Manual Requests for Asset Verification through the Asset Verification System (AVS), OPS180103 (Published January 30, 2018)
The CAO is required to complete an “ex-parte” review of information and use information available through electronic data sources or information in the existing case record before requesting paper verification from the individual.
An “ex-parte” review is required to be completed at application, renewal, and when a change is reported. See Appendix I for the MA Ex-Parte Review Checklist.
The CAO will request information from the individual if the CAO is unable to verify information through electronic data sources or if information obtained through electronic data sources is not reasonably compatible with the information reported by the individual.
The CAO will decide what information needs to be confirmed from:
The information on the application.
Prior case information.
Statements made by the individual.
Information from automated sources. (See Section 378.6, Automated Sources.) 55 Pa. Code § 201.1
Sometimes it may be impossible to get proof beyond the applicant’s statement on certain eligibility factors. The caseworker must use his or her judgment and make a decision using the proof on hand. As long as the applicant cooperates in getting proof, the CAO must approve MA within 30 calendar days from the date when the application is received. If all other conditions of eligibility for MA are met except proof of identity, and the individual is cooperating with CAO staff in getting the proof, MA must not be denied or stopped while waiting for proof.
Sources of proof include the following:
Automated sources (see Section 378.6)
Written information
Public records
Collateral contacts
Anything that shows that the individual's statement is true
PMA17324378 Changes in SSA Field Office Verification Services October 2, 2014
The CAO must help the applicant, when necessary, in getting the required proof.
The caseworker should keep in mind that, because of age, physical or mental disabilities, language problems, and other reasons, an individual may not be able to help or prove he or she is eligible for MA. The individual will always be told that the worker can help him or her. The CAO will take an active role in helping individuals with mental or physical disabilities obtain needed citizenship or identity papers or third-party resources that can help pay medical expenses.
The CAO will not require the individual to provide original documents for verification purposes. The CAO will accept duplicates including copies, faxed, or scanned documents as verification, unless there is a genuine issue as to the authenticity of the duplicate.
If the proof the individual uses is not appropriate, not complete, or not consistent with other information, the caseworker will tell the individual that more proof is needed. The caseworker and the individual must decide what other proof can be used. If the proof the individual provides is still unacceptable, the caseworker will make a collateral contact, using a copy of the PA 4 when it is needed. 55 Pa. Code § 201.4(1)(iv)
If the individual is unable to provide necessary verification due to a third party delay and is cooperating in the verification process, the CAO will authorize/reauthorize MA and will set up a plan with the individual for obtaining the needed proof within the following time limits:
At application, thirty calendar days from the date the CAO authorizes MA.
NOTE: It is the CAO’s duty to get the needed proof before approving benefits.
Thirty working days from the date the CAO processes the renewal. 55 Pa. Code § 133.23(a)(3)(i)
Information about medical resources is needed within thirty calendar days after the renewal.
Thirty calendar days from the date a partial renewal is processed. 55 Pa. Code § 133.84(d)
Thirty calendar days from the date the CAO processes the change in eCIS. 55 Pa. Code § 133.84(d)
NOTE: For verification of U.S. Citizenship and satisfactory immigration status, cooperation is not a factor.
If an applying individual declares to be a U.S. Citizen or to have satisfactory immigration status, the CAO must attempt to verify Citizenship/Immigration Status for all applying individuals through electronic data sources. If the CAO is unable to verify information through an electronic data source, the CAO must request verification from the individual in writing and allow a reasonable opportunity period of 90 days for the individual to provide the verification. The CAO must allow five days for mailing the request and set an alert for 95 days from the day the request is mailed.
See Chapter 322, Citizen/Noncitizen for additional information.
Reminder: The CAO will clearly identify and explain to the applicant what proof is needed to determine eligibility for MA. Approval of MA must not be delayed while waiting for proof for Cash Assistance or SNAP.
If the applicant has cooperated but is still unable to provide acceptable evidence, the CAO must make a collateral contact. (See Section 378.4, Collateral Contacts.)
If the individual does not cooperate in obtaining proof, the CAO will send a PA 162 Not Eligible notice to applicant if the individual is an applicant or a PA 162 Advance Notice if the individual is a recipient. These notices include the following:
A list of information that was not provided or action that was not taken.
The policy citation stating the information or action that was needed.
NOTE: See Chapter 377, Notices, for complete information about client notices.
