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us/statute/42/1396a/xx/5 — Ex parte verifications.— · Axiom

Ex parte verifications.—

“(5) Standards. Processes. Ex parte verifications.— For purposes of verifying that an applicable individual has met the requirement to demonstrate community engagement under paragraph (1), or determining such individual to be deemed to have demonstrated community engagement under paragraph (3), or that an individual is a specified excluded individual under paragraph (9)(A)(ii), the State shall, in accordance with standards established by the Secretary, establish processes and use reliable information available to the State (such as payroll data or payments or encounter data under this title for individuals and data on payments to such individuals for the provision of services covered under this title) without requiring, where possible, the applicable individual to submit additional information.

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Rules

monthly_activity_hours_requirement

Parameter

source: 42 USC 1396a(xx)(2)(A)-(E)

- name: monthly_activity_hours_requirement
  kind: parameter
  dtype: Decimal
  source: 42 USC 1396a(xx)(2)(A)-(E)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: amount
          source:
            corpus_citation_path: us/statute/42/1396a/xx
            excerpt: not less than 80 hours
  versions:
    - effective_from: '2026-12-31'
      formula: '80'

seasonal_worker_income_lookback_months

Parameter

source: 42 USC 1396a(xx)(2)(G)

- name: seasonal_worker_income_lookback_months
  kind: parameter
  dtype: Count
  source: 42 USC 1396a(xx)(2)(G)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: amount
          source:
            corpus_citation_path: us/statute/42/1396a/xx
            excerpt: average monthly income over the preceding 6 months
  versions:
    - effective_from: '2026-12-31'
      formula: '6'

hardship_unemployment_rate_threshold

Parameter

source: 42 USC 1396a(xx)(3)(B)(ii)(II)(bb)(AA)

- name: hardship_unemployment_rate_threshold
  kind: parameter
  dtype: Rate
  source: 42 USC 1396a(xx)(3)(B)(ii)(II)(bb)(AA)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: amount
          source:
            corpus_citation_path: us/statute/42/1396a/xx
            excerpt: 8 percent
  versions:
    - effective_from: '2026-12-31'
      formula: '0.08'

hardship_national_unemployment_rate_multiplier

Parameter

source: 42 USC 1396a(xx)(3)(B)(ii)(II)(bb)(BB)

- name: hardship_national_unemployment_rate_multiplier
  kind: parameter
  dtype: Decimal
  source: 42 USC 1396a(xx)(3)(B)(ii)(II)(bb)(BB)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: amount
          source:
            corpus_citation_path: us/statute/42/1396a/xx
            excerpt: 1.5 times the national unemployment rate
  versions:
    - effective_from: '2026-12-31'
      formula: '1.5'

community_engagement_met_by_activity_or_income

Derived

source: 42 USC 1396a(xx)(2)

- name: community_engagement_met_by_activity_or_income
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(2)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: formula
          source:
            corpus_citation_path: us/statute/42/1396a/xx
            excerpt: meets 1 or more of the following conditions
  versions:
    - effective_from: '2026-12-31'
      formula: >-
        monthly_work_hours >= monthly_activity_hours_requirement

        or monthly_community_service_hours >= monthly_activity_hours_requirement

        or monthly_work_program_hours >= monthly_activity_hours_requirement

        or enrolled_in_educational_program_at_least_half_time

        or monthly_combined_engagement_activity_hours >= monthly_activity_hours_requirement

        or monthly_income >= applicable_minimum_wage_hourly_rate *
        monthly_activity_hours_requirement

        or (seasonal_worker and average_monthly_income_over_preceding_6_months >=
        applicable_minimum_wage_hourly_rate * monthly_activity_hours_requirement)

educational_program

Derived

source: 42 USC 1396a(xx)(9)(B)

- name: educational_program
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(9)(B)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: definition
          source:
            corpus_citation_path: us/statute/42/1396a/xx
        - path: versions[0].formula
          kind: import
          import:
            target: us:statutes/26/3304#institution_of_higher_education
            output: institution_of_higher_education
            hash: sha256:86fc1e04b86968a3fea7737fce53a8297bc20be9c7896e4527512caed95bff86
  versions:
    - effective_from: '2026-12-31'
      formula: |-
        institution_of_higher_education
        or enrolled_in_career_and_technical_education_program

mandatory_community_engagement_deeming_applies

Derived

source: 42 USC 1396a(xx)(3)(A)

