Element Policy Section

Case Record Documentation

Verification and Sources

General Acceptable
Documentation

Telephone:
Telephone number called.
Person(s) spoken to, including title (authority to release information being requested).
Date and time of call.

Document all information from responder, including dates, values and/or balances. Indicate source(s) responder references.

Verbal Documentation:
Verbal documented statements are acceptable unless the guide specifies that written statements are the minimum acceptable verification.

Internet information located at the links below may be an acceptable source of verification and should be printed and filed in the case record.

http://reg03.dhs.state.tx.us/-mepd/resources.htm

http://ofs.hhsc.state.tx.us/-mepd/default.aspx

Note: Other forms of documentation may be acceptable with proper, complete documentation. This may be allowed with supervisor approval, but is not recommended for case actions other than routine reviews.

Blanks on Most Recent Application/Review:

Blanks on the most recent application/review are considered uncleared, unless documentation clearing each item left blank exists in the case record.

Only one type of verification is required for all case documentation, unless noted otherwise.
Example: If all required information is on bank statement, there is no need to request Form H1239, Request for Verification of Bank Accounts.

WTPY Use and Documentation

The WTPY can verify several things regarding an applicant/recipient’s eligibility and co-payment. Examples: Name on SSA record, DOB, citizenship, Medicare Part A, B, C and D, the Social Security amounts, dual entitlement to Medicare and Medicaid.

This list is not all inclusive.

Use the WTPY as a verification tool when possible. Because of the need to comply with SSA safeguarding requirements, a printed WTPY must be destroyed. Therefore, it is necessary to document (H1201, H1202, MECM, etc.) details needed for specific eligibility elements.

Documentation must include the:

• type of information verified by viewing the WTPY,
• WTPY request number, and
• date on which the WTPY was viewed.

Example: To verify the amount of RSDI, include the “Type of information verified by viewing WTPY request number #### on MMDDYYYY.”

The documentation (H1201, H1202, MECM, etc.) would be … RSDI amount of $795.00 verified by viewing WTPY request #1234789 on 01/02/2010.

WTPY

Record correctly in the file.

Streamlining Methods for Community Based Applications

• All COLA disregard programs such as Pickle, DAC, Widow/Widower
• All Medicare Savings Programs
• The Community Attendant Services  (CAS) program.

• an institution,
• a 1915(c) Home and Community Based Waivers services, or
• Medicaid Buy-In.

This procedure is available online under the Office of Family Services (OFS) website for Medicaid for the Elderly and People with Disabilities (MEPD) for LTC Information and Referrals.

Simplification for Community Based Programs

Streamlining Methods for Redeterminations

B-8440

Apply the three options to redeterminations for both institutional cases and community-based cases.

Guardians and Other Agents

F-1231

Determine guardian of the estate and person. Determine if there is a power of attorney (POA). If there is no guardian or POA, determine other fiduciary agent.

Obtain a copy of the guardianship or POA document.

Citizenship/ID, Residence, Alien Status

D-3000, D-5000, D-8000

Document level of evidence of citizenship used. If Level 1 is not used, document the reason a more reliable source is not used. Identity verification must also be documented. Copies of documents are acceptable if they are legible and not questionable.

See Appendix V, Levels of Evidence of Citizenship and Acceptable Evidence of Identity Reference Guide, for acceptable documentation.

Excess Income or Resources

Hint: Notification of denial should include that denial is based on applicant/recipient declaration. Document name and type of contact, date, time and any additional comments to substantiate decision.

Excess Resources:

• If excess resources can be designated as burial funds, allow the person the opportunity to do so. Section F-4227, Burial Funds.
• If a person is determined ineligible because of excess funds in a joint account, allow an opportunity to disprove the presumed ownership of all or part of the funds. The person must also be allowed to disprove ownership of joint accounts that do not currently affect eligibility but may in the future. Section F-4121, Joint Bank Accounts.

Excess Income:

See Section G-6200, Special Income Limit for the Eligibility Budget; Section F-6800, Qualified Income Trust (QIT); Appendix XXXVI, Qualified Income Trusts (QITs) and MEPD; and Section R-2500, Explanation of Benefits.

Third-Party Resources

D-7000

Case record documentation must result in complete and accurate Form H1039-A and Form H1039-B on file in case record.
 
State/MEPD specialist judgment call:
Assignability of the policy may be pursued on a follow-up basis if it appears reasonable that the policy is assignable.
 
Casework Hints:
Check bank draft(s) for premiums for third-party resource (TPR) policies.
Check employment history/retirement income for possible TPR(s).

Names, address and policy number of insurance policies (assignability). 

• Copy of policy
• Form H1253, Verification of Health Insurance Policy
• Copy of insurance card

The amount of the premium, proof that premiums are being paid and policy is in force.

Copies of canceled checks are very good proof of payment of an insurance premium.

