Medi-Cal Handbook
page 8-1
Verifications
8. Verifications
Verification is the process of obtaining acceptable evidence of items necessary to
determine Medi-Cal eligibility which substantiates statements made by the
applicant/beneficiary on the Statement of Facts form (MC 210 or MC 321 HFP) or
the annual Redetermination form (MC 210 RV). Verification must be provided at:
• Initial application, reapplication and restoration.
• Annual Redetermination (only for items necessary to determine continued
Medi-Cal eligibility that are subject to change and not previously verified).
• When a change in amount/source/provider of resources, income, or expenses is
reported by the applicant/beneficiary or discovered by the EW (except at MSR).
• Requests for retroactive Medi-Cal coverage.
When required verification is unavailable and all attempts to obtain the verification
have been made and are unsuccessful, a sworn affidavit signed under penalty of
perjury by the applicant/beneficiary is acceptable as verification except for the
Social Security Number (SSN).
8.1
Responsibility of Obtaining Verification [50167,
50168, 50169, 50171, 50172]
8.1.1
Who
The Applicant/Beneficiary, or the Eligibility Worker (EW) shall make every effort to
obtain documentation necessary to verify all items of income and resources. Such
a search shall include, at a minimum, one contact with the appropriate person/
organization having the documentation.
8.1.2
Lacking Verification
When the EW determines that such documentation cannot be obtained either by
the client or by the County within the time requirements, the EW shall:
Update # 16-38
Revised: 11/4/16
Medi-Cal Handbook
page 8-2
Verifications
• Enter in Case Comments all actions taken to obtain required verifications.
• Obtain from the client, and retain in IDM, an affidavit dated and signed under
penalty of perjury that lists a description and value of any item and/or the
amounts of earned or unearned income received for which documentation for
verification purposes is not available.
8.1.3
Electronic Verifications
In addition to the verifications provided by the client, the EW must use the following
available electronic data exchange methods to verify eligibility:
• Income Eligibility Verification System (IEVS)
• Payment Verification System (PVS)
• Systematic Alien Verification of Eligibility (SAVE).
8.1.4
Mandatory Verifications
The remainder of this chapter contains information regarding mandatory
verifications for the following eligibility criteria:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Face to face interview
Rights and Responsibilities
Timeliness of Application Process
Identity
Social Security Numbers
Citizenship
Noncitizen Status
California Residence
Blindness and Disability
Incapacity
SGA Disability
Legal responsibility for Child Applying
Need for Minor Consent Services
Medicare Eligibility
Health Care Benefits
Income
Property, and
Additional Requirements.
Revised: 11/4/16
Update # 16-38
Medi-Cal Handbook
8.2
page 8-3
Verifications
Face to Face Interview [50157, 50189]
Effective July 1, 2000, ALL Medi-Cal applications may be completed and
processed by mail. A face-to-face interview is not required.
Exception:
Applications and reapplications for Minor Consent Services must be made in
person.
8.2.1
When Required
• Minor Consent applications and reapplications
• When an applicant or beneficiary requests a face-to-face interview.
Note:
The EW may require a face-to-face interview prior to approval ONLY for good
cause or suspicion of fraud.
8.2.2
Documentation Required
• The reason for requesting a face-to-face interview must be THOROUGHLY
DOCUMENTED in Case Comments
• Document in Case Comments that the CHDP program was explained and the
pamphlet was given
8.3
Rights and Responsibilities [50157]
8.3.1
When Required
• Intake
• Restoration
• Redetermination.
Update # 16-38
Revised: 11/4/16
Medi-Cal Handbook
page 8-4
Verifications
Note:
The Rights and Responsibilities (MC 219) form is included in all Medi-Cal
Intake and RD packets. When the joint MC 321 HFP application is received,
the MC 219 must be mailed to the client.
8.3.2
Documentation Required
The client is not required to sign and return the MC 219 at Intake or at annual
redetermination. However, it must be documented in Case Comments that it was
given or mailed to the client and the date provided. The original of the MC 219 (if
signed and returned) and the Beneficiary Representative checklist, (DHCS 7068) if
applicable, must be scanned into IDM.
NOTE: When a CalWORKs/CalFresh application is denied and the applicant is also
requesting Medi-Cal, the signed SAWS 2A for the CalWORKs/CalFresh application
is sufficient to meet the Rights and Responsibilities requirement at Intake.
8.4
Timeliness of Application Process [50177(a)]
8.4.1
When Required
• Determination of eligibility and share of cost must be made within 45 days of the
date of application.
• When determination depends on establishing disability or blindness within 90
days, unless good cause is established.
8.4.2
Documentation Required
Approval or Denial NOA in CalWIN or manual shelf stock NOA scanned into IDM.
• If the application cannot be processed within the required time limit, good cause
must be documented in Case Comments.
• Extended time limit shall not exceed three months from application date.
Revised: 11/4/16
Update # 16-38
Medi-Cal Handbook
8.5
page 8-5
Verifications
Social Security Numbers [50168]
8.5.1
When Required
• Within 60 days of initial application but not necessarily prior to approval
• Whenever there is a change.
Note:
A U-Parent must have a Social Security Number verification prior to approval.
Exception:
Noncitizens eligible only for restricted benefits are not required to provide an
SSN. However, if he/she has a SSN, he/she is asked to provide it.
Deemed Eligible newborns whose mother received Medi-Cal in the month of
delivery. The EW must inform the parent that a SSN application will be
required in the month the infant turns one year of age.
8.5.2
Documentation Required
• J-Verified thru IEVS, or
• Social Security Card, or
• An Award letter, Medicare card or a check from SSA showing applicant's name
and SSN, with the letters A, HA, J, T, or M following SSN, or
• MC 194 (requires follow-up in 60 days)
• A parent may request an SSN at the time that the hospital obtains information for
birth registration. The SSA-285-OP3 “Message from Social Security” can be
used as evidence of SSN application when signed by a hospital official.
