520 ELIGIBILITY REQUIREMENTS THAT FOLLOW APA POLICY
520 A. APPLICATION AND REVIEW PROCESS
Applications
Refer to APA Manual Section 410-2 for policy on the application form.
An individual may file an application for Medicaid on DPA form GEN 50B or on any other form DPA designates for that purpose.
Medicaid also uses the MED 4 application form for an individual applying for or receiving institutional or HCB waiver services. The application must be completed and necessary forms signed by the applicant, a relative or a guardian acting on his or her behalf. If the applicant is married and living with his or her spouse or entering a nursing home, collect income and resource information of the spouse in order to determine if the community spouse should receive an income maintenance allowance from the institutional or HCB waiver spouse.
Exceptions:
A
new application is not
required:
When
an individual is already part of an active public assistance case and
the existing case file already includes the information needed to make
a prospective Medicaid determination. The caseworker must carefully document
the source of information used to make the eligibility determination.
TPL,
a disability determination, or any other missing information
must be requested separately.
When the individual is already
a Medicaid recipient in another eligibility category (i.e. DKC to TEFRA
or Working Disabled to another APA
related Medicaid).
The Interview
Refer to APA Manual Section 410-3 for policy on interview requirements for applicants.
Exception:
If a client has an active public assistance case and submits a new application
for Medicaid, an interview is not required unless the caseworker feels
it is necessary to correctly determine eligibility.
Reviews
Refer to APA Manual Section 480-1 for policy on reviews.
Children in SSI-related categories (for example, SSI, TEFRA, HCB waiver services, Special LTC Standard, etc.) are reviewed annually.
520 B. U.S. CITIZENSHIP AND ELIGIBLE ALIEN STATUS
Refer to APA Manual Section 421 for policy on U.S. citizenship and eligible alien status.
See this section for U.S. citizenship verification procedures. See section 520-C for identity verification procedures.
Note:
Verification of U.S. citizenship and identity is not required for an alien
applying for treatment of an emergency medical condition. See section 576.
Individuals who declare they are U.S. citizens or nationals must be given a reasonable opportunity (90 days) to provide verification of their citizenship and identity. Eligibility for Medicaid may not be denied or delayed during this reasonable opportunity period if the individual meets all other eligibility factors except for verification of U.S. citizenship and identity.
In most cases, proof of citizenship and identity will be available within a few days through a SVES data match with SSA. More information on the SVES data match is shown below. If the SVES response does not verify citizenship and identity, the caseworker must:
Confirm that the correct name and Social Security Number was used for the SVES data match. If not, the caseworker must make the corrections in EIS and request a new SVES data match.
Determine if the individual is exempt from the requirement to provide verification of U.S. citizenship and identity or if verification of citizenship or identity is readily available through some other means.
If the caseworker determines that verification of U.S. citizenship or identity is still necessary, the caseworker must request that the household provide verification of U.S. citizenship or identity for the individuals in question, giving the household 90 days to provide this required verification.
If, by the end of the 90 day period, the verification has not been received and the caseworker has not been able to verify citizenship or identity in any other way, the individuals will have their Medicaid eligibility terminated with timely notice of adverse action.
Individuals that have received a 90-day period to provide proof of U.S. citizenship or identity are not entitled to receive it again. No further Medicaid benefits will be authorized for the individuals until verification of their U.S. citizenship or identity is received.
Note:
Children under the age of 19 are not eligible for a 12-month continuous
eligibility period if their claim to be a U.S. citizen or national is
not verified. See Section 515.
Verification of U.S. citizenship and identity is not required for:
A current SSI recipient;
A current Medicare recipient;
An individual receiving
SSDI benefits;
Children in state
foster care or Title IV-E adoption assistance; or
A newborn that is eligible for and receives Medicaid in their birth month. This includes a newborn whose mother is a non-qualified alien and is determined eligible under Emergency Treatment for Aliens. These newborns are considered to have provided satisfactory documentation of citizenship and identity, and no further documentation will be necessary in the future.
Note:
Although recipients of SSDI,
SSI, or Medicare are
exempt from verifying their U.S. citizenship, this exemption only applies
to individuals that claim to be U.S. citizens or nationals. If the individual
does not claim to be a U.S. citizen or national, they are not exempt from
verifying their alien status. Medicaid cannot be approved until proof
of alien status is received (except Emergency Treatment for Aliens).
Verification of U.S. citizenship and identity or immigration status is needed only for the individuals who will receive benefits, not for individuals applying for or renewing Medicaid on behalf of someone else.
Documenting U.S. Citizenship
Verification of citizenship must be obtained from original documents or certified copies from the issuing agency, unless verification is obtained through the Bureau of Vital Statistics (BVS), State Verification and Exchange System (SVES), or Permanent Fund Dividend (PFD) interface as described below.
