In situations where self-attestation is not permitted, CAOs must not require individuals to provide additional documentation if it can be obtained electronically or the information obtained electronically is reasonably compatible with information provided by an individual on the application or if information can be obtained from the existing case record.
Caseworkers are required to conduct an ex parte review of information at every MA application and renewal before requesting paper documentation from the individual.
If unable to obtain verifications electronically, caseworkers must determine if self-attestation is acceptable or if the applicant/recipient must provide verifications necessary to determine eligibility. See section 312.61, Verification Requirements, for situations where self-attestation must be accepted.
CAOs must verify:
Social Security Number (SSN).
NOTE: Those who are not applying for MA or receiving MA are not required to provide SSNs.
U.S. Citizenship/Immigration Status.
NOTE: If an individual declares to be a U.S. Citizen or to have satisfactory immigration status and 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 (Refer to PMA-17124-322).
Income.
CAOs must request paper documentation only if income verification cannot be obtained electronically or information obtained electronically is inconsistent and the individual cannot give a reasonable explanation of the inconsistency.
Tax Deductions.
If an individual does not provide verification of deductions, no deduction will be given.
NOTE: Individuals can submit a copy of their most recently filed Form 1040 as verification of tax deductions that have not changed from the previous year. Individuals can also provide statements from financial institutions or receipts of paid expenses.
CAOs must accept the individual’s statement and require no verification of the following items (unless there is a reason to question an applicant’s statement):
Pregnancy.
Residency.
Household composition.
Who is the Caretaker relative.
American Indian/Alaska Native status.
If the CAO finds information that is inconsistent with what the individual reports, the caseworker must contact the individual to provide verification.
Reasonable compatibility exists when income information reported by an individual and available to CAOs through trusted data sources (verified upon receipt) is relatively consistent and does not vary significantly or in a way that is meaningful for eligibility. If the reported and data source information is relatively consistent but there is a discrepancy that is meaningful to eligibility, the CAO will reach out to the individual to resolve the discrepancy.
Reasonable compatibility must be used when determining income eligibility for MA determinations based on MAGI and non-MAGI rules. The threshold for reasonable compatibility is 5 percent.
Scenarios for Reasonable Compatibility:
Example 1: James is applying for MA for his son, Alex (age 13). He reports income of $400 a week, which equals $1,600 a month. Exchange 1-Equifax shows income for James as $1,700 a month.
The income limit for MA for a two-person household at 133 percent FPIG is $2,266 a month.
Alex is determined eligible for MA without requesting paper verification of current income because the information reported and received electronically is below the MA eligibility level. The caseworker will enter $1,700 a month on the “Employment and Wage” screen in eCIS.
Example 2: Juniper submits a renewal for MA and does not provide documentation of income. Juniper reports zero income on the renewal, and there is no income on file. Exchange 1-Equifax shows income for Juniper as $1,000 a month.
The income limit for MA for a one-person household at 133 percent FPIG is $1,670 a month.
Juniper is re-determined eligible for MA without requesting paper verification of current income because the information reported/on file and received electronically is below the applicable income standard. The caseworker will enter $1,000 a month on the "Employment and Wage" screen in eCIS.
Example 3: Julius is applying for MA for himself and his son, Jules (age 13). He reports income of $800 a month from Employer A, and lists no other income on the application. Exchange 1-DLI shows income for Julius of $600 a month from Employer A, and $400 a month from Employer B.
The income limit for MA for a two-person household at 133 percent FPIG is $2,266 a month.
Julius and Jules are determined eligible for MA without requesting paper verification of current income because the information reported and received electronically is below the applicable income standard. The caseworker will enter $600 a month for Employer A and $400 a month for Employer B on the "Employment and Wage" screen in eCIS.
Example 4: Brad and Rebecca, a married couple, are applying for MA for themselves. The application lists income of $800 a month from Brad’s employer and income of $800 a month from Rebecca’s employer. Exchange 1-DLI shows income for Brad of $900 a month and $900 a month for Rebecca.
The income limit for MA for a two-person household at 133 percent FPIG is $2,266 a month.
