3400, Verification Procedures

3410 Verification of Public Assistance Status

Revision 17-1; Effective March 15, 2017

Within 24 months of the last financial review, verify the correct categorical financial status of current Temporary Assistance for Needy Families (TANF), Supplemental Security Income (SSI), Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individuals (QI), Supplemental Nutrition Assistance Program, Medicaid Buy-In or Medicaid individuals and certify eligibility on this basis. Documentation on Form 2064, Eligibility Worksheet, or a printed copy of an HHSC computer inquiry placed in the individual's case folder will satisfy verification requirements for an individual receiving service(s) based on categorical financial status.

Refer to Section 7110, TIERS Inquiries, for a full listing of programs that provide categorical eligibility for Community Care for Aged and Disabled programs.

 

3420 Verification of Income and Resources

Revision 17-1; Effective March 15, 2017

Program Standard: The case worker must accurately establish the countable amount of income and resources to determine the income-eligible applicant's financial eligibility.

Determine the amount of countable assets for persons applying as income eligibles. Within 24 months of the last financial review, financial eligibility must also be redetermined for these individuals. An individual's declaration of income/resources for all programs is acceptable (excluding waiver services) unless:

  • there is reason to doubt the reliability of the applicant's statement. The case worker has the option of requesting verification whenever any doubt exists.
  • the applicant's declared resource amount is within $100 of the resource eligibility limit.
  • the applicant's declared income amount is within $10 of the income eligibility limit.
  • the applicant appears unsure about the amount of income or resources available. The case worker may accept a certain level of uncertainty. Example: The individual may state that he receives "about $350 per month." Since this is well below the income eligibility cap, the applicant's statement may be accepted even though the individual is not absolutely sure about the amount. However, if the applicant responded with "somewhere around $1,500," it would be necessary to verify the amount of income, given the uncertainty and the proximity to the eligibility limit.

If an individual meets the criteria in Section 3430, Eligibility Before Verification, refer the individual for services before verifying income and resources, and complete the verification within 30 days of the application.

Applicants are responsible for providing all information needed to establish eligibility. Ask the applicant or responsible party to provide the needed information to verify income and resources.

When information is requested from the applicant or responsible party, give a specific due date and explain the result of not providing the requested information. During a review, make the due date two weeks before the day the current certification period ends. This will allow a few more days to give the individual a second chance before terminating services effective the last day of certification. Follow up at least one time before denying the applicant for failure to cooperate.

During a financial review, if an individual reports closing a bank account or no longer having an account that was included in the last review, and adding the last known balance would bring the individual to within $100 of the resource eligibility limit, verify with the bank that the account has been closed.

If the information can be obtained by making a telephone call or mailing a verification form, attempt to obtain the information before denying the application. If the case worker cannot obtain the information and the applicant does not provide the information, deny the application. If the case worker cannot obtain information needed for a financial recertification and the individual does not provide the information, send Form 2065-A, Notification of Community Care Services, at least 12 days before termination becomes effective.

The case worker may, without verifying the income or resources, deny an application because the individual reports excess income or resources. Explain the reason for the denial to the individual or responsible party. Explain in the comments section of Form 2064, Eligibility Worksheet, that the denial was due to the individual's declaration of excess income or resources.

See Appendix XII, Examples of Methods to Verify Income and Resources, for examples of methods to verify income and resources. The case worker may use a verification source not listed in Appendix XII if it is determined the source is both knowledgeable and objective. A person is considered knowledgeable if that person routinely assesses values on that type of resource in the area where the resource is located. A person may not be considered objective if that person has a vested interest in the individual's eligibility.

Documentation on Form 2064 should contain enough information to determine what, when, where and how the applicant's/individual's income/resources were verified, so that they can be traced to the original source. For categorically eligible applicants and individuals (Temporary Assistance for Needy Families (TANF), Medical Assistance Only (MAO), Supplemental Security Income (SSI), Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individual (QI) and the Supplemental Nutrition Assistance Program), the case record must:

  • show that categorical status was verified, or
  • include a printed copy that shows the applicant's categorical status.

Form 2064 must show that verifications were received before the date eligibility rules were processed.