An agency staff member or out-stationed staff will make a photocopy of the documents for the case file and stamp or note on the copy that an original or a certified copy was seen. A DPA contracted fee agent or authorized member of a tribal health organization may also verify and note on the photocopy that an original or certified copy was seen. Uncertified copies, including notarized copies are not acceptable. A list of currently approved fee agents and tribal health agency staff is available on the DPA web under DPA related links.
Although some documents contain a statement DO NOT COPY, DPA staff may copy and file these documents in the case file for the official purpose of establishing Medicaid eligibility.
Note:
Once a person’s citizenship is documented and recorded, it is not necessary
to get proof again unless that person’s citizenship becomes questionable.
Data Matches and Interfaces
For citizenship, verification may be obtained from a data match or online access with the Bureau of Vital Statistics (BVS), the State Verification and Exchange System ( SVES ) interface, or from information on the PFD interface.
BVS Data Match. When birth information is verified through an automated data match with BVS, the EIS HERC screen will be coded with BV overriding any prior code. No screen print is required for the case file.
SVES Data Match. The SVES interface may be used to verify a person's SSN . It may also be used to verify US citizenship. The caseworker may accomplish this by submitting an SVES inquiry for one or more persons on the INME/SVIR or SSDO screens. If the person is a Medicaid applicant or recipient and has a valid Social Security Number, EIS will enter an SV code in the SSN, and Citizenship verification fields on the SSDO and HERC screens, as follows:
SSN verification, SSDO screen. If the SVES response shows that the person's SSN is valid, an SV code will be entered in the SSN verification field. If the SSN verification field has a PE code and a pend date entered, the SV code will replace the PE code, remove the pend date, and advise the caseworker of the change through a client alert.
Citizenship verification, HERC screen. If the SVES inquiry confirms that the person is a US citizen, an SV code will be entered in the citizenship verification field. The SV code will not replace higher priority codes of 1A, 2A, 3A, 4A, or BV. If the verification field has a PE code and a pend date entered, the SV code will replace the PE code, remove the pend date, and advise the caseworker of the change through a client alert.
PFD Data Match. The PFD interface may be used for individuals
who applied for a PFD for the first time in 1989 or after
and claim US citizenship. The PFD Division requires that an original
or certified copy of a birth certificate, certificate of naturalization
or other acceptable document be submitted. When a birth certificate
is received, the state of birth is recorded in the PFD data with a two letter state identifier.
The PFD interface can be accepted as verification
of citizenship when all of the following information appears on the screen:
US Citizenship (CITIZEN FLAG) is Y
Place of birth (BIRTH STATE) is two digit state code
Year of first application (FIRST APP YEAR) is 1989 or later
When the birth state field shows //, other verification of citizenship is required as this code means the individual was born in another country, for example when someone is a naturalized citizen.
If information obtained from the client, is not consistent with information from the PFD interface, additional documentation must be obtained from the client to verify citizenship.
When birth information is verified through the online BVS access look up, or the PFD interface, enter the "IN" code in the verification field on the EIS HERC screen. A screen print of the information must be placed in case file. For BVS, the screen print must be marked For DPA Use Only. These screen prints should not be copied for other uses.
If verification is not available through the BVS, SVES , or PFD interface, and there is no record that an original or certified copy was seen, this documentation must be requested from the applicant or recipient.
Levels of Acceptable
Documents
The list below provides allowable documentation for verifying U.S. citizenship. There are four
levels of verification listed in order of preference. If a higher
level document is not available, a lower level may be used.
Level One: Acceptable for Both Proof of Citizenship and Identity.
A U.S. Passport;
A Certificate of Naturalization (Forms N-550 or N-570);
A Certificate of U.S. Citizenship (Forms N-560 or N-561); or
A document issued by a Federally-recognized Indian Tribe evidencing membership or enrollment in, or affiliation with, such tribe, (such as a tribal enrollment card or Certificate of Degree of Indian blood); or
Verification of citizenship status and identity by the Social Security Administration through the State Verification and Exchange System ( SVES ).
Level Two: Acceptable for Proof of Citizenship. (The client must have an additional form of identity verification. See section 520-C.)
Verification
of birth through a Bureau of Vital Statistics ( BVS ) online access
or an electronic BVS data match;
Permanent Fund Dividend ( PFD ) interface;
A U.S. birth certificate showing birth in one of the 50 States, the District of Columbia, Puerto Rico (if born on or after January 13, 1941), Guam (on or after April 10, 1899), the Virgin Islands of the U.S. (on or after January 17, 1917), American Samoa, Swain’s Island, or the Northern Mariana Islands (after November 4, 1986) recorded before 5 years of age;
A Certification of Report of Birth (Forms FS-545 or DS-1350);
A Report of Birth Abroad of a U.S. Citizen (Form FS-240);
A U.S. Citizen I.D. Card (Forms I-179 or I-197);
An American Indian Card (I-872) issued by the Department of Homeland Security with the classification code KIC;
A Northern Mariana Identification Card (Form I-873);
A final adoption decree showing the child’s name and U.S. place of birth;
Evidence of U.S. Civil Service employment before June 1, 1976;
U.S.
