219.03 Required Verification SR 04-11, 05/04 (FAM-A)

The individual who signs Form 800, Application for Assistance, Form 800HR, HEIGHTS-generated Application for Assistance,* 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: If the 800P is received by an authorized outreach agency, the outreach agency staff person’s signature on the Form 800P certifies that required verification has been provided. It is not additionally required that outreach agency staff provide written verification to the District Office for those areas in which verbal declarations by the client are acceptable proof.

*

Within 10 days of determining presumptive eligibility for HKG-185 or HKG-300, qualified entities must provide the following to the District Office or New Hampshire Healthy Kids Corporation (NHHK):

• * all required verifications;

• Form 800P indicating a determination of presumptive eligibility;

• Form 800PEN, Presumptive Eligibility Decision for Medical Coverage for Children and Pregnant Women, indicating the interim eligibility period for medical coverage pending the client’s receipt of a permanent Medicaid ID card, or until a previously issued card is activated; and

• Form 11, Authorization to Release Information.

*

See 117, Application Processing Time Frames.