Incurred Medical Expenses

Chapter H,
Co-Payment

Incurred medical expenses (IMEs) should be properly determined (co-payment issue). Is the IME being paid by the applicant/recipient? No IME should be given if there is no proof that the applicant/recipient paid the insurance premium and/or incurred other medical expenses. If someone else has been paying the insurance premium and/or medical expenses and the applicant/recipient clearly plans to make the payment, a special review should be scheduled to consider the IME deduction.

Completed, signed and dated Form H1263, Certification of Medical Necessity.

See Appendix XXXII, IME Deductions for Medicare Rx Drugs, for treatment and processes.
 

Names, address and policy number of insurance policies

Name, address of other medical providers the applicant/recipient may be paying, such as a dentist.

For what is the charge; is it for an allowable medical expense; how many payments will be required for complete pay off; how much has been agreed to be paid; is there any private health insurance that might pay the expenses? If no documentation field present in TIERS, use case comments.

Name, address of any other source of payment. Copies of canceled checks are very good proof of payment of a medical bill.

Do not allow deductions for non-assignable health or non-assignable dental insurance policies. Assignable insurance policies must be reported on Form H1039, Medical Insurance Input, and sent to the Office of Inspector General (OIG), Third-Party Resources Unit.

Transfer of Assets

Chapter I
 

Evaluate that the transfer took place. Document the when, what, how much was it worth as of 12:01 a.m. on the first day in the month of transfer and how much was received, the “from(s)” and the “to(s).”

Date of transfer.

Establish the look-back period. Were assets transferred within the look-back period?

Presume transfer took place for Medicaid eligibility. Is there any value that is uncompensated?

Evaluate transfer for exceptions. Document applicable exception as needed.

Value of resource at time of transfer. Amount of income being transferred.

Offer rebuttal.

Compensation received to offset value transferred.

Documentation of rebuttal offered and record of time frames observed. Rebuttal notices properly sent? If rebuttal is attempted, document evidence used during rebuttal process.

Document factors used to determine validity of rebuttal. Document supervisor concurrence of rebuttal decisions.

See Section I-3000, Exceptions to the Transfer of Assets.

See also:

Section F-6500, Irrevocable Trusts

Section F-6800, Qualified Income Trust (QIT)

Section F-7000, Annuities

Section E-4400, Other Annuities, Pensions and Retirement Plans

Section E-3320, Alimony and Support Payments, and Section E-3370, Gifts and Inheritances

Section E-3372, Effective Date of Receipt of Inheritance; Disclaimers

Sources for verifying validity of a transfer:

• Copies of documents transferring assets. (Documentation from viewing documents is acceptable if copies cannot be obtained. Document reason copy could not be obtained.)
• Contact with companies or firms such as a financial institution that is knowledgeable of the transfer. (The contact must be documented using telephone contact documentation.)
• Verify the fair market value according to handbook requirements for the asset transferred.

Sources for verifying the amount of compensation offered:

• If compensation is other than cash, document the formula used for determining the value of the tendered compensation.
• Verification should include a copy of the sales document or agreement. If an oral agreement was made, obtain a written statement from the applicant/recipient and the person who received the transferred asset.
• If more than one source of verification is required (for example, one to verify transfer and another to verify compensated value), document the additional sources and pertinent information in case comments.

Receipts used to verify compensation: Bank deposit slips or bank statements (for verification of the amount only).

Bank Accounts

F-4120

Document the name of the financial institution and account number. Account accessibility by applicant/recipient.

Document the account balance as of 12:01 a.m. on first day of appropriate month(s).

Give consideration to encumbered funds.

Give consideration to timing of consistent income deposits.

Is interest being paid on the account? Amount and frequency of payment. Source of verification. For treatment of interest paid, see interest and dividends section, and the treatment for eligibility and co-payment budgets.

Identify the source of all deposits. All questionable deposits should be verified.

Identify withdrawals  that reoccurred at least three times a month. Identify payee of all bank drafts. Do not develop a transfer penalty when the total amount of all transfers per month is $200 or less, as outlined in Section I-3600, Administrative Procedures of Transfers of Nominal Amounts.

Document information, in case comments, on all deposits and withdrawals, as identified above.

Applications:
Obtain bank statements covering month of application and three prior months to substantiate financial flow/management and statements regarding potential transfers of assets.

Reviews:
Verify resources as of 12:01 a.m. on the first day of the month Form H1200, Application for Assistance – Your Texas Benefits/Form H1200-A, Medical Assistance Only (MAO) Recertification, was received, the preceding two months or any month up to the month the review is completed. Reminder: All resources must be verified as of 12:01 a.m. on the same month.

Verify an applicant's/recipient's bank account balance using one of the following methods:

• Bank statements or completed Form H1239. Payment for completion of the form cannot be made by HHSC.
• Letter from the financial institution.
• Telephone contact with an employee of the financial institution, using telephone contact documentation.
• Pursue written follow-up if unable to obtain information by telephone call or this information results in the applicant/recipient being ineligible.

