Verification for Medicaid Applications

All applications for ABD Medicaid require that the applicant’s basic eligibility be verified. See ABD Manual Section 2201-4. Applications for long-term care Medicaid also require verification of income and resources, but caseworkers are instructed to “For ABD Medicaid verification requirements, see the sections pertaining to the specific COA and the Income and Resource Chapters.” ABD Manual 2051-4.

According to Georgia’s ABD Manual: “Verification is the use of electronic data sources/computer matches, related active program(s), client statements, documents, collateral contacts with a third party, home visits, computer matches and documentation which confirm the accuracy of statements and information.” Section 2051-1. Eligibility for each class of assistance varies, but generally, the following must be proven to establish eligibility:

• Enumeration. 42 C.F.R. § 435.910 requires that each applicant furnish his or her Social Security number. Subsection (h) lists exceptions to this rule such as being ineligible to receive a SSN or refusal to obtain one based on a well established religious exception. ABD Section 2005 and 2220.
• Aged, Blind or Disabled. Only those persons who are aged (65 and older), blind or disabled (as defined in the Social Security Act) are eligible for long-term care Medicaid. Other classes of assistance, such as assistance for children or pregnant women do not include this requirement. See ABD Manual 2205.
• Residency. An applicant (usually) applies for Medicaid in the State where care is received. States must provide Medicaid to eligible residents. 42 C.F.R. § 435.403(a). In general terms, if an individual with legal capacity is present in the State with an intent to reside there, then he or she is a resident. § 435.403(h)(2). For any institutionalized individual who became incapable of indicating intent at or after age 21, the State of residence is the State in which the individual is physically present, except where another State makes a placement. § 435.403(h)(4). The agency may not deny Medicaid eligibility because an individual has not resided in the State for a specified period. § 435.403(j). Georgia waives the residency requirement for nursing home residents, applicants under age 18, applicants over 18 who became mentally incapable prior to age 18, and individuals from States that have an Interstate Residency Agreement. Georgia has an Interstate Residency Agreement with the following States: West Virginia, Alabama, California, Mississippi, Florida, Louisiana, Tennessee, Minnesota, Kentucky, New Mexico, New Jersey, Ohio, Pennsylvania, Wisconsin and New York; however, Georgia’s agreement with North Carolina is limited. See ABD Manual 2205-4.
• Citizenship. The agency must verify the declaration of citizenship or satisfactory immigration status of each applicant. 42 C.F.R. § 435.406(c). Acceptable documentation of citizenship status is listed at 42 C.F.R. § 435.407. See also ABD Manual 2215.
• Medical Necessity and Level of Care. For nursing homes, medical neessity and level of care are documented on Form DMA-59. See also ABD Manual 2240 regarding how to document level of care for different classes of assistance.
• Length of Stay. ABD Manual Section 2235 states: An individual must remain in one of the above COAs for 30 continuous days to meet the LOS requirement:
  • Community Care Services Program (CCSP)
  • Hospice Care
  • Hospital
  • Independent Care Waiver Program (ICWP)
  • Nursing Home
  • New Options Waiver (NOW)
  • Comprehensive Supports Waiver Program (COMP)
  • Note: The LOS requirement is waived for individuals who die while residing a long-term care institution.
• Identity. The Agency must verify the applicant’s identity and acceptible documents are listed at 42 C.F.R. § 435.407(c).
• Income. Each class of assistance has its own income requirements, but verification of all income is required.
• Resources. Each class of assistance has its own resource requirements, but verification of all resources is required

Georgia allows applicants to deliver verification in the following ways: via mail; e-mail; in person; by facsimile or other electronic device; through a personal representative (PR); by upload through GA Gateway or Document Imaging System (DIS) selfservice kiosk; or through a Community Partner agency. The agency may not require the AU to present verification in person. 2051-1.

Attorneys assisting with a Medicaid application should upload all supporting verification as quickly as possible because some caseworkers will review it before the telephone interview. If all  of the necessary informatin is there, the case can be approved during the phone interview. If any necessary information is missing, the caseworker will send out a request for additional information on what used to be known as Form 981 (See alternate request form).

In Georgia, the applicant/recipient (A/R) is the primary source of information for him/herself. ABD Section 2050-2. Eligibility determinations must be based, to maximum extent possible, on self-attestation of income that is verified by information from electronic data sources. ABD Section 2051-2. When information from electronic data sources is consistent with an individual’s attestation of income, the income is considered verified. Self-attestation may be accepted from the following:

• The applicant
• An adult in the applicant’s household
• A Personal representative (PR)
• Someone acting responsibly for the individual (if the individual is a minor or
  incapacitated).

For some classes of assistance, such as Q-Track Medicaid and Medicaid for Pregnant Women and Newborns, a client statement is sufficient verification. ADB Manual 2051-3.

Georgia caseworkers must accept reasonable verification. Reasonable verification can be self-attestationi when permitted, but may also come from documents and collateral contacts.

Third Party Verification

• Third party verification includes the following: documents – legal agreements, contracts, bills, leases, medical or doctor’s statements, prescription receipts, check stubs, employer statements, social security cards, driver’s license, etc.
• collateral contacts – an oral or written statement from a third party, contact with a social service agency, etc.

Documents:

ABD Manual Section 2051-6 states: When possible, documents are used as the primary source of verification. Documents provide written evidence of the AU’s statements. Documents or photocopies of documents are filed in the case record and/or scanned into the Document Imaging System (DIS) as proof of the AU’s circumstances. All documents scanned into DIS will be tagged, at a minimum, with the Client ID(s) of the individual(s) the document(s) pertain(s) to and the AU ID(s) of the case(s) impacted. Documents should also be scanned is under the appropriate document “type” (e.g. pay stubs as income verification).

Collateral Contacts:

ABD Manual Section 2051-6 states: A collateral contact is an oral or written confirmation of the AU’s circumstances by a non-AU member. The collateral contact may be made in person, over the telephone, or in writing. NOTE: A collateral contact alone is not sufficient for verification of income. Documentary evidence such as a signed statement or Form 809 must be received, with the collateral contact made to validate.
If a written statement is provided by the collateral contact, the statement must be signed by the individual who wrote the statement. The statement should be dated but, if not dated, DFCS must date stamp or record on the statement the date it is received. The telephone number and/or address or way to contact the collateral contact must be furnished. This information may be provided as a part of the written collateral statement or recorded in the case file. If a collateral statement is unacceptable to the agency because it is not completed correctly or lacks the required information and the AU is cooperating with providing information, the agency must offer assistance to the AU. The agency may ask the AU to provide another collateral contact, select another one for the AU or contact the collateral contact directly.

The Medicaid agency is required to document it’s case file and include in each applicant’s case record facts to support the agency’s decision. 42 C.F.R. § 435.914.

Medicaid will not approve an application until everything has been verified. If you don’t submit the required verification, you should assume your application will be denied.