Verification of “Stable” Income and/or Resources at Renewal for Medical Assistance (MA), PMA 21443-378 (Published August 2, 2023)
The use of Social Media to verify Applicant/Recipient Information, PMA-20723-378 (Published October 15, 2021)
Beneficiary and Earnings Data Exchange (BENDEX) State Code Issue, PMA-20561-378 (Published June 10, 2021)
Income and Resource Verification at Renewal PMA-19504-387 (Published June 26, 2019)
Opening MG 18 C When a Supplemental Security Income (SSI) Budget is Closing for a Child under 4, PMA-19169-378 (Published October 30, 2018)
Change to ARRC 123 alert due date, PMA-18914-378 (Published September 4, 2018)
The CAO must accept an individual’s statement of the following factors of eligibility for Medical Assistance (MA) unless there is a reason to question an applicant/recipient’s statement:
Pregnancy
Residency
Household Composition
Caretaker/Relative status
American Indian/Alaskan Native status
The CAO will require the individual to provide verification of eligibility factors that can be accepted based on the individual’s statement only if the CAO finds information that is inconsistent with what the individual reports.
In situations when accepting the individual’s statement is not permitted, the CAO is required to complete an “ex-parte” review of information, and attempt to verify information through trusted electronic data sources or from the existing case record, before requesting verification from the individual.
An “ex-parte” review is required to be completed at application, renewal and when a change in circumstances occurs in order to avoid unnecessary verification requests for information from the individual when it can be obtained and verified by the CAO. See Appendix I for the MA Ex-Parte Review Checklist.
The checklist is a resource that the CAO can use when completing an “ex parte” review. 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.
Any information from a trusted data source (verified upon receipt) must be considered “reasonably compatible” in order to be used as verification.
Reasonable compatibility exists when income information reported by an individual and available to CAOs through trusted data sources 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:
If reported income and information obtained electronically through a data source are both above, at or below the applicable income standard, they are considered reasonably compatible. The CAO will use the information from the data source as verification of income
Example 1: James is applying for MA for his son, Alex (age 13). He reports income of $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 $1,875 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 $1,385 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 $1,875 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 $1,875 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 an individual reports income below the applicable FPIG but the data source indicates income above the applicable FPIG then:
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 $1,795 a month. Exchange 1-Equifax shows income for Joseph as $1,880 a month.
The income limit for a two-person household at 133 percent FPIG is $1,875 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 $1,880 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 $1,600 a month. Exchange 2 shows unemployment compensation for Susan as $3,080 a month.
The income limit for a two-person household at 215 percent FPIG is $3,030 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 $3,200 a month. Exchange 1-Equifax shows income for Michelle as $1,700 a month.
The income limit for a two-person household at 215 percent FPIG is $2,950 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.
378.13 Reasonable Compatibility for Resources
Resource information received from the Asset Verification System (AVS), Data Exchange 12, will be considered when determining eligibility for non-MAGI MA.
Resources are considered reasonably compatible if individual-reported resources match the AVS response AND both the individual-reported resources and the AVS response are at or below the resource limit. When the AVS results are reasonably compatible, they are considered verified.
AVS responses alone should not be used to determine eligibility. Resource types and values reported by the client must also be considered when evaluating resource eligibility because there are limitations to the AVS. Smaller financial institutions and institutions located outside a fifty-mile radius of the applicant/recipient’s current address may not have been sent the AVS request. Since the AVS provides verification of financial account balances as of 12:01 AM on the first day of the calendar month, the resources reported may not be the most current. Income may have been deposited or withdrawn after the account balance provided that would affect eligibility.
NOTE: MA benefits will not be rejected or closed solely based on individual-reported and AVS-reported resources exceeding the resource limits. Before rejecting or closing benefits due to excess resources, the applicant/recipient must be given the opportunity to provide documentation.
Scenarios for Reasonable Compatibility:
If individual-reported resources and AVS-reported resources match and are both at or below the resource limit then they are considered reasonably compatible.
Example: Amy is aged and is reviewed for Healthy Horizons which has a one-person resource limit of $2,000.00. She reports a Belco bank account valued at $1,500.00. The AVS reports the same account with a value of $800.00.
The CAO will consider the resource verified because the values Amy and the AVS reported are reasonably compatible.
If individual-reported resources are below the resource limit but AVS-reported resources are above the resource limit then they are not considered reasonably compatible.
Example: Bob is aged and is reviewed for Healthy Horizons which has a one-person resource limit of $2,000.00. He reports a PSECU bank account valued at $1,800.00. The AVS reports the same account with a value of $2,100.00.
The CAO will send a PA 253 request for verification of the PSECU bank account balance.
If individual-reported resources are above the resource limit but AVS-reported resources are below the resource limit then they are not considered reasonably compatible.
Example: Carl is aged and is reviewed for Medically Needy Only (MNO) MA which has a one-person resource limit of $2,400.00. He reports a Chase bank account valued at $2,500.00. The AVS reports the same account with a value of $1,800.00.
The CAO will send a PA 253 request for verification of the Chase bank account balance.
If individual-reported resources and AVS-reported resources are both above the resource limit then they are not considered reasonably compatible.
Example: Dan is disabled and is reviewed for Medical Assistance for Workers with Disabilities (MAWD) which has a $10,000.00 household resource limit. He reports a M&T bank account valued at $10,500.00. The AVS reports the same account with a value of $10,300.00.
The CAO will send a PA 253 request for verification of the M&T bank account balance.
If individual-reported resources and AVS-reported resources are inconsistent because the name of the financial accounts reported vary, then they are not considered reasonably compatible.
Example: Levi is aged and is reviewed for Healthy Horizons which has a one-person resource limit of $2,000.00. He reports a Belco bank account valued at $1,800.00. The AVS reports a Chase account valued at $1,800.00.
The CAO will send a PA 253 request for verification of Levi’s bank accounts.
NOTE: If the CAO is aware of a recent merger of financial institutions, then the CAO will take this into consideration when determining whether to reject for failure to provide resource documentation.
Reminder: A PA 253RM requesting current resource information is included in the non-MAGI renewal packets. The CAO does not need to send a second PA 253 request for verification when the individual is renewing benefits.
Updated June 9, 2023, Replacing April 27, 2023