Medicaid Policy
Medicaid Policy
A. Accepting Client Statement for All Medical Programs
1. Accept client statement for proof of pregnancy and the number of children expected.
2. Accept a client’s statement of residency in Utah unless the agency has information that conflicts with such statement.
3. Exception for special circumstances:
We may accept client statement, on a case by case basis, for almost all eligibility criteria when documentation does not exist at the time of application or review or is not reasonably available. This may apply in the case of individuals who are homeless or have experienced domestic violence or natural disaster. Client statement never applies to verification of citizenship and immigration status, though.
a. For a case by case exception:
i. The eligibility worker will forward the special circumstance request and all supporting documentation to the Office of Eligibility Policy (OEP). OEP will review the request and the supporting documentation to determine if a special circumstance exists.
ii. Eligibility workers must
· Verify all eligibility items that are reasonably available.
· Document in the case notes:
§ Why the special circumstance was requested.
§ If the special circumstance was approved or denied.
iii. OEP will inform the worker when to review the exception for special circumstances.
b. In the event of a larger scale event that affects more than just one case, OEP may issue a statement to DWS approving this exception for these cases. The statement will also notify DWS of the duration of the exemption.
B. Reasonable Compatibility of Assets
A reasonable compatibility asset test must be conducted prior to requesting hard copy verification. If the assets the customer attest and the results of electronic asset searches are both below, both at, or both above the program asset limit, the results are reasonably compatible, and no further verification should be requested.
C. Medically Needy Family, Child, Pregnant Woman Medicaid
1. Accept client statement of assets for medically needy Family, Child and Pregnant Woman programs when the declared assets do not exceed the applicable asset limit. Ask the individual to provider hard copy verification of any assets described is Subsection E or assets that cannot be verified. If client statement is not appropriate and assets cannot be verified electronically, do not close or deny a program until you have given the individual the opportunity to provider hard copy verification.
2. If the client's statement of assets may be used, compare the declared countable assets to the asset limit.
· If assets are below the asset limit, the individual has passed the asset test. Do not request other verification of the individual's assets.
· If the declared countable assets exceed the asset limit, the individual is ineligible.
D. Asset Threshold for Aged, Blind and Disabled Medicaid (Non-Institutional/Non-Waiver)
1. At application and review, accept client statement of assets for the Aged, Blind or Disabled Medicaid programs (non-institutional/non-waiver), when the declared assets do not exceed $1000. If the individual declares assets over the $1000 threshold, assets defined in Subsection E, or if the client's statement is not compatible with other information, client statement may not be used as a form of verification.
· Some assets increase in value over time, such as whole life insurance. Also, the value of a non-excluded vehicle may increase as the loan on it is paid off.
· For individuals with a trust, see 512-2.4 concerning the trust accounting review.
2. If the value of declared assets exceeds $1000, ask the individual to verify all assets with hard copy unless they can be verified electronically.
· If an individual has assets over the asset limit, or over the asset threshold for aged, blind and disabled Medicaid, determine if any are exempt assets (521). Some exempt assets can be verified using client statement, but most need another form of verification.
3. SSI recipients are not subject to the asset threshold (731-4).
E. Asset Verification for Nursing Home and Home and Community Based Waiver Coverage
Applicants for nursing home or home and community based waiver coverage must verify all assets held during the look-back period that may be subject to the transfer of assets policy.
This lookback period requirement is satisfied if all of the following conditions are met:
Verify assets at review when there is a reason to believe they may be close to the asset limit. Some assets increase in value over time, such as whole life insurance. Also, the value of a non-excluded vehicle may increase as the loan on it is paid off. For individuals with a trust, see 512-2.4 concerning the trust accounting review.
At review, only verify questionable assets subject to the transfer of assets policy that have occurred since the previously completed review or application. (575-10)
F. When Client Statement is not Allowed
Client statement by itself cannot be accepted as verification for the following eligibility factors.
1. Citizenship/immigration status: Citizenship and immigration status must be verified by electronic verification or hard copy when data from electronic data sources are not available. See Table IV for acceptable sources.
2. Income: Verify household income with electronic data sources first. If income cannot be verified through a computer match, or the electronic data is not reasonably compatible with what the individual has told you, ask the individual for an explanation, request hard copy verification, or make a collateral contact with the employer or the entity providing the income to the individual.