The following three pieces of information must be in the case record:

• Name of the financial institution
• Account number(s)
• Amount of the balance as of 12:01 a.m. for the appropriate month(s)

If the verification that the person provides does not meet the three criteria above, ask specifically for the information that is missing. For example, request a copy of the bank statement that will indicate (1) the name of the financial institution, (2) the account number, and (3) the balance as of 12:01 a.m. for XX (the appropriate) month(s).

Cash
F-4110

Cash is a countable resource. Accept the person's statement as to the amount of cash on hand. Address the amount as of 12:01 a.m. on the first day of the month.

Accept statement.

Joint Bank Accounts

F-4121

Document the name of the financial institution and account number(s).

Document the name of the person(s) with access to the account(s).

If disproving ownership, Form H1299, Request for Joint Bank Account Information, or a written statement by the applicant/recipient (or from the applicant's/recipient's authorized representative if other than a person listed as an owner of the account) as to the applicant’s/recipient's ownership of the funds in the account. (Authorized representative’s statement can be accepted if no other statement is available and there is additional evidence to support the statements, such as deposits and canceled checks.)

Whose funds were used to establish the account?

Whose income was used to make subsequent deposits, and who made withdrawals? Use case comments to document how and when ownership is disproved.

Written statement(s) from co-holders of the account verifying the applicant’s/recipient's statement. A third party's statement may be necessary if either party is mentally incompetent.

Evidence that a change has been made to restrict the applicant's/recipient's accessibility to the account (funds) or establish separate accounts.

If account is not disproved, follow guidelines for case record documentation for bank accounts.

If all monies belong to the applicant/recipient, no Form H1299 is required. Follow guidelines for case record documentation for bank accounts.

Name of the financial institution and account number(s).

Name of the owner (or owners) of the account.

The applicant/recipient must be given the opportunity to disprove or prove ownership of part or all funds/income in the account before denial.
 

Trusts

F-6100 through F-6900

Type of trust.

Is the trust revocable or irrevocable? Document if the trust revocable or irrevocable. If irrevocable, review transfer of assets treatment in Section F-6500, Irrevocable Trusts; Section F-6713, Transfer of Assets; and Chapter I, Transfer of Assets.

Is the trust a Qualified Income Trust (QIT)? Are deposits being made to a trust account? Determine the source(s) of deposits to the account. Who is the beneficiary?

Document the value of trust corpus.

Document the amount and frequency of income produced by the trust. Amount of corpus and income available to the applicant/recipient.

Countability of corpus and income being produced.

Document the source of verification.

Send copies of trust(s) to regional legal staff for interpretation.

• Copy of the trust agreement.
• Copy of the will, if the trust is a testamentary trust.
• Statement(s) from the financial institution, trust management company, attorney.
• Legal staff interpretation. (Contact with legal staff should be via designated procedures.)

Note: If the trust is exempt document the basis for the exemption.

Patient Trust Funds

F-4123

Document whether the applicant/recipient maintains a trust fund at the facility; balance in the account as of 12:01 a.m. on the first day of appropriate month(s).

Is interest being paid on the account? Amount and frequency of payment. Source of verification. For treatment of interest paid, see interest and dividends section.

If the applicant/recipient resided in another nursing facility and indicates that a trust fund was maintained at the previous facility, a contact must be made with that facility to determine if the applicant/recipient owns a trust fund at that facility and to verify funds have been transferred to current facility.

Use one of the sources of verification listed below:

• Documented viewing of the facility's records;
• Copy of the statements provided by the facility; or
• Contact with a knowledgeable representative at the facility, such as a telephone call to the facility bookkeeper, using telephone contact documentation.

Stocks

F-4130

Name of company, number of shares and type of shares. Document in case comments: 

• number of shares,
• type of shares, and
• calculation(s) of countable value.

Market value as of 12:01 a.m. on the first day of the appropriate month.

Source of verification.
 

Use one of the following sources for verifying the closing prices of stocks.

• Newspaper;
• Statement from a brokerage firm;
• Research department of a local library; and
• Documented contact with the issuing company, using telephone contact documentation.

Use one of the following sources to verify ownership of stock:

• Copies of stock certificates;
• Written statement from an authorized employee of the brokerage firm or issuing company; and
• Documented contact with brokerage firm or issuing company, using telephone contact documentation.

Bonds

F-4140

Name of company, type of bond, serial number. Serial number is required to verify face value. Document serial number in case comments.

Market value as of 12:01 a.m. on the first day of the appropriate month.

Document the source of verification.

Note: There is no need to redetermine the value of a bond if there is evidence that the value will not change from year to year.

Verify ownership by examining the front of a bond.

Use one of the following sources for verifying the cash value of municipal, corporate and government bonds:

• Newspaper (closing price on the last day of the month before the appropriate month(s));
• Statement from an authorized employee of a savings or banking institution or a brokerage or securities firm; and
• Research department of a local library.

