Verifications of Applications

Each case, whether the application is filed in person, by mail-in, or forwarded by SPE, must contain adequate information and support documents to verify eligibility. Initially, this information can be electronically verified through the Federal Data Services Hub (Federal Hub), MEDS, and/or IEVS. If a client’s information cannot be electronically verified, then paper verifications (i.e. paystubs, bank statements, SSN card, etc.) may be required. For the ex parte review, documents/information must be within 90 days.

The eligibility rules for MAGI Medi-Cal and Covered California program are stored in CalHEERS, while eligibility rules for Non-MAGI Medi-Cal are stored in SAWS. Although Non-MAGI Medi-Cal determinations are required to be completed in the SAWS system, relevant e-verified information may be used for more streamlined processing in order to reduce requests for documentation from the applicant/recipient.

Non-MAGI MC Verification

While "true Non-MAGI only cases,” (such in the case of a new non-MAGI application, etc.), will not be run through the Federal Data Services Hub (FDSH), if e-verified information is received for the Non-MAGI individual, then these e-verifications must be utilized for Non-MAGI eligibility determinations without further request for verification. Such situation can occur but is not limited to the following scenarios:

When one or more Non-MAGI members of the household are in a mixed household with MAGI members whose individual eligibility is run through the BRE. Or,
When a MAGI individual has transitioned to Non-MAGI eligibility but still has relevant e-verified information on file, such as SSN or citizenship information, etc.

In instances like the ones mentioned above, the Non-MAGI applicant’s e-verified information is transferred from CalHEERS to SAWS, and it is available, and should then be used to complete the Non-MAGI eligibility determination.

The use of e-verified information for Non-MAGI Medi-Cal eligibility determinations shall be used at:

Application,
Annual Renewal, or
Change of Circumstance

For any Medi-Cal application or redetermination, the ex parte process must be followed through gathering all available information relevant to the determination prior to contacting the applicant/recipient for additional verification. This includes information available electronically from other state or federal agencies or other programs, such as CalFresh.

Once the information is received and ran through the BRE, e-verified information must be used in the Medi-Cal eligibility determination. if there is not enough data collected with the use of e-verified information to make an eligibility determination, the Eligibility Worker must request from the applicant/recipient the appropriate forms and/or verifications needed to complete the application, change in circumstance, or renewal. EW’s must not request unnecessary or duplicative information and only request verifications required to make an eligibility determination.

E-Verifications for Use in Non-MAGI Eligibility Determinations

The following are verifications that, when e-verified, must be used in Non-MAGI Medi- Cal eligibility determinations:

Citizenship and Identity Verification
Immigration Status
SSN Verification
Medicare Verification
Incarceration Verification
Disability Verification

MAGI MC Verification

At initial application, verifications must only be requested from MAGI MC clients after a CalHEERS BRE eHIT and ex parte review are completed. If information is verified via the Federal Hub, then paper verifications are not required. [Refer to “Federal Data Services Hub,” page 16-3] If information cannot be verified by the Federal Hub, then paper verification is required.

It is mandatory that each case contains adequate information with support documents in the CalSAWS Journal Entry to determine eligibility, including any follow-up activities needed.

The following information must be verified before an MC eligibility determination can be completed:

