Family and Children's Medicaid MA-3210 VERIFICATION REQUIREMENTS FOR APPLICATIONS

iii. procedures

A. Complete the on-line matches. See MA-3515, Automated Inquiry and Match Procedures, and MA-3520, Automated SOLQ Procedures.

B. Document/review the individual’s statement.

1. Document the individual’s statement for each eligibility factor on the base document at the face-to-face interview. Review the individual’s statement on the mail-in application.

2. If the individual is only able to give you the value of an asset or resource as a range, document the range.

a. Determine the midpoint.

b. If the midpoint results in ineligibility but the lower range does not, request verification from the individual and pursue third party verification. If verification is not received by the 45th day, deny the application. See MA-3215, Processing the Application.

C. Identify each element that must be verified.

1. Determine the eligibility factors for which the individual’s statement is acceptable verification.

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(III.C. 1.)

a. For the factors where the individual’s statement is acceptable verification, ensure the statement is complete. For example, if accepting the individual’s statement of the balance in a checking account, document the institution name, account number, and the balance in the account.

b. If a statement cannot be provided (face-to-face), is incomplete, or is not provided (mail-in), request a complete statement or other verification following the procedures in D.

2. Determine those eligibility factors for which the individual’s statement is not acceptable. Follow policy in the appropriate manual section to determine what kind of verification is acceptable for each eligibility factor.

3. During the face-to-face interview or via a telephone call for mail-in applications explain to the individual what information is required.

a. Explain that the sooner the information is received, the sooner a decision can be made on his application.

b. Discuss with the individual who can more easily and quickly obtain the information.

c. Unless DSS must take responsibility for obtaining the verification (See II.G.), negotiate who will provide each piece of information.

D. Request the information from the individual or third party.

1. Notify the individual of all information he is required to or has agreed to provide using the DMA-5097/DMA-5097S, Request for Information. The information must be requested in an easily understood manner.

a. When possible, give the individual the notice at the face-to-face interview.

b. For mail-in applications, send the notice as soon as possible after receipt of the complete application.

2. Request information from the third party using the appropriate verification forms.

3. Include on the notice to the individual or third party the date by which the information is to be returned. The date for return may be negotiated with the individual if he is responsible for or has agreed to provide the information.

4. When requesting information from the individual or a third party, always include a pre-addressed envelope.

5. If the information is not returned by the established deadline or if the information is returned but is incomplete, send a second request.

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(III.D.5)

a. The county may request information as often as it wishes; however, there must be two requests with at least 12 calendar days between them.

b. The second request for information to the applicant must be a written request. However, the second request to a third party may be verbal.

Ensure that the case record is clearly documented when verbally requesting information from a third party.

6. Anytime during the processing of the application that the county becomes aware of additional information needed to complete the application, the county must make a written request and, if needed, a second request following the procedures above.

7. If the individual or third party requests additional time to provide the requested information, allow at least an additional 12 calendar days.

8. If the individual or third party provides the information but it is incomplete (not sufficient to determine eligibility), make at least one follow-up request using the DMA-5097/DMA-5097S, Request for Information, or other third party verification form.

a. Allow at least 12 calendar days for the individual or third party to respond to the follow-up.

b. The follow-up request for information to the applicant must be a written request. However, the follow-up request to a third party may be verbal. Ensure that the case record is clearly documented when verbally requesting information from a third party.

9. When the only information needed to determine eligibility is bills to meet a deductible, the DMA-5099/DMA-5099S, Your Application for Medicaid is Pending for a Deductible, can be used to request the bills.

a. The DMA-5099/DMA-5099S should never be used as the initial request for medical bills. The DMA-5097/DMA-5097S, Request for Information, should be used as the initial request.

b. The DMA-5099/DMA-5099S, Your Application for Medicaid is Pending for a Deductible, can be used as the second request or a follow up request, provided all other information to determine eligibility has been received and eligibility has been established except for meeting the Medicaid deductible.

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(III.D.9)

c. The DMA-5099/DMA-5099S, Your Application for Medicaid is Pending for a Deductible, is used to provide the individual with information regarding the Medicaid deductible and to allow the county to stop the application processing time. Refer to MA-3215, Processing The Application, for procedures regarding the exclusion of days during the application processing time.

d. If the individual provides some bills, but not enough to meet a deductible, use the DMA-5099/DMA-5099S, Your Application for Medicaid is Pending for a Deductible, to notify the individual of the deductible amount remaining after the bills are applied.

e. If there is a change in the individual’s situation after the application has been made, but prior to disposing of the case, and the change affects the deductible amount, use the DMA-5099/DMA-5099S, Your Application for Medicaid is Pending for a Deductible, to notify the individual of the new deductible amount.

10. When the only information needed to complete the determination of eligibility is one of the items in a. through g. below, use the DMA-5098/DMA-5098S, Your Application for Medicaid is Pending, to notify the individual of the missing information.

The DMA-5098/DMA-5098S, Your Application for Medicaid is Pending, is not considered a request for information. It should not be used as the initial request, second request, or a follow up request for information. The DMA-5097/DMA-5097S, Request for Information, or other third party verification form must be used to request information needed to determine eligibility.

The DMA-5098/DMA-5098S, Your Application for Medicaid is Pending, is used to provide the individual with information regarding the status of the application and to allow the county to stop the application processing time. Refer to MA-3215, Processing The Application, for procedures regarding the exclusion of days during the application processing time.

a. Medical bills to meet a deductible, or

b. A disability determination by DDS, or

c. Medical records from providers to determine emergency days for non-qualified aliens, or

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(III. D.10)

d. An FL-2/MR-2, when the applicant has been placed in a Medicaid certified medical facility. Refer to MA-3325, Long Term Care Budgeting, for the definition of a CAP Medicaid certified medical facility, or

e. CAP Plan of Care, when CAP participation is expected within the application processing time, or

f. Undue hardship documentation, and/or

g. Citizenship/identity documentation.

E. Evaluating Conflicting Information

1. Evaluate whether the individual’s statement is questionable based on the following criteria:

a. Contradictory or inconsistent information is presented during the interview or on the mail-in application or contradictions exist with other information available through the agency, or

b. Automated queries (DMV, ESC, etc) provide information that is inconsistent with the individual’s statement.

2. If the statement is questionable, pursue third party verification.

3. If documentary verification is received from the third party:

a. During the application process, use the current verified amount to process the application, or

b. After the application is approved, treat as a change in situation and take action immediately. Evaluate for suspected fraud and refer if appropriate.