County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Verification Requirements Number Page 040701 1 of 3 Revision Date 04012021 BackgroundMediCal customers are responsible for making available all documents needed for the determination of eligibility As part of the applicationredetermination process explain verification requirements to the customer evaluate the customers ability to obtain verifications and assist in obtaining the verifications whenever necessary Purpose Included with the reformatting this section is being updated to include information implemented by the Affordable Care Act ACA previously issued in Special Notice SN 1309 Addendum A and updates to verifications to be accepted electronically Policy 040701A Verification Required Before Approval Certain information indicated on the Statement of Facts by the customer must be verified prior to approval of the application Information which must be verified PRIOR to approval of the application includes Income including verification of application for Unconditionally Available Income UAI Income deductions Real and Personal Property Identity CitizenshipAlienage Status AgeBlindnessDisability Legal Responsibility for a child if child is applying alone except for Minor Consent Substantial Gainful Activity SGA With the implementation of the ACA UAI requirements can be met after approval of the application See MPG 041201 for more information Only required to allow deductions 040701B Verification Required within 60 Days Eligibility may be established and approved prior to the receipt of the following information provided that the approval occurs within 60 days from the date of application Social Security Number SSN or application for an SSN Medicare entitlement The following individuals are exempt from the SSN requirement Deemed Eligible infants Applicants requesting restrictedlimited benefits or minor consent services Refugees applying for Refugee Medical AssistanceEntrant Assistance RMAEMA Refer to MPG 0411 for detailed information on SSN requirements County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Verification Requirements Number Page 040701 2 of 3 040701C SelfAttestation Selfattestation is when an individual is stating that something is true Unless questionable selfattestation is acceptable for Age Date of birth Family size Residency Pregnancy 040701D Electronic Verifications everified for Use in NonModified Adjusted Gross Income MAGI Determinations The following are verifications that when everified are used to determine NonMAGI eligibility Citizenship Identity Immigration Status SSN Medicare Incarceration Deceased Disability Note For information on which applications must be run through the California Healthcare Eligibility Enrollment and Retention System CalHEERS Business Rules Engine BRE see MPG 040222 040701E TelephoneElectronic Signature Accept telephonically recorded and electronic signatures as well as handwritten signatures transmitted via fax or email for any form that must be signed for the MediCal program Please see Eligibility Policy and Procedure Guide EPPG for methods of accepting telephonicelectronic signatures If a customer must provide a sworn statement for purposes of written verification where electronic verification was not successful and other methods of paper verification are not available the sworn statement may not be signed telephonically and written verification is required However the written verification including a sworn statement may be provided electronically such as via email fax or upload Note If a method of obtaining a signature meets the definition of a telephonicelectronic signature for CalFresh the method also meets the definition for MediCal 040701F Verifications for Retroactive MediCal When No change is reported on the MC 210A form no verification is required beyond that used to determine current and ongoing MediCal eligibility If a change is reported then it must be verified 040701G Verifications for ReDetermination The only items that must be reverified at redetermination are those which have not been previously verified or are subject to change Also if verification was unavailable previously research to see if that County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number Page Verification Requirements 040701 3of 3 verification is currently available See to MPG 0415 for more information on redetermination requirements 040701H Additional Verifications Do not request verification of items not listed in MPG 0407 or the crossreferenced section which specifically addresses the item unless the HSS considers it necessary to ensure correct eligibility determination in a specific case In those instances document in case comments the nature of the additional verification requested and the reason for the request Procedures None Program Impacts None References 22CCR 50101 50167 50168 50169 50185 MEPM 4M 24B MEPM Letter 274 Letter 285 ACWDL 0615 0712 0803 0826 0829 08541913 1917 2017 MEDIL I 1312 1416 1423 1431 Clarifications from DHCS County Policy Processing Guide 01MediCal Annual Redetermination Desk Aid 08MediCal Verification Requirements Chart Desk Aid 97Verification Processing Guidelines for CFCWMC Applications Sunset Date This policy will be reviewed for continuance by 04302024 County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number Page Verification of Income 040702 1of 5 Revision Date 07012021 BackgroundAll nonexempt income of a customer must be verified prior to approval of the application Purpose This sections update incorporates the use of a Federal Income Tax Return to verify income and Methods of Verifying Veterans Education Benefits that were previously in MediCal Program Guide MPG 1002 EarnedUnearned Income Policy 040702A Earned Income The following are acceptable verifications of earned income One Pay Stub Does not have to be dated within the last 30 days or within a certain period if it is the most recent available to the customer and it accurately reflects the amount reported on the applicationredetermination form A discrepancy does not exist if income reported on the application is clearly NET earnings Additional pay stubs may be requested if income reported is inconsistent with that of the submitted pay stub If additional pay stubs are requested enter a case comment explaining why additional verification was requested Desk Aid 33 Paycheck and Other Income Stubs General Information provides information on pay stub term definitions items to review on a pay stub and information regarding pay stubs that include tip income Income Tax Return A copy of the previous years federal income tax return that accurately reflects current income See 040702D regarding the use of the federal income tax return Statement from Employer Signed letter from the employer that shows the gross amount and date of payment Form 0721 HHSA may also be used to assist the customer obtain this verification When verification cannot be obtained by one of the above see 040710 for information regarding the use of a sworn statement and the use of the Statement of Facts SOF as a sworn statement 040702B SelfEmployment Income The following are acceptable forms of selfemployment income verification Receipts showing gross earnings and expenses Business records or Profit and Loss PL statements These records are not required to be for the entire year A copy of the most recent federal income tax return and appropriate schedules o Schedule C Profit or Loss from Business o Schedule D Capital Gains and Losses o Schedule F Profit or Loss From Farming Refer to 040702D for information on how to use the federal income tax return for purposes of selfemployment income verification Accept bookkeeping records that are available to the customer or additional records which the customer feels will more accurately reflect the net income of their business County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Verification of Income Number Page 040702 2 of 5 040702C Unearned Income Acceptable verifications for unearned income Award letter or most recent CostofLiving Adjustment COLA increase notice Income Eligibility and Verification SystemPayment Verification System IEVSPVS reports See MPG 1601 regarding IEVS reports and IEVS as a verification source Current bank statement for unearned income that is direct deposited Copy of check or check stubs Signed statement from person or organization providing income SOF or a sworn statement for income received from the United States government shall constitute verification pending receipt of verification from the appropriate government agency when verification stated above cannot be provided See MPG 100201 for information on unearned income Amount shown may be net amount if Medicare premiums are being deducted or an overpayment is being collected Do not require copiesof checks issued by the United States government The customer should be asked if they are paying for Medicare or repaying an overpayment and this clarification must be narrated in case comments Verification of this amount may be necessary if IEVS is not available Health care premiums may be allowed as a deduction and overpayment deductions may be considered unavailable income See MPG 1001 and MPG 1006 040702D Use of Federal Income Tax Return to Verify Income A photocopy of the previous years federal income tax return IRS 1040 andor 1040SR is acceptable verification of income if the income tax return reflects the income reported on the SOF When using form 10401040SR the following procedures will be followed Do not count income