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State of Wisconsin |
HISTORY |
The policy on this page is from a previous version of the handbook.
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).
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.
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:
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).
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:
Verify the SSN only once.
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.
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:
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.
Verify if a member or spouse has divested assets when determining eligibility for institutional Medicaid and community waivers (see Section 17.1 Divestment Introduction).
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.
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.
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:
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Calculation |
Description |
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1: Total Countable Assets (Self-Reported)
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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. |
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2: Total Countable Assets (AVS and/or Self-Reported)
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Sum of the following:
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CARES will compare the results of calculations 1 and 2 to determine reasonable compatibility.
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.
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Example 1: Lauren applies for EBD Medicaid and reports the following asset amount, without providing verification:
AVS returns the following information and the worker processes the information as shown:
Reasonable Compatibility Determination
No further verification is requested from Lauren. A Notice of Decision is sent, listing only the self-reported amount.
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Example 2: Mike applies for EBD Medicaid with a MAPP request and reports the following asset amounts, without providing verification:
AVS returns the following information and the worker processes the information as shown:
Reasonable Compatibility Determination for EBD Medicaid
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
No further verification is requested from Mike. A Notice of Decision is sent, listing only the self-reported amounts. |
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Example 3: Tasha applies for EBD Medicaid and MSP and reports the following asset amounts, without providing verification:
AVS returns the following information and the worker processes the information as shown:
Reasonable Compatibility Determination for EBD Medicaid
Reasonable Compatibility Determination for MSP
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.
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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.
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.
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.
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:
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:
Verify a temporary hardship for MAPP applicants and members who apply for a temporary MAPP premium waiver due to hardship, Section 26.5.8.
The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.
Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.
Publication Number: P-10030