Update # 16-38
Revised: 11/4/16
Medi-Cal Handbook
page 8-6
Verifications
8.6
Citizenship/Alien Status/Residence [50169, 50301,
50302]
8.6.1
Citizenship
When Required
When an applicant or beneficiary declares U.S. citizenship or U.S. national status.
Note:
Citizenship verification is not required for persons applying or receiving State
only Medi-Cal benefits. Please refer to [“Exempt Individuals,” page 41-32]
Verification Required
Documents must be either originals or copies certified by the issuing agency.
Acceptable documents are listed below along with a description of each one:
PRIMARY DOCUMENTS (TIER 1) - Provides proof of BOTH Citizenship and Identity
Primary Documents
Explanation
U.S. passport issued without
limitation.
The Department of State issues this. A U.S. passport does not
have to be currently valid to be accepted as evidence of U.S.
citizenship, as long as it was originally issued without limitation.
NOTE: Spouses and children were sometimes included on one
passport through 1980. U.S. passports issued after 1980 show
only one person. Citizenship and identity of the included person
can be established when one of these passports is presented.
EXCEPTION: Do not accept any passport as evidence of U.S.
citizenship when it was issued with a limitation. However, such
a passport may be used as proof of identity.
Certificate of Naturalization
(DHS Forms N-550 or N-570)
Department of Homeland Security issues for naturalization.
Certificate of Citizenship
(DHS Form N-560 or N-561)
Department of Homeland Security issues a Certificate of
Citizenship to persons who derive citizenship through a parent.
Revised: 11/4/16
Update # 16-38
Medi-Cal Handbook
page 8-7
Verifications
NOTE: References to documents issued by the U.S. Department of Homeland Security (DHS)
include documents issued by the former Immigration and Naturalization Services (INS), now
known as the U.S. Citizenship and Immigration Services (USCIS) within DHS.
The following documents must be provided with an identity document from TIER 5:
SECONDARY DOCUMENTS (TIER 2)
Secondary Documents
Explanation
Electronic Birth Record
Match
The California Department of Health Care Services’ electronic
birth record verification meets the requirement for citizenship
documentation. No further citizenship documentation is
necessary; however, identity will still need to be verified.
A U.S. public Birth
Certificate showing birth in:
The birth record document may be issued by the State,
Commonwealth, Territory or local jurisdiction. It must have been
issued BEFORE the person was 5 years of age.
• One of the 50 States
• District of Columbia
An amended birth record document that is amended after 5 years
of age is considered fourth level evidence of citizenship.
• American Samoa
• Swains Island
• *Puerto Rico (if born on or
after January 13, 1941)
• *Virgin Islands of the U.S.
(on or after January 17,
1917)
NOTE: If the document shows the individual was born in Puerto
Rico, Guam, the Virgin Islands of the U.S., or the Northern
Mariana Islands before these areas became part of the U.S., the
individual may be a collectively naturalized citizen. Collective
naturalization occurred on the dates listed for each of the
Territories.
*See additional requirements for Collective Naturalization.
• *Northern Mariana
Islands (after November
4, 1986 (NMI local time)),
OR
• Guam
(on/after April 10, 1899).
Certification of Report of
Birth (DS–1350)
The Department of State issues a DS-1350 to U.S. citizens in the
U.S. who were born outside the U.S. and acquired U.S.
citizenship at birth, based on the information shown on the
FS-240. When the birth was recorded as a Consular Report of
Birth (FS-240), certified copies of the Certification of Report of
Birth Abroad (DS-1350) can be issued by the Department of
State in Washington D.C. The DS-1350 contains the same
information as that on the current version of Consular Report of
Birth FS-240. The DS-1350 is not issued outside the U.S.
Report of Birth Abroad of a
U.S.Citizen (Form FS-240)
The Department of State consular office prepares and issues this.
A consular Report of Birth can be prepared only at an American
consular office overseas while the child is under the age of 18.
Children born outside the U.S. to U.S. military personnel usually
have one of these.
Update # 16-38
Revised: 11/4/16
Medi-Cal Handbook
page 8-8
Verifications
Certification of Birth issued
by the Department of State
(Form FS-545 or DS-1350)
Before November 1, 1990, Department of State consulates also
issued Form FS-545 along with the prior version of the FS-240. In
1990, U.S. consulates ceased to issue Form FS-545. Treat an
FS-545 the same as the DS-1350.
U.S. Citizen I.D. Card
(I-197) or prior version I-179
(Note Section 1903(x) of the
Act incorrectly refers to the
same document as an I-97)
INS issued the I-179 from 1960 until 1973. It revised the form and
renumbered it as Form I-197. INS issued the I-197 from 1973
until April 7, 1983. INS issued Form I-179 and I-197 to
naturalized U.S. citizens living near the Canadian or Mexican
border who needed it for frequent border crossings. Although
neither form is currently issued, either form that was previously
issued is still valid.
American Indian Card
(I-872)
DHCS issues this card to identify a member of the Texas Band of
Kickapoos living near the U.S./Mexican border. A classification
code “KIC” and a statement on the back denote U.S. citizenship.
Northern Mariana
Identification Card (I-873)
The former Immigration and Naturalization Service (INS) issued
the I-873 to a collectively naturalized citizen of the U.S. who was
born in the Northern Mariana Islands before November 4, 1986.
The card is no longer issued, but those previously issued are still
valid.
Final Adoption Decree
The adoption decree must show the child’s name and U.S. place
of birth. In situations where an adoption is not finalized and the
State in which the child was born will not release a birth
certificate prior to final adoption, a statement from a State
approved adoption agency that shows the child’s name and U.S.
place of birth is acceptable. The adoption agency must state in
the certification that the source of the place of birth information is
an original birth certificate.
Evidence of U.S. Civil
Service Employment
The document must show employment by the U.S. government
before June 1, 1976. Individuals employed by the U.S. Civil
Service prior to June 1, 1976 had to be U.S. citizens.
U.S. Military Record
The document must show a U.S. place of birth (for example a
DD-214 or similar official document showing a U.S. place of
birth).
