Documentation Policy Technical Assistance Training HRA 1 Documentation

Documentation Policy Technical Assistance Training HRA 1

Documentation § A/R’s Responsibilities § Worker’s Responsibilities § Factors of Eligibility that MUST be verified/documented § Factors of Eligibility that do not need to be verified/documented 2

Verification § Evidence used to establish or confirm the accuracy of information obtained during the eligibility determination process Validation § Information that is validated or confirmed by another agency 3

Verification May Be in the Form of: § Documents § Written statements § Oral communication 4

Documentation § Entering into the case record the verification which is obtained during the eligibility process 5

Documentation May Be in the Form of: § Originals, photocopies of documents, facsimiles, scanned or other copies § Written statements by the examiner § Statements by other individuals 6

Source of Verification § Primary: A/R and members of their household § Secondary/Collateral: Relatives or other persons & agencies 7

A/R Responsible for: § Providing informational documents that are readily available to verify eligibility § Providing information that will help the worker obtain verification not readily available 8

Eligibility Worker Responsible for: § Checking to see if the active case record or closed case record contains information not subject to change § Checking WMS/MMIS (Clearance Report) for demographic information: – Date of Birth – SSN 9

Eligibility Worker (cont’d) § If the evaluation of the Clearance Report shows an active, closed or denied case, certain demographic data associated with that CIN is considered to be verified even if entered by another district, unless there is reason to believe otherwise 10

Eligibility Worker (cont’d) § Providing the A/R with a written list or form – Documents Needed When You Apply for Health Insurance (DOH-4220 B) § Noting the required date of return for required documents § Make calls or write to sources to obtain verification that the A/R cannot acquire 11

Documentation/Verification § Only factors of eligibility must be requested § Always use each form of verification for as many aspects of eligibility as possible 12

Incomplete Application § If information is missing on an application LDSSs have 2 choices: – Call applicant and notate findings on application OR – Photocopy incomplete pages of the application and mail them to the applicant to be completed and returned 13 • Documents Needed When You Apply for Health Insurance (DOH-4220 B) indicating a return date, and DOH-4418

Application Referrals from NY State of Health § An Access NY Health Care application (DOH-4220) and, for SSI-Related, Supplement A (DOH-4495 A) must be completed, signed and returned with appropriate documentation within 15 working days § If returned without complete documentation, a request for missing documentation should be sent 14

Express Lane Eligibility Applications § Documentation is not required for Express Lane Eligibility (ELE) cases – 12 OHIP/ADM-2 – Except for Immigration documents § Information given on CHPlus renewal and CHPlus Screening Worksheet is sufficient § ELE cases must not be pended for additional information 15

Social Security Number § A/Rs are required to tell the LDSS what their SSN is, but are not required to show proof of the SSN initially – Children will be denied/discontinued if parent/caretaker relative does not provide or apply for a SSN for them 16

Social Security Number (cont’d) § Individuals exempt from SSN rules: – Pregnant women – Children up to the age of one who are born to a mother in receipt of Medicaid (Deemed Newborns) – Undocumented aliens/temporary non immigrants 17

Social Security Number (cont’d) § Documentation is necessary only if the SSN cannot be verified or validated through the SSA – SSN card – Correspondence from SSA § Applicants will have 10 days to resolve a SSN that does not validate 18

SSN Validation - No History on Clearance LDSS enters SSN Code 1 SSA Validated SSN Code 8 No further action required 19 Not Validated SSN Code other than 8 A/R has 10 days to provide verification of SSN Process is repeated

SSN Validation - History on Clearance SSN Code A B D 9 7 8 20 Request verification of SSN validated – no further action required

Social Security Number (cont’d) § If A/R does not have an SSN they must apply for one – Application must not be denied or delayed pending issuance of SSN – A/R has until the end of the renewal period to provide SSN or the attestation form – An individual who declares U. S. citizenship or nationality under penalty of perjury at time of application is not required to document their citizenship, identity, or date of birth 21

Citizenship & Identity Requirements § All United States citizens applying for and renewing Medicaid coverage are required to provide “satisfactory documentary evidence” of their identity and U. S. citizenship – Applies to natural born citizens and individuals who acquire citizenship through naturalization 22

Citizenship & Identity Requirements (cont’d) § Presentation of documentary evidence of citizenship and identity is a one-time activity 23

Federal Exemptions for Citizenship & Identity Documentation § A/Rs eligible for or enrolled in Medicare; § Receiving Supplemental Security Income (SSI); § Receiving Social Security Disability Income (SSDI); § Children under Title IV-B (on the basis of being a child in foster care); or § Adoption/foster care assistance under Title IV-E 24

