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2004 Chartbook of Major Indicators

 

The Burden of Proof:

How Much is Too Much for Child Health Coverage?

Verification Requirements at Redetermination

Income

Question 1
What are the minimum requirements for verification according to federal regulations?

For Medicaid, the only federal income verification requirement is the post-eligibility requirement in Section 1137 of the Social Security Act for the state to have an income and eligibility verification system (IEVS). Under IEVS, the state must request information from other federal and state agencies to verify the applicant’s income and resources to the extent that it is useful. The applicant must be informed in writing, at the time of the application, that the agency will be requesting this information. The regulations implementing IEVS are at 42 CFR 435.940.965.

For CHIP, there are no income verification requirements.

Question 2
Can a state accept self-declaration for CHIP? Medicaid?
Yes. For both CHIP and Medicaid, the state can use self-declaration to establish eligibility.

For Medicaid, verification of self-declared income is required under the IEVS system. For income that cannot be verified under IEVS, HCFA encourages random post-eligibility verifications or the adoption of other procedures designed to assure program integrity is being maintained. (See HCFA letter dated September 10, 1998, in Appendix C.)

For CHIP, there are no federal income verification requirements. However, HCFA encourages random post-eligibility verification of self-declared income or the adoption of other procedures designed to assure program integrity is being maintained.

Question 3
Is self-declaration of income acceptable if a client is within a certain range of the income limit?
Yes. Self-declaration of income, based on income limits, can be used to establish eligibility for both Medicaid and CHIP.

Question 4
Can verification for CHIP be limited to information required for only poverty-level children?
For a separate CHIP program, the state may establish whatever income verification requirements it desires. Verification of income is not required under CHIP by current federal law.

Question 5
What about income earned in a family unit that is ultimately given to another family unit for child support, health insurance, day care, etc?
For Medicaid, income earned by a member of the Medicaid family unit but either used to pay child support, health insurance, day care or withheld from the salary to pay for something is considered available to the family and counted as income.

(Exception: Day care expenses of up to $200 per month for a child under 2 and $150 per month for an older child must be excluded from income if the care is necessary for the adult to work.)

States do have the option under sections 1902(r)(2) and 1931 to exclude income that is used for a certain purpose because this would be a more liberal method of determining countable income than required.

For CHIP, there are no federal requirements on determining what income counts in the eligibility determination. The state, therefore, may follow Medicaid policy or adopt another policy.

Question 6
How can we predetermine eligibility with other programs that require income verifications, such as free and reduced school meal programs?
For Medicaid, it is not likely that states can rely on the eligibility determinations of other programs because eligibility requirements vary among programs. However, the application processes can be integrated through use of joint application forms.

Under a separate CHIP program, the state would have the flexibility to deem eligible for CHIP a child who is eligible under another program. States do not have the flexibility, however, to deem CHIP eligibility for individuals who already are Medicaid eligible.

Verifications of income obtained by other programs can be used under Medicaid or CHIP if that information is disclosable by the program.

Question 7
Should the income of a live-in boyfriend or girlfriend be counted in the family’s total income?
Under Medicaid, the income of a live-in boyfriend or girlfriend would not be counted in determining the eligibility of the child, except to the extent that it is actually contributed (e.g., money actually changes hands). A boyfriend’s income is not counted even if the child is pregnant and eligibility is being established under the group for poverty-level pregnant women. After the birth of the infant, if the live-in boyfriend is the father, his income would be considered in establishing the eligibility of the infant after the one-year period of deemed newborn eligibility ends.

Under CHIP, there are no federal requirements for determining what income counts in the eligibility determination. The state may, therefore, follow Medicaid policy or adopt another policy.

Question 8
For applicants who are paid in cash, will a statement from a credible third party to corroborate stated income be acceptable?
That determination is within state discretion for both Medicaid and CHIP. (See HCFA letter dated September 10, 1998, in Appendix C.)

Resources

Question 1
What are the minimum requirements for verification according to federal regulations?
For Medicaid, the only requirement to verify resources is the IEVS verification requirement that is discussed in the answer to the first question under income. (See HCFA letter dated September 10, 1998, in Appendix C.)

For CHIP, there are no verification requirements for resources.

Question 2
Is self-declaration acceptable?
Yes. For both Medicaid and CHIP, the state can use self-declaration to establish eligibility.

For Medicaid, verification of self-declared resources is required under the IEVS system. For resources that cannot be verified under IEVS, HCFA encourages states to conduct random post-eligibility verifications or the adoption of other procedures designed to assure program integrity is being maintained.

For CHIP, there are no federal resource verification requirements. However, HCFA encourages random post-eligibility verification of self-declared resources or the adoption of other procedures designed to ensure program integrity.

Question 3
Is self-declaration of resources acceptable if a client is within a certain range of the resource limits?
Yes. Self-declaration of resources, based on resource limits, can be used to establish eligibility for both Medicaid and CHIP.