SAVE Verification
Verification of citizenship through the Systematic Alien
Verification of Entitlements (SAVE) system is acceptable proof of
citizenship. However, under current federal rules, U.S. citizen
applicants are not eligible for Medi-Cal during the time it takes to
verify citizenship using SAVE.
SAVE may be used to verify the current status of immigrants who
claim to be United States Citizens if they have an A-Number or
an I-94. If SAVE indicates an individual is a naturalized U.S.
citizen, it is acceptable proof for Medi-Cal eligibility purposes.
Revised: 11/4/16
Update # 16-38
Medi-Cal Handbook
Proof of adoption under the
Child Citizenship Act
page 8-9
Verifications
Verification that an adopted child meets the requirements for
establishing citizenship under the Child Citizenship Act is
acceptable evident of citizenship. To establish citizenship in this
way requires evidence that all of the following conditions have
been met on or after February 27, 2001:
• At least one parent of the child is a U.S. citizen
• The child is under 18
• The child is residing in the U.S. in the legal and physical
custody of the U.S. citizen parent
• The child was admitted to the U.S. for lawful permanent
residence
• If adopted, the child satisfies the specified Immigration and
Nationalization Act (INA) requirements pertaining to
international adoptions.
Update # 16-38
Revised: 11/4/16
Medi-Cal Handbook
page 8-10
Verifications
The following documents must be provided with an identity document from TIER 5:
THIRD LEVEL DOCUMENTS (TIER 3)
Third Level Documents
Explanation
Extract of a hospital record on
hospital letterhead established at
the time of the person’s birth that
was created 5 years before the
initial Medi-Cal application date
and indicates U.S. place of birth.
Do not accept a souvenir “birth certificate” issued by the
hospital.
Life, health, or other insurance
record showing a U.S. place of
birth that was created at least 5
years before the initial Medi-Cal
application date (or near the time
of birth if under 16) and indicates
a U.S. place of birth
Life or health insurance records may show biographical
information for the person including place of birth; the record
can be used to established U.S. citizenship when it shows a
U.S. place of birth.
Early school records
Early school records must show the name of the child, the
date of admission to the school, the date of birth (or age of
child at the time the record was made), a U.S. place of birth,
and the name(s) and place(s) of birth of the child’s parents.
Religious records recorded in the
U.S. within 3 months of birth
Religious records recorded in the U.S. within 3 months of
birth must show that the birth occurred in the U.S. and must
show either the date of birth, or the individual’s age at the
time the record was made. The record must be an official
record with the religious organization. In questionable cases
(for example, where the record was recorded near a U.S.
international border and the child may have been born
outside the U.S.), the EW must verify the religious record or
must document that the mother was in the U.S. at the time of
the child’s birth.
NOTE: For children under 16, the document must have been
created near the time of birth or 5 years before the date of
application.
The following documents must be provided with an identity document from TIER 5:
FOURTH LEVEL DOCUMENTS (TIER 4)
Fourth Level Documents
Explanation
Federal or state census record
showing U.S. citizenship or a
U.S. place of birth
(Generally for persons born from
1900 through 1950).
The census record must also show the applicant’s age.
Revised: 11/4/16
NOTE: Census records from 1900 through 1950 contain
certain citizenship information. To secure this information,
the applicant, recipient, or State should complete a Form
BC-600, Application for Search of Census Records for Proof
of Age. Add in the remarks portion “U.S. citizenship data
requested.” Also, add that the purpose is for Medicaid
eligibility. This form requires a fee.
Update # 16-38
Medi-Cal Handbook
One of the documents as listed
in the explanation that show a
U.S. place of birth and was
created at least 5 years before
the application for Medi-Cal.
page 8-11
Verifications
This document must be one of the following and show a U.S.
place of birth:
• Seneca Indian tribal census record
• Bureau of Indian Affairs tribal census records of the
Navajo Indians
• Bureau of Indian Affairs Roll of Alaska Natives*
• U.S. State Vital Statistics official notification of birth
registration
• An amended U.S. public birth record that is amended
more than 5 years after the person’s birth
• Statement signed by the physician or midwife who was in
attendance at the time of birth
*For children under 16, the document must have been
created near the time of birth or five years before the initial
date of application and must show a U.S. place of birth.
Institutional admission papers
from a nursing facility, skilled
care facility, or other institution
Admission papers showing biographical information for the
person can be used to establish U.S. citizenship when it
shows a U.S. place of birth and was created at least five
years before the initial date of application.
Medical (clinic, doctor, or
hospital) record created at least
5 years before the initial
application date that indicates a
U.S. place of birth
Medical records generally show biographical information for
the person including place of birth; the record can be used to
establish U.S. citizenship when it shows a U.S. place of birth.
Note: An immunization record is not considered a medical
record for purposes of establishing U.S. citizenship.
Note: For children under 16, the document must have been
created near the time of birth or 5 years before the date of
application.
Update # 16-38
Revised: 11/4/16
Medi-Cal Handbook
page 8-12
Verifications
Written Affidavit
Affidavits may be used by native-born U.S. born citizens and
naturalized U.S. citizens in circumstances where no other
acceptable documentary evidence of citizenship is available.
In order for an affidavit to be acceptable to establish
citizenship, the following requirements must be met:
• No other evidence of citizenship can be easily obtained by
the applicant or beneficiary.
• The affidavit(s) must be signed under penalty of perjury by
at least two individuals who have personal knowledge of
the event(s) establishing the applicant’s or beneficiary’s
claim of citizenship. The affidavits do NOT need to be
notarized.
• At least one of the individuals providing an affidavit must
not be related to the applicant or beneficiary who is the
subject of the affidavit.
• The individuals making the affidavit must provide proof of
their own citizenship and identity.
• If the affidavits do not explain why other evidence is
unavailable, an additional affidavit should be requested
from the applicant or beneficiary which includes that
information.
• The applicant or beneficiary whose citizenship is
addressed in the affidavit must provide acceptable
evidence of identity.
8.6.2
Alien Status [50167 (a) (3), 50301.1, 50301.2, 50301.6,
MEPM Article 7]
When Required
• Application
• Reapplication
• Restoration
• Whenever there is a break in aid.
