About These Materials

Prepared by Families USA for use in the District of Columbia

About These MaterialsFamilies USA developed these materials under contract with DC Health Link, the District of Columbia's Health Benefits Exchange, for a training program for DC eligibility workers. These workers determine eligibility for Medicaid and other benefit programs (including SNAP and TANF). They will help consumers apply for coverage and financial assistance, report changes, renew coverage, and verify the information that is needed to determine eligibility. These workers will not be responsible for helping consumers select health plans.

These training materials are posted here as an example that can be adapted for other training programs. They contain information that is specific to the District of Columbia, which would have to be changed if used in another state. Contact Families USA at [email protected] for assistance with adapting these materials.

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ESA Policy Training Day 4


The Verification Process


Changes to Verification

• Current Medicaid rules:• Documentation required for most

eligibility factors• New rules:

• Use electronic data sources and self-attestation as much as possible

• Use paper documentation as a last resort


Electronic Data Sources

• DC Health Link will get data from two hubs, which include several sources each:• Federal data hub• Local data hub

• DC Health Link will get this information automatically. You will not need to know which source to get information from.


The Federal Data Hub

• Connects DC Health Link to federal government data sources

• Data sources include, among others:• Social Security Administration• Internal Revenue Service (IRS)• The Work Number• Department of Homeland Security


The Local Data Hub

• Connects DC Health Link to local data sources

• Data sources include:• DMV• ACEDS• Department of Employment Services


How DC Health Link Uses Electronic Data Sources

1. Checks federal and local data hubs

2. Pre-populates information in application

3. Asks applicant to confirm or change pre-populated information and add additional information

4. Asks for documentation if needed


Important Things to Remember about Electronic Data Sources

• Some electronic data will be months old• Always remember to check pre-

populated data

• If a data source is temporarily unavailable, DC Health Link will automatically check other data sources if one hub is down


When is paper documentation needed?

• When electronic data sources have no information for applicant

• When electronic data sources are not “reasonably compatible” with applicant’s self-attestation

• When a non-applicant does not provide a Social Security number


New Ways of Accepting Documentation

• Accept scanned or photocopied versions of all documentation, including citizenship and immigration status

• Documentation can be submitted:• Online through “My Account”• In person • By mail• By fax• By email


Timeline for Providing Documentation: Medicaid

• If verification needed for an eligibility factor other than citizenship/immigration status:• 45 days to provide documentation• Applicant does not receive Medicaid during this

time

• If verification needed for citizenship/immigration status:• 90 days to provide documentation• Applicant receives Medicaid during this time


Timeline for Providing Documentation: DC Health Link

• Applicant has 90 days after receiving notice

• If inconsistency is not resolved in this time, financial assistance level may change and/or coverage can be terminated


What if applicants cannot provide documentation?

• In some circumstances, applicants cannot provide documentation• For example, in cases of homelessness or

domestic violence• ESA supervisory staff can waive paper

documentation requirements on a case-by-case basis


Review: Question #1

TRUE or FALSE: Applicants providing documentation of citizenship or immigration status must bring the original version into an ESA service center.


Answer: Question #1

FALSE Scanned and photocopied versions of all documents, including citizenship and immigration status, are accepted.


Review: Question #2

TRUE or FALSE: ESA workers will need to remember which data sources are in which hub and choose which hub to ask for information when electronic data is needed.


Answer: Question #2

FALSEDC Health Link automatically checks the right hubs and data sources for you.


Verifying Household CompositionElectronic data sources are not available for household composition, so DC Health Link will accept self-attestation unless:• Two tax filers who do not file jointly say they

will claim the same dependent• Two people who do not file taxes claim that

the same person lives with them

In these cases, documentation is required.


Tax Forms to Document Household Composition

• Tax forms are the strongest type of documentation

• Form 8332• Custodial parent allows non-custodial parent

to claim child

• Form 2120• Multiple taxpayers supported dependent• Form indicates which person gets to claim

dependent


Other Documentation of Household Composition

If neither person has tax forms, use:• School or medical records• Childcare records• Statements from non-relatives• Leases• Mail to or regarding the person being claimed• Records of religious or recreational activities


Five Steps for Verifying Income

1. DC Health Link checks IRS data• If potentially eligible for premium tax credits,

application will ask for expected annual income

• If potentially eligible for Medicaid, and IRS data is not available or applicant disagrees with IRS data, continue with steps 2-5

2. DC Health Link checks federal and local data hubs and pre-populates application


Five Steps for Verifying Income (cont’d)

3. Applicant confirms or changes pre-populated information

4. DC Health Link asks about any additional sources of income

5. DC Health Link calculates total income and asks applicant to confirm


Reasonable Compatibility

Reasonable compatibility: any difference between self-attestation and electronic data sources is either small or does not make a difference in eligibility


Reasonable Compatibility for Income: Medicaid

As long as both self-attestation and electronic data sources show household income is below Medicaid eligibility level, the information is reasonably compatible.