Question 4
Is it possible to eliminate resource tests, streamline resource rules and standardize resource limits for all family and children covered groups?
Yes, for both Medicaid and CHIP.

Under Medicaid, this can be achieved through the use of the authority in Sections 1902(r)(2) and 1931 of the Social Security Act to adopt more liberal resource methodologies than those in effect under the state’s AFDC plan in effect on July 16, 1996.

For CHIP, the state has complete discretion in terms of setting resource requirements, including no resource test at all.

Citizenship

Question 1
What is the minimum standard?
For Medicaid, as a condition of eligibility, citizens or nationals must declare in writing under penalty of perjury that they are U.S. citizens or nationals. Current Medicaid policy permits states to accept that declaration or to require further verification as a condition of eligibility.

Immigrants who are neither U.S. citizens nor nationals, as a condition of eligibility for Medicaid, must declare in writing, under penalty of perjury, whether they are a qualified alien and, if so, present reasonable evidence of satisfactory immigration status. [Qualified aliens are defined in section 431 of the Personal Responsibility and Work Opportunity Act of 1996 (PRWORA)]. In addition, for Medicaid, states are required to verify with the Immigration and Naturalization Service (INS) the immigration status of qualified aliens. Current policy on Medicaid verification of immigration status is found at Section 3212.9 of the State Medicaid Manual.

The requirement to verify immigration status is a long-standing requirement of the Social Security Act, which applies to Medicaid. PRWORA also includes a requirement for verification of immigration status by federal public benefit programs, such as Medicaid and CHIP. It was amended to add a new requirement for federal public benefit programs to verify citizenship. Policy is under development by the Justice Department in consultation with the Department of Health and Human Services on the PRWORA requirements to verify citizenship or national status and immigration status.

For CHIP, there are no verification requirements in the CHIP law (Title XXI of the Social Security Act) or elsewhere in the Social Security Act. However, the requirements for verification of citizenship or national status under PRWORA apply to CHIP as do the PRWORA requirements for verification of immigration status of qualified aliens with INS.

Pending the issuance of final rules by the Department of Justice, for CHIP, states should establish procedures for verification of citizenship or national status and for verification of immigration status in accordance with the Interim Guidance on Verification of Citizenship, Qualified Alien Status and Eligibility under Title IV of PRWORA issued by the Justice Department on November 17, 1997, 62 Fed. Reg. 61344-61416. For citizenship or national status, these guides allow federal benefit programs to accept self-declaration or require further verification.

Question 2
Must the state verify alien status for Medicaid? For CHIP?
See the response to Question 1 under Citizenship above. Verification is not required for those who are not qualified aliens. However, non-qualified aliens are eligible under Medicaid only for coverage of emergency services. Non-qualified aliens are not eligible for coverage under CHIP.

Question 3
Can the state accept self-declaration that the client is lawfully admitted for Medicaid? For CHIP?
Yes. See the response to Question 1 under Citizenship above.

Question 4
Will the State Medicaid Manual be revised per the January 23, 1998, letter to state health officials from HCFA stating that there are no verification requirements under federal law other than those related to alien status of noncitizens?
The State Medicaid Manual will be updated at some future data to incorporate the applicable requirements, including the requirement to verify citizenship or national status.

It should be noted that the January 23 letter also cited the post-eligibility IEVS requirement to verify income and resources under Medicaid. (See HCFA letter dated January 23, 1998, in Appendix D.)

Question 5
When verifying alien status via SAVE, should the alien’s date of entry into the U.S. be part of the response?
While it would be desirable, the alien’s date of entry is not part of the response provided by INS under automated primary verification at this time. The date of entry can be obtained under the secondary verification process.

Age of Child

Question 1
What is the minimum requirement?
There is no federal requirement for verification of the age of the child under either CHIP or Medicaid.

Question 2
Is self-declaration acceptable if the state does not do presumptive eligibility?
Self-declaration is acceptable for both Medicaid and CHIP (whether or not the state has adopted presumptive eligibility). However, HCFA encourages a random post-eligibility verification of age or the adoption of some other process that assures program integrity is being maintained.

Question 3
If a female is pregnant and delivers after age 19, can CHIP coverage be extended?
No. However, the state should determine whether the child is eligible as a poverty-level pregnant woman under Medicaid.

Question 4
If a child is involved in an accident at age 18 and turns age 19 while still needing treatment, can CHIP coverage be extended?
No.

Family Composition

Question 1
Is self-declaration acceptable?
Yes. Under both Medicaid and CHIP, self-declaration can be used to establish eligibility. However, HCFA encourages random post eligibility verifications or the adoption of other procedures to assure program integrity is being maintained.

Question 2
Should a live-in boyfriend or girlfriend be counted as a member of the family and part of the household size?
For Medicaid, if the live-in boyfriend or girlfriend is a parent of the born child in the family, the live-in is counted as a member of the family of the child. For more detail, see the response to Question 7 under Income above.

For CHIP, there are no federal requirements. The state may, therefore, follow Medicaid policy or adopt another policy.