 
Use one of the following sources for verifying the cash value of U.S. savings bonds:

• Table of redemption values for U.S. savings bonds (the table may be available at a savings or banking institution),
• Statement from an authorized employee of a savings or banking institution, and
• Copy of bond.

Promissory Notes, Loans and Property Agreements

F-4150
(for resource treatment)

I-6200
(cross reference for transfer of assets)

Document the following:

Ownership of note.

Accessibility by applicant/recipient.

Whether note is negotiable. If non-negotiable, why? Does a transfer of assets exist?

Whether the note is an excluded resource.
Reason for exclusion, if excluded.

Current market value of note, if countable. Amount of income (interest) generated by the note.

Source of verification.
 
State/MEPD specialist judgment call: If the appraisal value is $0, based on reason given by the appraising entity, document your evaluation of the validity of the appraisal.

Note: The applicant/recipient must own the note. Notes the applicant/recipient owes are not a resource.

Send copies of notes, loans and property agreements to legal for interpretation.
 
Use one of the following sources for verifying ownership of a promissory note, loan or property agreement:

• Copy of the instrument (note, mortgage, agreement); and
• Statements from the purchaser and note holder.

Use one of the following sources for verifying negotiability of a promissory note, loan or property agreement:

• Copy of the instrument that indicates whether it is negotiable; and
• Statement from a bank or other financial institution, private investor or real estate agent.

Use one of the following sources for verifying the value of a promissory note, loan or property agreement:

• Copy of the instrument; and
• Amortization schedule.

Statement from a bank or other financial institution, private investor or real estate agent (if the fair market value is being rebutted). The following information must be included:

• Current principal owed;
• Appraised market value (if value is $0 document reason);
• Date the original instrument was signed;
• Interest rate; and
• Payment schedule.

Note: If the appraisal value is not likely to change, there is no need to reverify the value each year, unless circumstances involving the resource change.

Home as an Excluded Resource

F-3000

Document the address or location description of the home.
 
Verify and document one of the following reasons for exclusion:

• Principal place of residence
• Spouse residing in home
• Dependent relative residing in home
• Home is placed for sale
• Life Estate/Remainder Interest (also see section on life estate/remainder interest in this document)
• Intent to return

The primary evidence of an applicant's/recipient's intent to return home is applicant's/recipient's statement, as documented on a signed Form H1245, Statement of Intent to Return Home, or written statement from applicant's/recipient's spouse or authorized representative.

Source of verification.

Current residence address of applicant/recipient and/or spouse (prior to NF admission). Sources for verification of exclusion are as follows:

For spouse/dependent relative residing in home:

Document statement establishing residence as spouse's/dependent relative's primary residence. Use case comments for documentation.

For intent to return:

Form H1245 or comparable written statement on intent to return to the described residence. Document receipt of form in case comments.

For home placed for sale:

• Copy of real estate listing agreement.
• Newspaper ad.
• Picture of visible for sale sign on property.
• Collateral contact with someone viewing visible for sale sign on property, using telephone contact documentation.

Document these sources in case comments.

Review status of home placed for sale at each annual review. If a shorter time frame is referenced in real estate listing agreement, set special review to monitor at the specified time.

The Home as a Countable Resource

F-3300

Document the location and ownership of homestead.

If property does not meet exclusion, determine current equity value of homestead or applicant's/recipient's equity interest in homestead.

Document in case comments applicant's/recipient's ownership, if less than 100%, and the formula used for determining countable equity value.

See MEPD, Section I-3000, Exceptions to the Transfer of Assets.

See MEPD, Section F-3800, The Home and Transfer of Assets.

Source of verification.

Use one of the follwing sources for verification of location, ownership and current market value of a home: 

• Tax statement with current assessment, using 100% evaluation;
• Copy of the appraisal from the local taxing authority or appraisal district;
• Statement from a local knowledgeable source (for example, realtor); and/or
• Telephone contact with a previously listed source, using telephone contact documentation.

Use one of the follwing sources for verifying equity value of a home:

• Copy of a lien, note or other outstanding debt;
• Statement from the mortgage company or a copy of the amortization schedule; and/or
• Statement from the tax office (if taxes are in arrears).
• In TIERS, “court record or other legal document” includes copy of lien, note or other outstanding debt, statement from mortgage company or copy of the amortization schedule.

Home Equity

F-3600

Treatment of a homestead as a resource in Section F-3000, Home, continues but does not impact the determination of disqualification for vendor payment in an institution or denial of waiver services due to substantial home equity. Evaluation of the substantial home equity is required for institutional or waiver services at application and redetermination. Consider reverse mortgage and home equity loans when determining the equity value. Consider undue hardship. 

Obtain verification of home equity value, including a copy of the reverse mortgage or home equity loan if applicable, for the case record. Thoroughly document in case comments the home equity value and information about the reverse mortgage or home equity loan, if applicable.
 