Military Record showing a U.S. place of birth, such as a DD-214,
or similar official document that shows a U.S. place of birth; or
Evidence of meeting the automatic criteria for U.S. citizenship under the Child Citizenship Act of 2000. See Family Medicaid Manual sections 5011-8 and 5011-9.
Level Three: Acceptable for Proof of Citizenship. (The client must have an additional form of identity verification. See section 520-C.)
Level three documents are allowed when both primary and secondary verification is not available and include:
For individuals who are age 16 or older, an extract of a hospital birth record on hospital letterhead established at the time of the person’s birth that was created five years before the initial application date and that indicates a U.S. place of birth. This may also include medical records of post-natal care. For children under age 16, the document must have been created near the time of birth or five years before the date of application;
Note:
A souvenir birth certificate issued by
a hospital is not acceptable verification.
Life, health, or other insurance record showing a U.S. place of birth that was created at least five years before the initial application date and that indicates a U.S. place of birth. For children under age 16, the document must have been created near the time of birth or five years before the date of application;
Religious record
recorded in the U.S. within three months of birth showing the birth
occurred in the U.S. and showing either the date of the birth or the
individual's age at the time the record was made. The record
must be an official record, such as a baptismal certificate that is
recorded with the religious organization. This does not
include entries in a family bible; or
Early school
record showing a U.S. place of birth. The school record must
show the name of the child, the date of admission to the school, the
date of birth, a U.S. place of birth, and the names(s) and place(s)
of birth of the applicant's parents.
Level Four: Acceptable for Proof of Citizenship. (The client must have an additional form of identity verification. See section 520-C.)
Level four documents are allowed when first, second and third level verification is not available and include:
One of the following
documents that shows a U.S. place of birth and was created at least
five years before the application for Medicaid For children
under 16, the document must have been created near the time of birth
or 5 years before the date of application:
Seneca Indian tribal census record.
Bureau of Indian Affairs tribal census records of the Navajo Indians.
U.S. State
Vital Statistics official notification of birth registration.
A delayed
U.S. public birth record that is recorded more than five years after
the person’s birth;
Statement
signed by the physician or midwife who was in attendance at the time
of birth;
Medical (clinic,
doctor, or hospital) record created at least five years before the
initial application date that indicates a U.S. place of birth;
Federal or State
census record showing U.S. citizenship or a U.S. place of birth;
The Roll of Alaska Natives maintained by the Bureau of Indian Affairs. The Roll only contains information for individuals who were born prior to December 18, 1971. Using a release of information, staff may contact the Bureau of Indian Affairs to request information and documentation on the individual from the Roll;
Institutional admission papers from a nursing facility, skilled care facility or other institution created at least 5 years before the initial application date that indicates a U.S. place of birth; or
Written
declarations. As a last resort a written declaration
made by at least two individuals of whom one is not related to the
applicant/recipient and who have personal knowledge of the event(s)
establishing the applicant’s or recipient’s claim of citizenship.
If known, the declaration should also explain why documentary
evidence establishing the applicant’s claim of citizenship does not
exist or cannot be readily obtained. The person(s)
making the declaration must be able to provide proof of his/her own
citizenship and identity for the declaration to be accepted.
A separate declaration is needed from the applicant/recipient or other
knowledgeable individual (guardian or representative) explaining why
the evidence does not exist or cannot be obtained. The declarations
must be signed under penalty of perjury.
See this section for identity verification procedures. See section 520-B for U.S. citizenship verification procedures, including level one documents that are acceptable for both proof of citizenship and identity.
Documenting Identity
Verification of identity must be obtained from original documents or certified copies from the issuing agency, unless verification is obtained through the State Verification Exchange System (SVES) interface as described below.
Note:
An additional form of identity verification is required when citizenship
verification is obtained through the Bureau of Vital Statistics or the
Permanent Fund Dividend interface. An additional form of identity
verification is not required when citizenship is verified through SVES .
An agency staff member or out-stationed staff will make a photocopy of the documents for the case file and stamp or note on the copy that an original or a certified copy was seen.
A DPA contracted fee agent or authorized member of a tribal health organization may also verify and note on the photocopy that an original or certified copy was seen. Uncertified copies, including notarized copies are not acceptable. A list of currently approved fee agents and tribal health agency staff is available on the DPA web under DPA related links.
Although some documents contain a statement, DO NOT COPY, DPA staff may copy and file these documents in the case file for the official purpose of establishing Medicaid eligibility.