Reasonable Compatibility for Income: DC Health Link• If attestation of household income is above

electronic data source amount or is no more than 10% below • Reasonably compatible• DC Health Link uses self-attestation to calculate

premium tax credits and cost-sharing reductions

• If attestation is more than 10% below electronic data sources• Not reasonably compatible• Documentation is needed


Reasonable Compatibility between Medicaid and DC Health Link

• When self-attestation is above Medicaid eligibility limit and electronic sources are below, use self-attested data

• When self-attestation is below Medicaid eligibility limit and electronic data sources are above:• Not reasonably compatible, unless the

difference is less than 10%• Documentation is needed


Reasonable Compatibility: Example #1

Sasha is 35 and has no one else in her household. • Electronic data sources say her income is

$23,000 (200% of poverty)• She says her income is $9,000 (128% of

poverty)

Is this reasonably compatible?



Yes, this is reasonably compatible.

Even though there is a difference of 72% of poverty between self-attestation and data sources, this is reasonably compatible because both are below the Medicaid eligibility level for childless adults.



Christine is 48 and has no one else in her household.• Electronic data sources say her income is

$36,900 (320% of poverty)• She says her income is $33,200 (289% of

poverty)



No, this is not reasonably compatible

This is not reasonably compatible because she is eligible for premium tax credits and her attestation is more than 10% below what electronic data sources report.



Bernie is 35 and intends to claim his 10-year-old son, Marcus. He has no one else in his household. • Electronic data sources say his income is $34,432

(about 222% of poverty for a family of two)• He says his income is $33,036 (about 213% of

poverty)

Is this reasonably compatible?



Yes, this is reasonable compatible.

Because self-attestation is less than 10% below electronic data sources, the information is reasonably compatible.


Documentation of Income

Documentation of income includes:• Most recent paystubs• Letter from employer• Award letters (such as Social Security)• Documentation of non-wage income,

such as interest, dividends, annuities• Documentation of any planned

adjustments to income


Verifying Citizenship and Immigration Status

• DC Health Link uses federal data hub to verify citizenship and immigration status

• If verification is not possible:• Applicant has a 90-day “reasonable

opportunity period” to provide documentation

• Applicant gets coverage based on income during this time


Documentation of Citizenship

Two types of documentation: 1. Primary 2. Secondary

Applicant can provide:• Primary documentation by itself• Secondary documentation plus another

form of ID


Documentation of Immigration Status

DC Health Link will need:

1. Nine-digit alien number

2. Copy of something that shows immigration status


Verifying Residency

• Verification needed only for those over age 19• DC Health Link checks:

• Department of Employment Services• Department of Motor Vehicles• The BENDEX file

• Residency verified even if sources show a different DC address


Documentation of Residency

• Paper documentation of residency:• Current driver’s license• Current lease• Current rent receipt• Current utility bill• Current letter from landlord

• Homeless applicants are not required to provide paper documentation


Verifying Incarceration Status

DC Health Link will accept self-attestation of incarceration status for the applicant and applicant’s household members.


Verifying Age

• DC Health Link checks federal data sources

• Verification needed only if difference between attested age and electronic data sources affects eligibility• Example: a person who has income of 250%

of poverty and could qualify for Medicaid as a child, but not as an adult


Documentation of Age

• Birth certificate• Driver’s license• Other government-issued photo ID• Other photo ID with name and date

of birth


Verifying Pregnancy

Application accepts attestation of:• Pregnancy• Number of children the pregnant

woman expects to deliver


Verifying Caretaker Relative Status

Application accepts attestation that an applicant is a caretaker relative.


Review: Availability of Other Coverage

• Availability of other coverage affects:• Eligibility for premium tax credits and cost-

sharing reductions• Match rate that DC receives for certain

pregnant women and children

• Coverage can come from:• Other government programs (for example,

Medicare or the VA)• An employer (or a family member’s

employer)


Verifying Availability of Other Coverage

• Government coverage• DC Health Link will check for eligibility

determination for other programs• If found, applicant must provide documentation

that coverage has been cancelled

• Employer coverage• Electronic data available for some federal

employees • DC Health Link relies on information provided by

applicant and employer


Verifying an Applicant’s Social Security Number

• DC Health link will check federal data hub for match

• If no match is found, applicant must provide documentation or resolve the inconsistency with the Social Security Administration


Verifying American Indian Status

• Important for:• Treatment of income in Medicaid• Ability to enroll in DC Health Link at any time• Higher levels of cost-sharing reductions