reported on the tax return that is no longer being received Count positive gross amounts that are still being received reported in the Income Section Lines 18 of the tax return before taxes are applied Negative amounts reported in the Income Section will be treated as zero Use the positive income amounts divided by 12 or the number of months the income was actually received as the average monthly gross income figures Use the average monthly gross income figures to compute the correct level of benefits unless there is a discrepancy with the income reported on the SOF Small discrepancies which are due to a pay increase or COLA adjustment may be clarified over the phone and a case comment must be entered The most accurate income amount between the amount reported on the 10401040SR and the amount reported on the SOF will be used Request current information to clarify significant discrepancies other than those due to a pay increase or COLA adjustment Note When a customer is reporting selfemployment income procedures for selfemployment income verification using Schedule C or F will be followed according to MPG 100503 Example 1 Elaine applies for MediCal on November 5th She reports income from a job that she has had for several years and income from spousal support Her SOF indicates that she earns 2000 per month and receives 165 per month in spousal support She provides her previous years tax return as verification of income which verified the information reported on her SOF Therefore her tax return is used to compute eligibility as follows County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number Page Verification of Income 040702 3of 5 Step Action 1 Review Line 1 Wages salaries tips on IRS Form 1040 2 Review Line 2a Alimony spousal support received on IRS Form Schedule 1 3 Calculate gross earnings by dividing each line by 12 Calculation 24000 per year 2000 per year Gross earned income 2000 per month Gross unearned income 16666 per month Example 2 Jerry Applies for MediCal and his SOF indicates that he currently earns 4000 per month He provides his previous years tax return as verification of income The tax return reflects both earnings and unemployment benefits Jerry explains that he received unemployment benefits for one month and received income from employment for the remainder of the year 11 months He continues to work at the same job Therefore his tax return is used to compute eligibility as follows Step Action Calculation 1 Review Line 1 Wages 46000 per year salaries tips on IRS Form 10401040SR Review Line 7 Unemployment compensation on IRS Form Schedule 1 Calculate gross earnings by dividing Line 1 by 11 the number of months he had earnings 200 per year Gross earned income 418181 per month Because the unemployment benefits have stopped they will not be counted toward determining his MediCal NonModified Adjusted Gross Income MAGI eligibility 040702E InKind Income Verification is only required if the customer claims the amount is lower than the allowed standard A written statement from the provider is acceptable See MPG 111A Appendix A Assistance Standards Chart for the inkind standards 040702F Fluctuating Income Fluctuating income may be verified by pay stubs copies of checks or a signed statement the signed statement must include the gross amount and frequency of the payments from the person or organization making the payments 040702G Tip Income Acceptable verifications of tip income are the amount reported On pay stub By the customer If a discrepancy exists regarding the amount of tips reported the customer may sign a sworn statement clarifying the reason for the discrepancy County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Verification of Income Number Page 040702 4 of 5 040702H Temporary Workers Compensation Accept an award letter from the insurance company or other entity which identifies the payment as temporary the amount of the payment and the schedule of payments 040702I Veterans Assistance VA Acceptable verifications of VA or Aid and Attendance Payments are A complete Veterans Benefits Verification and Referral Form MC 05 Documentation in case comments that the Human Services Specialist HSS has viewed the VA check A VA Benefit Summary Letter sometimes called a VA Award Letter 040702J Veterans Education Benefits General Issue GI BillThe VA Benefit Summary Letter sometimes called a VA Award Letter is acceptable evidence to document type amount and frequency of payments Post 911 GI Bill Post 911 GI Bill payments are identified as VAChapter CH 33 payments The VA Benefit Summary Letter sometimes called a VA Award Letter is acceptable evidence to document type amount and frequency of payments Veterans Educational Assistance Program VEAP Verify receipt of payments under the VEAP program by completing form MC 05 On form MC 05 include a request for the VA to identify under which program educational benefits are being issued 040702K Interest or Dividends Acceptable verification of interest or dividends are Internal Revenue Service IRS Interest Income Statement Form 1099 Bank statement Account statement Payment record 040702L ChildSpousal Support Acceptable verifications of childspousal support are Court documents Department of Child Support Services DCSS records Sworn statement from the absent parent Copy of check 040702M Educational GrantsLoans Educational GrantsLoans may be verified by viewing the Financial Aid papers provided by the collegeuniversity Document information in case comments 040702N Net Income from Property Acceptable verifications of net income from property are Lease or sales agreement County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Verification of Income Number Page 040702 5 of 5 Bookkeeping records 040702O Unconditionally Available Income UAI The application of unconditionally available income must be verified With the implementation of the Affordable Cate Act ACA UAI requirements can be met after approval of the application see MPG 0412 for more information 040702P Zero Income Not Electronically Verified everified When a customer reports zero income the individual is run through the California Healthcare Eligibility Enrollment and Retention System CalHEERS Business Rule Engine BRE if the income is not everified the customer must provide a sworn statement of their zero income The attestation on the applicationredetermination forms is not sufficient For more information on cases that are required to be run through the CalHEERS BRE see MPG 040222 Procedures None Program ImpactsNone References 22CCR 50101 50167 50185 MEPM 4M MEPM Letter 274 ACWDL 0150 1917 Sunset Date This policy will be reviewed for continuance by 07312024 Approval for Release Rick Wanne Director SelfSufficiency Services County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number Page Verification of Income Deductions 040703 1of 3 Revision Date 04012021 Background Verification of expenses is only required to allow the deduction from the total countable income Purpose Included with the reformatting this section is updated to remove the use of form DHCS 6155 Health Insurance Questionnaire Policy 040703A Verification of Expenses Verification of expenses is NOT required as a condition of eligibility 040703B GuardianConservator Fees When a guardianconservator asserts that reasonable court approved fees exist and they have provided verification that the customer has income from which fees are an allowable deduction take the following actions Step 1 Action Request A copy of the court order authorizing payment of fees from the customers account to the guardianconservator The order must include the amount of the fee and the month for which the fee is authorized AND A written statement from the guardianconservator describing the services provided during the month how the fee was calculated including hours spent on the conservatees affairs and the rate being charged as well as any other costs included in the fee Review the verifications requested in Step 1 and determine whether the fee amount is reasonable If fee is Then Reasonable Proceed to step 4 Not reasonable Proceed to step 3 Presume the fees billed in the statement are reasonable provided that the amount matches the amount shown in the court order and there is no circumstance which leads the Human Services Specialist HSS to question the fee amount Examples of questionable fees which may require further review and documentation include Fees for personal services Charges for services not related to the administration of the conservatees estate Fees which vary from month to month when there is no change in income property etc and there is no court activity County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Verification of Income Deductions Number Page 040703 2 of 3 3 Request a written statement from the guardianconservator to clarify fees determined to be questionable The statement needs to address why the Personal services are required Fees fluctuate from month to month when there is no change in income property etc and there is no court activity Fees are higher than what is normally charged for similar service The guardianconservator must be given a reasonable time to respond The share of cost SOC is to be calculated without the fee deduction until the reasonableness of the fee is verified 4 Calculate the SOC with the fee deduction 040703C Dependent Care Deduction The dependent care deduction shall encompass the cost of childcare or the cost for care of an incapacitated person The cost of childcare or care of an incapacitated person