Revised: 11/4/16
Update # 16-38
Medi-Cal Handbook
page 8-13
Verifications
Verification Required
INS documents including but not limited to: I-551, I-94, I-688, I-181B. Once
documents are provided, initiate SAVE. [Refer to “Citizenship/Immigration Status,”
page 41-1 to determine the level of benefits.]
Systematic Verification of Entitlements (SAVE)
The SAVE system is used to verify immigration status of Medi-Cal applicants and
beneficiaries who claim Satisfactory Immigration Status (SIS). A SAVE request is to
be completed and forwarded to USCIS on every person who claims SIS. When the
primary SAVE request is returned by USCIS and indicates “institute secondary
verification,” then the G-845S form must be completed and forwarded to USCIS. If
provided, Allow 30 days to provide verification if alien is claiming to have
Satisfactory Immigration Status (SIS). Grant full scope benefits if otherwise eligible.
Verify when there is a change in status.
8.6.3
MC 13
All noncitizens, including undocumented noncitizens, and any citizen who did not
make a declaration of citizenship on the signed Statement of Facts who apply for
for Medi-Cal only must complete an “Statement of Citizenship, Alienage, and
Immigration Status” (MC 13).
When Required
• At application, reapplication, restoration or whenever there is a break in aid of
one month or more.
• Whenever a change in immigration status is declared.
8.6.4
California Residency [50167 and 50320.1]
California (CA) residency is a requirement for Medi-Cal eligibility. To establish CA
residency, the client must meet all of the following conditions:
• Is physically living in CA
• Declares the intent to remain permanently or indefinitely, or if a migrant worker,
entered CA to work or seek work (entry into CA to work or seek work must be
verified).
Update # 16-38
Revised: 11/4/16
Medi-Cal Handbook
page 8-14
Verifications
Proof of CA residency is not required for:
• The spouse of a person whose residency has been verified. (Married couple
must be living together)
• The children in a family, if one of the parent’s CA residency has been verified.
• Individuals applying for Minor Consent services
• Adults or children in the care of a CA state or county agency (including persons
receiving Foster Care or Adoption Assistance under Title IV-E of the Social
Security Act.
• Persons in CA institutions unless placed by another state and CA does not
accept responsibility.
When Required
• Prior to application approval. (Once established, CA residence continues until
residence is established in another state or country.)
• At redetermination, only if not previously verified; or if residency becomes
questionable.
Verification Required
In determining whether a Medi-Cal applicant/beneficiary meets residency
requirements, the EW must consider all available evidence, including evidence that
supports a claim of CA residency, as well as, evidence that contradicts a claim of
residency.
Documents provided as proof of California residency must include a CA address for
the applicant/beneficiary. However, the address on the document need not be the
current address. A document provided by a homeless person must be considered
even if it does not include an address.
• Verification includes but is not limited to:
• Current & valid CA driver’s license or ID card
• Current & valid CA DMV vehicle registration form
• Document showing the client is employed in California
Revised: 11/4/16
Update # 16-38
Medi-Cal Handbook
page 8-15
Verifications
• Papers showing that the client has registered with a public or private
employment agency in CA.
• Papers showing children's enrollment in CA schools
• Papers showing client is receiving public assistance/government benefits
other in CA
• CA voter registration papers
• Current rent/mortgage receipt or statement; or utility bill showing the
client's name and a CA address.
An applicant who cannot provide a “specified” document must sign the “Important
Information About Residency” (MC212) and provide other evidence of CA
residence such as:
• CA church records
• Current & valid CA school ID
• Recent CA marriage or divorce papers
• Recent court documents which show client's CA address
• CA insurance documents
• Police records from a CA law enforcement agency.
IMPORTANT: To be acceptable as evidence of residency, rent receipts or
income-in-kind statements from a relative must be verified on Form MC 210 S-I.
UNACCEPTABLE EVIDENCE: SC 101, other sworn statements or affidavits
completed by the applicant or any other person.
Update # 16-38
Revised: 11/4/16
Medi-Cal Handbook
page 8-16
Verifications
8.7
Identity [50167 (a), (6)]
Identity of all applicants must be verified except as listed below.
• Individuals applying for Minor Consent Services
• Medically Indigent (MI) children not living with a parent/caretaker relative, and
a public agency has financial responsibility. (Foster Care, AAP or Kin-Gap)
• Individuals not acting on their own behalf, e.g., Public Guardian is the
representative.
8.7.1
When Required
Prior to application approval (a copy must be scanned into IDM).
Revised: 11/4/16
Update # 16-38
Medi-Cal Handbook
8.7.2
page 8-17
Verifications
Verification Required
IDENTITY DOCUMENTS (TIER 5)
NOTE: Identity documents that have expired are acceptable as long as there is no
reason to believe the document does not match the individual.
Document
Explanation
Certificate of Degree of Indian
Blood, or other U.S. American
Indian/Alaska Native Tribal
document.
Acceptable if the document carries a photograph of the
applicant or recipient, or has other personal identifying
information relating to the individual such as age, weight,
height, race, sex or eye color.
Identity documents described
in 8 CFR 274a.2(b)(1)(v)(B)(1)
8 CFR 274a.2(b)(1)(v)(B)(1) describes the following acceptable
documents:
• Driver’s license issued by a State or Territory either with a
photograph of the individual or other identifying information
of the individual such as name, age, sex, race, height, weight
or eye color.
• School identification card with a photograph of the individual
• U.S. military identification card or draft record
• Identification card issued by the Federal, State, or local
government with the same identifying information included
on driver’s licenses
• U.S. military dependent’s identification card
• Native American Tribal document
• U.S. Coast Guard Merchant Mariner card.
EXCEPTION: Do not accept a voter’s registration card or
Canadian driver’s license as listed in 8 CFR
274a.2(b)(1)(v)(B)(1).