The record must clearly show eligibility or ineligibility. The CAO will explain in the record any decision to ask for more sources of proof or proof of inconsistent information.
The CAO must verify all income used in an MA eligibility determination even if it appears that the individual is not eligible for MA based on the income reported. Children who have no private health insurance and are ineligible for MA due to income are referred to the Children’s Health Insurance Program (CHIP) through Healthcare Handshake process. When CHIP receives a referral, CHIP accepts income information as verified upon receipt and does not request verification.
If the reported income can be verified through a data source and both reported income and data source income are above the MA income limits, income is considered reasonably compatible and the verified electronic data source income can be used to reject the application or close the budget.
If income cannot be verified through a data source or reasonable compatibility is not a factor (reported income is above the income limit and data source income is below the limit, refer to Chapter 378.1) then the caseworker must request income documentation from the individual by sending a PA 253. If income verification is not returned by the applicant, the application must be rejected using reason code (042), Failure to Furnish Required Information.
PMA18434378 - No Income Reported at Application and Renewal - April 18, 2017
PMA18433378 - Verification of Terminated Income - April 18, 2017
At application an “ex-parte” review must be completed. The CAO will review electronic data sources and information in the existing case record to obtain verification before requesting the documentation from the individual. If the individual’s statement is required to be verified and the verification is not available through electronic data sources or if information obtained electronically is not reasonably compatible with the information reported by the individual, the CAO will ask for verification from the individual.
Reminder: For a child under age 21, the following items will be obtained from the parent’s or caretaker’s statement: Social Security Number, age and date of birth, and who is in the household. If the family notes on the CHIP application there is third-party insurance, contact the family and get the information.
Items that must be verified include the following:
Social Security Number (SSN) for all applying individuals. The CAO must use electronic data sources for verification or information from the existing case record. The CAO will request a Social Security card only if the electronic verification fails and the SSN is not already verified in the existing case record.
The CAO must not delay or deny MA to an otherwise eligible individual pending issuance or verification of an SSN by SSA or if the individual meets one of the following exceptions to providing or applying for an SSN:
An individual is not eligible to receive an SSN,
Does not have an SSN and may only be issued an SSN for a valid non-work reason, or
Refuses to obtain an SSN because of well-established religious objections.
Gross income, including income to be deemed (see Chapter 350, Income, and Chapter 355, Deeming Income and Resources For MAGI MA determinations, see (Chapter 312.5, Income).
If the CAO is unable to verify income through electronic data sources or information obtained through electronic data sources is not reasonably compatible with the information reported on the application, individuals can provide a single pay stub (weekly, bi-weekly or monthly) that is representative of the income received and the information will be used in the eligibility determination, either at application, renewal, or SAR. Pay stubs for a full month's income are not required.
It is acceptable verification for individuals to provide a single pay stub received within a 60-day period prior to the application date if it is representative.
Income expense deductions (see Chapter 360, NMP Deductions, and Chapter 361, MNO Deductions. For MAGI MA determinations, see (Chapter 312.6, Income Deductions).
NOTE: If the individual fails to verify any allowable deductions, the CAO must determine eligibility without giving the deductions. The CAO will not deny benefits if the individual failed to provide verification of allowable deductions and no other eligibility factors require verification.
Child support the household gets.
Note: Child support is excluded for MAGI MA eligibility determinations but may still need to be verified if household members can potentially qualify for non-MAGI MA.
Resources for non-MAGI MA determinations, unless the applicant, the applicant’s spouse, or the applicant’s children or stepchildren who are living in the household are under age 21 or the applicant has care and control of a child under age 21 living in the household (see Chapter 340, Resources).
Resources are excluded for MAGI MA eligibility determinations.
The equity value and ownership of resources for non-MAGI MA determinations, unless the applicant, the applicant’s spouse, or the applicant’s children or stepchildren who are living in the household are under age 21 or the applicant has care and control of a child under age 21 living in the household (see Chapter 340, Resources).
Health insurance or other third-party resources that can be used to pay medical expenses (see Chapter 340.13, Third-Party Resources).
Citizenship or Alien status for applying individuals only (see Chapter 322, Citizen/Noncitizen).
If an applying individual declares to be a U.S. Citizen or to have satisfactory immigration status, the CAO must attempt to verify Citizenship/Immigration Status for all applying individuals through electronic data sources. If the CAO is unable to verify information through an electronic data source, the CAO must request verification from the individual in writing and allow a reasonable opportunity period of 90 days for the individual to provide the verification. The CAO must allow five days for mailing the request and set an alert for 95 days from the day the request is mailed.