will be verified by viewing Receipts Cancelled checks Signed statement from the person or organization receiving the payment Additionally if the cost of care is for an incapacitated person the incapacity must be verified with a written statement from a physician The statement must specify that the person requires care due to the incapacity Set an alert on the case to review the incapacity or discontinue allowing the deduction based on the information on the statement When the incapacity is permanent the review and reverification will be obtained at the annual redetermination 040703D Health Insurance Premium Acceptable verifications of health insurance premiums are Information about coverage Procedures None Program Impacts None References 22CCR 50101 50167 50185 MEPM 4M MEPM Letter 274 ACWDL 1312 Sunset Date This policy will be reviewed for continuance by 04302024 County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Verification of Income Deductions Number Page 040703 3 of 3 County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number Page Verification of Real and Personal Property 040704 1of 4 Revision Date 04012021 Background Verification of real and personal property is required prior to application approval Purpose This section is being updated to the new format no other changes have been made Policy 040704A Verification of Bona Fide Effort to Sell Establish and verify a bona fide effort to sell by viewing a copy of the listing contract and appraisal Advise the customer or representative to report all offers at fair market value or higher and the acceptance of such offers Set a case alert to review the month the listing contract expires or on a quarterly basis whichever comes first If the property has not been sold at the time the beneficiary or representative must provide evidence that the property has been listed again In general the case record must include evidence that the property continuously meets the criteria of bona fide effort to sell as stated in MPG 0904 040704B Verification on Market Value of Other Real Property Verify the market value of other real property by viewing any of the following A current tax statement from the Tax Assessors Office Records maintained by the Tax Assessor A written statement from a qualified real estate appraiser which gives the appraised value of the property if the customer has chosen the option discussed in MPG 0905 item 3B Refer to MPG 0905 Appendix B for sample letter which may be used to verify the value of property located outside of San Diego County 040704C Verification of Encumbrance of Other Real Property Verify encumbrances by viewing either A payment book issued by the institution or person holding the encumbrance which indicates the amount owed Written correspondences from the institution or person holding the encumbrance which states the current amount owed 040704D Oil Leases Mineral Rights Timber Rights Verify the values of oil leases mineral rights and timber rights by viewing one of the following Written or telephone contact with a member of a recognized professional appraisal society which establishes the current value of the lease or right Records maintained by the Tax Assessor where the lease or right is located Written or telephone contact with the company or organization developing the natural resource which establishes the current market value County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number Page Verification of Real and Personal Property 040704 2of 4 040704E Bank Accounts Bank account balance verification must show that the customer is property eligible in the month for which eligibility is being determined This verification can be dated within the month for which eligibility is being determined or on the last day of the month immediately preceding this month Verify account balances by viewing one of the following An account statement from the institution holding the funds Signed correspondence from the institution holding the funds A teller receipt from the institution holding the funds if it contains the entire account number the date and the name of the individual who owns the account A copy of an internet bank verification printout if it contains the owners name financial institution name date complete account number and account balance 040704F Income Tax Refunds Verify income tax refunds by one of the following Viewing the check Viewing the income tax return 540 1040 Written correspondence from the State Franchise Tax Board or Internal Revenue Service 040704G Recreational Vehicles Verify the values of recreational vehicles by Viewing the registration of the recreational vehicle Obtaining appraisal statements or Obtaining the purchase contract 040704H Stocks Bonds Mutual Funds Verify the values of stocks bonds and mutual funds using either Method A or Method B below Method A 1 View a certificate of signed statement from the issuing institution stating a description of the investment including the number of shares owned 2 Establish the current selling price of the property by either o Contacting a recognized stock exchange broker via phone o Reviewing listings in a current newspaper 3 Compute Value Method B Viewing a copy of an internet verification if all the following information is included Owners name Issuing institutions name Date Complete account number Account balance County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number Page Verification of Real and Personal Property 040704 3of 4 040704I United States Savings Bonds Verify United States Savings Bonds values by viewing the bond Document in case comments Contact any bank or institution where the bonds can be redeemed to obtain the current value 040704J Austrian Social Insurance Payments The customer must present at least one of the following items An award letter from an Austrian pension insurance agency may be written in German in favor of the client which contains the language Die Beguenstigungsvorschriften fue geschaedigte aus politischen oder relgioesen gruenden der abstammung wurden angewendet 500ff ASVG Translation The regulations were applied which give preferential treatment for persons who suffered because of political or religious or reason of origin 500ff ASVG A check copy or stub showing an Austrian pension payor If after making reasonable attempt and the customer is unable to produce either a check stub or a copy of an award letter they may attest under penalty of perjury that they were imprisoned or unemployed in or forced to flee from Austria during the period of 19331945 because of political or religious reasons or that a particular account deposit represents such a payment Additionally the customer must obtain a corroborating statement from a bank family member guardian conservator etc stating that the payment isbased inwhole or inparton wage credits under Paragraphs 500506 of the GSIA In the absence of such documents the customers statements do not suffice as verification for this exemption 040704K Deeds of Trust Mortgages Promissory Notes Verify the value of deeds of trust notes and mortgages by viewing documents which state a description of the item and one of the following Viewing the documents from the lender which identify the principal amount remaining on the deed of trust or mortgage Viewing an appraisal from a party that is qualified to appraise deeds of trust and mortgages Making a phone contactwitha recognized broker who buyssellsor appraises deedsof trust and mortgages 040704L Life Estates Verify the value of life estate by viewing a copy of the legal document which created the life estate This is usually a grant deed Document in case comments See MPG 0909 for information on the treatment of Deeds of Trust Mortgages Life Estates 040704M Loans To determine if a loan requires repayment it is necessary to view the documentation Documentation should include either County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number Page Verification of Real and Personal Property 040704 4of 4 The actual formal contract that indicates the repayment arrangement and method for written contracts A statement from the borrower and the lender that documents that the conditions of repayment existed when the loan occurred for oral agreements or personal loans See MPG 091001 for instructions on evaluating loans 040704N Life Insurance Policies Verify the Cash Surrender Value CSV of nonexempt life insurance policies by viewing either the following the value tables located in the policy signed correspondence from the insurance company which indicates the current value 040704O Burial Plots Vaults Crypts The net market value of nonexempt burial plot vault or crypt will be the amount listed on the statement of facts with no additional verification required unless the value exceeds 1800 If the value exceeds 1800 the customer will be required to submit a statement of value from the organization from which the plot vault or crypt was purchased Determine the net market value by taking the value shown on statement and subtracting any encumbrances Procedures None Program Impacts None References 22CCR 50101 50167 50185 MEPM 4M MEPM Letter 274 DHCS Clarification E Bank Accounts Sunset Date This policy will be reviewed for continuance by 04302024 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Number Page Verification of California Residency 040705 1of 3 Revision Date 04012021 Background California residency of an applicant must be verified prior to approval of the application Purpose Included with the reformatting this section is updated