Citizenship & Identity Documentation § Deemed Newborns – Born to mothers who were on Medicaid at the time of their birth – Considered to have provided satisfactory documentation of citizenship and identity by virtue of being born in the United States when renewed on their first birthday – Will not be required to further document citizenship or identity at any subsequent Medicaid eligibility redetermination 25

Citizenship & Identity Documentation (cont’d) § Deemed Newborns (cont’d) – Documentation must be kept in case record • Newborn’s automated Medicaid enrollment form • Copy of the mother’s Medicaid coverage history screen at the time of birth • Correspondence from managed care plans or hospital – District worker must make note in case record 26

A/Rs Not Required to Prove Citizenship/Immigration Status § Immigrants applying for Medicaid for the treatment of an emergency medical condition § Pregnant women § Verification of identity is still required 27

CHIPRA Citizenship Verification Process § A Medicaid A/R declaring U. S. citizenship is not required to provide documentation of identity, citizenship and date of birth initially at application § They must attest to their U. S. citizenship and provide an SSN that will go through a validation process with SSA § If their SSN is validated by SSA their information will again be matched with SSA Data to validate identity, U. S. citizenship and date of birth 28

CHIPRA Citizenship Verification Process (cont’d) § Once an A/R’s SSN is validated by the SSA with an SSN validation code of 7 or 8, and the ACI code is C in Field No. 382 of the TAD, the A/R’s information will go through the SSA Citizenship Data Match 29

CHIPRA Citizenship Verification Process (cont’d) § If verified by SSA a Birth Verification Indicator (BVI) will be system generated with a code of a “ 1” in WMS (Field No. 366) – No further action is required and no additional documentation of identity, U. S. citizenship or date of birth is required 30

CHIPRA Citizenship Verification Process (cont’d) § If there are “inconsistencies” a BVI of B, C, or D will be system generated in Field No. 366 – If the BVI generates a B (B=“Bad Match”), the LDSS must resolve the inconsistency 31

CHIPRA Citizenship Verification Process (cont’d) § If the SSN code is an 8, and changes are made to the demographic data (Name, Sex, DOB), SSN code must be changed to a 1 – BVI of B or 5 will automatically be reset to blank and the information will go through the SSN and citizenship validation process with the new information 32

CHIPRA Citizenship Verification Process (cont’d) § If an inconsistency is not resolved, the LDSS must request citizenship and identity documentation from the applicant – Send “Request to Provide Additional Documentation – Citizenship/Identity Match 90 Day Notice” – Must also include a copy of the appropriate “Request for Verification of Birth” form and a copy of the DOH-4418 33

Reasonable Opportunity § Medicaid must not be denied, delayed, reduced or terminated pending the receipt of citizenship documentation for an applicant declaring U. S. citizenship – If the only missing documentation is proof of identity, citizenship and date of birth, Medicaid coverage must be authorized – Applicant has 90 days from when notice is sent to provide satisfactory documentation of identity, citizenship and date of birth 34

Reasonable Opportunity (cont’d) § If an applicant shows an inconsistency with the SSA citizenship data match, and does not comply with the request for proof of citizenship and identity within the 90 days, reasonable opportunity period, the LDSS must close the case 35

Special Situation § Naturalized Citizens – May provide originals, photocopies, facsimiles, scanned or other copies of U. S. citizenship and identity documents Certificate of Naturalization from USCIS (N-550 or N-570) • Or U. S. passport book/card with foreign place of birth • – “Reasonable Opportunity” rules apply 36

SSA Data Match – No BVI on Clearance Report LDSS has validated SSN Code of 7 or 8 SSA 37 Validated Not Validated System Generated BVI = B, C, D BVI = 1 Bad Match No further action required A/R has 90 days to provide verification of Identity and Citizenship If satisfactorily verified – LDSS changes BVI to 3

SSA Data Match – BVI on Clearance Report BVI Code 1 2 3 5 6 B 38 Identity & Citizenship verified – no further action required Request verification of Identity & Citizenship If satisfactorily verified LDSS changes BVI to 3

Documentation of Citizenship § When an applicant fails the SSA data match, they must provide “satisfactory documentary evidence” of U. S. citizenship and identity – Effective 1/1/14, original documents for citizenship status are no longer required for any Medicaid category of assistance. (13 OHIP/ADM-04) 39

Documentation of Citizenship (cont’d) § There are two levels of documentation that can be provided – The most reliable document must be used to document citizenship if available – Refer to DOH-4418 40

Verification of Birth § If an A/R is unable to provide verification of birth upon request because their citizenship and identity were not able to be verified through the SSA data match – 41 Eligibility workers must assist in requesting verification of birth records from the appropriate agency (GIS 09 MA/014)