See Chapter 322, Citizen/Noncitizen for additional information.
Identity of the applicant (see Chapter 320, Identity). 55 Pa Code § 125.1(b)
The CAO must use electronic data sources for verification. The CAO will request verification of identity only if the electronic verification fails. Once identity has been verified, the CAO must not require the individual to provide verification in the future.
The following must be verified if part of the case record:
The relationship of the specified relative to the child, if the CAO has reason to question the applicant’s statement (see Chapter 327, Specified Relatives).
Note: For MAGI-related MA, an individual does not need to be related to the child to be a specified relative in the parents/caretakers category.
Deprivation of a TANF dependent child, if the CAO has reason to question the applicant’s statement (see Chapter 329, Deprivation).
For GA-related MA only, the need to obey a summons or bench warrant to appear as a defendant at a criminal court case (see Chapter 304, Appendix C).
62 P.S. 481.1
Disability. If an individual reports a disability which has not been verified by the SSA or MRT, the CAO will review the individual for MAGI MA and request verification of the disability. The CAO will not reject an application if the disability verification is not provided and the individual is eligible for MAGI MA.
Medical Expenses.
Student Status.
Child Support paid to someone outside the household (for deeming computations).
For MAWD: Need to prove employment.
Note: Proof of employment includes, but is not limited to, pay stubs, tax records, and letters from employers.
For category PD, proof of GA-related eligibility. 55 Pa Code § 141.61(c) (1)
If a case record already has proof of information that is not likely to change (for example, birth date, citizenship, identity, health insurance, address, or Social Security number), the CAO must not require proof again unless information does not match up.
As long as the applicant cooperates in getting proof, the CAO will approve MA within thirty calendar days from the date of application. If the CAO cannot make a decision in thirty days, they may extend the period to forty-five calendar days, as long as the applicant is told the following in a letter:
Why there is a delay.
The expected date of decision.
The right to a fair hearing.
If the CAO approves MA while waiting for proof, they will allow thirty more calendar days after the approval date for proof to be provided. As long as the applicant cooperates and the delay is caused by a third party, the CAO will continue benefits for thirty more calendar days. The CAO will allow more thirty-day periods if they are needed due to a third party delay. 55 Pa Code § 125.21(b) (2)
If the applicant refuses to cooperate in getting proof, the CAO will deny benefits. 55 Pa Code § 201.1
Past management is considered when an individual states how he or she has been living or who is the source of the income used to meet the individual’s needs.
Proof of past management is only needed if information provided is questionable or inconsistent. The CAO should accept the individual’s statement if it is reasonable. If proof of the individual’s past management is needed, the individual must give the name and most recently known address of the source. The individual will be asked to give written or other proof, including a letter from the source, of how much assistance is currently available.
Past management, like the other factors,will be discussed only as much as is necessary to understand the individual’s present situation and to find out how much assistance is still provided.
55 Pa Code § 125.24(c) (7) (ii)
Social Security Administration (SSA) Renewal and Redetermination Verification (RRV) Interface Service at Enhanced Medical Assistance Renewal (EMAR), OPS180305 (Published March 22, 2018)
Automatically Scheduled Renewals
When an MA automatically scheduled renewal form is returned to the CAO, the CAO must complete an ex parte review of the case, which includes checking all available data sources and the information in the case record in an attempt to verify the reported information on the renewal.
If the required verification is available through existing data sources or the case record, the CAO must process the renewal.
If the required information is not provided with the renewal and not available through existing data sources or the case record, the CAO will close the budget(s) for failure to provide verification.
If the auto-scheduled renewal form is not returned to the CAO, the CAO will complete an ex parte review.
If the required verification is available through existing data sources or the case record, the CAO must process the renewal.
If required verification needed to determine eligibility cannot be obtained through data sources or case record, close MA for failure to provide a completed renewal packet.
Manual Renewal Process
MA- Only Budgets
For MA-only budgets due for renewal, the CAO will first complete an “ex-parte” review by checking all available electronic data sources and information in the existing case record to determine if a renewal can be completed without sending a renewal packet to the household. See Appendix I for the MA Ex-Parte Review Checklist.
