20.3 Mandatory Verification Items

20.3.1 Mandatory Verification Items Introduction

Verify the following mandatory items:

SSN (see Section 20.3.2 Social Security Number).
Alien Status (see Section 7.3 Immigrants).
Disability and Incapacitation (see Section 5.2 Determination of Disability).
Assets for the Elderly , Blind, and Disabled (see Section 16.1 Assets Introduction).
Divestment, for EBD long-term care (see Section 17.1 Divestment Introduction).
Medical expenses, for deductibles only (see Section 24.7 Meeting the Deductible).
Medical/remedial expenses for noncovered services for an institutionalized person (see Section 27.7.7.2 Disallowed Expenses).
Documentation for Power of Attorney and Guardianship (see Section 20.3.7 Power of Attorney and Guardianship).
Migrant workers eligibility in another state (see Section 31.2 Simplified Application), if applicable.
Physician certification (verbally or in writing) that the person is likely to return to the home or apartment within six months for institutionalized persons maintaining a home or property (see Section 15.7.1 Maintaining Home or Apartment) and is entitled to a home maintenance allowance.
Income.
Citizenship and Identity (see Section 7.2 Documenting Citizenship and Identity).

Accept self declaration for all other items, unless you document them as questionable.

20.3.2 Social Security Number

Social security numbers (SSNs) need to be furnished for household members requesting Medicaid unless they are exempt from the SSN requirement (see Section 10.1.1 Social Security Number Requirements). SSNs are not required from non-applicants.

An applicant is not required to provide a document or social security card. He or she only needs to provide a number, which is verified through the CARES SSN validation process.

If the SSN validation process returns a mismatch record, the member must provide the social security card or another official government document with the SSN displayed. If an applicant does not yet have a SSN, he or she must be willing to apply for one.

Agencies must assist any household that requests help with applying for an SSN for any applicant or member who does not have one. “Assisting the applicant” may include helping with filing the SS-5 SSN Application form, obtaining a birth certificate on behalf of the applicant, or assisting with obtaining another document needed to apply for the SSN.

Health care eligibility may not be delayed if the person is otherwise eligible for benefits and any of the following are true:

The person has provided an SSN, even if the SSN has not yet been verified.
The person has requested assistance with applying for an SSN.
The person has verified that he or she has applied for an SSN.

In cases where an application for SSN has been filed with the Social Security Administration, an SSN must be provided by the time of the next health care renewal for the case or health care eligibility will be terminated for that individual. In addition, if eligibility for another program pends for provision of an SSN and the SSN application date on file is six months or older, eligibility for health care will also pend. Members must be given a minimum of 10 days to provide an SSN, but if they do not, health care eligibility must be terminated.

Even when citizenship cannot be verified due to a lack of a verified SSN, health care benefits should not be pended for lack of an SSN during the reasonable opportunity period for verification of citizenship (see Section 7.2.4.4 Reasonable Opportunity Period for Verification of Citizenship).

20.3.2.1 Fraudulent Use of SSN

The member should be informed if the SSN validation process indicates another individual is using the same SSN. The member should contact the Social Security Administration and request they conduct an investigation. The IM worker cannot provide the member with any information that would identify the individual who is using the member's SSN.

If the Social Security Administration finds that the SSN has been used fraudulently it may:

Recommend further action be taken.
Provide the member with the information on the fraudulent action so that the member may pursue action through the legal system.

Verify the SSN only once.

20.3.3 Immigration Status

Verification of the individual’s immigration status is done through the FDSH or the Systematic Alien Verification for Entitlement (SAVE) system. Women applying for BadgerCare Plus Prenatal Program (see BadgerCare Plus Handbook, Chapter 41 BadgerCare Plus Prenatal Program) and people applying for Emergency Services (see Chapter 34 Emergency Services do not have to verify their immigration status.

Applicants who are otherwise eligible and are only pending for verification of immigration status must be certified for health care benefits during the reasonable opportunity period (see Section 7.3.2.2 Reasonable Opportunity Period for Verification of Immigration Status.