to include information implemented by the Affordable Care Act ACA previously issued in Special Notice SN 1309 Addendum G and MediCal Memos 1415 2009 Policy 040705A General MediCal applicants must verify California residency prior to approval of their application It does not need to be the current address A PO Box address will not meet the residence requirement if listed as the physical address A PO Box can be used as a mailing address With the implementation of the ACA paper verification requirements are suspended until further notice Procedure 040705B Verification of California CA Residency The following are evidences of CA residency Verbal attestation Entry of a California physical address on the application as verification to meet the residency requirement unless questionable 040705C Residency is Questionable If residency is questionable request the following evidence of CA residency to clarify Documentation CA Drivers License or Identification Card CA vehicle registration Employment Employment Services School enrollment Public Assistance PA recipient Voter Registration Form VFR andor Receipt See MPG 0705 Appendix B1 B2 Description Issued by the California Department of Motor Vehicles in the applicants name must be current and valid A current and valid CA vehicle registration in the applicants name A document showing that the applicant is employed in CA for either parent even if that parent did not sign the statement of facts A document showing that the applicant is registered with public or private employment services in CA Evidence that the applicant has enrolled his or her children in a school in CA Evidence that the applicant is receiving PA other than MediCal in CA The VFR when completed and signed by the person who wishes to register to vote constitutes a written declaration which shows that the bearer has declared under penalty of perjury to live at the address shown on the form Voter Notification County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Number Page Verification of California Residency 040705 2 of 3 If the VRF is mailed by someone other than the registrant the registrant is given a Registration Form Receipt signed by the person who will forward the completed registration form to the appropriate election administrator for processing The VFR or Receipt by itself is NOT sufficient to establish that the applicant is a resident of CA However a copy of the form along with other evidence the applicant may provide to support hisher claim of CA residency is acceptable Card VNC The VNC is the document mailed to the voters as official evidence of registration to vote This card is sent to the address indicated on the VRF and is not forwarded by postal authorities to another address Therefore the VNC serves as rudimentary evidence that the bearer lives at the address indicated and by itself is acceptable evidence of CA residency However if there is credible evidence which contradicts an applicants claim of CA residency a VNC by itself may not be sufficient to support a finding of CA residency Other evidence must also be considered in making a residency determination Also if the VNC was issued by a previous county of residence it might not be indicative of current residency in the state In this situation determine if the applicant has established residence in another state or country since the time the VNC was issued If the applicant recently resided in another state or country and provides a VNC issued by a CA county during a prior period of residence in this state the VNC card in itself is not sufficient to establish current CA residence in absence of other credible evidence Abstract of Voter Registration The abstract of Voter Registration is an official document issued to a registrant who has lost their Voter Registration Card This replacement document shows that the person named was on record as a registered voter in that county at the time the abstract was issued Such a document is similar in substance to the VNC In determining residency an Abstract of Voter Registration should be viewed like a VNC as discussed above RentMortgage Receipt or Utility Bill A current CA rentmortgage receipt or utility bill in the applicants name Note Rent receipts provided by a relative to the applicant will be acceptable only if no other documentation listed above can be obtained and the relative completes and signs form MC 210 SI declaring under penalty of perjury that the information provided is true and correct This includes situations where the applicant is receiving inkind housing The applicant who pays rent to a relative within inkind services may provide verification of such payments as evidence of CA residence Evidence of inkind payment can include a written statement from the County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Verification of California Residency Number Page 040705 3 of 3 relative identifying the type of service provided along with an MC 210 SI Other evidence If unable to obtain one of the above specified documents consider other evidence Other evidence includes but is not limited to evidence provided by an agency located in CA that supports a finding that the applicant is a residence of CA for example affidavit from a homeless shelter or court documents Before considering other evidence the applicant must sign form MC 214 Initiate a fraud referral when there is inconsistent or questionable information that cannot be resolved Program Impacts None References MEPM Letter 274 MEDIL I 1420 1429 1444 SN 1309 Addendum G MediCal Memo 2009 Sunset Date This policy will be reviewed for continuance by 04302024 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Verification of Identity Number Page 040706 1 of 2 Revision Date 04012021 BackgroundThe identity of an applicant must be verified prior to approval of the application Purpose This section is updated to the new format no other changes have been made Policy 040706A General Documents which may be used to verify identity depends on the applicants citizenshipimmigration status and whether they are requesting MediCal Procedure 040706B United States US Citizens Unless otherwise exempt US citizens including US nationals applying for MediCal benefits are required to provide acceptable evidence of identity as specified in MPG 070202 US citizensnationals not requesting MediCal benefits are not subject to requirements specified in MPG 070202 However these individuals must still provide verification of identity in the same manner as noncitizens as specified below MPG 040706C 040706C NonCitizens Unless otherwise exempt noncitizens are required to provide verification of identity The following persons are not required to provide verification of identity Institutionalized individuals whose identity has been verified by the facility Individuals receiving MediCal through the Adoption Assistance Program Children when the identity of one parent is verified Note If the application is being made for only the children and not for the parents do not request the parents social security number SSN Children requesting MediCal for Minor Consent services Individuals not acting on their own behalf and a government representative such as a public guardian is acting for them The spouse of a person whose identity has been verified 040706D Acceptable Verification for NonCitizens Acceptable verifications for the identification of noncitizen applicants are California Drivers License California Identification Card or photo identification United States citizenship or Immigration Status document Birth certificate School Identification card A Social Security Card or document containing an SSN Marriage record Work badge or building pass Church membership or baptismconfirmation record County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Verification of Identity Number Page 040706 2 of 2 Divorce decree Adoption record Court order for name change Electronic Verification everified Program ImpactsNone References ACWDL 0712 0803 0927 2017 Clarification from DHCS SN 0704 0704 Addendum A B Change Request CR 5188 Sunset Date This policy will be reviewed for continuance by 04302024 County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Verification of CitizenshipNonCitizen Status Number Page 040707 1 of 1 Revision Date 04012021 BackgroundPrior to requesting verification documents staff should attempt to electronically verify customers who request MediCal report having United States US citizenship or Satisfactory Immigration Status SIS and require having their applicationredetermination processed through the California Healthcare Eligibility Enrollment and Retention System CalHEERS Business Rule Engine BRE See MPG 0702 for detailed information on the requirements for United States citizensnationals and their level of benefits See MPG 040222 for applications that must be run through CalHEERS BRE Purpose This section is being reviewed for sunset review and to provide guidance on when electronic verification everification is acceptable Policy040707A US CitizensNationals Refer to MPG 040209 Statement of CitizenshipImmigration Status Procedure 040707B NonCitizens Refer to MPG 0703 for more information on the requirements for noncitizens and their level of benefits Program ImpactsNone References ACWDL 0712 0803 0927 1701 1816 2017 Clarification from DHCS SN 0704 0704 Addendum A B Change Request CR 5188 County Policy Sunset Date This policy will be reviewed for continuance by 04302024 County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Verification of Pregnancy Number