 

3421 Financial Documentation Requirements

Revision 17-1; Effective March 15, 2017

This chart is designed to assist in determining what is required for financial eligibility documentation.

If the individual's: and then:
income is not within $10 of the eligibility limit
and/or
resources are not within $100 of the eligibility limit
information gathered by the case worker matches information on the application form, no verification is required. Enter the monthly dollar amount in SASOW and select the client statement option. No other documentation is required.
income is not within $10 of the eligibility limit
and/or
resources are not within $100 of the eligibility limit
information gathered by the case worker does not match information on the application form, no verification is required. Enter the monthly dollar amount in SASOW and select the client statement option. No other documentation is required.
income is within $10 of the eligibility limit
and/or
resources are not within $100 of the eligibility limit
information gathered by the case worker matches information on the application form, view verification containing all information listed in Column 3 of Appendix XII. Enter the monthly dollar amount and select the appropriate documentation source in SASOW/TIERS. No further documentation is required.

If the case worker is not able to view adequate documentation, verification of income and resources is required.

income is within $10 of the eligibility limit
and/or
resources are not within $100 of the eligibility limit
information gathered by the case worker does not match information on the application form, view verification containing all information listed in Column 3 of Appendix II. Enter the monthly dollar amount and select the appropriate documentation source in SASOW/TIERS. Explain the discrepancy in documentation.
income is within $10 of the eligibility limit
and/or
resources are within $100 of the eligibility limit
N/A verification of income and resources is required.

 

3422 Exceptions to Verification Requirements

Revision 18-1; Effective June 15, 2018

Within 24 months of the initial financial determination, income-eligible individuals must complete a new Form H1200, Application for Assistance – Your Texas Benefits,/Form H1200-EZ, Application for Assistance — Aged and Disabled. Subsequent financial redeterminations will not require completion of Form H1200/Form H1200-EZ, unless the case worker has reason to believe the individual's financial eligibility may be in question.

Even though a new Form H1200/Form H1200-EZ is not needed, the case worker still must contact the individual and confirm that significant changes in income and resources have not occurred.

If there is a new source of income at a financial review or a new resource, then re-verify all of the individual's resources. If adding the individual's new assets to existing income/resources brings the total income within proximity of financial eligibility limits, re-verify all of the individual's resources.

Following these guidelines, at a review the case worker may need to verify both income and resources, income but not resources, resources but not income, or neither income nor resources.

If an individual loses categorical eligibility (for example, stops receiving Temporary Assistance for Needy Families or the Supplemental Nutrition Assistance Program) between reviews, that individual may be able to continue receiving services without a financial review until the next financial review is due (see Section 3441, Loss of Categorical Status). If the individual or case worker reports income and resources within eligibility limits (and no other information exists to contradict this report), the individual may continue to receive Title XX (block grant) services.  In such a case, the case worker must verify both income and resources at the next financial review.

 

3430 Eligibility Before Verification

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.3901(g). A Medicaid-certified applicant for CCSE-purchased services who requires a verbal referral is eligible to receive CCSE-purchased services when his eligibility for Medicaid is verified. A non-Medicaid certified applicant who meets the requirements for a verbal referral is eligible to receive CCSE purchased services while income and resources are verified. [See Section 1130, Definitions, and Section 2631, Negotiated Referrals.]

(1) To be eligible, this applicant must:

(A) be a new applicant for CCSE services;
(B) appear to be eligible based on the declaration of income and resources on his application for services or to have possession of a current medical care identification card; and
(C) meet the age and need criteria for the CCSE service he requires.

(2) The eligibility period for non-Medicaid applicants begins on the date of application.
(3)To continue receiving services, a non-Medicaid applicant must provide within 30 days of the application date the information needed to verify the applicant's income and resource amounts.

If, pending financial eligibility verification, the non-Medicaid applicant appears eligible for immediate service initiation, use the following procedures, as appropriate.

  1. Refer the applicant to the provider according to Section 2631.
  2. On Form 2101, Authorization for Community Care Services, enter the earliest date negotiated with the provider as the date services begin.
  3. If the applicant is determined ineligible within the 30-day verification period, or if the applicant does not provide the information needed to verify income and resource amounts by the 30th day, send Form 2065-A, Notification of Community Care Services, to the individual to terminate services 12 days after the Form 2065-A date. (Refer to Appendix IX, Notification/Effective Date of Decision.)