· Exception: For Waiver Medicaid Programs, if the reported total earned income is below $65 per month, the income can be verified by client statement (435-2).
· For SSI recipients, see 731-4.
3. Medical expenses to meet spenddown: Request verification of medical expenses an individual has that may be used to meet a spenddown.
· The individual may provide receipts of payments, copies of bills or statements from providers.
· The agency may need to do collateral contacts to verify the amount still owed to providers.
· Verification must include sufficient information such as dates of services, providers, charges, individual's obligation such as copayments, etc.
4. Disability status: For verification of disability or blindness, follow the policy in 303. If Social Security has not made a decision about someone's disability or blindness, we must request medical documentation for the Medicaid Disability Office to determine disability or blindness.
5. Breast and Cervical Cancer: See Sec. 390 on how to verify eligibility for the Breast and Cervical Cancer program, and the continued need for treatment at reviews.
6. Assessment of Assets: Request hard copy verification of assets to complete an assessment of assets for individuals entering long-term care facilities or seeking waiver services (573).
7. Transfers: Before imposing a penalty, request hard copy verification if you determine a transfers of assets may have occurred. Verify the amount of such transfers for individuals seeking long-term care services in nursing facilities and under home and community based waivers (575).
8. Waivers: The referring agency must confirm the individual has met the medical criteria for eligibility for a home and community based services waiver (380).
9. Trusts: Request hard copy of trusts and the associated trust account. (512).
10. Burial/funeral arrangements or funds, but not including fully-paid burial spaces (592, 594, 596).
11. Whole life insurance (521-16).
12. Non-exempt real property (real property not excluded as a home, or self-employment)
13. Assets of self-employment when the individual claims to be self-employed, declares self-employment assets and the individual's assets exceed the resource limit or the asset threshold for Aged, Blind or Disabled Medicaid due to the value of those assets, or the individual is seeking nursing home or home and community based waiver services (521-8).
· Refer to 731-4 for verification requirements for SSI recipients.
14. Questionable Assets: Decide if any declared assets are questionable.
a. A questionable asset is one for which the agency has a documented reason to question the client's statement and the value of the asset could affect eligibility. A documented reason may include information found through an electronic data match, or other documentation that conflicts with a client's declaration.
b. The eligibility worker may contact the individual to try to resolve questions when a documented reason to question declared assets exists, for example ownership of vehicles. If the eligibility worker can resolve the issue by talking to the individual, it is no longer questionable.
Example: Individual reports having only one vehicle; however, the electronic match shows three vehicles in the individual's name. The worker calls the individual to see why there is a discrepancy. Individual reports that his father has the same name, and two of the vehicles belong to the father. If the explanation is credible and no other documented reason to question ownership exists, the worker can accept the client's statement.
c. Request verification other than client statement of the questionable assets if you cannot resolve the questions by discussing it with the individual. Help the individual get verification if the individual requests help.
d. Request verification of any asset that may have an availability issue and would affect eligibility if the individual's share of the value is counted (511-5).
e. Decide if an individual has declared any exempt assets, or if you have information about an asset that is exempt under policy (521).
i. Decide if counting the potentially exempt assets causes the individual to exceed the asset limit.
ii. If the individual is under the asset limit for Family Medically Needy Medicaid, or is under the asset threshold for Aged, Blind or Disabled Medicaid even when counting a potentially exempt asset, do not request other verification of the asset.
iii. If the individual will fail the asset test or threshold when counting a potentially exempt asset, request verification of the asset. Use data match information to verify excluded SSA/SSI lump sums when possible. If the exempt assets are co-mingled with non-exempt assets, the individual must state the amount that is exempt and the verification must support the statement.
iv. If a individual declares having an exempt IIM account, a Dedicated Account for an SSI Child, or an IDA, accept client statement unless there is a documented reason to question the client's statement. (Sec. 521-5, IIM accounts; 521-30, Accounts for SSI child; 521-37, IDAs.)
v. When an individual has an account containing both exempt and non-exempt assets, assume the individual uses the non-exempt funds first.
f. If the individual does not provide enough information about assets and asset values to make a decision, request verification of the assets. Help the individual get verification if the individual requests help.