Proof of Identity § If none of the identity documents listed on DOH-4418 are available, a combination of two or more corroborating documents listed below may be acceptable: – Marriage certificates, divorce decrees, high school or college diplomas, employer ID cards or property deeds/titles § Voter registration cards are not acceptable 42

Proof of Identity (cont’d) § Children under age 18 may have their identity documented using other means: – Clinic, doctors or hospital record – School records § If no other documents are available, an affidavit signed under penalty of perjury by a parent, guardian, or caretaker relative may be used – An identity affidavit should not be used if a citizenship affidavit was used 43

Date of Birth § Applicants are required to provide verification of date of birth – An SSN validated with a 7 or 8 may be used as verification of date of birth 44

Date of Birth (cont’d) § Other acceptable forms of verification may include: – Birth Certificate – Baptismal/Other Religious Certificate – Official Photo ID – Passport Book or Card – Driver’s License/Learners Permit – Official School Records 45

Relationship § A signed application with an indication of relationship is sufficient 46

Marital Status § For community budgeting; marital status does not need to be verified – includes same sex couples 47

Category § MAGI, ADC-Related – Verification of date of birth for child – Signed application with indication of relationship of child to caretaker relative – Information written on application or information gathered during a discussion with the A/R for deprivation factor – Signed application with attestation of household composition 48

Category (cont’d) § SSI-Related – Proof of age 65 years or older – Receipt of SSD or Railroad Retirement benefits (as “totally and permanently” disabled) – LDSS-639 (Disability Review Team Certificate) – Certification from the New York State Commission for the Blind (NYSCB) 49

Category (cont’d) § Pregnancy – Effective 1/1/14, documentation of pregnancy is not required for any Medicaid eligibility determination for a pregnant woman (13 OHIP/ADM-04) – EDC (due date) is still required • PW may attest 50

Shelter § A/R statement of shelter cost is sufficient – Includes rent, mortgage and/or property taxes – Signed application with indication of expense § Verification is not required 51

Shelter (cont’d) § In order for a water expense to be allowed, it must be verified § If this information is not verified, the case cannot be denied – The expense will not be allowed 52

School Status § Must be verified for college student under 21 with earnings to allow disregard – Statement from school – Current grade report § No verification needed for high school students to allow disregard 53

Health Insurance § Health insurance coverage and scope of benefits must be verified – Insurance Policy – Insurance Card – Certificate of Insurance – Medicare Card § Discontinuance of health insurance must be verified – Termination Letter 54

Health Insurance Costs § Health insurance premiums must be verified to allow the deduction – Health insurance deduction not allowed if premium is not verified 55

Residency at Application § All residency documents must be dated within 6 months of application – Official Identification with address – Driver’s License (issued w/in past 6 months) – Utility bill (showing date of service) – Lease/Rent receipt – Letter from landlord with home address 56

Residency at Application (cont’d) § All residency documents must be dated within 6 months of application (cont’d) – Postmarked envelope, postcard or magazine label with name and date (cannot use if sent to a P. O. box) – Correspondence with another government agency – Property tax records or mortgage statement 57

M A M J 3 months retro Apply Residency 58

Income at Application § Every attempt should be made to obtain the most current proof of gross income for applicants § 4 consecutive weeks for prospective coverage § If A/R is requesting retro-coverage EXACT income for each of the months requested must be verified 59

M A M J 3 months retro Apply Residency Income for each month 60

Income at Application (cont’d) § Pay Stubs for earnings § Monthly benefit statement for Unemployment Insurance Benefits (UIB) § Award letter for: – Social Security Benefits – Workers’ Compensation – Veterans’ Pay – Military Pay 61 § Letter from agent for royalties

Income at Application (cont’d) § Self-Employment – Federal Tax Return • Can be used until March 31 st of following year – E. g. 2015 tax return filed in 2016 can be used until March 31, 2017 • Must be signed, dated, and include all applicable tax forms and schedules 62

Income at Application (cont’d) § Self-Employment (cont’d) – Self-Employment Worksheet (13 OHIP/ADM-4, Attachment V) is used when A/R indicates that: • S/he does not file a tax return; • The business is new and a tax return had not been filed; or • Last year's earnings are not representative of the current year's earnings. 63

Income at Application (cont’d) § Letter from court or statement from the person paying child support/alimony § Letter from renter or roomer/boarder for rent being received § Signed statement or letter from family member for support received by the A/R § Statement or stubs for: – Private Pensions – Annuities 64

Income at Application, cont’d. § When an applicant claims $0 income, and is living with someone who is providing shelter, meals and personal items, the explanation on the application is sufficient, a letter of support is not required. 65