20.3.4 Disability

Disability and blindness determinations are made by the DDB in the DHS . Items that can be used to verify disability status include, but are not limited to:

Proof of SSI or other SS Disability payment,
SOLQ-I,
Award letter or verbal statement from SSA , or
Proof of MADA approval, including presumptive disability

20.3.5 Assets

Verification of countable assets is mandatory.

Note: The value of exempt assets, such as an EBD Medicaid member’s burial plot, may not be verified unless the worker has information that deems the member-reported amount to be questionable.

If reported assets exceed the asset limit, do not pursue verification.

Do not verify cash on hand.

Verify AVS liquid assets using the Asset Verification System (AVS) integrated within CARES Worker Web. If current asset information is not available through AVS, the applicant/member is required to verify their assets through other sources (for example, bank statements). Assist the applicant/member in obtaining verification if he or she has difficulty in obtaining it.

20.3.5.1 Divestment

Verify if a member or spouse has divested assets when determining eligibility for institutional Medicaid and community waivers (see Section 17.1 Divestment Introduction).

20.3.5.2 Reasonable Compatibility for Assets

As defined in federal regulations, information from an electronic data source (in this case, AVS) is reasonably compatible if it results in the same eligibility outcome as self-reported information.

If the individual reports assets that are above a given asset limit, the self-reported asset information will be used to deny or terminate health care benefits, regardless of what the outcome would be from using AVS information. Verification is not required.
If both AVS and the self-reported information put the individual’s total countable assets below a given asset limit, the two data sources are considered to be reasonably compatible and further verification may not be requested or required.
If AVS puts the individual’s total countable assets above a given asset limit, but the self-reported information puts his or her total countable assets below that same limit, the two data sources are not reasonably compatible and further verification is required as a condition of eligibility.

The reasonable compatibility test will only be applied to AVS liquid assets that have not otherwise been verified (for example, if a member submits bank statements as part of their initial application, or if the asset has been verified by another program). It can only be applied when asset information is available through the Asset Verification System.

20.3.5.2.1 Determination of Reasonable Compatibility

The reasonable compatibility test will be performed during the eligibility determination for EBD Medicaid if there is an AVS-returned amount for at least one unverified liquid asset. To determine reasonable compatibility, CARES will perform the following calculations:

Calculation

Description

1: Total Countable Assets (Self-Reported)

Sum of all the self-reported amounts for all countable assets.

If the self-reported countable assets are over the asset limit, eligibility will fail right away and no reasonable compatibility test will be performed.

2: Total Countable Assets (AVS and/or Self-Reported)

Sum of the following:

All verified, countable asset amounts.
For all countable AVS assets, if an AVS amount was returned for an asset and that asset has not been verified: the higher of the AVS-returned or the unverified self-reported amounts.
All unverified, self-reported countable asset amounts with no AVS match, including non-AVS assets.
All countable AVS assets that were not reported.

CARES will compare the results of calculations 1 and 2 to determine reasonable compatibility.

If reasonably compatible, verification of the AVS-matched asset amounts will not be requested, and eligibility will not pend for verification of these assets, even when there is a ?, Q?, WN, NV, or QV in the verification field. If otherwise eligible, the individual will receive a Notice of Decision listing the self-reported asset amounts. If eligibility is pending for other assets, a Verification Checklist will be sent.
If not reasonably compatible, a Verification Checklist will be sent to the individual to request verification for all assets for which the individual has not already provided verification. If the individual does not provide the requested verification by the due date, eligibility will be denied or terminated for lack of verification.

Note: When there is an MSP request in addition to a request for EBD Medicaid, an additional, separate reasonable compatibility determination will be performed for MSP. In situations where the assets are reasonably compatible for MSP but exceed the asset limit for other programs, the individual may enroll in MSP without being required to provide further verification of assets for that program.