Verifications

Verification	Documentation
Signed Application	CalHEERS e-signature, telephonic signature, or a signature on a paper application. NOTE: All MC applications received through the External Referral Data (ERD) subsystem have been electronically signed. Exception: One-e-App will fax the signature page.
Identity
Social Security Number	Copy of card, IEVS Report, or MEDS showing SSN verified status
California Residency	Driver’s license, utility bill, vehicle registration, school enrollment, rent receipt, or current check stub.
Immigration Status	USCIS documents
Income Verification	Check stub, income tax return, signed statement from employer, bank statement with direct deposit, child support court order. REMINDER: MC applicants are only required to provide one pay check stub for the purpose of calculating earned income.
Income Deductions	Child care receipts, court ordered child support paid, health insurance premium paid.
Medicare	Health insurance card, award letter showing the individual's health insurance claim number (HIC), explanation of Medicare benefits (EOMB) issued by Medicare fiscal intermediary, bill for premium for Medicare Part A, B or D, IEVS and/or MEDS information
Property/Assets	Bank statements, vehicle registrations, life insurance policies, stocks, bonds, IRAs, 401Ks, real property.
Pregnancy Verification	Women may self-attest to pregnancy. The EW must only request paper verification if the pregnancy reported is questionable.
Marital Status of Parents	Clients Statement for Sneede Determination (Not required for Sneede Property Waiver)
OHC Information	Information for ALL Family Members with Other Health Coverage, Insurance policy which specifically names the applicant/recipient, Health benefit ID card, Letter from health care benefit provider, Health care benefits from Workers Compensation employers or insurance companies

Documentation Needed for Retro Applications

MC 210 A	Retro MC Application (Up to 3 prior months)
Income Verification	Actual income for ALL retro months requested
Property Verification	Actual amounts for ALL retro months requested prior to 1/1/2024. (Not applicable for children/pregnant women).

SSN Verification

SSNs are required for citizens and documented non-citizens.

Once an individual’s SSN is entered in CalSAWS/CalHEERS, MEDS verifies the SSN through daily SSN validation process. If the individual has a MEDS record with fully or partial unverified SSN-VER code and they receive full scope benefit, MEDS alerts in “4xxx” series will be generated to display discrepancies. An EW should follow the instructions outlined in the UGSS Chapter 4 “County Eligibility Worker Alerts: 400-8999” and/or Chapter 3 “MEDS/CDB Record Changes to clear the discrepancies to fully verify an individual’s SSN. If the SSN cannot be verified through MEDS, the EW must request verification and allow the client 60 days to provide. If verification is not provided, the individual must be discontinued from MC.

Note: An SSN is not required for Victims of Human Trafficking and Serious Crimes and for undocumented children under the age 19 under SB75 to receive full scope MC benefit.

Identity Proofing and Identity Verification

For MC there are two layers of identity checks:

Identity Proofing
- A process to make sure that a person who is applying, or acting on behalf of another individual, is who they say they are. Identity Proofing is required to allow an application to be submitted for an eligibility determination (i.e., to run EDBC or to complete a CalHEERS online application) or to allow certain record changes to be made (i.e., CalHEERS Primary Contact information changes).
Identity Verification
- A process to meet identity verification requirements as a condition of eligibility for MC. These verification requirements include DRA requirements.

Identity Proofing

There are three options for Identity Proofing:

Signature
1. The applicant can complete and send or deliver a paper application to the county or the Covered California Service Center for processing. The applicant’s signature on an application qualifies as proof of identity when a Covered CA Service Center Representative (SCR), or county EW processes the application.
Visual Verification
1. The applicant can mail in or upload a digital copy of an identity verification document, which an EW or Covered CA SCR can then visually verify (this is also known as Administrative User Attestation). Or, if in person, the EW or Covered CA SCR can scan and upload the document received from the applicant. Visual Verification can be accomplished via the MC Identification process described under Identity Verification below.
Remote Identity Proofing
1. (CalHEERS ONLY) This process is used when using the electronic/phone signature process (i.e., while applying online via CalHEERS or over the phone via Covered CA). Either the applicant, EW, or Covered CA SCR can use the Remote Identity Proofing (RIDP) service to which CalHEERS connects through the Federal Hub.
2. To complete the RIDP process for phone and online applications, do the following:
  1. Client will complete an electronic check through Experian using CalHEERS.
  2. EW completes an ex-parte review of any prior case or current CF case in the IDM to determine if acceptable identity documentation is on file to serve as proof of identity. If so, the Identity Proofing requirement is met.
  3. Client provides a copy of acceptable ID documentation, in person, by mail, by fax, or electronically.
3. A telephonic or electronic application can be submitted to CalSAWS without Identity Proofing. However, the Remote Identification Process Verification Complete [Y/N] field under the [DRA Detail] tab must be completed on the Collect Individual Demographics Detail window prior to running EDBC.