Page 040708 1 of 2 Revision Date 04012021 BackgroundThis section provides information regarding verification for pregnancy Purpose This section is updated for sunset review no other changes have been made Policy Selfattestation of pregnancy is acceptable do not ask for medical verification A written verification of pregnancy is not required Procedure The following are acceptable pregnancy verifications SelfAttestation of Pregnancy A customer may selfattest their pregnancy by writing it on the application the Statement of Facts or by another signed statement Customers may also declare their pregnancy by telling the Human Services Specialist HSS they are pregnant Such declaration must be documented in case comments Selfattestation of pregnancy is sufficient for a customer to receive pregnancy related or fullscope services A customer who selfattests their pregnancy may claim that the pregnancy has been medically verified by either one of the following methods A positive pregnancy result which has been confirmed by a medical Provider A positive pregnancy result which has been confirmed by a home pregnancy test Written Pregnancy Verification Written verification of pregnancy may be submitted but is not required for an otherwise eligible customer to receive MediCal benefits Unborns in MFBU A selfattestation of pregnancy is sufficient to include an unborn or multiple unborns in the MediCal Family Budget Unit MFBU in which benefits are being issued Estimated Date of Confinement EDC The EDC expected date of birth should be provided with the declaration of pregnancy A statement giving the estimated date of confinement must be documented in case comments Program ImpactsNone References MEDIL I 1609 County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Verification of Pregnancy Number Page 040708 2 of 2 Sunset Date This policy will be reviewed for continuance by 04302024 County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Verification of Other Information Number Page 040709 1 of 2 Revision Date 04012021 BackgroundThis section provides information regarding verification of other information Purpose This section is updated to the new format no other changes have been made Policy 040709A Age Blindness and Disability ABD Refer to MPG 0503 for verification of ABD linkage 040709B Legal Responsibility If a child is applying alone verify that no parent or agency will accept responsibility Contact either verbal or written with the parent or agency must be documented except for Minor Consent 040709C Medicare The receipt of Medicare is verified by viewing one of the following and narrating in case comments The customers Medicare Beneficiary Identifier MBI or Health Insurance Card HIC number A Social Security Administration SSA Title II award letter displaying the MBI or HIC number A bill for Medicare Part A or Part B premium SSA 1545 A MediCal Eligibility Data System MEDS print INQB screen 040709D Substantial Gainful Activity SGA An SGA determination requires that the following two items be verified The customers monthly gross earnings If irregular earnings will be averaged Earnings derived from InHome Supportive Services IHSS are treated as earned income The customers ImpairmentRelated Work Expenses IRWE andor subsidies 040709E Social Security Number SSN An SSN verification or an application for an SSN is required for each member of the MediCal Family Budget Unit MFBU within 60 days from the date of application Eligibility can be established and approved prior to receipt of SSN or proof of an SSN application if the approval occurs within 60 days from the date of application SSN requirements can be found in MPG 0411 Procedure None Program ImpactsNone References MEPM Letter 285 ACWDL 0615 0712 0803 0826 0829 0854 Clarification from DHCS County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Verification of Other Information Number Page 040709 2 of 2 SN 0704 0704 Addendums A B County Policy Sunset Date This policy will be reviewed for continuance by 04302024 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Verification Not Available Number Page 040710 1 of 2 Revision Date 04012021 BackgroundThis section provides information to determine if income and property are to be considered unavailable Purpose This section is updated to the new format no other changes have been made Policy 040710A General Verifications of income or property are to be considered unavailable when any of the following or similar conditions exist Pursuit of the verification would put the applicant in some bodily danger or would result in loss of employment Records were destroyed for example by fire or flood The source of the verification is uncooperative 040710B Reasonable Attempt Evaluate each situation where the applicant states that verification is unavailable A reasonable attempt by either the applicant or the Human Services Specialist HSS is to be made to obtain the verification The attempt may be made by telephone or in writing to the source of the verification All actions taken by the applicant andor HSS to obtainverification must be documented in case comments The requirement to contact the verificationsource may be waived if the applicant states that the contacts would jeopardize employment or put the applicant in danger of physical harm In this situation the applicant must complete a sworn statement describing the basis for their contention that pursuit of the verificationmay jeopardize them physically or lead to loss of employment 040710C Use of Sworn Statement When the HSS determines that verification is unavailable a sworn statement from the applicant dated and signed under penalty of perjury must be obtained The signed Statement of Facts SOF can serve as a sworn statement and verification of declared income or property if The declared information is not available in any other form other than a sworn statement The declared information is sufficient to determine eligibility and A case comment that documents the steps taken to obtain the verification and why it was not available in any other form Procedure None Program ImpactsNone References MEPM Letter 274 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Verification Not Available Number Page 040710 2 of 2 MEPM 4M 22CCR 50167 ACWDL 0712 Sunset Date This policy will be reviewed for continuance by 04302024 County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Ex Parte Verification from Other Public Assistance PA Cases and Number Page Automated Systems 040711 1of 3 Revision Date 04012021 Background Whenever possible use information available on county accessible automated systems or from other Public Assistance PA case records in determining eligibility Other PA cases include other MediCal CalFresh CF General Relief GR California Work Opportunities and Responsibility to Kids CalWORKs Cash Assistance Program for Immigrants CAPI County Medical Services CMS InHome Supportive Services IHSS and Foster Care FC cases Purpose Included with the reformatting this section is updated to include information implemented by the Affordable Care Act ACA previously issued in Special Notice SN 1309 Addenda A D Policy 040711A Ex Parte Overview Use the ex parte process when determining MediCal eligibility at application redetermination or when a change in circumstance occurs that affects MediCal eligibility Ex parte is the process whereby a MediCal only determination is made without the involvement of the customer Under ex parte attempt to complete the MediCal evaluation based on informationverifications included in any of the following An active PA cases A PA case that closed within the last ninety 90 days Other PA case records of beneficiaries and their immediate family members that have been obtained within the last 12 months and are not subject to change such as Identification and Social Security Card Always attempt to obtain needed informationverification by means of the ex parte process prior to Denying a case for failure to provide for applicants Requesting the informationverification from beneficiaries Ex Parte for Applicants Necessary verifications may be requested from applicants after initiating an ex parte review Always attempt to locate needed informationverification by means of an ex parte review prior to requesting it from the applicant Ex Parte For Beneficiaries When a change that affects ongoing eligibility is reported always attempt to locate needed informationverification by means of an ex parte review prior to requesting it from the beneficiary When the ex parte process reveals a change in circumstance that requires a referral or update of information to other agencies the beneficiary must complete the appropriate forms County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Ex Parte Verification from Other Public Assistance PA Cases and Automated Systems Number Page 040711 2 of 3 040711B Automated Systems Examples of county accessible automated systems include but are not limited to the following Statewide Automated Welfare System SAWS Income Eligibility Verification System IEVS Systematic Alien Verification for Entitlements SAVE Employment Development Department EDD RealTime Match State Data Exchange SDX MediCal Eligibility Data System MEDS for Birth Record Data Match County Birth record extracts AuthMed Information Data Exchange IDX Federal Data Services Hub 040711C Other PA Cases Verification of US citizenshipNational Status Documentation of citizenshipnational status from existing case files is acceptable and may be used to meet the citizenshipidentity verification