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All Medicaid Programs |
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Obsolete Policy |
Previous Table
Try to verify all factors of eligibility electronically for all medical programs before asking client to provide hard copy verifications.
Unless otherwise indicated, client attestation may be accepted to verify everything except Citizenship/ID & Immigration Status. When client attestation is not reasonably compatible with information obtained through an electronic data match, request
· a statement from the client that explains the discrepancy, or
· Other documentation to verify the item of eligibility.
This table shows the interface matches that are available and gives EXAMPLES of hard copy verifications that may verify the information you need, although not every example listed will verify all of the information shown under the Eligibility Factors column.
* INDICATES Client statement or Prudent Person Concept cannot be used to meet verification of this category.
** INDICATES – Client statement may not be used to verify a factor of eligibility for Long Term Care Medicaid.
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Eligibility Factor |
Interface or Match |
Other |
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* U.S. Citizenship; Age; Identification
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Federal Data Services Hub SVES |
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*Alien (INS) Status |
Federal Data Services Hub eFIND - Social Security screens, Alien Registration |
Alien Registration Card Correspondence from the Department of Homeland Security |
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Social Security Number; Social Security Claim # |
Federal Data Services Hub eFIND Birth Record SAVE SVES SOLQ |
Social Security Card SSA form 5028 or 2880 Birth Certificate showing SSN applied for Official Social Security document |
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Utah Residence; Resident of an Institution |
Federal Data Services Hub eFIND New Hire Registry Prisoner System Information |
Current Utah Drivers license Employment payroll check stubs Current UTES registration House payment receipt Current rent receipt Utah telephone book listing (referenced) Tribal Record correspondence Children's residence usually follows that of parents Nursing home resident (unless placed by another state) Form 131- Affidavit of Intent to Become a Utah Resident; or other statement of intent to remain in Utah. Duty of Support |
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Relationship (Including Specified Relative); Paternity |
eFIND, Birth Record |
Birth Certificate Court Order Marriage Certificate Form 941 - Acknowledgment of Paternity County Records Adoption Finalization forms (placement forms may be used to determine that child is not with birth parents) |
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Duty of Support |
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Completed Application for Child Support Enforcement on each non-custodial parent |
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Pregnancy |
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Current physician's or nurse mid-wife’s statement Current statement from Planned Parenthood Statement from a health clinic |
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School Attendance |
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DWS form 126 Form 114 and telephone contact with school |
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Medicare Part A and/or Part B Coverage |
Federal Data Services Hub eFIND - Social Security Screens SOLQ |
Medicare Card Official document from SSA
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*Blindness, Disability |
eFIND - Social Security Screens SOLQ (does not have start date. BDX shows the start date.) |
Award letter from SSA or SSI Form 121 |
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*Incapacity |
eFIND - Social Security Screens
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Disability established Form 21 Doctor Statement (must show incapacity, person can’t work or care for children, date of onset, estimated ending date |
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Application for Other Benefits |
eFIND - Paris (VA income), Workers Comp, Social Security, Unemploy-ment |
Statement from other agency |
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American Indian/Alaska Native Status |
o Tribal Identification/Enrollment Card with Number o Certificate of Degree of Indian or Alaska Native Blood (CDIB) signed by the Bureau of Indian Affairs (BIA) o Tribal court documents. o The tribal documents must contain identifying information about the client. IE, name, date of birth. o The tribe must be recognized by the Federal government. Click on the following link for a list of federally recognized tribes: http://www.bia.gov/cs/groups/xofa/documents/document/idc012038.pdf
o Indian Health Services (IHS) Face Sheet. An Indian Health Services IHS face sheet is a medical record certified by IHS as being from their original records. o The face sheet must contain identifying information about the client. IE, name, date of birth. o The face sheet must contain tribal association. Tribal membership verification must be on the Medicaid eligible individual and the tribe must be recognized by the Federal Government. Click on the following link for a list of federally recognized tribes: http://www.bia.gov/cs/groups/xofa/documents/document/idc012038.pdf |
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Earned Income
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*Wages; *Self-Employment |
Federal Data Services Hub eFIND, Wages Work Number New Hire Registry
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Employment payroll check stubs Employer's wage record Statement from employer Self-employment records Copy of most recent tax return |
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Training, Work Study |
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Award letter Contracts |