Identity Verification

There are three options for Identity Verification:

CalHEERS BRE
1. The CalHEERS BRE verifies identity and citizenship by checking the Federal Hub during a determination of eligibility. This process includes verifying an SSA match.
2. If identity and U.S. citizenship are verified through an SSA match (i.e., through the Federal Hub), both the original MC Identification requirement (Title 22 of California Code of Regulations 50167(a)(6)) and DRA requirement are met, and remain met without any further verification.
MC Identification
1. Original MC regulations [Title 22 of California Code of Regulations 50167(a)(6)] require EWs to verify the identity of a client. This verification is required from the primary applicant at every application.
2. This requirement is met by SSA Match which verifies citizenship (e.g., through the Federal Hub). Requirement can also be met with a photocopied document. In addition, current and old information can be matched up. For example, there is an old picture ID in the case, and the signature on the current SOF matches.
3. The following are acceptable forms of identity verification:
  1. A Driver’s License or ID card issued by the DMV
  2. Marriage Record
  3. US Citizenship or Alien Status document (i.e., passport)
  4. Work Badge
  5. Social Security Card
  6. School Identification Card
  7. Church Membership or Baptism/Confirmation Record
  8. Birth Certificate.
    1. Note: If an individual has no other possible method of verifying identity a signed affidavit may be accepted as a last resort.
Deficit Reduction Act (DRA): Citizenship and Identity Verification
1. The DRA passed in 2005 and in 2007 California introduced the requirement that every applicant alleging US Citizenship (adult and child) must prove citizenship and identity.
2. Always check MEDS to see if the DRA citizenship and identity requirements have already been met.
3. Do not pend for verification of citizenship and identity until an SSA match is attempted. According to DHCS, the SSN Data match results should be used prior to requesting acceptable documents.
4. Once DRA is met, it remains met. If the MEDS [INQE] screen shows that DRA requirements are met, send a copy of the MEDS [INQE] screen to IDM.
5. Photocopies are not acceptable for DRA; in cases where the SSA match fails, and DRA requirements were not otherwise met, the client must present in-person original documents to verify ID and citizenship. EWs should use the MC 239 DRA-6 to pend a case for verification of citizenship and identity after an unsuccessful SSA match.
6. Reminder: Clients should not mail original documents to the county. They must provide original documents in-person.

The following table summarizes examples of Identity Proofing and Identity Verification process depending on how the application is submitted.

Application submitted through...	Citizen	Identity Proofing	Identity Verification
Paper application to Covered CA	Yes	Signature on paper application is sufficient.	BRE call verifies identity. DRA is met by BRE SSA citizenship verification.
Paper application to Covered CA	No	Signature on paper application is sufficient.	BRE call pends for identity and citizenship. Perform MC identification. DRA is not appropriate for non-citizen.
Paper application to the county	Yes	Signature on paper application is sufficient.	BRE call verifies identity. DRA is met by BRE SSA citizenship verification.
Paper application to the county	No	Signature on paper application is sufficient.	BRE call pends for identity and citizenship. Perform MC identification. DRA is not appropriate for non-citizen.
BCW	Yes	EW visual verification.	BRE call verifies identity. DRA is met by BRE SSA citizenship verification.
BCW	No	EW visual verification.	BRE call pends for citizenship. MC identification completed with visual verification at Identity Proofing. DRA is not appropriate for non-citizen.
Phone call to Covered CA	Yes	Client performs RIDP. If RIDP fails, follow alternative Proofing paths.	BRE call verifies identity. DRA is met by BRE SSA citizenship verification.
Phone call to Covered CA	No	Client performs RIDP. If RIDP fails, follow alternative Proofing paths.	BRE call pends for identity and citizenship. Perform MC identification. DRA is not appropriate for non-citizen.
Phone call to the county	Yes	Telephonic signature is sufficient. If no telephonic signature, follow visual verification Proofing paths.	BRE call verifies identity. DRA is met by BRE SSA citizenship verification.
Phone call to the county	No	Telephonic signature is sufficient. If no telephonic signature, follow visual verification Proofing paths.	BRE call pends for identity and citizenship. Perform MC identification. DRA is not appropriate for non-citizen.