 

3440 Changes in Financial Circumstances

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.3901(f). The client must report promptly any changes in income, resources, or family size; loss of assistance grant or Medicaid benefits; or other changes in functional ability or circumstances that affect eligibility. The client is subject to fraud prosecution if he willfully fails to report changes and continues to receive services for which he is not eligible.

Individuals must report promptly any changes in income or resources. Note in the case record, but do not verify, reports of changes in income or resources that do not affect eligibility. Newly acquired resources that may affect eligibility, such as an inheritance involving property, are disregarded for 30 days from the date received. After 30 days, determine the amount of resources and terminate the individual's eligibility if the amount exceeds the resource limit.

 

3441 Loss of Categorical Status or Financial Eligibility

Revision 17-1; Effective March 15, 2017

In situations in which a Community Care Services Eligibility (CCSE) individual temporarily loses categorical or financial eligibility, the case worker must contact the individual and/or the appropriate agency to determine the reason for the denial and determine if reinstatement is likely.

If the individual loses Medicaid eligibility because his Supplemental Security Income (SSI) is being denied, the case worker must contact the individual and/or the Social Security Administration (SSA) to determine the reason for the denial and if the individual may be reinstated without a break in coverage.

Case workers may receive a copy of a denial notice or the monthly Loss of Eligibility Report for eligibility for the following programs:

  • Community Attendant Services (CAS)
  • Medicaid Buy-In (MBI)
  • Medicaid through Temporary Assistance for Needy Families (TANF)
  • Categorical eligibility through the Supplemental Nutrition Assistance Program (SNAP)
  • Qualified Medicare Beneficiary (QMB)
  • Specified Low-Income Medicare Beneficiary (SLMB)
  • Qualifying Individual (QI)
  • Medicaid through Type Program (TP) 03 (Pickle), TP 18 (Disabled Adult Children), TP 19 (SSI Denied Children) or TP 22 (Widow/Widower).

Upon learning of the denial, the case worker must check the Texas Integrated Eligibility Redesign System (TIERS) to verify the denial and the reason. The case worker must contact the individual to discuss the situation and, if feasible, assist the individual with completing the actions necessary for reinstatement of eligibility. If the individual has been denied on failure to furnish information, the case worker must contact the individual as soon as possible to advise him of the loss of service and the necessity of providing the information required by Medicaid for the Elderly and People with Disabilities (MEPD) or TANF. The case worker may also contact the MEPD or TANF specialist involved, ask about the individual's current income and resource amounts, and whether reinstatement will be occurring.

 

3441.1 Procedures Pending Reinstatement

Revision 18-1; Effective June 15, 2018

If the case worker is advised by the Social Security Administration (SSA), Medicaid for the Elderly or People with Disabilities (MEPD) or Temporary Assistance for Needy Families (TANF) that the individual will be reinstated within a month or is working on reinstatement, the case worker explores transferring the individual to Family Care (FC), if enrollment is possible in the region.

If the individual has not responded to requests for information and continues to fail to furnish information to the appropriate agency by the agency's deadline, he is not eligible to transfer to FC and the case is denied.

During times of extreme budget limitations on a regional or statewide basis, no individual may bypass the FC interest list. In absence of these budget limitations, the following procedures may be used.

If the individual or case worker reports income and resources within eligibility limits (and no other information exists to contradict this report), the individual may continue to receive Title XX (block grant) services or be transferred from Primary Home Care (PHC) to FC. Note the individual's changed status and record the self-declared income and resources in the case record. Update the Service Authorization System Online (SASO) to show the individual as income eligible. It is not necessary to obtain Form H1200, Application for Assistance – Your Texas Benefits, or Form H1200-EZ, Application for Assistance – Aged and Disabled, from the individual or to verify income and resource amounts until the next financial review is due.