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*Earned income in-kind (food, clothing, free housing, etc.) |
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Employer's records Statement from employer Written agreement |
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Unearned Income
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*Social Security Benefits (SSA); Supplemental Security Income (SSI); VA Benefits; Retirement; Labor Union Benefits; Pensions; Annuity; Disability Compensation; Scholarships/loans; Tribal Income; Cash gifts and prizes |
Federal Data Services Hub eFIND, Social Security Screens SOLQ (does not show correct amount if deductions are being taken out of benefits. Compare both the BDX and the SOLQ to verify the correct amount is counted.) |
Client statement of benefits until information appears on the SDX/BDX Award letter Legally acceptable copy of check Correspondence from issuing agency Form 114 Bank statement showing direct deposit specifying source of income Tribal Records |
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*Unemployment Compensation |
eFIND, Unemployment |
Statement from DWS Bank statement showing direct deposit
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*Alimony and Child Support |
eFIND, Recovery Services screens |
County Clerk records Divorce decree or other court order about payments including judgment for past due amounts. Copies of checks received Statement from ORS |
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*Dividend and Interest |
Federal Data Services Hub |
Bank Statements, dividend letters or statements Currently posted saving passbook Current credit union statement Form 114 Internet on-line banking |
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*Real Property Sales |
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Sales Contract Mortgage |
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Payment of household expenses by others |
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Client's statement Form 702 - Statement of Contribution Form 17 - Statement of Head of Household |
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Expenses
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*Health Insurance |
Federal Data Services Hub |
Receipt for health insurance premiums paid Insurance records/billing statement Check stubs/statements showing amount paid by individual |
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Medicare Part A & B Premium Amounts |
Federal Data Services Hub eFIND - Social Security screens |
Medicare Card Official document from SSA |
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*Alimony and Child Support Paid Out |
eFIND, Recovery Services screens (Unemployment Claim Adjustment Field) |
Court order showing alimony or child support owed and copies of checks showing payments made Income tax records |
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Shelter costs (waiver or nursing home cases) |
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Utility bills Mortgage/rental agreements Canceled checks |
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*Medical bills owed |
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Copies of medical services received and current statement of amount owed Statement from provider of amount owed |
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Assets
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**Checking/Savings, Credit Union; Shares; Retirement Fund |
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Copy of current statement from bank or credit union Savings passbook dated within 30 days Form 114 Internet on-line banking |
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*/** Trusts |
Trust documents |
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**Vehicles: Automobile, Trailer, Camper, Boat, Snowmobile, Motorcycle, Farm/Business Equipment Water Craft |
eFIND, Motor Vehicles |
Title Registration CountyTax Records Current NADA average trade-in value Local dealer appraisal, if necessary
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*/**Land/Acreage or Building in which you do not live |
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Deed Tax Notice Sales Contract County Property Tax Records |
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**Money-Making Resources (rental/ personal property) |
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Leases Contracts Agreements Depending on type of property, obtain deeds, tax notices, statements from knowledgeable source of value, etc. |
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**U.S. Savings Bonds |
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Examine the original bonds for: Face value, date of issue, and net value (statement from bank may be needed to get current value. Internet site to calculate current value - http://www.treasurydirect.gov/indiv/tools/tools_savingsbondcalc.htm
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**Stocks, Bonds; Convertibles |
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Stocks, Bonds, Convertibles Form 114 to "retaining" brokerage as to current market value
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*/**Life Insurance Burial Assets
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Policies from issuing company: purchase contract Written statement from the issuing company as to cash value, whether there are accumulations and how much it is worth. |
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Tools / Cash |
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Client's statement as to value or amount |
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Other
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TPL: Auto No Fault, Health (hospital), Accident, Homeowners |
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Policies Insurance Card Written or verbal notice from ORS Client's statement |
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Health Insurance Coverage (PCN) |
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Policies Insurance Card Written or verbal notice from ORS Client's statement |