Income at Application (cont’d) § Medicaid applicants with no resource test can attest to their interest and dividend income generated by resources – Verification may be required if LDSS finds information provided is questionable and inconsistency could affect eligibility • Statement from bank, credit union or financial institution for interest • Letter from broker for dividends 66

Medicaid Requirement for Potential Income § An applicant for Medicaid must “Apply for and pursue any benefit that would reduce and/or eliminate their need for Medical Assistance” § A case may be closed or an application may be denied for failure to pursue a benefit that could reduce or eliminate their need for Medical Assistance. 67

Types of Potential Income § Social Security Benefits Disability – Retirement – Dependent – Survivors – § Unemployment Benefits 68 § NYS Disability Benefits § Workers’ Compensation § Veterans’ Benefits § Retirement Benefits § Union Benefits

Financial Maintenance 69 § Financial maintenance refers to the manner in which an applicant meets basic non-medical living expenses § Guidelines have been established and standardized by NYS OHIP for the assessment of financial maintenance § Used for application and renewal § Not required for Nursing Home, Medicare Savings Program or child-only applications

Financial Maintenance (cont’d) § A/R’s monthly housing expenses compared to the household’s gross monthly income – Housing expenses: • Include rent, mortgage and/or property taxes • Do not include the cost of utilities, even if paid separately – 70 Only consider the amount of the housing expenses that the A/R is responsible to pay • i. e. , his/her portion or share of the expense

Financial Maintenance (cont’d) § LDSS must pursue further information to evaluate how basic living expenses are being met if the A/R’s housing expenses exceed the regionally set standards for financial maintenance 70% for Bronx, Kings, Manhattan, Nassau, Putnam, Queens, Richmond, Suffolk and Westchester – 60% for all other counties – 71

Financial Maintenance Examples Rent/Mortgage = $1, 200/mo Gross Income = $2, 080/mo $1, 200 ÷ $2, 080 = . 576 or 58% Does not exceed regionally set standards 72 Rent/Mortgage = $1, 200/mo Gross Income = $1, 560/mo $1, 200 ÷ $1, 560 = . 769 or 77% Exceeds regionally set standards

Financial Maintenance (cont’d) § LDSS must send the Financial Maintenance form (DOH-4443) to the A/R when his/her monthly housing expenses are in excess of the regional maintenance percentage Prior to sending LDSS completes name and app. reg. or case number – A/R must complete: – • Monthly living expenses • Explanation of expenses • Signature and date 73

Financial Maintenance (cont’d) § LDSS compares total reported expenses to the A/R’s income and evaluates if the A/R’s explanation for meeting monthly living expenses is sufficient – If explanation is not sufficient: • LDSS must require further information to explain the discrepancy • LDSS must not require documentation 74

Financial Maintenance (cont’d) § If the A/R fails to explain how they are paying their monthly expenses they may be denied/discontinued for failing to provide required information if: Bills are paid, and – Bills are not being paid by someone else – 75

Dependent Care Costs at Application § Should show much is paid and how often § Written statement from day care center or other child/adult care provider § Canceled checks or receipts 76

Resources § Resource requirements apply only to SSIRelated A/Rs when eligibility is based on SSI-R budgeting methodology including: Medicaid Buy-In for Working People with Disabilities (MBI-WPD) – Qualified Disabled and Working Individuals (QDWIs) – COBRA Continuation Program – 77

Resources § Resource requirements do not apply to non-SSI-Related categories: ADC-Related – MAGI categories – • • • 78 Pregnant Women Infants and Children under 19 New Adult Group Parents/Caretaker Relatives 19 & 20 Year Olds Living with Parents Child in Foster Care (Chaffee)

Resources (cont’d) § Additional Medicaid programs that do not have a resource test include: – Medicare Savings Program (MSP) – Family Planning Benefit Program (FPBP) – Medicaid Cancer Treatment Program (MCTP) – AIDS Health Insurance Program (AHIP) 79

WMS Codes For Recipients with No Resource Test § RVI code of 9 is used for individuals who are not subject to a resource test on a case type 20 § Coverage codes for Medicaid: – Non-spenddown coverage code is 01 – Spenddown individuals coverage is 01 or 02, as appropriate 80

Mary and Robert Needabrake Application Case Example 1 81

Resources (cont’d) § Choices Of Medicaid Coverage For SSI-R A/Rs – Community Coverage Without Long-Term Care – Community Coverage With Community-Based Long-Term Care – Medicaid Coverage for All Covered Care and Services (including coverage for nursing home) 82