Three corroborating identity
documents
Identity may be established based on three corroborating
documents that, taken together reasonably establish the
identity of an individual (if there is no other evidence of identity
available), provided the documents were not used to establish
citizenship and the individual provided second or third level
proof of citizenship. These documents must at a minimum
include the individual’s name and any other identifying
information) and must contain consistent identifying
information. Documents that could be used to establish identity
in this way include a marriage license, divorce decree, high
school or college diploma (including general education or high
school equivalency), employer ID card, or property deed/title.
U.S. passport issued with
limitation
The Department of State issues this. Do not accept any
passport as evidence of U.S. citizenship when it was issued
with a limitation. However, such a passport may be used as
proof of identity. Such a passport does not have to be currently
valid to be acceptable evidence of identity.
Update # 16-38
Revised: 11/4/16
Medi-Cal Handbook
page 8-18
Verifications
Affidavit of identity for disabled
individuals in institutional care
facilities
These affidavits must be signed under penalty of perjury by a
residential care facility director or administrator on behalf of an
institutionalized individual in the facility but do not need to be
notarized. The DHCS 0010 may be used as an affidavit of
identity under these circumstances.
Clinic, doctor or hospital
records for children under 16
For a child under 16, identity may be established through clinic
records, doctor records or hospital records.
Special identity rules for
children
• For children under 16, school nursery or day-care records
including report cards may be used as proof of identity. The
EW must verify them with the issuing school.
• For children under 16, if none of the above documents in the
preceding groups are available, an affidavit may be used. An
affidavit is only acceptable if it is signed under penalty of
perjury by a parent, guardian or caretaker relative stating the
date and place of birth of the child and cannot be used if an
affidavit for citizenship was provided. The affidavit does not
need to be notarized.
• For children under 18, an affidavit of identity may be used if
all of the following conditions are met: (1) an affidavit was not
used to establish citizenship for the child, and (2) the child
cannot obtain a school ID card and (3) the child does not
have a Drivers License.
8.8
Blindness and Disability [50167 (a) (1),
MEPM Article 22]
8.8.1
When Required
• Prior to approval.
• Whenever there is a change.
• Disability must be re-verified at each annual RD.
8.8.2
Documentation Required
Acceptable verification includes:
• Proof of Social Security (Title II) benefits based on disability or blindness
Revised: 11/4/16
Update # 16-38
Medi-Cal Handbook
page 8-19
Verifications
• Proof of Supplemental Security Income/State Supplemental Payment (SSI/
SSP) benefits based on disability or blindness.
• Proof of Railroad Retirement Benefits (RRB)
• Receipt of one of the above types of disability benefits can be adopted for a
Medi-Cal disability determination and a referral to State Programs-Disability
Determination Service Division (SP-DDSD) is not needed. However, if the
applicant is not in receipt of one of the above disability benefits, then a disability
packet must be completed and sent to SP-DDSD for a disability determination.
• Presumptive disability (PD) may be established by obtaining a letter from a
physician verifying that one of the PD conditions exist.
[Refer to “DDSD,” page 27-1 before establishing presumptive disability.]
• By following procedures established by SP-DDSD. A full DDSD packet must be
sent to Oakland no later than 10 days after receipt of the completed MC 223,
except when the delay is due to circumstances beyond control of the County. If
medical records are available, they may be submitted with the packet. However,
in no case should submission of the packet be delayed to obtain those records.
8.9
Incapacity [50167(a)(2), 50211]
8.9.1
When Required
• Prior to approval
• Redetermination
• Month when incapacity is to end.
8.9.2
Verification Required
• Proof of Social Security (Title II) benefits based on disability or blindness
• Proof of SSI/SSP benefits based on disability or blindness
• Proof of DIB or Worker’s Compensation.
Update # 16-38
Revised: 11/4/16
Medi-Cal Handbook
page 8-20
Verifications
If the client does not receive one of the above types of disability benefits, one of the
verifications below is required:
• Current Medical Report (MC 61)
• Current certificate of disability - DM 3 or MC 221
• Written statement signed by a physician, licensed or certified psychologist, or
authorized member of their staff which documents that incapacity exists and
gives the expected duration of the condition.
Note:
When a current Medical Report or a written statement cannot be obtained
without delay, a verbal statement from a licensed physician or authorized
member of their staff may be accepted as verification for up to sixty (60) days
pending receipt of written verification.
8.10 SGA Disability [50167, MEPM Article 22]
8.10.1
When Required
• Prior to approval
• Redetermination.
8.10.2
Documentation Required
Return of MC 221 from DDSD verifying disability exists.
Note:
Disability evaluation forms (MC 220, 221, and 223) must be sent to Oakland
within 10 days after receipt of MC 210.
Revised: 11/4/16
Update # 16-38
Medi-Cal Handbook
page 8-21
Verifications
8.11 Legal Responsibility for Child Applying Alone
[50167 (a)(4)]
Whenever a child is applying alone on the basis that neither the parents nor any
agency will accept legal responsibility for the child, it must be verified.
8.11.1
When Required
• Prior to approval
• Redetermination.
8.11.2
Verification Required
Verification can be any verbal or written or verbal communication with the parents
and/or agencies (documented in Case Comments).
8.12 Need for Minor Consent Services [50147.1(a)]
8.12.1
When Required
• Prior to approval
• Monthly thereafter.
8.12.2
Documentation Required
“Request for Limited Services” (MC 4026).
Update # 16-38
Revised: 11/4/16
Medi-Cal Handbook
page 8-22
Verifications
8.13 Medicare Eligibility[50168]
8.13.1
When Required
• Within 60 days of initial application but not necessarily prior to approval
• Whenever there is a change.
8.13.2
Verification Required
• Viewing health insurance card
• An award letter showing the individual's health insurance claim number (HIC)
• An 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
Note:
NOTE: Aged aliens in the U.S. less than five years are not eligible for
Medicare, but are still required to apply.
• Use form SC 169 and note in the comments section “Alien here less than five
years. Is he/she eligible for Medicare?”
• Scan the returned SC 169 into IDM.
8.14 Health Care Benefits [50167]
8.14.1
When Required
Other health coverage (OHC) must be verified prior to approval.