• DC Health Link does not currently have an electronic data source for this information

• Applicant must provide documentation


Documentation of American Indian Status

Any formal documentation that verifies American Indian status from:

• A tribe• Indian Health Services (IHS)• Bureau of Indian Affairs


Documentation of American Indian Status

For those born outside of the U.S.:• Form 1-94 with a notation of “S1-3”• 1-551 Permanent Resident Card stamped “S1-3”• Temporary 1-551 stamp coded “S1-3” in a

Canadian passport• Tribal record or document certifying at least 50%

American Indian blood, and satisfactory evidence of birth in Canada

(cont’d)


Review: Question #1

Travis and Maggie have one daughter, Lindsay, who is three. They say their income is $20,000 (102% of poverty for family of three). Electronic data sources say their income is $39,000 (200% of poverty for a family of 3).

Is this information reasonably compatible?


Answer: Question #1

YES, the information is reasonably compatible.

Both sources of information say their income is below the Medicaid eligibility threshold, so their information is reasonably compatible.


Review: Question #2

Tomas gives you an address in SE. DC Health Link finds an address for Tomas in NW.

TRUE or FALSE: Tomas must provide documentation to prove his residency.


Answer: Question #2

FALSEEven though the addresses are different, both Tomas and the data sources say he is a DC resident, so he does not need to provide documentation.


Review: Question #3

DC Health Link cannot verify Ivan’s immigration status, but his SSN and all other Medicaid eligibility factors are verified and he is otherwise eligible.

TRUE or FALSE: Ivan cannot get covered by Medicaid until his immigration status is verified.


Answer: Question #3

FALSEIvan has 90 days to provide documentation of immigration status, and he can get Medicaid during this time.


Recap: The Verification Process• What you will do:

• Enter information into the application• Help applicant check pre-populated

information• Explain documentation requirements• Verify documentation

• What DC Health Link will do:• Check all electronic data sources automatically• Pre-populate application• Check for reasonable compatibility• Let you know when documentation is needed


Case Processing


The “Happy Path”

Eligibility determined when:• Necessary eligibility factors are verified

electronically• Information is reasonably compatible

with what the applicant says on the application


Dealing with Inconsistencies

Before asking for documentation:• Check for typographical or clerical

errors• Contact the applicant about possible

application mistakes


Reasonable Opportunity Periods: Medicaid

• If verification needed for something other than citizenship/immigration status:• 45 days to provide verification• Applicant does not get Medicaid during this

time• If verification needed for

citizenship/immigration status:• 90 days to provide verification• Applicant gets Medicaid during this time


Reasonable Opportunity Periods: DC Health LinkIf documentation is needed:• Applicant has 90 days to:

• Provide documentation that resolves the inconsistency with the data source

• 90-day period can be extended by 30 days if applicant makes a good faith effort to get documentation

• Documentation requirement can be waived in special circumstances (except for SSN and citizenship/immigration status)


Coverage while Dealing with Inconsistencies

• If otherwise eligible, applicant can receive premium tax credits during reasonable opportunity period• Must pay back tax credits if found ineligible

• If otherwise eligible, applicant can receive Medicaid if citizenship/immigration status is the only inconsistency


MAGI-Eligible Applying for Non-MAGI Medicaid

• Can receive premium tax credits or Medicaid based on income while waiting for a determination – this helps someone waiting for Medicaid based on disability.

• Will not have to pay back premium tax credits taken while waiting


Retroactive Medicaid Eligibility

Just like now, Medicaid starts three months prior to the date of application if the person was eligible during that time

• Ask the person to submit any back bills for payment


Reporting Changes


The Importance of Reporting Changes

• Enrollees must tell DC Health Link when information provided on their application changes

• Even a small change can affect eligibility

• If changes are not reported, enrollees may:• Not be getting as much help as they could • Have to pay back money at the end of the year • Be incorrectly receiving Medicaid benefits


Example: Alejandro

Alejandro is single and has no dependents. When he applied, his income was at 265% of poverty. A few months later, his hours are cut at his job, and his income goes down.

Why is it important for Alejandro to tell DC Health Link about this change?


Why Alejandro Should Report the Change

Alejandro should report the drop in his income because:• He could now be eligible for Medicaid and

would not need to pay monthly premiums, OR

• He could be eligible for a bigger premium tax credit and cost-sharing reductions


When to Report a Change

Enrollees must update DC Health Link if they experience changes in:

• Income• Household size • Address or state of residence• Employer coverage• Eligibility for other coverage• Student status• Incarceration status• Immigration status• How they expect to file taxes


Income Thresholds for Reporting Changes

• Medicaid enrollees: Must report any change (no threshold)

• DC Health Link plans with premium tax credits:• Only required to report changes in income of

more than $150 per month ($1,800 annually)• Should report smaller changes too because any

income change can affect premium tax credit amount


Example: Teresa

Teresa is enrolled in a DC Health Link plan and receives premium tax credits. Every year, Teresa’s boss gives her a bonus. The exact amount varies from year to year, but it is usually around $1,000.