Note:
Once a person’s identity is documented and recorded, it is not necessary
to get proof again unless that person’s identity becomes questionable.
Data Match and Interface
SVES Data Match. The SVES interface may be used to verify a person's identity. The caseworker may accomplish this by submitting an SVES inquiry for one or more persons on the INME/SVIR or SSDO screens. If the person is a Medicaid applicant or recipient and has a valid Social Security Number, EIS will enter an SV code in the Identity verification field on the HERC screen, as follows:
Identity verification, HERC screen. If the SVES inquiry confirms the person's identity, an SV code will be entered in the identity verification field. The SV code will not replace higher priority code of 5A. If the verification field has a PE code and a pend date entered, the SV code will replace the PE code, remove the pend date, and advise the caseworker of the change through a client alert.
If verification is not available through the SVES interface, and there is no record that an original or certified copy was seen, this documentation must be requested from the applicant or recipient.
Level Five: Acceptable Proof of Identity. The list below provides allowable documentation for verifying identity. (The client must have an additional form of citizenship verification. See section 520-B.)
A driver’s license issued by a state or territory with a photograph of the individual or other identifying information such as name, age, sex, race, height, weight, or eye color. A voter's registration card or Canadian driver's licenses are not acceptable verification;
Identification card issued by the federal, state, or local government with the same information included on driver’s licenses listed above;
U.S. military card or draft record;
Military dependent’s identification card;
U.S. Coast Guard Merchant Mariner card; or
School identity card with a photograph of the individual.
When no Other Identity Document is Available
Three or more documents
that together reasonably confirm the identity of an individual, such
as employer identification cards, high school and college diplomas
from accredited institutions (including general education and high
school equivalency diplomas), marriage certificates, divorce decrees
and property deeds/titles. The documents must list the individual's
name, plus any additional information establishing the individual's
identity and must have consistent identifying information. This form
of identity may not be used when U.S. citizenship is documented under
level four (see section
520-B).
Identity for Children
under age 16
Clinic, doctor or
hospital records;
School records, which
may include nursery or daycare record and report cards. Verification
of these records must be made with the issuing school; or
A Medicaid application or a declaration that states the date and place of the child’s birth that is signed by a parent, guardian, or caretaker relative under penalty of perjury. The Medicaid application or an identity declaration may be used for children under age 18 in limited circumstances, such as when school ID cards and drivers' licenses are not available to the individual in their locality.
Note:
Verification of identity for children under age 16 that is obtained through
clinic, doctor, hospital or school records or the signature on a Medicaid
application should be coded 5A on the HERC
screen.
Example:
An 15-year old individual has been receiving Medicaid. A recertification
is due in September and the individual will be 16 years old. When the
individual submits the Medicaid recertification, the caseworker does not
need to verify the identity of the 16-year old again, unless that individual’s
identity is questionable.
Identity for Disabled Individuals in Institutional Care
A declaration signed under penalty of perjury by a residential care facility director or administrator on behalf of on behalf of the individual in the facility when the individual does not have or cannot get any of the documentation listed above.
Note:
A declaration for identity may not be accepted if a declaration for citizenship
was provided.
Refer to APA Manual Section 420 for policy on development of income requirements.
Exception #1:
Pursuit of SSI benefits
is not a requirement for Medicaid and APA
Manual Section 420-2 does not
apply to a Medicaid-only case. However, an individual must still
meet APA/SSI criteria for blindness, disability,
or age. See APA
Manual Sections 424
- 425.
520 E. DISABILITY DETERMINATIONS
The case file should contain a copy of the recipient’s long-term care medical authorization, approval for HCB waiver services from the DSDS, and the SSI or SSA approval, whichever are applicable. If the person is disabled, it is very important to record the SSA date of disability onset, as this date may determine the start date for retroactive Medicaid eligibility.
Refer to APA Manual Section 425 and Administrative Procedures Manual Section 115-9 for policy and procedures on disability determinations.
Exception:
SGA is not a factor for
Working Disabled Medicaid Buy-In. See Section
534.
520 F. VERIFICATION AND DOCUMENTATION
Refer to APA Manual Section 400-4 for policy on verification, and APA Manual Section 400-5 for policy on documentation.
Refer to APA Manual Section 480-3 for policy on changes.
Refer to APA Manual Section 481 for policy on notices.
Refer to APA Manual Section 480-7 and Administrative Procedures Manual Section 117 for policy and procedures on fair hearings.
Refer to APA Manual Section 480-6 for policy on loss of contact.
Refer to APA Manual Section 424 for policy on qualifying age.
Exceptions:
• SSI
Child Cases. A blind or disabled child receiving a SSI payment and related Medicaid must
be under age of 18. These children are not included in any other
Medicaid categories.
• Disabled Child at Home ( TEFRA ). To be eligible
for the TEFRA eligibility
category, an individual must be under the age of 19.
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