Revised: 11/4/16
Update # 16-38
Medi-Cal Handbook
8.14.2
page 8-23
Verifications
Verification Required
• Insurance policy which specifically names the applicant/beneficiary
• Health benefit ID card
• Letter from health care benefit provider
• Health care benefits from Workers Compensation employers or insurance
companies
8.15 Income [50167(a)(7), 50507, 50518, 50186,
MEPM Article 10 and 15]
[Refer to “Nonexempt Earned Income,” page 56-1]
[Refer to “Nonexempt Unearned Income [50507],” page 57-1]
8.15.1
When Required
• Prior to approval
• Redetermination
• When a change in circumstances occurs.
Reminder:
Income-In-Kind only needs to be verified when a client claims the value of the
in-kind item received is less than the chart value.
8.15.2
Verification Required
Earned Income
• One pay stub (most current pay stub available to the client; not required to
have been issued within the last 30 days but must accurately reflect the
amount reported on the application).
Update # 16-38
Revised: 11/4/16
Medi-Cal Handbook
page 8-24
Verifications
• Copy of last year’s federal tax return that accurately reflects current income
• Signed letter from employer showing the gross amount and date of paycheck
• Statement from checking or savings account indicating direct deposit
• If verification cannot be obtained by one of the above methods, the applicant/
beneficiary may sign an affidavit under penalty of perjury indicating his/her
gross monthly earned income
• If there is a discrepancy between the pay stub submitted and the amount
reported on the application, the EW may request additional pay stubs to
determine the correct monthly income.
Note:
If income reported on the application is clearly “NET” earnings, it is NOT a
discrepancy.
Unearned Income
• Award letter or most recent cost-of-living increase notice
• IEVS/PVS abstract or printout
• Current bank statement if the applicant has direct deposit
• Copy of the applicant’s current benefit check
Note:
The deposit or check may not reflect gross income if Medicare premiums are
being deducted or an overpayment is being collected from the client’s check.
• Signed statement from the person or organization providing the income.
• Applicant's affidavit for income received from U.S. Government (pending
receipt of verification).
Self Employment
• Receipts showing gross earnings and expenses
• Business records (Profit and Loss Statements)
Revised: 11/4/16
Update # 16-38
Medi-Cal Handbook
page 8-25
Verifications
• Copy of most recent federal individual tax return (IRS 1040) and appropriate
Schedule D - Capital Gain or Loss.
Use of Tax Return to Verify Income
A copy of the most recent federal individual income tax return (IRS 1040, 1040EZ,
etc.) is acceptable verification of any type of income if it accurately reflects the
income reported on the application.
Unconditionally Available Income
Unconditionally available income is income the applicant/beneficiary only has to
claim or accept. AN APPLICANT/BENEFICIARY MUST APPLY FOR
UNCONDITIONALLY AVAILABLE INCOME AS A CONDITION OF ELIGIBILITY.
Only the individual who refuses to apply for or accept unconditionally available
income will be ineligible. Examples are:
• Disability Insurance Benefits (DIB) - IEVS abstract or check stub
• Unemployment Insurance Benefits (UIB) - IEVS abstract or check stub
• Retirement, Survivors, Disability Insurance (RSDI) benefits
• Veterans Administration Benefits - MC 05or receipt
All applicants/beneficiaries should be considered potentially eligible for UIB and
should be referred to the Employment Development Department (EDD) to apply for
UIB; however do not refer applicants/beneficiaries in the following situations:
• Individuals who have not worked in employment covered by UIB
• Individuals who have a UIB claim pending
• Individuals who are receiving or have exhausted their UIB
• Individuals who are receiving DIB
• Individuals who are employed full time
• Individuals who are covered under Title 22, CCR, Section 50201
• Individuals denied or discontinued from the UIB program
• Children under 16 years of age with no employment history
• Applicants who are applying for restricted Medi-Cal benefits.
Update # 16-38
Revised: 11/4/16
Medi-Cal Handbook
page 8-26
Verifications
Income-In-Kind
Verification is only required if it is earned income in-kind or the client claims the
amount is a lower value than the chart value.
• Case Comments
• Written statement from the provider
• Actual receipts for housing, utilities, etc.
• SC 101 when provider of income-in-kind will not cooperate.
Fluctuating Income
Check stubs or a signed statement from the person or organization making the
payments including the amount and frequency of the payments
Tip Income
• Amount on the pay stub
• The amount actually reported by the client
• If there is a discrepancy between the amount reported on the pay stub and
the amount reported by the client, the client may sign an affidavit declaring the
reason for the discrepancy.
Temporary Workers Compensation
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.
Veteran’s Benefits or Aid and Attendance Payments
• Completed “Military Verification and Referral Form” (MC 05)
• Viewing the Veterans Administration check and scanning into IDM (Document
in Case Comments if unable to copy check).
Revised: 11/4/16
Update # 16-38
Medi-Cal Handbook
page 8-27
Verifications
Interest and Dividend Income
• IRS Interest Income Statement Form 1099
• Bank Statement (yearly, quarterly, monthly)
• Account Statement
• Payment Records (Notes/Mortgages).
Child Support Spousal Support
• Court Papers
• District Attorney/Family Support (DAFS) records
• Sworn affidavit (SC 101) from the Absent Parent
• Copy of check.
Educational Grants and Loans
Financial aid papers provided by the college
Net Income from Property
• Lease or sales agreement
• Bookkeeping records (including expense receipts, tax returns, sales records).
Income Deductions
• Acceptable verification for expenses paid for child care or care of an
incapacitated person while someone is employed:
• Receipts
• Cancelled checks
• Signed statement from the person or organization receiving the payments.
• Court ordered child support actually paid
• Health insurance premiums.
Update # 16-38
Revised: 11/4/16
Medi-Cal Handbook
page 8-28
Verifications
8.16 Property [50167]
8.16.1
When Required
• Prior to approval when reported
• Redetermination.
Exception:
Property Waiver Programs
8.16.2
Verification Required
The Principal Residence Questionnaire must be completed only when the
information is not included on the most recent Statement of Facts. Also available as
SC 1407.
