State of Wisconsin Department of Health Services

HISTORY

The policy on this page is from a previous version of the handbook. 

20-04 Version of 20.3 Mandatory Verification Items

20.3.1 Mandatory Verification Items Introduction

Verify the following mandatory items:

1. SSNSocial Security number (see Section 20.3.2 Social Security Number).
2. Alien Status (see Section 7.3 Immigrants).
3. DisabilityThe law defines disability for Medicaid as "The inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." and Incapacitation (see Section 5.2 Determination of Disability).
4. Assets for the ElderlyAnyone 65 years old or older, Blind, and Disabled (see Section 16.1 Assets Introduction).
5. Divestment, for EBD long-term care (see Section 17.1 Divestment Introduction).
6. Medical expenses, for deductibles only (see Section 24.7 Meeting the Deductible).
7. Medical/remedial expenses for noncovered services for an institutionalized person (see Section 27.7.7.2 Disallowed Expenses).
8. Documentation for Power of Attorney and Guardianship (see Section 20.3.7 Power of Attorney and Guardianship).
9. Migrant workers eligibility in another state (see Section 31.2 Simplified Application), if applicable.
10. 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.
11. Income.
12. 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 applicantA person who has submitted a request for coverage for whom no decision has been made regarding eligibility 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 CARESThis system supports the income maintenance operations for DHS and DCF. CARES is used to determine eligibility, issue benefits, track premium payments, and manage support for BadgerCare Plus, EBD Medicaid, W-2, Child Care, and Work Programs. SSN validation process.

If the SSN validation process returns a mismatch record, the memberA recipient of Medicaid; formerly referred to as a "client." 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 FDSHFederal Data Services Hub 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 DDBDisability Determination Bureau in the DHSDepartment of Health Services. Items that can be used to verify disability status include, but are not limited to:

• Proof of SSISupplemental Security Income. A program based on financial need operated by the Social Security Administration that provides monthly income to low income people who are age 65 or older, blind, or disabled. or other SS Disability payment,
• SOLQ-I,
• Award letter or verbal statement from SSASocial Security Administration. A federal agency which administers the SSI, OASDI, and Medicare programs., or
• Proof of MADAMedicaid — Disability Application approval, including presumptive disability

20.3.5 Assets

Verification of countable assetsnon-exempt and available 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 spouseA spouse is that person recognized by Wisconsin law as another person's legal husband or wife. Wisconsin does not recognize common law marriage. 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 IMincome maintenance 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:

1. Ineligible persons who do not provide an SSN and whose income would be counted in the eligibility determination (Fiscal Test Group member);
2. 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.
3. 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:

1. The applicant/member does not have the power to produce verification, and
2. 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.

Note:

Accept a member’s or suspended member’s statement and do not require verification of income earned by an inmate from a prison or jail job that pays less than minimum wage, such as jobs through Badger State Industries (BSI). See Section 15.5.18 Prison or Jail Job.

20.3.8.1 Reasonable Compatibility for Income for Health Care

This section addresses reasonable compatibility for income.  Reasonable compatibility for assets can be found in Section 20.3.5.2 Reasonable Compatibility for Assets.

Agencies may not request verification from health care applicants and members unless the information cannot be obtained through an electronic data source, the income is jail or prison earnings of an inmate (see Section 15.5.18 Prison or Jail Job), or information from the data source is not “reasonably compatible” with what the applicant has reported. Information from the data source is “reasonably compatible” if it results in the same eligibility outcome as member-reported information:

• If both the electronic data source and the member-reported information put the individual’s total countable income below a given income threshold, the two data sources are considered to be reasonably compatible and further verification may not be requested or required.
• If the electronic data source puts the individual’s total countable income above a given income threshold, but the member-reported information puts the individual’s total countable income below that same threshold, the two data sources are not reasonably compatible and further verification is required as a condition of eligibility.
• If the member reports income that is above a given threshold, the member-reported income information will be used to deny or terminate health care benefits, regardless of what the outcome would be using information from the electronic data source. In this scenario, verification is not required.

The reasonable compatibility test will only be applied to job earnings that have not otherwise been verified (for example, as part of another program’s verification process). It can only be applied when earnings information is available through the State Wage Information Collection Agency (SWICA) or through Equifax from the Federal Data Services Hub (FDSH).

Unearned income (as defined in Section 15.4) will continue to be verified as outlined in this chapter and in Process Help Chapter 44. If there is an electronic data source available to use for verifying a type of unearned income, it should be used as verification for that income. If no data source is available, the applicant or member must provide verification of the unearned income.

