medi-cal handbook verifications 8. verifications · verifications 8. verifications verification is...

Medi-Cal Handbook page 8-1Verifications

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

2 Medi-Cal HandbookVerifications

• 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


8.2 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.



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.


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.


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.



8.5 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.


• 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.



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.



The following documents must be provided with an identity document from TIER 5:

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.

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:

• One of the 50 States

• District of Columbia

• 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)

• *Northern Mariana Islands (after November 4, 1986 (NMI local time)), OR

• Guam (on/after April 10, 1899).

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.

An amended birth record document that is amended after 5 years of age is considered fourth level evidence of citizenship.

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.

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.



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.



Proof of adoption under the Child Citizenship Act

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.





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.

NOTE: For children under 16, the document must have been created near the time of birth or 5 years before the date of application.

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.

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.

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.



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.

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.



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.

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.




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).



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.


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



• 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.



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).



8.7.2 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.



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.


Acceptable verification includes:

• Proof of Social Security (Title II) benefits based on disability or blindness

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.



• 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.


• 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.



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


• Redetermination.


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.



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.





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)]



• Monthly thereafter.


“Request for Limited Services” (MC 4026).



8.13 Medicare Eligibility[50168]


• Within 60 days of initial application but not necessarily prior to approval

• Whenever there is a change.


• 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]


Other health coverage (OHC) must be verified prior to approval.




• 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]



• 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.


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).



• 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)



• 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.



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).



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.



8.16 Property [50167]


• Prior to approval when reported


Exception:Property Waiver Programs


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).



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



• 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.



8.17 Pregnancy


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


• 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).



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.



• 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.



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/



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.



[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.



• Redetermination

• At any point needed.

Note:The EW must document in Case Comments the reason why additional verification is needed.


Verification necessary to ensure a correct eligibility determination.

Note:If verifications are not obtainable, take an affidavit until verification can be obtained.
