Person Composite Service (PCS) Age/Date of Birth SVES BENDEX Federal Hub Person Composite Service (PCS) Birth Certificate Driver’s License Lawful Presence Status, Lawful Permanent Resident) SAVE Federal Hub Person Composite Service (PCS) SVES (40 Work Quarters) USCIS Document Residency Client Statement Out-of-State Benefits Client Statement Marital Status Client Statement Relationship Client Statement Household Composition/ Tax Filing Status Client Statement Income If total reported income is under $300, the client’s statement is accepted as verification Unearned Income BENDEX SDX UCB Retirement System Collateral Call Award Letter Check Stub DHHS Verification Forms Earned Wage Match Person Composite Service (PCS) Wage Verification VerifyDirect CHIP Collateral Call Check Stub DHHS Form 1245 or other written statement from employer Self-Employment Tax Return Contributions Client Statement Category Specific Pregnancy (Pregnant Woman) Client Statement School Attendance (If the only Qualifying Child for a PCR is Age 18) Client Statement Disability (Non-MAGI with Applicant under age 65) BENDEX SDX SSA/SSI Award Letter MAO99 Electronic Source Client Statement Hard Copy 105.01.02 Resource Verification Matrix (Eff. 09/01/16) Acceptable Sources Only consider resources for non-MAGI programs Resource Verification Sources Instruction
Bank Checking Account Savings Account Certificate of Deposit Documented call to Financial Institution Asset Verification System (AVS) Bank Statement Account Information from Bank website Verify: Name of Bank Account Number Account Balance Obtain balance for month of application Obtain balance for each Retroactive month IRA, 401-K, Retirement Account Documented call to Financial Institution Asset Verification System (AVS). Does not include brokerage firms Financial Institution Statement Verify: Name of Institution Account Number Account Balance DirectExpress (Direct deposit account for U.S. government benefits) Client Statement Accept client statement of account balance Property Homestead Property Non-Homestead Property County Tax Assessor Use county website if available Send DHHS Form 1255 if the county does not have property records online Property Tax Notice Verify if the client alleges property: Owner(s) Location/Address Map/block/parcel number Value Accept client statement if no real property is alleged* *Exception: Long Term Care Vehicle County Tax Assessor Use county website if available Send DHHS Form 1255 if the county does not have property records online Property Tax Notice DMV Webtool Accept client statement if only one or two vehicles are alleged Verify if the client alleges more than two vehicles Owner(s) Make and Model Value Accept client statement if no vehicles are alleged
Life Insurance Life Insurance Policy (Do not verify term life insurance provided through employment) Documented call or written statement by agent Documented call to insurance company (automated system or call center) Copy of policy DHHS Form 1280 to verify if client alleges having life insurance: Name of Company Policy Number Type – or Term Face Dividends, if any If total face value of all policies for each insured person is greater than $10,000, verify the Cash value Accept client statement if no insurance is alleged
Home Maintenance Allowance Allowance can be given for up to six full calendar months for necessary household expenses Six count begins the first full calendar month the applicant is in an institutional setting (Hospital or Nursing Facility) Allowance is for actual household expenses not to exceed the current SSI limit Deduction is applied during recurring income calculation Deduction can be requested at any point within the six month period and applied retroactively Letter from physician certifying the applicant is expected to return home within six months Written or verbal statement of household expenses. Must detail the type and amount of expenses Only request copies if the reported expense is excessive and is needed to give the full allowance Deduct household expenses in the following order until full allowance is used or Rent Water and Sewer and internet and other utilities and expenses Spousal Allocation An allocation can be given to a community spouse by the institutionalized spouse The institutionalized spouse must to provide the allocation The community spouse must cooperate and provide income and resource information to receive the allocation Question must be answered on DHHS Form 3401 or the DHHS Form 3400-B Verification of spousal income/resources Dependent Allocation An allocation can be given to a dependent relative by the institutionalized person The institutionalized person must agree to provide the allocation The dependent relative must cooperate by providing information to receive the allocation Written Statement which has the: of the dependent relative; of the dependent relative to the institutionalized person; of the dependency of the dependent relative; and and relationship to the person with whom the dependent relative will be living Other Element Policy Reminder Verification/Documentation Separated Spouse If a person who is separated but not divorced applies for an institutional program, the eligibility worker MUST attempt to contact the community spouse and obtain resource information. If the community spouse receives SSI, no contact is required If the location of the spouse is known, attempt contact: spouse does not cooperate, document and treat Institutional Spouse as an individual If a DHHS 1233 is sent, continue processing the application. Process as a change if something is returned Cooperating: Document income for spousal
Veterans Benefits Retirement/Pension → Is any other income that may not have been listed? 1233 – Income Verification Requested Total Reported Income: 0.00 If reported income is greater than $2000, go to Income Trust script. If Income Trust script is not required, continue Application Script None Additional Income: Source Amount → Do you have any deductions taken out of your check? Anything such as health/dental insurance premiums or taxes withheld? If you have medical deductions, we may be able to not count the premiums. No Deductions Deductions (List all deductions) 1233 – Verification Requested → If taxes are being withheld, you have the option to ask whoever is paying the income to stop withholding taxes. Medicaid must use the full amount even if taxes are being deducted. Income – Spouse or other dependent relative Complete before call. Make any notes or corrections as necessary: → You listed the following income on your application: Source Amount SSA/RRB Veterans Benefits Retirement/Pension Other: 1233 – Income Verification Requested → Is any other income that may not have been listed? 1233 – Income Verification Requested None Additional Income: Source Amount Resources Complete on-line property Complete before call. Make any notes or corrections as
Vehicles → In the past five years have you or your spouse given away any motor vehicles including cars, boats, RVs, etc.? 1233 – Verification Requested The transfer of one vehicle that is otherwise excluded is not subject to the transfer of assets penalty and no further verification is needed. No Yes Details: Other Transfers → In the past five years have you given away money or anything else to anyone in the past five years that we may not have asked about? 1233 – Verification Requested No Yes Details: Inheritance → Have you received an inheritance from anyone within the past five years? 1233 – Verification Requested No Yes – Person, when and where probated, and description Details: 105.02.04 Income Script (Eff. 08/01/15) Income Script 105.02.04 Step Script Actions INCOME SCRIPT Why an Income Trust is needed Based on the income information you have given us, it appears the gross income before deductions may be at or above the Income Limit or Medicaid Cap of $____. The applicant may still qualify for Medicaid by setting up a special Income Trust for their income to flow through. If an Income Trust is set up, the income deposited into the trust does not count toward the Medicaid Cap but is considered when determining how much he/she as to pay toward their cost of care each month.
Disability Report: MAO99: Result To Be Completed By SCDHHS Support at Voc Rehab Only: General Comments/Reported Contacts Date: Worker ID: Note/Comment: Date: Worker ID: Note/Comment: Date: Worker ID: Note/Comment: Date: Worker ID: Note/Comment: Date: Worker ID: Note/Comment: Date: Worker ID: Note/Comment: Date: Worker ID: Note/Comment: Date: Worker ID: Note/Comment: Date: Worker ID: Note/Comment: Date: Worker ID: Note/Comment: Date: Worker ID: Note/Comment: Date: Worker ID: Note/Comment: Date: Worker ID: Note/Comment:
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