If an individual is applying for health care and has also requested MAPP, the reasonable compatibility test may provide different results based on the EBD Medicaid and MAPP asset limits. Because CARES considers these two programs to be part of the same health care request, the reasonable compatibility test will be performed using the MAPP asset limits only if the individual is found ineligible for EBD Medicaid because of excess assets or failure to provide verification of assets. This means an individual can still be eligible for MAPP based on the reasonable compatibility test for assets, even if they failed to submit verification of assets as required for EBD Medicaid (see Example 2 below).

If the worker is running with dates and an AVS amount is entered for a given asset, the reasonable compatibility test will be performed as long as the eligibility month is June 2018 or later.

The following examples show various results of the reasonable compatibility test.

Example 1: Lauren applies for EBD Medicaid and reports the following asset amount, without providing verification:

Checking account: $5

AVS returns the following information and the worker processes the information as shown:

Savings account: $200 | Match with A
Undisclosed checking account: $800 | Add as new information

Reasonable Compatibility Determination

EBD Medicaid Asset Limit: $2,000
1. Total Countable Assets (Self-Reported): $5
2. Total Countable Assets (AVS and/or Self-Reported): $200 + $800 = $1,000
Result: Reasonably Compatible, because the sum of both calculations is less than the asset limit.

No further verification is requested from Lauren. A Notice of Decision is sent, listing only the self-reported amount.

Example 2: Mike applies for EBD Medicaid with a MAPP request and reports the following asset amounts, without providing verification:

Checking account: $500
Savings account: $700
Savings bond" $300 (non-AVS asset)

AVS returns the following information and the worker processes the information as shown:

Checking account: $800 | Match with A
Savings account: $400 | Match with B
Undisclosed checking account: $900 | Add as new information

Reasonable Compatibility Determination for EBD Medicaid

EBD Medicaid Asset Limit: $2,000
1. Total Countable Assets (Self-Reported): $500 + $700 + $300 = $1,500
2. Total Countable Assets (AVS and/or Self-Reported): $800 + $700 + $900 + $300 = $2,700
Result: Not Reasonably Compatible, because the sum of countable assets from data sources is above the EBD Medicaid asset limit.

In this case, the $700 savings account amount is used when calculating the total countable assets based on data sources, as it is the higher of the self-reported and AVS-returned information. A Verification Checklist is sent to Mike. All self-reported assets and the undisclosed checking account returned by AVS are included in the Proof Needed section.

If Mike provides verification of his assets and is found to be over the $2,000 asset limit for EBD Medicaid, CARES will then consider his MAPP eligibility without a reasonable compatibility test because all assets have been verified. If he meets all financial and non-financial rules for MAPP, his MAPP eligibility will be approved.

However, if Mike provides verification of his savings bond (the non-AVS asset) but fails to verify his checking and savings accounts, CARES will consider his MAPP eligibility using a reasonable compatibility test based on the MAPP asset limit.

Reasonable Compatibility Determination for MAPP

MAPP Asset Limit: $15,000
Total Countable Assets (Self-Reported): $500 + $700 + $300 = $1,500
Total Countable Assets (AVS and/or Self-Reported): $800 + $700 + $900 + $300 = $2,700
Result: Reasonably Compatible, because the sum of countable assets from data sources is below the MAPP asset limit.

No further verification is requested from Mike. A Notice of Decision is sent, listing only the self-reported amounts.

Example 3: Tasha applies for EBD Medicaid and MSP and reports the following asset amounts, without providing verification:

Checking account: $1,000
Savings account: $500

AVS returns the following information and the worker processes the information as shown:

Checking account: $2,000 | Match with A
Savings account: $2,500 | Match with B

Reasonable Compatibility Determination for EBD Medicaid

EBD Medicaid Asset Limit: $2,000
1. Total Countable Assets (Self-Reported): $1,000 + $500 = $1,500
2. Total Countable Assets (AVS and/or Self-Reported): $2,000 + $2,500 = $4,500
Result: Not Reasonably Compatible for EBD Medicaid because the sum of countable assets from data sources is above the EBD Medicaid asset limit.

Reasonable Compatibility Determination for MSP

MSP Asset Limit: $7,730
1. Total Countable Assets (Self-Reported): $1,000 + $500 = $1,500
2. Total Countable Assets (AVS and/or Self-Reported): $2,000 + $2,500 = $4,500
Result: Reasonably Compatible for MSP because the sum of countable assets from data sources is below the MSP asset limit.