Teresa asks if she needs to report the bonus when she finds out the amount.

How would you respond?


Should Teresa report the change?

• Teresa has a DC Health Link plan with premium tax credits, so she must report changes of more than $1,800 per year• Her bonus will be below this threshold, so

she is not required to report change

• It is a good idea to report anyway so she does not end up owing back any of her premium tax credit


Review: Question #1

TRUE or FALSE: Consumers may not end up getting the full amount of assistance they are eligible for if they do not report changes in income.


Answer: Question #1

TRUEFor example, someone may be paying premiums for a DC Health Link plan but be eligible for Medicaid.


Review: Question #2

TRUE or FALSE: Because people with DC Health Link plans and premium tax credits are not required to report changes of less than $150 per month, a change of $100 that was not reported would not affect the value of the premium tax credit a person could get.


Answer: Question #2

FALSEPremium tax credit amounts are based on annual income. Any change in income can change the amount of the premium tax credit a person gets, even if the change is below $150 per month.


How DC Health Link Handles Changes

1. When an enrollee reports a change to DC

Health Link

2. When DC Health Link gets information about a change from electronic data sources

There are two ways DC Health Link finds out about a change:



How to Report a Change

Enrollees can report changes by:• Using “My Account” online• Calling the customer service call center• Getting help from ESA, either in person

or over the phone• Mailing information to ESA


The Process for Reporting Changes

1. Enrollee reports the change within 30 days

2. DC Health Link sends a notice to the enrollee:• Confirming that the change report was received• Requesting documentation, if needed• Explaining how the change affects eligibility

3. If a change affects eligibility, DC Health Link will ask the consumer to enroll in new coverage or explain how the amount of their premium credit is changing


When DC Health Link Finds a Change

• DC Health Link will check electronic data sources to find changes• For example, DC records will show if a

household member who was eligible for premium tax credits has enrolled in Medicaid

• If DC Health Link finds a change the enrollee has not reported, a notice will be sent to the enrollee to get confirmation


Change Reporting Timeline: Medicaid

• Enrollee has 15 days to respond to a notice with documentation if the change is incorrect

• If enrollee does not respond, eligibility is re-determined


Change Reporting Timeline: DC Health Link

• Enrollees have 30 days to confirm or disagree with change

• If enrollee disagrees, given 90 days to provide documentation and coverage continues

• If enrollee does not respond, eligibility re-determined only if change is not related to:• Household size• Income


When Changes to Tax Credits Will Go into Effect

• Changes to premium tax credits and cost-sharing reductions will be made:• At the end of the month, if redetermined by the 15th of

the month• At the end of the next month, if redetermined after the

15th of the month


When Coverage Will End: Medicaid

If a Medicaid enrollee is no longer eligible, coverage will end:

• At the end of the month, if 15 or more days left in the month from the date of re-determined

• At the end of the next month, if less than 15 or more days left in the month from the date of re-determined


When Coverage Will End: DC Health Link

If a DC Health Link enrollee is no longer eligible or cancels their coverage, it will end:

• At the end of the month after the month in which eligibility is re-determined

• When the enrollee requests coverage to end, if the request is submitted at least 14 days in advance


Example 1: Pia

Pia is currently getting premium tax credits. Pia loses her job and gets a notice from DC Health Link telling her that data sources say that she is receiving a certain amount in unemployment.

The amount Pia is receiving in unemployment is actually higher.

What should Pia do?


Example 1: What should Pia do?

Let DC Health Link know that the information from the electronic data sources is wrong within 30 days to make sure the amount she is receiving in premium tax credits is correct.


Example 2: Santiago

Santiago has Medicaid and gets a notice from DC Health Link saying that data shows his income has increased.

TRUE or FALSE:If Santiago does not respond to the notice, his eligibility for Medicaid will not be re-determined.


Example 2: Answer

FALSE Since Santiago has Medicaid, DC Health Link will re-determine his eligibility even if he does not respond to the notice.


Things to Remember

• When consumers apply for coverage, tell them they must inform DC Health Link of any changes within 30 days

• Tell consumers they may receive notices about changes that DC Health Link identifies through data sources and must respond within 30 days

• DC Health Link will determine if a change affects eligibility and tell the consumer what to do

• ESA is one of the ways consumers can get help reporting changes

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