5.13.4 Self-Attestation for Plan to File Taxes

An EW must accept an individual’s self-attestation as true to the following questions:

Is the tax filer planning to file taxes this year?
Is the tax filer’s child or tax dependent expected to be required to file taxes this year?

The self-attested answers to the above tax filing questions must be accepted as true, regardless of other information provided within the application that may appear to conflict with the individual’s statements, such as the amount of their income and/or deductions.

This is due to the fact that there may be circumstances known to the Internal Revenue Service (such as partnership losses and net loss carryovers for up to 20 years) or to the individual (such as an upcoming marriage or a terminal diagnosis) that are not included or reported on the application. Such circumstances may affect the individual’s expectations/requirements for filing taxes or claiming deductions.

Asset Verification Program (AVP)

The Asset Verification Program (AVP) is a process to generate reports with enhanced financial information on Non-MAGI Medi-Cal applicants and recipients, excluding Pickle, DAC, and DW. AVP assists EWs in identifying unreported assets. The AVP process excludes trust information; therefore, if an applicant declares they own a trust, the trust must be administratively verified.

Ex-parte AVP Processing

Ex-parte processing of declared assets allows eligibility staff to use existing case information, AVP results, and other electronic data sources to complete eligibility determinations without contacting individuals. If the Ex-parte review results in assets under the applicable asset limit for the individual, eligibility can be processed with no further information request. This helps ensure uninterrupted acces to care for the individual if all other eligibility requirements are met.

Requesting Asset Verification at Application

Eligibility Workers (EWs) must request asset reports at application, a report of change in circumstances, and a special case (responsible relative) for all Non-MAGI individuals excluding, Pickle, DAC, and DW. AVP reports provide asset information with a 90-day look-back for Non-MAGI and a 60-month look-back for LTC applicants and recipients.

Note: The outcome of the AVP report must be documented in a Journal Entry, and the report must be imaged to the case file.

Important AVP Considerations at Application

If the attested asset information and/or information found on electronic verification sources are at, or under $130,000 for one person and $65,000 for each additional person, eligibility can be granted if all other eligibility criteria are met (This excludes all trust assets). This includes attestations of zero assets at application. Once an AVP report is received, eligibility will need to be reviewed.
When asset verification is performed at application, eligibility approval must not be delayed solely based on the failure to receive the requested asset report (If the applicant has complied with all requirements and all other eligibility criteria is met, the Medi-Cal application must be approved).
If both the attested value on the application and the data received on the AVP report are below the asset limits, it is considered reasonably compatible, and the verification of assets is satisfied. The values must be recorded as appropriate in CalSAWS.
When eligibility is approved before the receipt of an AVP report, the currently assigned EW must evaluate the contents of the report once received and take appropriate action as needed.
For applicants who have an SSN but did not provide it during the early stages of the application process, the EW must request the asset report once the SSN has been verified.
Individuals without an SSN cannot have an AVP requested. Staff must administratively verify assets for these individuals.
The information on the AVP report is valid for 90 days from the date of receipt.
If the AVP report is received and the property value listed is more than the household's property limit, verification must be requested.

Responsible Relative

Federal and state law require EWs to obtain the financial records of “any other person” whose resources are required by law to be disclosed to determine the eligibility of a Medi-Cal applicant or recipient, or to determine the amount or extent of medical assistance. The relative responsible for contributing to the cost of health care services of a Medi-Cal applicant or beneficiary is limited to spouse for spouse and parent for child.