219.03 Required Verification SR 02-17, 07/02 (FAM-A)

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The individual who signs Form 800, Application, Form 800H, HEIGHTS Application Form, or Form 800P, Application For New Hampshire Healthy Kids Medical Insurance or Medical Coverage For Pregnant Women, on behalf of the child, must provide verification of all Healthy Kids-Gold eligibility criteria.

• Require verification of the child’s:

- residency;

- date of birth;

- enumeration status;

- alien or citizenship status;

- if the family claims it, child support payments or income deductions for allocation to legal dependents; and

- family income.

Exception: Accept a verbal declaration of the amount of child support income received.

• Accept a verbal declaration for the following income deductions if the family claims to have allowable expenses:

- child care; and

- legal wage garnishments.

• Require documentation of the most recent 4 weeks of earned income for families applying for HKG-185 or HKG-300.*

*

Exception: Require additional documentation if earnings fluctuate or do not appear to accurately reflect a reasonable estimate of regular earnings based on case information.

• Require verification of resources if required by policy for the coverage group through which medical coverage is requested.

Exception: Written verification is not required with Form 800P, Application For New Hampshire Healthy Kids Medical Insurance or Medical Coverage For Pregnant Women if the application for HKG-185 or HKG-300 is received by an authorized outreach agency.

• The required verifications listed above may be provided to the outreach agency staff. The worker signs and provides Form 808P, Information Necessary to Support your Medical Coverage Application, which includes information on the types of verifications seen, to the applicant and to the District Office.

• Qualified entities making presumptive eligibility determinations for HKG-185 or HKG-300 must complete Form 808P and provide a copy to the District Office along with Form 800P indicating a determination of presumptive eligibility. See 117117_APPLICATION_PROCESSING_TIME_FRAMES_FAM, Application Processing Time Frames.

• The attachment of copies of verification is not mandatory but is encouraged when feasible.