Policy Technical Assistance Training 1 Documentation A/Rs - - PDF document

Documentation Policy

Technical Assistance Training

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

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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

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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
• r closed case record contains information

not subject to change

• Checking WMS/MMIS (Clearance Report)

for demographic information:

– Date of Birth – SSN

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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-4220B)

• 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

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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

• Documents Needed When You Apply for Health

Insurance (DOH-4220B) indicating a return date, and DOH-4418

13

Application Referrals from NY State of Health

• An Access NY Health Care application

(DOH-4220) and, for SSI-Related, Supplement A (DOH-4495A) 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

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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

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SSN Validation - No History on Clearance

LDSS enters SSN Code 1

SSA

Validated SSN Code 8 No further action required Not Validated SSN Code

• ther than 8

A/R has 10 days to provide verification of

SSN Process is repeated

19

SSN Validation - History on Clearance SSN Code A B D 9 7 8

Request verification of SSN SSN validated – no further action required

20

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 4 months from SSN application to provide SSN – 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

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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

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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

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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 citizenship code in screen 3 is a “C” 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 (screen 3)

– No further action is required and no additional documentation of identity, U.S. citizenship or date of birth is required

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CHIPRA Citizenship Verification Process (cont’d)

• If there are “inconsistencies” a BVI of B, C,
• r D will be system generated in screen 3

– 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

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Reasonable Opportunity

• Medicaid must not be denied, delayed,

reduced or terminated pending the receipt

• f 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

• 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

Reasonable Opportunity (cont’d)

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

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SSA Data Match – No BVI on Clearance Report

LDSS has validated SSN Code of 7 or 8 SSA Validated System Generated BVI = 1 No further action required Not Validated BVI = B, C, D Bad Match A/R has 90 days to provide verification

• f Identity and

Citizenship If satisfactorily verified – LDSS changes BVI to 3

37

SSA Data Match – BVI on Clearance Report

BVI Code 1 2 3 5 6 B

Identity & Citizenship verified – no further action required Request verification of Identity & Citizenship If satisfactorily verified LDSS changes BVI to 3

38

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)

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• 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

Documentation of Citizenship (cont’d)

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

– Eligibility workers must assist in requesting

verification of birth records from the appropriate agency (GIS 09 MA/014)

41

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

• r property deeds/titles
• Voter registration cards are not acceptable

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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

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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

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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

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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

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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

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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

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

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M A M J

3 months retro Apply Residency Income

for each month

61

• Pay Stubs for earnings
• Monthly benefit statement for

Unemployment Insurance Benefits (UIB)

• Award letter for:

– Social Security Benefits – Workers’ Compensation – Veterans’ Pay – Military Pay

• Letter from agent for royalties

Income at Application (cont’d)

62

Income at Application (cont’d)

• Self-Employment

– Federal Tax Return

• Can be used until March 31st of following year

– E.g. 2014 tax return filed in 2015 can be used until March 31, 2016

• Must be signed, dated, and include all applicable

tax forms and schedules

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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.

64

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

65

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.

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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

67

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.

68

Types of Potential Income

• NYS Disability

Benefits

• Workers’

Compensation

• Veterans’ Benefits
• Retirement Benefits
• Union Benefits
• Social Security

Benefits

– Disability – Retirement – Dependent – Survivors

• Unemployment

Benefits

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Financial Maintenance

• 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

70

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 – 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

71

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

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

Financial Maintenance Examples

73

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

74

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

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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

76

Dependent Care Costs at Application

• Should show how much is paid and how
• ften
• Written statement from day care center or
• ther child/adult care provider
• Canceled checks or receipts

77

Resources

• Resource requirements apply only to SSI-

Related 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

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Resources

• Resource requirements do not apply to

non-SSI-Related categories:

– ADC-Related – MAGI categories

• 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)

79

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)

80

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

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Mary and Robert Needabrake Application

Case Example 1a

82

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)

83

Resources (cont’d)

• Regardless of which package an individual

needs, all SSI-R individuals must document:

– Trusts – Irrevocable burial agreements

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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

• Access NY Supplement A (DOH-4495A)
• Common Application (DSS-2921)
• Written signed statement for 3 months retro
• Renewal form

85

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

86

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

• f the month in which they are requesting

coverage

• May attest to current values at renewal

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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

88

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

89

Resource Verification

• Financial records
• Copies of life insurance policies
• Deeds
• Property appraisals
• Stock Certificates

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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

91

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

92

Mom (cert disab) Dad SSI-R/ADC ADC Child ADC Mom = BT 04 All = 01 04 + 01 = 05 BT Combination Budget Mom can have BOTH budgets!

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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

94

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

95

Tom Burns Application

Case Examples 2a & 2b

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Renewal Simplification

• Certain individuals may attest to:

– Income – Resources – Residency – Dependent Care Costs

• Applies to renewals and changes after

case opening

• Will receive simplified renewal packet

97

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

98

Renewal Simplification (cont’d)

• Who Can Attest:

– MA recipients who are exempt from resource test

• RVI code 9

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Renewal Simplification (cont’d)

• Who Cannot Attest

– SSI-R recipients of Institutional LTC

• RVI codes 1 or 4
• Must provide current documentation

100

Renewal Simplification & Income

• Can list income on renewal
• No documentation necessary
• LDSS must use available resources to

verify income

– Resource File Integration System (RFI)

101

Renewal Simplification & Resources

• SSI-R recipients who attested to resources

at application will be asked to itemize their resources at renewal

• Effective March 1, 2011, SSI-R recipients

who documented their current resources at application are also allowed to itemize their resources at renewal

• No documentation necessary

102

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Renewal Simplification & Resources (cont’d)

• Community Coverage w/CB-LTC

recipients requesting a change in coverage to Nursing Facility Services that have attested to resources at renewal since March 1, 2011, will be required to document resources for the period beginning March 1, 2011

103

Example

• Look-back period April 1, 2010 – March 31,

2015

• Documented resources at renewal in 2010

(prior to expansion of attestation policy) – No documentation of assets required for this period of the look-back

• Attested to resources at renewal for 2011,

2012, 2013, and 2014

– Documentation required to meet look-back period requirements

104

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

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Renewal Simplification & Dependent Care Costs

• Child or adult dependent care costs do not

need to be documented in order to allow the deduction

106

Case Examples 1b & 2c

Mary and Robert Needabrake Renewal and Tom Burns Renewal

107

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

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