requirement specified in MPG 070203 if the Human Services Specialist HSS is able to locate documentation in the case file indicating that the procedures used in initially obtaining the documents indicate that the documents were originals or certified copies Documents used in meeting the citizenshipidentity verification requirements under the Deficit Reduction Act DRA of 2005 must also fall within those that have been approved by the Department of Health Care Services DHCS as acceptable evidence of citizenship and identity For listing refer to MPG 0702 Appendix B Additional Verification Requirements No additional verification is required when a customer has been previously aided in another PA program such as CalWORKs CalFresh MediCal and IHSS and verifications in those case files are less than twelve 12 months old and consistent with reported information on the application for MediCal However when verifications in those case files are inconsistent with what is reported by the customer then current verification must be requested Procedure None Program Impacts None References ACWDLs 0136 0712 0803 1435 2017 Clarification from DHCS County Policy WI Code 140133b SN 0704 0704 Addendum A B SN 1309 Addendum A D County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Ex Parte Verification from Other Public Assistance PA Cases and Automated Systems Number Page 040711 3 of 3 MEPM 4M Sunset Date This policy will be reviewed for continuance by 04302024 County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Request for Additional InformationVerification Number Page 040712 1 of 3 Revision Date 04012021 BackgroundWhen a Human Services Specialist HSS must contact a customer for additional information the date method of contact and result of the contact must be documented in the case record Information may be clarified over the phone if the case comments thoroughly reflect the information received If the customer fails to respond to the first contact attempt a second contact either by telephone andor written notice and document this extra effort in case comments The written notification will include the date of the prior client contact and the requested informationverification the time frame for responding to this second notification and the consequences for not providing the requested information When the request is for verification of citizenship and identity documents required under the Federal Deficit Reduction Act DRA of 2005 refer to MPG 040713 for specific procedures PurposeIncluded with the reformatting this section is updated to include information on the correct forms to use when requesting verifications in writing Policy 040712A InformationVerifications Requested at Application First Request for Verification Upon review of the mailin application packet or during the facetoface interview complete an ex parte review If the ex parte review is unsuccessful generate a verification checklist VCL such as the CW 2200 Request for Verification if additional information andor verifications are needed Applicants must be given at least 10 calendar days to provide items listed on the VCL Second Request for Verification If the due date for the return of the initial request for verification passes without a response from the applicant send a second request and an additional 10 calendar days to provide allowed Good Cause When an applicant contacts the HSS before the due date on the denial Notice of Action NOA to indicate the requested item cannot be obtained in time evaluate for good cause and extend the due date if applicable Items Provided after Denial When an applicant provides the requested verifications within 30 days of the denial date evaluate for eligibility and if appropriate rescind the denial and approve ongoing benefits 040712B InformationVerifications Requested at Redetermination or Change in Circumstance When a change that affects eligibility is reported at renewal or otherwise always attempt to locate the information through ex parte County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Request for Additional InformationVerification Number Page 040712 2 of 3 Phone Contact When needed informationverifications cannot be located via ex parte and the beneficiary has provided their phone number attempt to contact the beneficiary to obtain the information When informationverifications are provided via phone case comments must thoroughly document the results for each item Please see Eligibility Policy and Procedure Guide EPPG for methods of accepting telephonicelectronic signatures MC 355 MediCal Request for Information MediCal Only Case When ex parte and phone contact attempts are unsuccessful send the MC 355 to request the missing informationverifications and allow the beneficiary 30 days to respond Do not use the CW 2200 for a MediCal only case Combined Case When ex parte and phone contact attempts are unsuccessful send either the MC 355 or the CW 2200 to request the missing informationverifications and allow the beneficiary 30 days to respond If the beneficiary does not provide the requested verifications within 30 days attempt a second contact by phone or in the customers preferred method then mail an adequate and timely discontinuance NOA to the beneficiarys last known address Partial Verifications Received When the beneficiary provides partial verifications with the MC 355 request attempt a second contact by phone or in the customers preferred method if not already completed then mail an adequate and timely discontinuance NOA at the end of the 30day period provided by the MC 355 Items Provided after Discontinuance If the requested verifications are received within 30 days of the discontinuance evaluate for ongoing eligibility and rescind the discontinuance if eligibility exists Reminders Do not request information which has been provided within 12 months from the date eligibility was determined is not subject to change is available for verification by the HSS is not necessary to make an eligibility determination Each action related to obtaining additional informationverification from the beneficiary must be documented thoroughly in the case comments 040712C Fraud Investigations When an investigation is completed on a MediCal beneficiary the investigator forwards their report to the HSS for review and potential action County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number Page Request for Additional InformationVerification 040712 3of 3 When the investigation reveals facts which were not reported by the beneficiary attempt contact by phone to obtain the informationverifications If phone contact is unsuccessful send the beneficiary an MC 355 requesting the information verifications and allow 30 days for a response If the requested informationverification is not received by the due date without good cause the individual or case must be discontinued effective the end of month in which the adequate and timely discontinuance NOA requirement is met Program Impacts None References ACWDL 0136 0139 616 0807 08270827E 0829 0854 1123 1127 1825 Clarification from DHCS as of 12108 SN 0108 0112 0210 MEDIL I 2013 Sunset Date This policy will be reviewed for continuance by 04302024 County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Request for CitizenshipIdentity Verification Required Under DRA 2005 Number Page 040713 5 of 8 Good cause determination for applicants inability refusal or failure to provide the required documents 040713D Providing Assistance 1 Reasonable Assistance Customers will be provided with reasonable assistance in obtaining and providing acceptable evidence of citizenship and identity Examples of reasonable assistance include but are not limited to Explaining how to provide evidence of good faith effort to obtain documents Reviewing and explaining acceptable evidence of citizenship identity Determining the possible acceptable documents that may be available to the customer based on individual circumstances Providing any resources available that the county must direct the customer to obtain the required documentation such as the name address and telephone number of the vital statistics agency for their state of birth County staff can find the vital statistics office contact information on the County S drive at SEnterpriseMediCal Spreadsheets and FormsCitizenship Reasonable Assistance Resources Using the Systematic Alien Verification for Entitlement SAVE system to verify citizenship for naturalized citizens Submitting birth information to MEDS for a birth record data match for all customers born in California Reviewing county eligibility files and records to locate evidence of citizenshipidentity documents that have already been provided Reviewing MEDS to determine prior history of public assistance in another county and contacting that county to determine if acceptable documentation of citizenshipidentity is available Note The county does not provide financial assistance for customers to pay for documents 2 Additional Heightened Assistance Customers incapable of acting on their own behalf to provide acceptable evidence of citizenship will be given additional assistance This includes customers who lack someone who can act on their behalf or those who cannot provide evidence of US citizenship or identity because they are Homeless Amnesia victims Mentally impaired Physically incapacitated In addition to providing reasonable assistance Contact any known family members who may have citizenship andor identity documents for the incapacitated person Contact any known current or past health