The case worker must process a change within 14 days resulting from the individual’s loss of Medicaid resulting in a need to transfer from PHC to FC. When applicable, submit Form 2101, Authorization for Community Care Services, to transfer an individual from PHC to FC. Use the comments section on Form 2101 to document the individual’s services being transferred from PHC to FC due to a loss of Medicaid. Enter the day after the last date of Medicaid coverage as the "from" date on Form 2101. (If the Medicaid denial is unknown until after the last day of Medicaid coverage, use the earliest date FC can begin as the "from" date.) In the event that the individual has been receiving a block grant service and will continue to receive the same service, the same authorization may be continued.

If transferring to FC is not an option due to regional constraints, the case worker may suspend services for 60 calendar days to allow a determination on the individual's Medicaid status to be made regarding the reinstatement of services. Within four business days of determining suspension is appropriate, the case worker sends the individual Form 2065-A, Notification of Community Care Services, checking the Notification of Ineligibility or Termination of Benefits, the date services end, and noting services are suspended pending reinstatement of Medicaid or financial eligibility (as applicable). The case worker also sends the provider Form 2067, Case Information, suspending services effective the date of Medicaid denial.

During the period in which services are temporarily suspended by Medicaid, all case actions, such as monitoring and annual visits, changes, and transfers will be suspended. However, the case worker must set a special review for the 60th day following the suspension to check  if eligibility has been re-established.

At any time during the initial 60-day period the case worker learns that eligibility has been re-established, the case worker has 14 days to resume services. Case workers must call the provider to negotiate the earliest date for services to resume. Case workers follow up the telephone call with Form 2067 to the provider, noting reinstatement of services with the negotiated date. Case workers must make any 90-day monitoring or annual reassessment visits which would have occurred during the suspension. The case worker documents the reinstatement of eligibility and the reason in delay for monitoring or annual reassessment visits due to the suspension of services in the case record and sends the individual Form 2065-A with a statement that services have been reinstated.

If, on the 60th day eligibility has not been re-established, the case worker may extend the temporary suspension for an additional 30 days for a total of 90 calendar days if the case worker determines the individual may still have eligibility reinstated. This determination will be established based on research of MEPD case-specific information. At any time during the additional 30 days the case worker learns that eligibility has been reinstated, the case worker has 14 days to resume services. Case workers must send Form 2067 to the provider to have services resumed, and must make any 90-day monitoring or annual reassessment visits which would have occurred during the suspension. The case worker documents the reinstatement of eligibility and the reason in delay for monitoring or annual reassessment visits due to the suspension of services in the case record and sends the individual Form 2065-A with a statement that services have been reinstated.

If reinstatement of eligibility will not be granted, the case worker sends the individual Form 2065-A denying services. The date of denial will be based on the:

  • Medicaid eligibility end date, as indicated in the Texas Integrated Eligibility Redesign System (TIERS); or
  • denial date on Form H4808, Notice of Change in Applied Income/Notice of Denial of Medical Assistance, from MEPD.

Form 2101 must be sent to the provider on the same date, noting services are denied effective the date of the financial denial.

 

3441.2 Reinstatement Procedures After Denial

Revision 17-1; Effective March 15, 2017

If financial or categorical eligibility is re-established within 60 days of the denial date and the individual reapplies for services, the case worker may use the information currently on file to determine eligibility. Completing new forms will not be required, except for a new Form 2110, Community Care Intake, and Form 2101, Authorization for Community Care Services. The case worker must note in the Comments section of Form 2110 that reinstatement procedures are being used within 60 days of the denial date and may use the following forms currently on file:

  • Form 2059, Summary of Client's Need for Service
  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide
  • Form 2307, Rights and Responsibilities
  • Form 1584, Consumer Participation Choice

The case worker must contact the individual and review the functional assessment, including Form 2060 and Form 2059, to determine if there have been any changes in the individual's physical condition or needs. If Form 2060 is over one year old, if there have been changes in the individual's condition or needs or if the individual has difficulty communicating by telephone, the case worker must make a home visit to review/revise the assessment. Initial eligibility time frames will apply.

The case worker must send an initial referral packet and initial Form 2101 referral to the selected provider. For Primary Home Care and Community Attendant Services, the provider must complete all pre-initiation activities, including obtaining a new Form 3052, Practitioner's Statement of Medical Need.