If all necessary verification is available through data sources or in the existing case record and the individual remains eligible at the same level of coverage, the CAO will process the renewal without requiring the renewal packet and will issue a notice to the household. The CAO must complete a full renewal narrative.
If all necessary verification is not available through data sources or in the existing case record, or if the information available would either change the level of coverage or make the individual ineligible, the CAO must issue a renewal packet and allow a minimum of 30 days for the recipient to return the packet and all necessary verification. The CAO must complete a narrative indicating that the review was completed and indicate the reason why the packet must be mailed.
If a renewal packet is returned without all required verification, the CAO must complete an ex parte review for the MA budget(s), which includes checking all available data sources in an attempt to verify the reported information on the renewal.
If the required verification is available through existing data sources or the case record, the CAO must process the renewal.
If verification is not available through existing data sources or the case record, close MA for failure to provide verification.
If a renewal packet is not received, the CAO will:
Close MA for failure to provide the completed renewal form and verification since the “ex-parte” review was completed prior to sending the renewal packet.
NOTE: If the recipient is cooperating in returning the renewal packet and verification, the CAO will give the individual additional time to provide the information.
Combination of MA, SNAP, and/or TANF (Cash) benefits
For cases open for a combination of MA, SNAP, and/or TANF benefits, the CAO does not need to complete an “ex-parte“ review for MA before a renewal packet is issued.
The following steps should be followed for the MA budget(s) when a combination renewal packet is not returned:
If all necessary verification is available through existing case record or electronic data sources, the CAO must process the renewal for MA.
If all necessary verification is not available through electronic data sources, the CAO should close the MA benefits.
NOTE: If a renewal is due for a TANF budget and the packet is not returned or requested verification is not returned, the CAO must review all available data sources and information in the existing case record to determine if MA can be continued after the TANF Cash budget is closed.
If the combination renewal packet is returned without all verification, the CAO must complete an ex parte review for the MA budget(s). The CAO should check all available data sources in an attempt to verify the reported information on the renewal.
If all necessary verification is available through existing case record or electronic data sources, the CAO must process the renewal for MA.
If all necessary verification is not available through electronic data sources, the CAO should close the MA benefits.
NOTE: The CAO must follow SNAP and TANF policy in determining if the electronically verified information can be used for processing SNAP and/or TANF. See SNAP Handbook Chapter 570 Appendix A and Cash Handbook Chapter 178 Appendix C.
At renewal, the CAO must verify the following:
Noncitizen status, if the information that the individual gives does not match up with other information.
Identity, if the information is not already in the case record.
Gross, nonexempt income, including deemed income.
Individuals can provide a single pay stub (weekly, bi-weekly or monthly) that is representative of the income received and the information will be used in the eligibility determination, either at application, renewal or SAR. Pay stubs for a full month's income is not required.
It is acceptable verification for individuals to provide a single pay stub received within a 60-day period prior to the date the renewal is received by the CAO.
Example: MA case is due for renewal for two children. The CAO was not able to verify the children's parents' income through electronic data sources and mailed a renewal packet requesting income verification. Mr. Smith provides a pay stub with a gross income of $613.75. He is paid bi-weekly. The caseworker will use this single pay stub to make the MA determination by converting the income to a monthly amount.
NOTE:This policy does not eliminate the requirements for the caseworker to verify income when another source of income does not support the determination made based on the single pay stub or income that was received within the 60 day period prior to application or renewal.
Example: Caseworker gets an IEVS hit for the third quarter that shows the individual received $7,500 wages from John Public Construction but the pay stub that was presented for this company stated $300 a week which converts to $1,200 a month. Since there appears to be a discrepancy, the caseworker must confirm the individuals past and present income to establish past and future eligibility.
Child support that the household gets.
Note: Child support is excluded for MAGI MA determinations.
Income expense deductions.
Note: If the individual fails to verify any allowable deductions, the CAO must determine eligibility without giving the deductions. The CAO must not deny benefits if the individual failed to provide verification of allowable deductions and no other eligibility factors require verification.
Resources, unless the applicant, the applicant’s spouse, or the applicant’s children or stepchildren who are living in the household are under age 21 or the applicant is taking care of and in charge of a child under age 21 living in the household (see Chapter 340, Resources)
Note: Resources are excluded for MAGI MA determinations.
The following things must be proven if they are part of the case record:
Medical Expenses.
Disability.
Age.
GA-related eligibility for NMP category PD and MNO category TD.