CCRC

F-3700

The entrance fee in a continuing care retirement community or life care community must be evaluated for consideration as a resource if certain criteria are met.

Document:

• CCRC contract date
• CCRC facility name
• CCRC entry date
• resource accessible (yes/no)
• contract specifies fee be used to pay for care (yes/no)
• eligible for refund on termination of contract or departure from the CCRC (yes/no)
• CCRC entrance fee value
• amount of entrance fee spent on care
• refundable amount

Obtain a copy of the CCRC contract.

Other Real Property

F-3210

Document the location and description of property.

Ownership interest in property.

Whether property is excluded.

Reasons for exclusion, if excluded.

Current equity value of applicant's/recipient's interest. If applicant's/recipient's interest is less than 100%, document the amount of interest and the formula used for determining value in case comments.

Source of verification.

Sources for verification include:

• Ownership interest in property.
• Tax statement with current assessment if 100% evaluation is used.
• Copy of appraisal from local taxing authority or appraisal district.
• Statement from a local knowledgeable source about value (for example, realtor).
• Telephone contact with a previously listed source(s) with knowledge of the property in the area, using telephone contact documentation.
• Copy of deed or will to verify ownership.

State/MEPD specialist judgment call:

If property is inherited via dissent and distribution, recipient's statement on degree of ownership may be used if no other documentation is available. Obtain assistance of legal staff to determine degree of ownership.

 Sources for verifying equity value of other property are as follows:

• Copy of a lien, note or other outstanding debt.
• Statement from the mortgage company or a copy of the amortization.
• Statement from the tax office (if taxes are in arrears).
• In TIERS, “court record or other legal document” includes copy of lien, note or other outstanding debt, statement from mortgage company or copy of the amortization schedule.

Proceeds from Sale of Home or Other Real Property

F-3400, F-4260

Determine the type of resource sold and whether the recipient received the current market value. If current market value not received, follow transfer-of-resources policy.

Selling price of home or other real property.

Gross amount received from sale of home/property and expenses involved in sale of home/property. Itemize and document expenses involved.

Document if applicant/recipient is purchasing a replacement home and time frame of exclusion of proceeds from sale of original home. Set special review to monitor.
 

Sources for verification of sale and amount received include:

• Copy of deed.
• Real estate contract or agreement.
• Statement from the mortgage company or a copy of the amortization.
• Statement from the tax office (if taxes are in arrears).
• Copy of the appraisal from the local taxing authority or appraisal district.
• Statement from a local knowledgeable source (for example, realtor).
• Sales receipt or contract.
• Bank deposit slip or copy of check/form of payment.

 
Sources for verifying expenses related to the sale of a resource include:

• Bill for repairs or services, and
• Copy of a lien or note that had to be paid to affect the sale. The copy should show final settlement.

Life Estates and Remainder Interest

F-4212

Location of life estate property.

Whether life estate is excluded as a resource, such as a home.

In TIERS, for remainder interest, use life estate as real property type and document this action in case comments.

Reason for exclusion.

Current equity value, if countable.

See the MEPD, Appendix X, for calculating life estate and remainder interest values.

Calculate equity value and document the formula used for determining value in case comments.

Source used to verify value.

Note: Clearance of life estate is required for subsequent reviews if the recipient is over the resource limit and older than when the value was initially determined.
 
Record if the applicant/recipient chooses to rebut the value, the basis of the rebuttal, the value from a knowledgeable source and verification to support the rebuttal.
 
For the purchase of a life estate, see MEPD, Section I-6100, Purchase of a Life Estate.

See MEPD, Section F-3800, The Home and Transfer of Assets.
 

Sources for verifying ownership of a life estate or remainder interest: 

• Copy of the deed.
• Copy of the will, court record or other legal document showing that the applicant/recipient has been granted a life estate or remainder interest. If the terms of the will, court record or other legal document are difficult to understand, obtain the assistance of legal staff.

Sources for verifying the current market value of a life estate or remainder interest: 

• If statement from knowledgeable source is obtained the MEPD formula for determining value is not necessary.
• Current tax statement or assessment notice.
• Statement from a local appraisal district office.
• Statement from a realtor or an authorized employee of a savings or banking institution.

Sources for verifying the equity value of a life estate or remainder interest:

• Copy of a lien, note or other outstanding debt.
• Statement from the mortgagee or a copy of the amortization schedule.
• Statement from the tax office (if taxes are in arrears).
• Copies of bills for essential repairs.
• Copy of a bill for legal fees.
• For rebuttal, written verification from knowledgeable source.

Note: Life estates cannot be inherited via descent and distribution, as the life estates would end at death. One cannot inherit another person's life estate.