care providers such as longterm care facilities to see if they have any acceptable evidence of citizenship andor identity Contact other social services agencies within and outside of the county that are known to have assisted the customer to obtain acceptable evidence of citizenship andor identity Follow the Diligent Search procedures in MPG 0409 if applicable to assist the customer to obtain the necessary evidence of citizenship and identity County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Request for CitizenshipIdentity Verification Required Under DRA Number Page 2005 040713 6of 8 040713E Setting Reasonable Opportunity Period ROP Reasonable opportunity to provide evidence of citizenship and identity is defined as the time needed for the customer to obtain valid documentation of citizenship and identity based on individuals Circumstances Ability to obtain that documentation Good faith effort When considering if a reasonable opportunity period ROP will be extended Make the determination on a casebycase basis depending on how much time the applicant needs to obtain the required information Follow up with the customer as necessary to ensure that acceptable documentation is in the case file or to provide additional time if needed Issue limited scope benefits to US citizens age 26 or older who are otherwise eligible and have not presented the required evidence of citizenship andor identity or who have failed to make or stopped making a good faith effort to obtain and provide the required verification See 040713G for required action when acceptable evidence is provided after limited scope benefits are granted EXCEPTION When an SSA CITID verification match is performed and the result shows a mismatch the ROP shall be limited to 90 days The 90day period starts 7 days from the date that the HSS mails the MC 239 DRA6 notifying the customer of the mismatch The customer will have 90 days to resolve the mismatch or to provide the required DRA CITID documents See MPG 070207 for more detailed information 040713F Establishing Good Faith Effort Good faith effort to provide evidence of citizenship and identity is defined as demonstration of effort to obtain and provide satisfactory documents to meet the evidence of citizenship requirement including evidence of identity if applicable Customers may provide oral or written statements of their efforts to obtain evidence of citizenship andor identity Document these efforts inthe caseincluding anybasisfora determination that the customer is or is not making a good faith effort Case comments must include dates to indicate how much time the individual will need to obtain the required documents to allow for appropriate followups Give additional time to the customer to acquire the required documents if they are demonstrating a good food effort to provide the documents Examples of good faith effort include but are not limited to Oral or written statements of efforts taken to obtain documentation The DHCS 0003 Affidavit of Reasonable Effort to Get Proof of Citizenship may be completed by the customer or the HSS upon telephone contact with the customer Providing a copy of a request for a document such as a photocopy of a letter a copy of an email or a receipt for the requested document from the agency issuing the document Providing a copy of a document request sent to the issuing agency or other appropriate entity Providing a copy of a document along with documentation that an original or certified copy of the document has been requested Providing a copy of a check receipt or other documentation indicating that a citizenship or identity document has been ordered Written or oral update of progress made in obtaining evidence of citizenship or identity County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Request for CitizenshipIdentity Verification Required Under DRA 2005 Number Page 040713 7 of 8 Written or oral explanation of attempts to locate two persons who could attest to the customers citizenship Accept and document any reasonable information provided by a customer which indicates a good faith effort to obtain necessary citizenship and identity documentation Note For information on restoring full scope benefits from limited scope see MPG 041305 Procedure None Program Impacts None References ACWDL 0712 0803 0927 0965 Clarification from DHCS SN 0704 0704 Addendums A B County policy Change Request CR 5188 Sunset Date This policy will be reviewed for continuance by 04302024 County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number Page Document Handling of CitizenshipIdentity Verification 040714 1of 4 Revision Date 04012021 Background United States US citizensnationals applying for fullscope benefits must provide verification of their citizenship and identity A photocopy fax scanned or other copy of a document must be accepted to the same extent as an original unless questionable Purpose Along with the reformatting of this section and removal of the Access role this section is updated to remove the requirement of US citizensnationals that are applying for fullscope benefits having to provide an original or certified copy of their citizenship and identity Policy 040714A General US citizensnationals may satisfy the requirement by Mailing the documents to their Human Services Specialist HSS Submitting the documents at any Family Resource Center FRC located in San Diego County Submitting their documents at any Federal Qualified Health Centers FQHCs or Disproportionate Share Hospitals DSHs staff 040714B FQHCs and DSHs Role FQHCs and DSHs who assist MediCal applicants with the initial application process or redetermination are authorized to view and copy documents of citizenshipidentity CITID Upon receipt of verifications of citizenship andor identity from a MediCal customer the FQHCDSH staff will View and photocopy the documents Complete a DHCS 0005 for each citizenshipidentity document they receive and view if an original or certified copy of the document was provided Mail the original DHCS 0005s and copies of the citizenshipidentity to the Document Processing Center DPC The mailing address is Health and Human Services Agency ERADPC PO Box 939043 San Diego CA 921939043 FQHCDSH staff have the option to hand deliver the documents along with the application to the FRC 040714C Reception Role Customers may submit their citizenshipidentity documents at any FRC regardless of their cases location Front line staff are authorized to view and copy documents of citizenship and identity When an original or certified copyof CITID documentsare submitted by MediCal customersexcluding those in the Breast and Cervical Cancer Treatment Program BCCTP at FRC reception front line staff County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Document Handling of CitizenshipIdentity Verification Number Page 040714 2 of 4 are not required to complete the DHCS 0005 Receipt of Citizenship or Identity Documentation if all steps outlined below are taken Step Action 1 Clear the client information in CalWIN 2 Determine that the document is an original or certified copy by the issuing agency 3 Photocopy the original document 4 Stamp the copy The Stamp must indicate that the document is a copy of an original or certified copy for example PHOTOCOPIED FROM ORIGINAL and contain all the following information Date Worker if applicable Staff Name FRC Contact Information address and phone number 5 Scan the stamped copy 6 Provide client with the stamped copy as a receipt 7 Return the original CITID documents to the customer Do NOT staple any receipts to the original document Front line staff are required to complete and sign the DHCS 0005 when the CITID documents are submitted by a BCCTP customer Refer to MPG 040716 for details 040714D Processing Documents Submitted through FQHCs or DSHs When evidence of citizenship and identity are viewed and the DHCS 0005 is completed by FHQCDSH staff the DHCS 0005 along with copies of the documents is transferred directly from FQHCDSH staff to the County Under no circumstances accept an original DHCS 0005 from a customer When documents are forwarded directly from FQHCS or DSHs to the County accept these forms and copied documents and do not require original documents Upon receipt of documents Step Action 1 Review each packet for completeness Every document must be accompanied by a corresponding original DHCS 0005 2 Complete the DHCS 0011 if the original DHCS 0005 is complete and accurate and the citizenshipidentity CITID document received falls within those that have been identified as acceptable evidence of CITID as specified in MPG 070204 3 Mail the original DHCS 0011 to the applicant 4 Retain in case file Original DHCS 0005 Copy of DHCS 0011 Copy of the evidence 5 If the original DHCS 0005 was not included in the packet or the DHCS 0005 is incomplete follow up with the FQHCDSH staff as follows If the FQHCDSH staff Then inform the FQHCDSH staff that states that County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number Page Document Handling of CitizenshipIdentity Verification 040714 3of 4 a copy of the DHCS 0005 and document are on file a copy of the DHCS 0005 or document is not on file they may complete another DHCS 0005 form and forward it along with a copy of the initial DHCS 0005 and document the packet cannot be processed and they have the option of contacting the customer to resubmit the required original citizenship andor identity documents or referring the customer to the HSS 040714E Processing Documents Submitted at FRC Reception Upon receipt of