Resources (cont’d) § Regardless of which package an individual needs, all SSI-R individuals must document: – Trusts – Irrevocable burial agreements 83

Resources (cont’d) § SSI-R individuals applying/renewing for Community Coverage without Long-Term Care may attest to the value of their resources – A/R’s statement of the value of each resource is sufficient • • 84 Access NY Supplement A (DOH-4495 A) Common Application (DSS-2921) Written signed statement for 3 months retro Renewal form

WMS Codes For Community Coverage w/o Long-Term Care § Resource Verification Indicator (RVI) Code is 3 § Coverage codes: – Non-spenddown coverage code is 20 – Spenddown individuals coverage is 20 or 22, as appropriate 85

Resources (cont’d) § SSI-R individuals applying for Community Based Long Term Care Services must provide documentation of current resource values at application – Values identified as of 12: 01 AM the first day of the month in which they are requesting coverage § May attest to current values at renewal 86

WMS Codes For Community Coverage w/ Community-Based LTC § Resource Verification Indicator (RVI) Code is 2 § Coverage codes: – Non-spenddown coverage code is 19 – Spenddown individuals coverage code is 19 or 21, as appropriate 87

Resources (cont’d) § SSI-R individuals in receipt of Nursing Facility Services must provide: – Documentation of resources for the past 60 months prior to the month of application – Documentation of trusts and annuities for the past 60 months prior to the month of application – Current documentation of resources at renewal 88

Resource Verification § § § 89 Financial records Copies of life insurance policies Deeds Property appraisals Stock Certificates

Documentation of Resources § SSI-R A/Rs cannot be denied for failure to provide documentation of resources – As long as the SSI-R A/R has attested to the value of their resources, and is otherwise eligible, they should be given Community Coverage w/o Long Term Care 90

Documentation of Resources (cont’d) § An SSI-R individual who also meets the requirements of the ADC-R category has a choice between the ADC-R budget or the SSI-R budget – If the income eligibility is the same under both budgets and the A/R is not eligible for, or does not wish to participate in MBI-WPD, the A/R is given the ADC-R category of assistance and does not have a resource test 91

Mom (cert disab) Dad SSI-R/ADC Child ADC Mom = BT 04 All = BT 01 04 + 01 = 05 Combination Budget Mom can have either budget 92

SSI-R Change In Need § If an SSI-R recipient requires an increase in coverage to Community Coverage with Community-Based Long-Term Care or Nursing Facility Services they must: – Complete Supplement A of the Access NY application – Document their resources appropriately – Verify their current income 93

SSI-R Change In Need (cont’d) § If an SSI-R recipient fails to provide the required documentation for the level of coverage that they are seeking, they should be given the level for which they have complied 94

Tom Burns Application Case Examples 2 a & 2 b 95

Renewal Simplification § Certain individuals may attest to: – Income – Resources – Residency – Dependent Care Costs § Applies to renewals and changes after case opening 96

Renewal Simplification (cont’d) § Who Can Attest (cont’d): – SSI-R MA recipients who attested to their resources and receive Community Coverage w/o LTC • RVI code 3 – SSI-R MA recipients who documented their resources and receive Community Coverage w/Community Based LTC • RVI code 2 97

Renewal Simplification (cont’d) § Who Can Attest: – MA recipients who are exempt from resource test • RVI code 9 98

Renewal Simplification (cont’d) § Who Cannot Attest – SSI-R recipients of Institutional LTC • RVI codes 1 or 4 • Must provide current documentation 99

Renewal Simplification & Income § Can list income on renewal § No documentation necessary § LDSS must use available resources to verify income – Resource File Integration System (RFI) 100

Renewal Simplification & Resources § SSI-R recipients who attested to resources at application will be asked to itemize their resources at renewal § SSI-R recipients who documented their current resources at application are also allowed to itemize their resources at renewal § No documentation necessary 101

Renewal Simplification & Resources (cont’d) § Recipients with Community Coverage w/CBLTC who are seeking coverage of nursing home care and have attested to resources at renewal for the past 5 years, will be required to document resources for the transfer of assets look-back period 102

Renewal Simplification & Residency § No verification of address needed if living situation is unchanged § Change in address: – A signed/returned renewal form listing new address is sufficient at renewal – A verbal statement by phone is sufficient if between renewals 103

Renewal Simplification & Dependent Care Costs § Child or adult dependent care costs do not need to be documented in order to allow the deduction 104

Tom Burns Renewal Case Example 2 c 105

Documentation – Wrap Up § A/R’s Responsibilities § Worker’s Responsibilities § Factors of Eligibility that MUST be verified/documented § Factors of Eligibility that do not need to be verified/documented 106