223.01 Verification: CM SR 13-35, 10/13 (MAM-A)

The individual who signs DFA Form 800, Application for Assistance, Form 800HR, HEIGHTS-generated Application for Assistance, or DFA Form 800P, Application For Children’s Medicaid (CM) and Medical Coverage For Pregnant Women (MCPW), on behalf of the child, must provide verification of all eligibility criteria.

• Require verification of the child’s:

- residency;

- date of birth;

- enumeration (SSN) 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.

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 assistance group through which medical assistance is requested.

Exception: If DFA Form 800P is received by an authorized outreach agency, the outreach agency staff person’s signature on DFA 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 *CM or MCPW, qualified entities must provide the following to the District Office*:

• all required verifications;

• DFA Form 800P indicating a determination of presumptive eligibility;

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

• DFA Form 11, Authorization to Release Information.