For GA-related MA only, the need to obey a summons or bench warrant to appear as a defendant at a criminal court case (see Chapter 304, Appendix C). 62 P.S. 481.1
Student Status.
Child Support paid to someone outside the household (for deeming purposes only).
Other eligibility factors for which a change has taken place or for which information about it does not match up with the facts or the available proof.
At a Partial Renewal for Breast and Cervical Cancer Prevention and Treatment (BCCPT), the need for continued treatment must be proven. The CAO will be notified by a fax from OMAP of the continued need for treatment, less treatment, or the stopping of treatment because (a) the treatment is no longer medically necessary or (b) because the individual has not provided proof of the need for treatment.
When processing a complete renewal for the BCCPT program, the continued need for treatment for breast or cervical cancer or for a precancerous condition of the breast or cervix must be proven. If credible coverage is shown on the renewal papers, it must also be proven.
If a case record already has proof of information that is not likely to change (for example, birth date, citizenship, identity, health insurance, address, or Social Security Number), the CAO will not ask for proof again unless information does not match.
The CAO will allow the recipient 30 days from the date the renewal form is mailed to provide any needed proof. If all other conditions of eligibility for MA are met except proof of identity, and the individual is cooperating with CAO staff in getting the proof, MA must not be denied or stopped while waiting for proof.
55 Pa Code § 133.23(a) (3) (i)
If the recipient cooperates but cannot meet the 30 day deadline because of a third party, then the CAO will continue MA and allow more time for proof to be provided. The CAO will review cooperation every thirty days.
55 Pa Code § 133.23(a) (3) (i)
If the recipient does not cooperate in giving proof, the CAO will send an Advance Notice that benefits will end. The notice must tell the recipient what proof is needed for continued eligibility for MA.
When the CAO learns of a change, the CAO must review the case for continued MA eligibility.
When there is a change that affects eligibility, the CAO must complete an “ex-parte” review and attempt to verify information through electronic data sources before requesting information from the individual. See Appendix I for the MA Ex-Parte Review Checklist.
If required verification is not available through electronic data sources or if information obtained electronically is not reasonably compatible with the information reported by the individual, the CAO will ask for verification from the individual.
The CAO will allow no more than thirty days from the date the CAO learns of the change for the recipient to provide the proof. If the recipient is cooperating but cannot get the proof because of a delay caused by a third party, MA will continue until proof is received. The CAO will review progress every thirty days.
When a recipient asks the CAO to close his or her case, the CAO will find out why. If it is because the individual has income, the CAO will verify when the individual received it and the gross amount. If the reason for the closing is unknown or cannot be confirmed, the CAO will narrate the information in the case record. If the individual applies for MA again, the CAO will verify the information that was unknown and verify that a resource causing the closure no longer exists.
An individual who files a timely appeal of adverse action may submit new or extra proof of eligibility at any time up to and including the fair hearing. If proof shows that the individual was eligible for MA, he or she can get retroactive benefits. 55 Pa. Code § 275.4(a)(3)
The individual does not need to show that the CAO made a mistake in stopping, denying, or reducing benefits.
When the individual provides the needed proof, the CAO will:
Decide whether proof confirms eligibility factors at issue in the appeal.
Decide what date the eligibility factor at issue in the appeal was met.
If proof shows the individual needed MA and was eligible in a retroactive month, approve benefits for that month.
If proof shows the individual was eligible on the date of application or the date when benefits were stopped, denied, or changed, approve benefits back to that date. All other eligibility factors must be met.
If proof shows the individual was eligible at a later date, approve benefits back to that date. All other eligibility factors must be met.
Example: Mr. Landry (age 67) submitted an MA application on February 2. Both Mr. Landry and his wife (age 65) applied for benefits. On February 8, he sent unpaid hospital bills from December to the CAO. Mrs. Landry had a life insurance policy with a face value of $5,000. The CAO calculates that the cash value of the insurance policy plus other resources puts the couple over the resource limit. The Landrys met all other eligibility factors. On February 19, the CAO issued a notice denying the Landrys’ application for MA.
On February 28, Mr. Landry files an appeal. Before the hearing, he gives the CAO a statement from his wife's insurance company saying that the cash value of her life insurance policy had been lowered because she borrowed against it several years ago. This proves that the couple’s total resources are less than the limit now and in December.
The CAO approves continuing MA effective February 2 and retroactive MA for the month of December.
Updated August 21, 2018 Replacing April 18, 2017