or more months during the review period assessed at the regular renewal or when redetermining eligibility based on a change in circumstances, does not apply to specified excluded individuals. In other words, there is no requirement that an individual who is a specified excluded individual meet that definition for the required number of months during the review period (as defined in section II.H. of this IFC). Rather, as is discussed in greater detail in this section, States will verify if an individual meets the definition of a specified excluded individual at the time of application or renewal or if the State receives information indicating a change in circumstances for the individual that may affect eligibility, similar to when States verify other factors of eligibility (for example, income).

In addition, the option in section 1902(xx)(4) of the Act to verify applicable individuals' compliance with the community engagement requirement more frequently than at each regular renewal does not apply to specified excluded individuals. Thus, States may not reverify a specified excluded individual's status as such between regular scheduled renewals as part of the more frequent verification process (if elected by the State), unless the State has information indicating the individual's status has changed. However, we remind States that when assessing compliance, including when conducting a more frequent verification, the State must first confirm the individual is an applicable individual and is not a specified excluded individual using reliable information available to the State. In other words, when conducting more frequent verifications, the State must not conduct a more frequent verification for a specified excluded individual but must begin the verification process by confirming that beneficiaries who have been applicable individuals have not become specified excluded individuals.

Section 1902(xx)(9)(A)(ii) of the Act identifies nine categories of specified excluded individuals: individuals who are described in section 1902(a)(10)(A)(i)(IX) of the Act (the FFCC group); certain American Indians; parents, guardians, caretaker relatives, or family caregivers of a dependent child or a disabled individual; veterans with a permanent or temporary total disability; individuals who are medically frail or otherwise have special medical needs (as defined by the Secretary); individuals who are compliant with TANF work requirements and individuals who are members of a household that receives SNAP benefits and must comply with SNAP work requirements; individuals who are participating in a drug addiction or alcoholic treatment and rehabilitation program; inmates of a public institution; and individuals who are pregnant or entitled to postpartum medical assistance under section 1902(e)(5) or (16) of the Act. See section II.E. of this IFC and the implementing regulations at § 435.554 for additional discussion of the definition of specified excluded individuals. The verification process a State implements when verifying if an individual is a specified excluded individual will depend on the reliable information available to the State. We note that in some instances, the process will differ at application and renewal based on available data and that there will likely be some categories of specified excluded individuals for which there is no reliable information available to the State for verification.

For many of the categories of specified excluded individuals, States may have information available to verify the status; for example, from the State's own records, claims, payment, and encounter data to verify medical frailty or participation in a drug addiction or alcoholic treatment and rehabilitation program. States may also have information from the records of another Federal, State, or local agency, that can be used, for example, to verify veteran disability status, that an individual is meeting TANF work requirements, or that an individual is or recently was in a county carceral facility. Additionally, for certain categories of specified excluded individuals, information needed to verify the individual's status may already have been verified as part of determining other factors of eligibility in Medicaid; therefore, no additional verification would be needed, such as for pregnancy or American Indian status. There are certain categories of specified excluded individuals for which no reliable information may be available to the State. Beginning on January 1, 2028, when there is no reliable information available to the State or the reliable information is not reasonably compatible with the information provided by or on behalf of the individual, States must generally require that the individual provide documentation when such documentation is reasonably available to verify that the individual meets the definition of a specified excluded individual under the relevant category. We discuss the requirements for States in verifying the different specified excluded individual statuses based on reliable information available to the State; the available reliable information; and the requirements when no reliable information is available to the State to verify an individual's qualification as a specified excluded individual.