Life Insurance

F-4223

• Name of insurance company, policy number and face value.
• Type of insurance coverage.
• Whether or not insurance is excluded as a resource.
• Reason for exclusion.
• Whether or not insurance is participating. If an applicant/recipient has a participating policy, determine and document whether dividends are used to:
• purchase additional insurance, then treat as an additional life insurance policy;
• increase the value of existing insurance policy coverage, then verify if face value or cash value is increased;
• apply toward the payment of premiums, then disregard dividends as income or resource; and
• pay cash to the policyholders, then verify how often paid, amount of payment and how the cash is used.
• Balance of any dividend accumulation and interest.
• For TIERS, if dividends are accumulating and considered in eligibility, add countable value of dividends to cash value of policy and enter this total in cash value section of life insurance screen. Use case comments to document the actual value of the policy and value of dividends separately. Do not utilize interest/dividend field on life insurance screen.

Current cash value, if countable.
Source used to verify value.
 
Casework Hints:

• Check bank draft(s) for life insurance premiums.
• Check policy for Application for Life Insurance page for indicators of other life insurance policies.

Sources of verification include:

• Copy of insurance policy.
• Completed Form H1238, Verification of Insurance Policies.
• Letter from insurance company.
• Telephone contact with insurance company's representative, using telephone contact documentation.

Note: For term insurance, no further verification is necessary.

Note: On reviews, if total face value equal to or less than $1,500 previously verified and policy is not participating, no further verification is needed.

Burial Spaces

F-4214
 

Document the name of cemetery and number of spaces.

All burial spaces are excluded, regardless of designation. However, if the person acknowledges that the spaces are purchased as an investment, count the equity value.

Ownership of a burial plot in another state does not affect residency requirements or excludability.

• Applicant's/recipient's statement,
• Cemetery association, or
• Funeral home (if associated with a particular cemetery or sells plots). 

Review the purchase contract for the burial spaces. 

Burial Funds

F-4227

Document the type of resource being designated.

Document the total amount of assets being designated.

Amount of asset excludable as designated for burial.

Written statement from the applicant/recipient or his authorized representative designating assets for burial, unless the resource designated is a prepaid burial contract or a bank account styled "for burial." A verbal designation is acceptable when the applicant/recipient or authorized representative is designating life insurance insuring the applicant/recipient (or spouse). Follow-up with a written statement from recipient/authorized representative.

For pre-need contracts, document the:

• name of the funeral home or insurance company;
• how the policy is funded, e.g. life insurance, cash;
• whether the policy is revocable or irrevocable;
• face value of the contract and who owns it;
• cash value if it is owned by the applicant/recipient;
• face value if irrevocable or owned by someone else;
• reason for exclusion if it is excluded; and
• source of verification.

Supervisor concurrence is recommended for not pursing a copy of either.

Other source of verification may be substituted.

See MEPD, Appendix XXXIV, Burial Resources, for calculation of pre-need.

Burial spaces can be excluded for anyone. However, the Burial Fund Designation exclusion is only allowed for the person and the person’s spouse.

Use one of  the following sources for verifying the designation of burial funds:

• Form H1252, Designation of Burial Funds.
• Written statement from applicant/recipient or authorized representative containing the same information requested on Form H1252.
• Written documentation of the verbal statement from the applicant/recipient or authorized representative containing the same information requested on Form H1252 for life insurance designation. Written documentation of the verbal statement must be in the case record documentation. It is optional to document the verbal designation using Form H1252.
• Copy of the ownership papers or the financial institution's record showing the burial fund designation.

If the designated burial funds are in the form of an irrevocable trust or arrangement, obtain a copy of the trust burial or agreement document.

Note: Burial space items are not excludable on insurance-funded burial contracts.

For pre-need contracts verification, obtain one of the following:

• A completed Form H1238-A, Verification of Pre-Need Information.
• A copy of the contract or letter from the funeral home or document a verbal contact with a funeral home representative, using telephone contact documentation.

Automobiles

F-4221

Year, make and model of all vehicles. 

• Exclude one vehicle, regardless of value.
• If the household is made up of more than one person and the additional member of the household requires an additional vehicle for transportation to and from work, exclude the additional vehicle for that member for work transportation.
• If the household is made up of more than one person and there is an additional member of the household who requires handicap accessible transportation, exclude an additional vehicle if the vehicle is specially equipped for that additional member of the household.

For all other vehicles, use current market value.

If the applicant/recipient still owes on the vehicle, consider current market value and equity value. If equity value is less than the market value, document formula used to determine countable value. Indicate the source used to verify current market value and equity value.

Verify the market value of a vehicle in any of the following situations: 

• The applicant's/recipient's statement is not reasonable.
• The applicant/recipient owns more than one the vehicle.

Sources for verifying the value of a car:

• "Blue" or NADA Book (trade-in wholesale value).
• Heart Corp/NARD Black Book.
• Statement from an automobile dealer.
• Newspaper ads.
• Source knowledgeable about antique cars. (In TIERS, use “other acceptable” and document in case comments.)

