Medicaid Policy
Medicaid Policy
A. Eligibility Requirement for Full Medicaid
Individuals eligible to receive full Medicaid services and QMB, SLMB or QI include the following. All others may only receive emergency Medicaid services, described in Section 205-6.
1. U. S. citizens. See Section 205-1.
2. Qualified non-citizens. See Section 205-2.
3. SSI recipients living in the U.S. on August 22, 1996 and meeting the criteria for one of the grand-fathered SSI recipient non-citizen groups. See Section 329.
4. Lawfully present children as described in section 205-2.1.
B. Proof of Citizenship, Qualified Non-Citizen and Identity
1. U.S. Citizens must document their Citizenship and Identity. Determine first if the individual meets a citizenship exemption. (See below and Table IV) Verify citizenship and identity electronically through electronic data sources before asking for verification from the customer. A positive match with SCHIP satisfies verification of citizenship and identity. If an electronic interface runs before determining an exemption, document in the case file which exemption the individual meets.
2. Applicants: Do not delay or deny benefits when an individual declares to be a US Citizen or US National or qualified non-citizen, and there is no evidence that contradicts their claim.
If otherwise eligible, provide Medicaid coverage and give the member reasonable time to provide the documentation.
a. “Reasonable time” is defined as (at least) 95 days from the date verification is requested. A member needs to either provide the documentation by the end of the time-frame given, or provide proof they are working to obtain the documentation. Give more time to members who show a good faith effort to provide the documentation.
b. If the member has been given reasonable time and does not provide the documentation or proof they are working on obtaining it, remove the member from the Medicaid coverage with proper notice.
3. Citizenship/Identity Documentation Exemptions
The following individuals are EXEMPT and do not have to meet the Cit/ID documentation requirement. If the individual loses an exempt status they must meet the Cit/ID requirement at their next scheduled review.
o SSI recipients and those in an SSI Protected group
o SS-DI recipients
o Medicare recipients
o Children in receipt of Title IV-B or Title IV-E Subsidized Adoption Assistance
o Children in receipt of Title IV-B or Title IV-E Foster Care Payments
o Qualifying non-citizens
o Members only eligible for Emergency Medicaid
o Household members who are not receiving Medicaid benefits
4. Children who received Child 0-1 eligibility
When a child receives Child 0-1 coverage, the child's citizenship and identity are verified and no additional verification is required at any time.
a. Make a collateral contact with the applicable State Medicaid agency to verify the claim that the child received Child 0-1 coverage.
b. Once the agency has verification of the child's eligibility under the Child 0-1 eligibility, the child never has to provide Cit/ID documentation again.
C. Documentation Requirements
1. States must obtain satisfactory documentary evidence of an applicant’s or recipient’s, citizenship and identity. Verify citizenship/identification and non-citizen status through electronic data sources first before requesting any documents from the customer.
o Table IV in Medicaid policy (Charts 1 and 2) outlines acceptable Citizenship documentation.
o Chart 3 on Table IV describes the acceptable sources of identity documentation.
o States are allowed to match with the State Children's Health Insurance Program - Internet (SCHIP-I) via the Social Security Administration (SSA) interface. A match satisfies the citizenship and identity requirement. See #3 below for additional information.
o States are allowed to match with the State Vital Statistics to obtain birth verification.
o When a member born in Utah does not have an original birth certificate, do an electronic search for birth years that have been computerized. For years that have not been computerized, they are to submit a Form 125 to Utah State Vital Records to obtain verification that a birth record is on file with the state.
o State Verification and Exchange System (SVES)
a. SCHIP verifies information regarding the person's claim of US citizenship or nationality.
i. The member's name, SSN and date of birth compares with data in the SSA Master File of SSN Holders (Numident).
ii. The interface is in real time.
iii. Two responses are possible: Y for positive, or N for no match with SSA records.
b. A positive response satisfies the Citizenship and Identity requirement. See Table IV, Chart 1.
i. The data submitted is consistent with SSA records.
ii. No additional information is required from the member.
c. A no inconsistency or no match response indicates the data submitted to SSA does not match. (IE, misspelled name, incorrect SSN, incorrect DOB or incorrect citizenship declaration.)
i. The agency first makes a reasonable effort to identify and resolve the cause of the inconsistency. For example, typographical or other clerical error.
ii. When an inconsistency is identified and corrected, resubmit the request.
iii. When an inconsistency is not found by the agency, OR if the second request result is the same, the member has 95 days to provide proper citizenship documentation.
o The 95 days starts with the date the member receives the notice.
o Medicaid benefits remain open during the 95 day verification period.
o If the case closes for any reason during the 95 day verification period, the 95 days continues to run.
o Once the 95 day verification period has expired, it cannot be extended or repeated.
iv. If proper citizenship documentation has not been provided by the end of the 95 day verification period, remove the individual from coverage at the end of the month for which 10-day notice can be given.