- name: mandatory_community_engagement_deeming_applies
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(3)(A)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: exception
          source:
            corpus_citation_path: us/statute/42/1396a/xx
  versions:
    - effective_from: '2026-12-31'
      formula: |-
        was_specified_excluded_individual_for_part_or_all_of_month
        or was_under_age_19_for_part_or_all_of_month
        or was_entitled_to_or_enrolled_for_medicare_part_a_or_b_for_part_or_all_of_month
        or was_described_in_subsection_a_10_A_i_I_through_VII_for_part_or_all_of_month
        or was_inmate_of_public_institution_during_3_month_period_ending_first_day_of_month

short_term_hardship_event

Derived

source: 42 USC 1396a(xx)(3)(B)(ii)

- name: short_term_hardship_event
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(3)(B)(ii)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: definition
          source:
            corpus_citation_path: us/statute/42/1396a/xx
  versions:
    - effective_from: '2026-12-31'
      formula: >-
        received_high_acuity_services_for_part_or_all_of_month

        or county_has_presidential_emergency_or_disaster_for_part_or_all_of_month

        or county_unemployment_rate >= min(hardship_unemployment_rate_threshold,
        hardship_national_unemployment_rate_multiplier * national_unemployment_rate)

        or
        individual_or_dependent_must_travel_outside_community_for_extended_medically_necessary_services

optional_hardship_deeming_applies

Derived

source: 42 USC 1396a(xx)(3)(B)(i)

- name: optional_hardship_deeming_applies
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(3)(B)(i)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: exception
          source:
            corpus_citation_path: us/statute/42/1396a/xx
  versions:
    - effective_from: '2026-12-31'
      formula: >-
        state_plan_provides_optional_short_term_hardship_deeming

        and short_term_hardship_event

        and (county_has_presidential_emergency_or_disaster_for_part_or_all_of_month or
        county_unemployment_rate >= min(hardship_unemployment_rate_threshold,
        hardship_national_unemployment_rate_multiplier * national_unemployment_rate) or
        individual_requested_hardship_deeming)

deemed_to_have_demonstrated_community_engagement

Derived

source: 42 USC 1396a(xx)(3)

- name: deemed_to_have_demonstrated_community_engagement
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(3)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: formula
          source:
            corpus_citation_path: us/statute/42/1396a/xx
  versions:
    - effective_from: '2026-12-31'
      formula: |-
        mandatory_community_engagement_deeming_applies
        or optional_hardship_deeming_applies

state_may_waive_verification_for_deemed_community_engagement

Derived

source: 42 USC 1396a(xx)(3)(C)

- name: state_may_waive_verification_for_deemed_community_engagement
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(3)(C)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: condition
          source:
            corpus_citation_path: us/statute/42/1396a/xx
            excerpt: may elect to not require an individual to verify information resulting in such deeming
  versions:
    - effective_from: '2026-12-31'
      formula: |-
        state_elects_not_to_require_verification_for_deemed_community_engagement
        and deemed_to_have_demonstrated_community_engagement

demonstrated_community_engagement_for_month

Derived

source: 42 USC 1396a(xx)(2)-(3)

- name: demonstrated_community_engagement_for_month
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(2)-(3)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: formula
          source:
            corpus_citation_path: us/statute/42/1396a/xx
  versions:
    - effective_from: '2026-12-31'
      formula: |-
        community_engagement_met_by_activity_or_income
        or deemed_to_have_demonstrated_community_engagement

specified_excluded_individual

Derived

source: 42 USC 1396a(xx)(9)(A)(ii)

- name: specified_excluded_individual
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(9)(A)(ii)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: definition
          source:
            corpus_citation_path: us/statute/42/1396a/xx
  versions:
    - effective_from: '2026-12-31'
      formula: >-
        described_in_subsection_a_10_A_i_IX

        or is_indian_urban_indian_california_indian_or_ihs_eligible_indian

        or
        is_parent_guardian_caretaker_relative_or_family_caregiver_of_dependent_child_age_13_or_under_or_disabled_individual

        or is_veteran_with_total_disability_rating

        or is_medically_frail_or_has_special_medical_needs

        or
        complies_with_tanf_work_requirements_or_is_nonexempt_snap_work_requirement_household_member

        or participates_in_drug_addiction_or_alcoholic_treatment_and_rehabilitation_program

        or is_inmate_of_public_institution

        or is_pregnant_or_entitled_to_postpartum_medical_assistance

applicable_individual

Derived

source: 42 USC 1396a(xx)(9)(A)(i)

- name: applicable_individual
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(9)(A)(i)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: definition
          source:
            corpus_citation_path: us/statute/42/1396a/xx
  versions:
    - effective_from: '2026-12-31'
      formula: >-
        not specified_excluded_individual

        and (eligible_or_enrolled_under_subsection_a_10_A_i_VIII or
        (eligible_or_enrolled_under_equivalent_minimum_essential_coverage_waiver and
        has_attained_age_19_and_is_under_age_65 and not pregnant and not
        entitled_to_or_enrolled_for_medicare_part_a_or_b and not
        otherwise_eligible_to_enroll_under_state_plan))

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Ex parte verifications.—

Official source

in view

Whole section

▸rulespec code

Shown source

statutes/42/1396a/xx.yaml

Displaying the canonical repository encoding.