• The questionnaire must be returned within 20 calendar days
• Send a case alert for return
• If not returned, contact applicant/client to determine reason for delay
• No valid reason, deny or discontinue with timely NOA for failure to provide
essential information.
Market value of real property other than home
• Tax statement
• Records maintained by tax assessor's office
• Written statement from a member of a recognized professional appraisal
society which gives the appraisal value of the property
• Checking account, savings account (current statement).
Revised: 11/4/16
Update # 16-38
Medi-Cal Handbook
page 8-29
Verifications
Note:
Computer printed passbooks or statements that have been updated/issued
within the past 30 days are both acceptable verification of bank balances.
Passbooks that use hand entries to record deposits and withdrawals are not
acceptable. FOR THOSE ACCOUNTS WITH HAND PRINTED PASSBOOKS
AND QUARTERLY BANK STATEMENTS, THE MOST RECENT BANK
STATEMENT IS ACCEPTABLE.
• Recently signed correspondence from the institution holding funds.
• An ATM receipt may be used only as a temporary verification until the next
routine bank statement is available.
Value of Stocks, Bonds, and Mutual Funds
• Viewing certificate or signed statement from issuing institution stating
description of investment, including number of shares owned, AND
• Telephone contact with a recognized stock exchange broker to establish the
current selling price of the property, through listing in current newspaper.
U.S. Savings Bonds
• View Bonds, and
• Contact bank or institution where bonds may be liquidated.
Deeds of Trusts, Mortgages and Promissory Notes.
• View documents, and
• Take one of following actions:
• View document from lender which establishes principal amount remaining
on note
• Appraisal from qualified person.
• Telephone call to recognized broker.
Value of Nonexempt Vehicles.
• Vehicle registration
Update # 16-38
Revised: 11/4/16
Medi-Cal Handbook
page 8-30
Verifications
• Kelly Blue Book, or
• Appraisal statement.
Note:
The value of an exempt vehicle does not have to be verified.
Nonexempt Insurance Policies
• Value tables included in policy
• Statement from insurance company.
Nonexempt jewelry (NMV over $100 each piece)
• Three appraisal statements (IDM in case record).
Burial Trusts or Pre-Paid Burial Contract
• View Trust or Contract (IDM in case record)
• Signed correspondence from trustor or contractor which details its value.
Nonexempt Property Held in Trust
• Document indicating current value
• Appraisal of property.
Value of Oil Leases
• Written or telephone contact with professional appraisal society
• Records maintained by tax assessor
• Written or telephone contact with company or organization developing the
natural resource which establishes the current value.
Revised: 11/4/16
Update # 16-38
Medi-Cal Handbook
page 8-31
Verifications
8.17 Pregnancy
8.17.1
Verification Required
Self-Attestation of Pregnancy
A client may self-attest pregnancy and Estimated Date Delivery verbally or in
writing on the application, the Statement of Facts form, or by any other signed
document.
• When the self-attestation of pregnancy is made verbally, the EW must document
this fact and the Effective Date of Delivery in Case Comments.
• The expected number of unborns must be included in the budget calculation.
(i.e. a mother expecting twins will have a household of at least 3, along with
anyone else relevant to her case)
• For purposes of self-attestation of pregnancy, “medically verified” is information:
• Received by the client from a medical provider indicating a positive
pregnancy result has been confirmed, or
• Through a home pregnancy test with a positive result.
• Women seeking pregnancy-related only services, whose income is at or below
the 213% FPL program limit are allowed to self-attest that their pregnancy has
been “medically verified.” Individuals must be income eligible to receive
pregnancy-related services only and placed under the appropriate aid code.
Paper Pregnancy Verification
The EW must only request paper verification from a medical provider if the
information is questionable.
When an EW determines that self-attestation of pregnancy is sufficient, acceptable
pregnancy Verification is:
• A written statement from:
• A physician
Update # 16-38
Revised: 11/4/16
Medi-Cal Handbook
page 8-32
Verifications
• A physician’s assistant
• A certified nurse midwife
• A certified nurse practitioner
• A licensed midwife, or
• A designated medical or clinic personnel with access to the patient’s medical
record.
• A signed stamped photocopy or carbon copy is acceptable, and does not need
to be initialed or counter-signed by the designated medical or clinic personnel
providing the verification.
• The carbon copy signature that appears on the pregnancy verifciation of the
presumptive eligibility, “Application for Medi-Cal Program Only” (PREMED2)
does not need to be initialed.
• Pregnancy verification should include the Estimated Date of Delivery. If the
pregnancy verification does not include the Estimated Date of Delivery, the EW
may ask the client and document clearly in Case Comments.
Reminder:
EWs must not deny or delay services to an otherwise eligible applicant
pending verification of pregnancy.
8.18 Verifications Required Within 60 Days of
Approval [50168]
8.18.1
Social Security Number (SSN)
Every person requesting Medi-Cal who has a Social Security Number (SSN) at the
time of application is asked to provide it to the EW regardless of immigration status
(Crespin).
Revised: 11/4/16
Update # 16-38
Medi-Cal Handbook
page 8-33
Verifications
U.S. citizens, U.S. nationals, and noncitizens claiming to be in a satisfactory
immigration status (SIS) who do not have an SSN, must apply for one and provide
it to the EW. An individual seeking full scope Medi-Cal, who does not have a
verified SSN or proof of application for a SSN, must be referred to SSA to apply for
a number.
Aliens eligible only for restricted benefits ARE NOT required to provide a SSN as a
condition of eligibility (this includes aliens who claim on the MC 13 that they are not
in a SIS).
The signature on the Statement of Facts is not acceptable as verification of a
person’s SSN or application for an SSN.
Note:
Aliens in a Satisfactory Immigration Status (SIS) include amnesty aliens with a
valid and current I-688, lawful permanent aliens, and aliens who are
Permanently Residing in the U.S. Under Color Of Law (PRUCOL).
Note: Although a PRUCOL alien must apply for a SSN, the Social Security
Administration will not assign a SSN to a PRUCOL alien.