A Verification Checklist is sent to the Tasha to request verification of the checking and savings account for EBD Medicaid. However, if Tasha does not return verification of these accounts, she will remain eligible for MSP.

20.3.5.2.2 Programs for Which Reasonable Compatibility Will Apply

The reasonable compatibility test will be performed as part of any eligibility determination for all EBD Medicaid programs with asset tests.

Populations not subject to an asset test (for example, children under age 19 and children who are members of the Children's Long-Term Support Waiver Program) will not have a reasonable compatibility test.

20.3.6 Medical or Remedial Expenses

Medical or remedial expenses used to meet a deductible or calculate patient liability, cost share, or premium amounts must be verified. The expense amount, any third party liability amount, and date of service must all be verified. If verification is not provided, do not include the expense to determine when a deductible has been met or in the liability, cost share, or premium calculation. Do not deny or terminate eligibility for failure to provide the requested verification.

For HCBW, Family Care, Family Care Partnership, PACE, and IRIS members, Care Managers, ADRC staff, and IRIS Consultant Agencies (ICAs) calculate medical and remedial expenses. Because care managers, ADRC staff, and ICAs already verify all medical and remedial expenses before reporting those expenses to IM, additional verification is not needed. Refer to 28.6.4.5 Medical/Remedial Expenses.

20.3.7 Power of Attorney and Guardianship

Verify power of attorney and any guardianship type as specified by the court. Ask for any documentation regarding durable power of attorney or court-ordered guardianship. For applications and other relevant applicant information, refer to Power of Attorney as "Power of Attorney for Finances."

The IM agency must determine the guardianship type specified by the court. Only the person designated as "guardian of the estate," "guardian of the person and estate," or "guardian in general" may attest to the accuracy of the information on the application form and sign it. Do not require a "conservator" or "guardian of the person" to sign the application form.

If verification is not provided, do not grant the claimed power of attorney or guardian access to case notices or follow any direction provided by that person unless he or she is an authorized representative. Do not deny or terminate eligibility for failure to provide the requested verification.

20.3.8 Income

Verify all sources of nonexempt income for EBD Medicaid applicants and members. Verify income using the automated data exchanges, when current (the month for which eligibility is being determined) information is available on a specific data exchange. If current income information is not available through a data exchange, the applicant/member is required to supply verification/documentation of their earned and unearned income.

In certain cases, data exchange resources do not exist or are unavailable to IM workers for eligibility determinations. For example, data exchanges are not available for persons who do not supply their SSN or where the income reported is not part of an existing data exchange. Under these circumstances, income must be verified by the member through other sources (i.e., checkstubs, award letters, etc.).

The following are examples of persons for whom a data exchange will never exist and, therefore, income verification is required at eligibility determination:

Ineligible persons who do not provide an SSN and whose income would be counted in the eligibility determination (Fiscal Test Group member);
Non-citizens without an SSN applying for emergency services. Persons whose employers do not report wages to the Department of Workforce Development (DWD) in Wisconsin, such as Wisconsin residents who work out of state and persons who work for the federal government.
Persons with income from sources that are never available to IM workers through a data exchange, such as self-employment, pensions, retirement income, etc.

The applicant/member is responsible for providing verification of income that is not available through data exchange. For example, data exchanges are not available for persons who do not supply their SSN or where the income reported is not part of an existing data exchange. Under these circumstances, income must be verified by the applicant/member through other sources (i.e. check stubs, award letters, etc.).

Assist the applicant/member in obtaining verification if he or she has difficulty in obtaining it.

Do not deny eligibility if reasonable attempts to verify the income have been made. Use the best information available to process the application or change timely when the following two conditions exist:

The applicant/member does not have the power to produce verification, and
Information is not obtainable timely even with your assistance. In this situation, continue to attempt to obtain the verification. Once the verification is received, benefits may need to be adjusted based on the verified information.