Note: If the vehicle is being declared as "junk" (not running or fixable), a $0 default value may be assigned.

Land Resources

F-4213

Document the following:

Location of property. Document location/address of property in case comments.

Percentage of interest in land resources. Document percentage of interest owned in case comments.

Applicant/recipient accessibility to interest in land resources.

Whether land resources are excluded as a resource.

Reason for exclusion.

Current equity value of applicant's/recipient's interest, if not excluded. Document calculation of countable equity value in case comments.

Source of verification.

Notes: 

• Clearance of value is not required for subsequent reviews unless circumstances that may change countability or value occur.
• If the mineral rights are non-producing, a $100 "default value" should be assigned. Document reason for $100 default value in case comments.
• If eligibility is negatively impacted by the "default value," a specific value must be verified.

Sources for verifying the value of land resources:

• Tax statement, if assessed.
• Contact a knowledgeable source in the community using telephone contact documentation. (Sources include oil and gas producers, tax assessors/collectors and petroleum lease agents – land men.)
• Form H1242, Verification of Mineral Rights, completed by an authorized employee of the producing company.
• IRS formula of 40 times the average monthly payout in assessing the value of mineral rights for inheritance purposes (to be used only when no other source is available). In TIERS, use “other acceptable” and document information in case comments.

Sources to verify ownership include:

• Copies of deeds, wills or leases. If the terms of the deeds, wills or leases are difficult to understand, obtain the assistance of legal staff.
• Copy of royalty statement.
• Division order, if producing.
• Statement from applicant/recipient about amount of interest (ownership).
• Completed Form H1242.

Sources of Earned Income

E-3100
(includes royalties from book publications)

Gross earned income (if income fluctuates, amounts for the previous six months or number of months available).

Document the following:

Source of earnings.

Calculations to determine average earned income, if appropriate.

Amount of protected earned allowance, if appropriate.

Source of verification.

Date of special review, if appropriate.

Amount of mandatory payroll deductions. In TIERS identify these payroll deductions on expenses screen, in case comments.

Use one of the following sources for verifying the gross earned income for the immediately preceding six months (or less, depending on review schedule):

• Statement from employer about wages (signed and dated).
• Copies of check stubs (for entire period if there is fluctuating earned income).
• Written statement furnished by ICF/MR provider only if verification cannot be obtained from employer.
• Completed and signed Form H1028, Employment Verification.

Support and Maintenance (Non-Vendor Only) Situations

E-8000

Document the name of person(s) who provided support and maintenance and type of in-kind benefit given to applicant/recipient.

Amount of any payment or contribution made or received by the applicant/recipient.

Countable value of in-kind benefit and any calculations to determine if applicant/recipient rebuts maximum presumed value.

Verify stated income is sufficient to provide for known living expenses.
 

Sources of verification include:

• Statement from owner as to current market rental value.
• Statements from applicant/recipient and head of household or authorized representative (use Form H1200 statement if reasonable).
• Copies of checks for payments made by the applicant/recipient.
• Copies of household bills (for example, utilities, rent).

Casework Hint: If support and maintenance income indicated and the maximum amount would not result in ineligibility, count the maximum amount in the eligibility budget. Only calculate actual amounts of support and maintenance if the maximum value results in ineligibility.

Farm Income

E-3130

Type of farm income, applicant's/recipient's interest in farm income, and accessibility of income to the applicant/recipient. If not fully owned by applicant/recipient, document applicant's/recipient's interest in case comments.

Most recent income tax return, including Schedule F.

Note: Project income based on countable income declared on most recent income tax return; depreciation is not an allowable expense. A review should be scheduled for six months to determine if the farm income for the period has changed significantly. If not, the projected income from the tax return should be continued until the annual review. A special review may be scheduled to obtain the next income tax return and put the annual review cycle in line with filing of the return.

In the absence of a recent (previous year) income tax return, use the amount of gross income and allowable expenses from previous six months. This is obtained from records provided by the applicant/recipient.

Reason for difference, if amount of income is anticipated to be different. Document this reason in case comments.

Amount of net countable income and calculations. Reference MEPD, Section E-3120 and Section E-6000, for allowable expenses/deductions. Itemize and document these expenses/deductions in case comments.

Source of verification.

Verify gross annual income and expenses as appropriate.

If the farmland is not part of applicant's/recipient's homestead, verify that income is at least 6% of equity value to ensure the farmland is exempt.

Note: If the farm qualifies as the applicant's/recipient's business, it can be excluded regardless of the value or the rate of return (MEPD, Section F-4300).

Sources of verification include:  

• Income tax return.
• Receipts, payments and statements from other knowledgeable sources (for example, county agent, co-op).

Self-Employment Income

E-3120, E-6000

• Type of self-employment income,
• Most recent income tax return, or
• Amount of gross income and expenses from the previous months (if income tax return is not available or earnings are expected to be significantly different).