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Rules

monthly_activity_hours_requirement

Parameter

source: 42 USC 1396a(xx)(2)(A)-(E)

- name: monthly_activity_hours_requirement
  kind: parameter
  dtype: Decimal
  source: 42 USC 1396a(xx)(2)(A)-(E)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: amount
          source:
            corpus_citation_path: us/statute/42/1396a/xx
            excerpt: not less than 80 hours
  versions:
    - effective_from: '2026-12-31'
      formula: '80'

seasonal_worker_income_lookback_months

Parameter

source: 42 USC 1396a(xx)(2)(G)

- name: seasonal_worker_income_lookback_months
  kind: parameter
  dtype: Count
  source: 42 USC 1396a(xx)(2)(G)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: amount
          source:
            corpus_citation_path: us/statute/42/1396a/xx
            excerpt: average monthly income over the preceding 6 months
  versions:
    - effective_from: '2026-12-31'
      formula: '6'

hardship_unemployment_rate_threshold

Parameter

source: 42 USC 1396a(xx)(3)(B)(ii)(II)(bb)(AA)

- name: hardship_unemployment_rate_threshold
  kind: parameter
  dtype: Rate
  source: 42 USC 1396a(xx)(3)(B)(ii)(II)(bb)(AA)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: amount
          source:
            corpus_citation_path: us/statute/42/1396a/xx
            excerpt: 8 percent
  versions:
    - effective_from: '2026-12-31'
      formula: '0.08'

hardship_national_unemployment_rate_multiplier

Parameter

source: 42 USC 1396a(xx)(3)(B)(ii)(II)(bb)(BB)

- name: hardship_national_unemployment_rate_multiplier
  kind: parameter
  dtype: Decimal
  source: 42 USC 1396a(xx)(3)(B)(ii)(II)(bb)(BB)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: amount
          source:
            corpus_citation_path: us/statute/42/1396a/xx
            excerpt: 1.5 times the national unemployment rate
  versions:
    - effective_from: '2026-12-31'
      formula: '1.5'

community_engagement_met_by_activity_or_income

Derived

source: 42 USC 1396a(xx)(2)

- name: community_engagement_met_by_activity_or_income
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(2)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: formula
          source:
            corpus_citation_path: us/statute/42/1396a/xx
            excerpt: meets 1 or more of the following conditions
  versions:
    - effective_from: '2026-12-31'
      formula: >-
        monthly_work_hours >= monthly_activity_hours_requirement

        or monthly_community_service_hours >= monthly_activity_hours_requirement

        or monthly_work_program_hours >= monthly_activity_hours_requirement

        or enrolled_in_educational_program_at_least_half_time

        or monthly_combined_engagement_activity_hours >= monthly_activity_hours_requirement

        or monthly_income >= applicable_minimum_wage_hourly_rate *
        monthly_activity_hours_requirement

        or (seasonal_worker and average_monthly_income_over_preceding_6_months >=
        applicable_minimum_wage_hourly_rate * monthly_activity_hours_requirement)

educational_program

Derived

source: 42 USC 1396a(xx)(9)(B)

- name: educational_program
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(9)(B)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: definition
          source:
            corpus_citation_path: us/statute/42/1396a/xx
        - path: versions[0].formula
          kind: import
          import:
            target: us:statutes/26/3304#institution_of_higher_education
            output: institution_of_higher_education
            hash: sha256:86fc1e04b86968a3fea7737fce53a8297bc20be9c7896e4527512caed95bff86
  versions:
    - effective_from: '2026-12-31'
      formula: |-
        institution_of_higher_education
        or enrolled_in_career_and_technical_education_program

mandatory_community_engagement_deeming_applies

Derived

source: 42 USC 1396a(xx)(3)(A)

- name: mandatory_community_engagement_deeming_applies
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(3)(A)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: exception
          source:
            corpus_citation_path: us/statute/42/1396a/xx
  versions:
    - effective_from: '2026-12-31'
      formula: |-
        was_specified_excluded_individual_for_part_or_all_of_month
        or was_under_age_19_for_part_or_all_of_month
        or was_entitled_to_or_enrolled_for_medicare_part_a_or_b_for_part_or_all_of_month
        or was_described_in_subsection_a_10_A_i_I_through_VII_for_part_or_all_of_month
        or was_inmate_of_public_institution_during_3_month_period_ending_first_day_of_month

short_term_hardship_event

Derived

source: 42 USC 1396a(xx)(3)(B)(ii)