SSN’s cannot be required for persons not applying for Medi-Cal (e.g., parents
applying for children only). EWs may request the parent’s SSN but must be aware
that providing the non-applicant parent’s SSN is voluntary.
8.18.2
Social Security Number Issuance
To get an SSN, individuals are required to show evidence that establishes their
age, identity, and lawful resident status.
SSA issues two kinds of SSNs:
(1) Work Authorized SSN, and
(2) Non-Work SSN.
A Non-Work SSN is for an individual who is an immigrant and not authorized to
work. He/she can apply for a SSN by submitting evidence that establishes his/her
age, identity, lawful alien status and a valid need for a SSN.
SSA will not assign a SSN or process an SS-5 for the following individuals:
• An individual who does not submit evidence of age, identity, and when
applicable, U.S. citizenship/lawful alien status.
Update # 16-38
Revised: 11/4/16
Medi-Cal Handbook
page 8-34
Verifications
• An undocumented immigrant
• An individual who submits questionable or fraudulent documents.
8.18.3
Social Security Number Has Been Lost
If an applicant indicates that he/she has a number but lost it, the applicant must be
sent to SSA to request a duplicate.
8.18.4
More Than One Social Security Number
If an applicant has more than one SSN, he/she must be referred to SSA with an
MC 194 form showing all the SSNs.
8.19 Verification of Railroad Disability
Railroad Retirement Board (RRB) Disability issues two types of disability benefits.
Of the two types, only receipt of benefits based on total and permanent disability is
acceptable as verification of disability for Medi-Cal.
• Occupational disability--This type of benefit is issued when it is determined that
individuals cannot perform their last railroad job. There is no determination of the
ability to perform other work in the national economy or other past work. This
type of disability status does not meet Title II (RSDI)/Title XVI (SSI-SSP) criteria.
• Total and permanent disability--This type of benefit is issued based on a
determination that the individual meets Title II/XVI criteria.
EWs shall follow the verification procedures listed below for both intake and
continuing.
8.19.1
Intake
Do not grant any application based on RRB disability until the type of RRB benefit
is identified or the DDSD evaluation is received, unless presumptive disability is
applicable.
Revised: 11/4/16
Update # 16-38
Medi-Cal Handbook
page 8-35
Verifications
For any new application based on RRB disability, or any beneficiary request for
reclassification as an RRB disabled person, the EW shall review the RRB
document. This document could be an RRB disability benefit award letter, an RRB
disability benefit change notice, or other written statement from RRB.
1. If the type of RRB disability benefit is identified, the EW shall follow the
procedures listed. [Refer to “EW Actions—Intake and Continuing,” page 8-35.]
2. If the type of RRB disability benefit is not identified, written verification must be
obtained before completing the intake process.
3. If applicants state that they are aware that the award basis is occupational
disability, and they do not wish to go through verification for that reason,
complete a DDSD packet as stated. [Refer to “EW Actions—Intake and
Continuing,” page 8-35.]
8.19.2
Continuing
All ongoing Medi-Cal cases which include a disabled person in the MFBU shall be
reviewed at the time of annual redetermination to determine if an RRB disability
notification was used to establish disability. If the disability was based on an RRB
disability award, follow the instructions below. Do not discontinue.
8.19.3
EW Actions—Intake and Continuing
The following actions are necessary depending on the type of benefits received
from RRB.
Total Disability
When the RRB notice shows total and permanent disability, no further action is
required. Complete the intake/redetermination process. Document the disability
onset date, type of award, and date of the RRB notice.
Occupational Disability
When the RRB disability notice shows occupational disability, permanent disability
has not been established. Have the beneficiary complete a DDSD packet. In
question 9 on the MC 223, Applicant's Supplemental Statement of Facts for
Medi-cal, RRB should be shown as an agency who has reviewed the applicant/
Update # 16-38
Revised: 11/4/16
Medi-Cal Handbook
page 8-36
Verifications
beneficiary's condition. A properly completed and signed MC 220, Authorization for
Release of Information, must be completed to authorize SP-DDSD to obtain copies
of the RRB awards.
DDSD Determination
1. Disability denied:
If no other basis for linkage exists, deny/discontinue Medi-Cal eligibility. A
State-issued copy of the reason for the denial must be attached.
2. Disability approved.
Have the MC 221 scanned into IDM. No further action is required if the case is
active.
8.20 Verification Requirements for Retroactive
Medi-Cal [50148 and 50197]
The EW must not require additional verification beyond that used to determine
initial and ongoing eligibility when the client completes the MC 210 A and indicates
there is no change for the requested retroactive month9s).
When the client completes the MC 210 A and indicates a change in either income,
property, health insurance, number of people living in the home or CA residence
between the retroactive month(s) requested and the current signed Statement of
Facts, then verification of the change is required.
8.20.1
Ex Parte Reviews [SB 87]
To avoid unnecessary and repetitive requests for verification that can add to
administrative burdens, create difficulty for individuals and families to retain
coverage, and cause eligible individuals and families to lose coverage, EWs must
conduct ex parte reviews to the extent possible.
Relevant information and verification from case files from all programs must be
reviewed when appropriate. Information and verification from other resources
including but not limited to MEDS, IEVS, SDX, BENDEX, and Child Support must
be used in the ex parte review.
Revised: 11/4/16
Update # 16-38
Medi-Cal Handbook
page 8-37
Verifications
[Refer to “Ex Parte Review Process,” page 8-4]
8.21 Additional Verification Requirements [50169]
EWs must not require additional verifications when the client has been previously
aided in another public assistance program (CalWORKs, Food Stamps, IHSS, etc.)
and verifications in those case files are less than 12 months old and consistent with
reported information on the Medi-Cal application. However, when verifications in
those case files are inconsistent with what is reported by the client, current
verification must be requested.
8.21.1
When Required
• Prior to approval
• Redetermination
• At any point needed.
Note:
The EW must document in Case Comments the reason why additional
verification is needed.
8.21.2
Verification Required
Verification necessary to ensure a correct eligibility determination.
Note:
If verifications are not obtainable, take an affidavit until verification can be
obtained.
Update # 16-38
Revised: 11/4/16