the CITID documents forwarded from reception Step Action 1 Review for completeness 2 Complete the DHCS 0011 if the CITID document received falls within those that have been identified as acceptable evidence specified in MPG 070204 3 Mail the original DHCS 0011 to the applicant 4 Retain in case file Copy of DHCS 0011 Copy of the evidence Original DHCS 0005 if available 5 If there is no evidence that the documents are copies of originals no STAMP or DHCS 0005 completed followup with reception staff and contact the customer to resubmit the required original CITID documents as appropriate 040714F Processing Documents Submitted to HSS When evidence of CITID are submitted directly to the HSS either in person or by mail Step Action 1 Complete and issue a DHCS 0011 if the CITID document received falls within those that have been identified as acceptable evidence of CITID 2 Return the originals within two business days if received by mail 3 Mail the original DHCS 0011 to the applicant 4 Retain a copy of the DHCS 0011 and copy of evidence in case file 5 Document the date and means by which the original document was returned for example Certificate of Naturalization returned to John Doe by mail on 1106 in case comments Note Do not complete a DHCS 0005 if all the above steps are taken Procedure None Program Impacts None References ACWDL 0712 0803 0826 0829 0854 Clarification from DHCS SN 0704 0704 Addendum A B County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Document Handling of CitizenshipIdentity Verification Number Page 040714 4 of 4 County Policy 42CFR435406f Sunset Date This policy will be reviewed for continuance by 04302024 County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Number Page Processing Changes to MediCal Contact Information 040715 1of 2 Revision Date 04012021 Background The MediCal Contact Information Form is not required for Managed Care Health Plans MCHPs to inform the County of changes in a beneficiarys contact information address telephone number etc Purpose This section is updated for the sunset review no other changes have been made Policy 040715A MCHPs can inform the County of changes by phone fax or email The information provided to the County must be sufficient to identify the beneficiarys case record including name identification number date of birth and former name when a name change is being reported and former phone number when a phone number change is being reported before changes are made No changes are made if the information provided to the County is insufficient to identify the case record Procedure 040715B MCHPs will contact the County to inform them of the updates and whether the beneficiary has approved providing the updated information to the County If the provision to updatethe County Has been approved by the beneficiary Has not been approved by the beneficiary Then Immediately input the information into the case record and no verification or beneficiary contact is required Verify the new information before making changes by 1 Looking for the same changes made to other county cases for the same beneficiary or their immediate family members including CalWORKs and CalFresh cases that are currently open or have closed within the last 90 days 2 If unable to verify the changes made to any of the case records then attempt to contact the beneficiary to verify the updated information using the beneficiarys preferred method of contact 3 If no confirmationverification is received make no changes Note Document in the case comments that the updates were provided by an MCHP References ACWDL 1530 Sunset Date This letter will be reviewed for continuance by 04302024 County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Processing Changes to MediCal Contact Information Number Page 040715 2 of 2 County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Processing Verification of CitizenshipIdentity for Breast and Number Page Cervical Cancer Treatment Program BCCTP 040716 1of 3 Revision Date 04012021 Background The Breast and Cervical Cancer Treatment Program BCCTP provides full scope zero SOC MediCal benefits to uninsured women and men breast cancer only under age sixtyfive 65 who are United States US citizensnationals or lawful immigrants and who are screened through an authorized screening provider and found in need of treatment for breast andor cervical cancer including some precancerous conditions Those who are otherwise eligible but who do not have Satisfactory Immigration Status SIS receive restricted scope benefits under the Statefunded BCCTP The BCCTP is administered by the California Department of Health Care Services DHCS located in Sacramento Purpose This section describes the responsibilities that the BCCTP unit has in the Deficit Reduction Act DRA process Additionally it describes the countys responsibilities upon receiving an original or certified copy of a citizenship or identity document for a BCCTP customer Included with the reformatting this section is updated to include additional BCCTP responsibilities Policy 040716A General In compliance with the federal DRA of 2005 US citizensnationals applying for fullscope benefits under the BCCTP must provide original proof or certified copy of citizenship and identity documents The requirements do not apply to individuals at the time accelerated enrollment is established for the BCCTP However evidence of citizenship and identity must be provided when ongoing MediCal eligibility is determined or at time of annual redetermination A BCCTP customer may satisfy the requirement by mailing the documents to the Sacramento BCCTP office or having the original or certified copies inspected by the Sacramento BCCTP unit a county social service office Federal Qualified Health Centers FQHCs or Disproportionate Share Hospitals DSHs 040716B BCCTP Responsibilities The Sacramento BCCTP unit is responsible for Informing BCCTP customers of the citizenshipidentity requirements under DRA and consequences for noncompliance Determining if the BCCTP customer is exempt from or has met the citizenshipidentity requirements via California Birth Record Data Match Instructing customers to present a copy of the letter concerning the DRA requirements to the County Serving as a point of contact for all DRA and program related questions for BCCTP customers Receiving copies of the DHCS 0005 and the BCCTP customers documentation from the counties FQHCs or DSHs Determining if the documentation is on the list of acceptable DRA documents Issuing DHCS 0011Proof of Receipt of Citizenship and Identity Document to the BCCTP customer upon a determination that the documents are acceptable Performing all MediCal Eligibility Data System MEDS transactions to indicate that citizenship and or identity documentation was provided County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Processing Verification of CitizenshipIdentity for Breast and Number Page Cervical Cancer Treatment Program BCCTP 040716 2of 3 Determining if the customer is making a good faith effort to provide documentation 040716C County Responsibilities BCCTP customers can submit originals or certified copies of their citizenship and identity documents at any county social service office regardless of county of residence The county is responsible for reviewing the citizenshipidentity documents to determine that they are originals or copies certified by the issuing agency and forwarding copies of the documents to the BCCTP unit The county will NOT determine whether documents submitted are on the list of acceptable DRA documents Take the following actions Step 1 3 4 5 6 7 Action Determine if the individual is a BCCTP customer as follows If the individual states that they are in the BCCTP presents a copy of the BCCTP DRA notification letter does not indicate that they are in BCCTP Then proceed to step 2 clear MEDS and proceed to step 2 if the customer is active with BCCTP aid code of 0N 0P 0U or 0V Review the documents and determine if that they are originals or copies certified by the issuing agency Make a photocopy of the original or certified citizenship andor identity CITID documents Complete and sign the DHCS 0005 form for each CITID documents provided by the BCCTP customerAuthorized Representative AR Return the original documents to the individual Provide the individual with a copy of the completed and signed DHCS 0005 forms Mail or fax copies of the documents and DHCS 0005 forms to the BCCTP unit Fax Transmissions Department of Health Care Services ATTN Breast and Cervical Cancer Treatment ProgramDRA Fax number 916 5529440 United States Mail Department of Health Care Services Breast and Cervical Cancer Treatment Program DRA MS 4611 PO Box 997417 Sacramento CA 958997417 If faxing a phone call must be made to 800 8240088 prior to faxing to comply with Health Insurance Portability and Accountability Act HIPAA County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Processing Verification of CitizenshipIdentity for Breast and Cervical Cancer Treatment Program BCCTP Number Page 040716 3 of 3 8 File copies of the documents viewed and the signed DHCS 0005s in the Family Resource Center FRC designated centralized location Additionally if the BCCTP customer has questions regarding the BCCTP process including any that are related to the DRA requirements refer them to the Eligibility Specialist ES identified on the BCCTP DRA Notice or the BCCTP tollfree number at 800 8240088 Procedure None Program ImpactsNone References ACWDL 0825 Sunset Date This policy will be reviewed for continuance by 04302024