Self-employment and in-kind job income will continue to be verified as outlined in Section 15.6 and 15.5.1 and Process Help Sections 16.2 and 16.6

20.3.8.1.1 Programs for Which Reasonable Compatibility Will Apply

The reasonable compatibility test will be performed as part of any eligibility determination for the following categories of Medicaid:

• Elderly, Blind or Disabled Medicaid (EBD MA), except deductibles
• Medicaid Purchase Plan (MAPP)
• Medicare Savings Program (QMB/SLMB/SLMB+)

20.3.8.1.2 Reasonable Compatibility Thresholds

The reasonable compatibility test will apply to each AG for which earned income is reported, has not been already been verified, and for which SWICA and/or Equifax data is available. Because different AGs are subject to different income and premium thresholds, the thresholds described below will be used by population to determine whether reported information is reasonably compatible. Because different thresholds are used for different populations, individual members of a household or a given AG may pass the reasonable compatibility test while others do not.

• EBD Categorically Needy SSI-Related MA and Medically Needy MA thresholds are based on the income limits shown in Section 39.4.1.
• MAPP and MSP thresholds are based on the income limits shown in Section 39.5.
• MAPP Premium thresholds are based on 100% FPL for a group of one as shown in Section 39.5. and described in the table below.

Reasonable Compatibility Test for MAPP Premiums
If total gross income using the monthly earnings amount reported by the member is:	And total gross income using the monthly earnings reported by SWICA or Equifax is:	Is it reasonably compatible?
Below the MAPP premium threshold (100 percent of the FPL)	Below the MAPP premium threshold (100 percent of the FPL)	Yes. Eligibility will be based on the member-reported earnings amount, and a premium will not be owed.
Below the MAPP premium threshold (100 percent of the FPL)	At or above the MAPP premium threshold (100 percent of the FPL)	No. Further verification must be requested.
At or above the MAPP premium threshold (100 percent of the FPL)	At or above the MAPP premium threshold (100 percent of the FPL)	A reasonable compatibility test was not done. Income must be verified for the correct premium amount to be determined.
At or above the MAPP premium threshold (100 percent of the FPL)	Below the MAPP premium threshold (100 percent of the FPL)	A reasonable compatibility test was not done. Income must be verified for the correct premium amount to be determined.

20.3.8.1.3 Reasonable Compatibility Test

The reasonable compatibility test is based on whether using member-reported information about earnings and information about earnings from data exchanges results in the same eligibility outcome when all other countable income is taken into account.

Reasonable compatibility will first be tested based on the household’s total countable income as reported to the agency or verified through other sources. This test will determine whether the member is required to provide verification of earnings.

If the member-reported earnings amount is not reasonably compatible (based on the household’s total reported income), verification of earnings will be required at the same time that verification is required for unearned income, self-employment, and/or tax deductions.

A second verification request will be required if the initial test leads to a determination of reasonable compatibility but the earnings are no longer reasonably compatible after other income types or deductions have been verified.

If earnings are determined to be reasonably compatible, the amount reported by the member should be used to determine eligibility and premium amounts for health care.

If the earnings are later verified (for example, because verification is required for another program), the verified earnings should then be used to determine eligibility and premium amounts for health care.  

In this situation, members are not liable for overpayments because the initial determination was based on income that was reasonably compatible with a data exchange.

Members with eligibility determinations that were based on income that was reasonably compatible are subject to regular change reporting rules and can be subject to benefit recovery if they fail to report income that exceeds their reporting threshold.

20.3.8.1.4 Use of Equifax Data for Verification of Income

Agencies may not consider Equifax data to be the final “verified” income amount unless the Equifax data is the same as what the member reported.  Agencies may not deny or terminate health care benefits based on earned income data received from Equifax without giving the applicant or member an opportunity to verify their reported earned income amount.

If the member reports that he or she is unable to obtain the requested verification, the worker should assist the member in obtaining verification (see Section 20.1.4). If the applicant and/or worker have made reasonable efforts to obtain verification and are not able to do so, then the agency should determine the income amount based on “best available” information, and then document how this amount was determined.

Note:

The same policies for use of Equifax data apply when a member is reporting a change in income. Equifax data can be used for verification if it is the same as what the member has reported. If it is not the same, health care will apply a reasonable compatibility test to determine whether further verification is required.

20.3.9 Proof of Temporary Hardship for MAPP members

Verify a temporary hardship for MAPP applicants and members who apply for a temporary MAPP premium waiver due to hardship, Section 26.5.8.

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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