Brad and Rebecca are determined eligible for MA without requesting paper verification of current income because the information reported and received electronically is below the applicable income standard. The caseworker will enter the $900 a month for Brad and the $900 a month for Rebecca on the “Employment and Wage” screen in eCIS.
If the reported
income and data source income are within 5 percent of each other,
use the income reported by the data source.
Example: Joseph is applying for MA for his son, Jaden (age 12). He reports income of $2,200 a month. Exchange 1-Equifax shows income for Joseph as $2,300 a month.
The income limit for a two-person household at 133 percent FPIG is $2,266 a month.
Because the difference between reported income and information received electronically is less than 5 percent, the income reported is considered to be reasonably compatible with the information obtained electronically. No additional verification is required from Joseph. The caseworker will enter $2,300 a month on the “Employment and Wage” screen in eCIS.
If the reported income and the data source income are not within 5 percent of each other, additional documentation is needed. The caseworker must contact the individual about the discrepancy. The data source information should be used if the client confirms that the data source income is correct. If income information is still questionable, a request for paper documentation must be made.
Example: Susan is applying for MA for her daughter, Jamie (age two months). She reports income of $750 a week, equaling to $3,000 a month.
Exchange 2 shows unemployment compensation for Susan as $4,000 a month.
The income limit for a two-person household at 215 percent FPIG is $3,663 a month.
The difference between reported income and information received electronically is greater than 5 percent; the income reported is not reasonably compatible with the information obtained electronically. The caseworker must contact the client to ask about the discrepancy first. If the difference in income is still questionable, the caseworker must request paper documentation before income determination is made.
If
an individual reports income above the applicable FPIG but
the data source indicates income below the applicable FPIG
then:
Reasonable compatibility standard is not a factor. Additional documentation must be provided.
Example: Michelle is applying for MA for her son, Jacob (age six months). She reports income of $925 a week, equaling $3,700 a month. Exchange 1-Equifax shows income for Michelle as $3,515 a month.
The income limit for a two-person household at 215 percent FPIG is $3,663 a month.
Reasonable compatibility is not a factor. A caseworker must request paper documentation before income determination is made, because the reported income is above the income limit but the data source indicates income below the income limit.
NOTE: MA eligibility must not be denied for individuals who are cooperating in obtaining income verification.
The CAO must decide who is eligible for MAGI- related MA as follows:
1. Decide who in the MAGI household. (See Section 312.1, General Policy and Section 312.2, Who is in the MAGI Household?).
2. Base household composition on how the household files taxes. (See Section 312.2, Who is in the MAGI Household?). Step-parents and parents are treated the same. A household can include an OOTH individual who has a tax-relation to an applicant and does not live in the household. If the individual does not answer tax questions on the application or renewal form, the tax relationships are considered unknown. The CAO will use non-filer rules to determine eligibility for MAGI MA.
3. Determine the countable monthly household income of every individual included in the individual's household. If the income is received weekly or biweekly, determine the average pay and multiply it by four or two to arrive at the monthly amount.(See Section 312.4, Income).
NOTE: Multiply the average weekly income by four (or biweekly by two) even if the individual gets paid three or five times in a calendar month.
4. Calculate each applicant's net monthly income by applying the allowable deductions. (See Section 312.5, Income Deductions and Disregard).
5. Compare the total net monthly income for all applicants with the MAGI income limits applicable for each individual. If income is within the applicable limit, proceed to #8. If income is not within the applicable limit, continue with #6.
6. Disregard 5 percent of the 100 percent FPIG for the applicable family size.
7. Compare the total net monthly income after the 5 percent disregard for all applicants with the MAGI income limits applicable for each individual.
8. Approve or deny benefits and issue the appropriate notice to the household.
REMINDER: If the household's monthly income exceeds the income limit and the income is expected to decrease or terminate, an annualized income calculation must be performed. the household's total earned and unearned income from January 1 through December 31 in the year eligibility is being determined is considered annual income. When calculating, be sure to allow for any periods in which the income is not received or will be decreased.
Updated April 17, 2024, replacing November 21, 2019