- name: short_term_hardship_event
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(3)(B)(ii)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: definition
          source:
            corpus_citation_path: us/statute/42/1396a/xx
  versions:
    - effective_from: '2026-12-31'
      formula: >-
        received_high_acuity_services_for_part_or_all_of_month

        or county_has_presidential_emergency_or_disaster_for_part_or_all_of_month

        or county_unemployment_rate >= min(hardship_unemployment_rate_threshold,
        hardship_national_unemployment_rate_multiplier * national_unemployment_rate)

        or
        individual_or_dependent_must_travel_outside_community_for_extended_medically_necessary_services

optional_hardship_deeming_applies

Derived

source: 42 USC 1396a(xx)(3)(B)(i)

- name: optional_hardship_deeming_applies
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(3)(B)(i)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: exception
          source:
            corpus_citation_path: us/statute/42/1396a/xx
  versions:
    - effective_from: '2026-12-31'
      formula: >-
        state_plan_provides_optional_short_term_hardship_deeming

        and short_term_hardship_event

        and (county_has_presidential_emergency_or_disaster_for_part_or_all_of_month or
        county_unemployment_rate >= min(hardship_unemployment_rate_threshold,
        hardship_national_unemployment_rate_multiplier * national_unemployment_rate) or
        individual_requested_hardship_deeming)

deemed_to_have_demonstrated_community_engagement

Derived

source: 42 USC 1396a(xx)(3)

- name: deemed_to_have_demonstrated_community_engagement
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(3)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: formula
          source:
            corpus_citation_path: us/statute/42/1396a/xx
  versions:
    - effective_from: '2026-12-31'
      formula: |-
        mandatory_community_engagement_deeming_applies
        or optional_hardship_deeming_applies

state_may_waive_verification_for_deemed_community_engagement

Derived

source: 42 USC 1396a(xx)(3)(C)

- name: state_may_waive_verification_for_deemed_community_engagement
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(3)(C)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: condition
          source:
            corpus_citation_path: us/statute/42/1396a/xx
            excerpt: may elect to not require an individual to verify information resulting in such deeming
  versions:
    - effective_from: '2026-12-31'
      formula: |-
        state_elects_not_to_require_verification_for_deemed_community_engagement
        and deemed_to_have_demonstrated_community_engagement

demonstrated_community_engagement_for_month

Derived

source: 42 USC 1396a(xx)(2)-(3)

- name: demonstrated_community_engagement_for_month
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(2)-(3)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: formula
          source:
            corpus_citation_path: us/statute/42/1396a/xx
  versions:
    - effective_from: '2026-12-31'
      formula: |-
        community_engagement_met_by_activity_or_income
        or deemed_to_have_demonstrated_community_engagement

specified_excluded_individual

Derived

source: 42 USC 1396a(xx)(9)(A)(ii)

- name: specified_excluded_individual
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(9)(A)(ii)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: definition
          source:
            corpus_citation_path: us/statute/42/1396a/xx
  versions:
    - effective_from: '2026-12-31'
      formula: >-
        described_in_subsection_a_10_A_i_IX

        or is_indian_urban_indian_california_indian_or_ihs_eligible_indian

        or
        is_parent_guardian_caretaker_relative_or_family_caregiver_of_dependent_child_age_13_or_under_or_disabled_individual

        or is_veteran_with_total_disability_rating

        or is_medically_frail_or_has_special_medical_needs

        or
        complies_with_tanf_work_requirements_or_is_nonexempt_snap_work_requirement_household_member

        or participates_in_drug_addiction_or_alcoholic_treatment_and_rehabilitation_program

        or is_inmate_of_public_institution

        or is_pregnant_or_entitled_to_postpartum_medical_assistance

applicable_individual

Derived

source: 42 USC 1396a(xx)(9)(A)(i)

- name: applicable_individual
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 USC 1396a(xx)(9)(A)(i)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: definition
          source:
            corpus_citation_path: us/statute/42/1396a/xx
  versions:
    - effective_from: '2026-12-31'
      formula: >-
        not specified_excluded_individual

        and (eligible_or_enrolled_under_subsection_a_10_A_i_VIII or
        (eligible_or_enrolled_under_equivalent_minimum_essential_coverage_waiver and
        has_attained_age_19_and_is_under_age_65 and not pregnant and not
        entitled_to_or_enrolled_for_medicare_part_a_or_b and not
        otherwise_eligible_to_enroll_under_state_plan))