Income must be reviewed at a special six-month review. If earnings are determined by using the applicant's/recipient's tax return, determine if the earnings are anticipated to change significantly. Continue to use the earnings determined from the income tax return for the following six months or until the next income tax return is filed.

Note: An income tax return should not be used for projecting income for more than one year. If the applicant/recipient fails to file a timely tax return, income and expenses must be determined from the previous six months and projected.

Amount of income, if anticipated to be different (explain reason). Document in case comments.

Amount of net countable income and calculations used to arrive at countable income if tax return is not used. Document information and calculations in case comments.

Source of verification.

• Most recent year's income tax return, and
• Receipts maintained by the applicant/recipient.

Note: Reconciliation must be done when new tax return is used for projecting the recipient's income or a change in the recipient's income is noted at the six-month review.

Hint: If the applicant/recipient cannot provide income records (income tax receipts, etc.), have the applicant/recipient provide a written self-declaration of projected income or use Form H1049, Client's Statement of Self-Employment Income. Use that statement to project income for one month. Explain the information needed to establish the applicant's/recipient's true income; set a one-month special to obtain the necessary information. Use the information gathered at the special to project the recipient's earnings for six months.

Social Security Benefits

F-4100

Document:

Amount of gross benefit and amount of SMIB premium, if appropriate.

Claim number.

Source of verification.

For applications, verify gross benefits.

For reviews, if the recipient's statement agrees with the conversion amount and no indication exists that the RSDI benefit has changed, no further verification is needed.

Helpful Hint: Check for dual entitlement.

Verify the amount of Social Security benefit by one or more of the following methods: 

• View or obtain a copy of the applicant's/recipient's award notice (letter) from the SSA.
• Obtain information from the SDX computer tape or the RG-09, Bendex Information Memorandum, if the recipient's case is being transferred from SSI to SSI-Related MAO Special Income Limit (SAVERR: Type Program 13 to Type Program 14). See Section A-3200, Special Income Limit.
• Obtain a SOLQ/WTPY.
• Contact a representative of the Social Security Administration using telephone contact documentation.
• View or obtain a copy of the applicant’s/recipient's most recent benefit check or direct deposit slip. This method is least desirable because it may not show the gross amount.
• At review, use the conversion amount in the system of record if there is no indication that the RSDI is different from the converted amount.

Railroad Retirement Benefits

E-4200

Gross amount of benefit and amount of SMIB premium, if appropriate. In TIERS, document deduction(s) on expenses screen and utilize case comments for explanation of deduction(s).

Check deduction(s) for potential life/health insurance. If deduction(s) is for health/life insurance, then pursue verifying and documenting these policies (See TPR/life insurance section(s).)

Railroad retirement claim number.

Source of verification.
 

Verification sources include:

• Obtain a completed Form H1026, Verification of Railroad Retirement Benefits, to furnish information.
• View or obtain a copy of the applicant's/recipient's award notice issued by the Railroad Retirement Board.
• Contact a representative of the Railroad Retirement Board, using telephone contact documentation.
• View or obtain a copy of the applicant's/recipient's most recent benefit check or direct deposit slip. This method is least desirable because it may not show the gross amount. A follow-up letter should be sent to payor.

VA Compensation and Pensions

E-4300

Document the following:

Gross amount of benefit and amount of any deductions (A&A, HB benefits or reimbursements for unusual or continuing medical expenses), if appropriate.

In TIERS, if pension is not full A&A, make two entries for Department of Veterans Affairs (VA) income. One entry for VA pension and the other entry for A&A.

VA claim number.

Source of verification.

Note: If the recipient's VA is capped at $90.00, there is no need to reverify at recipient's review or at COLA review. There is no need to reverify old law benefits at review if the recipient or authorized representative indicates no change.
 

Verify VA benefits by one or more of the following methods: 

• Obtain a completed Form H1240, Request for Information from Bureau of Veterans Affairs and Client's Authorization.
• Contact an appropriate VA representative, using telephone contact documentation.
• View or obtain a copy of the applicant's/recipient's award notice issued by the VA.
• View or obtain a copy of the most recent benefit check or direct deposit slip. This method is least desirable because it may not show whether the funds include aid and attendance, a housebound allowance, or reimbursements for unusual or continuing medical expenses. A follow-up letter should be sent to payor.

Other Annuities, Pensions and Retirement Plans

E-4400

Source of payments.

Document the following:

Amount of gross benefit and amounts of any deductions from gross benefit. In TIERS, document deduction(s) on expenses screen and utilize case comments for explanation of deduction(s).

Check deduction(s) for potential life/health insurance. If deduction(s) is for health/life insurance, then pursue verifying and documenting these policies (See TPR/life insurance section(s).)

Whether a special review is needed for an increase that can be anticipated.

Claim number, if civil service annuity.

Tape matches. Additional verification is not needed if tape matches agree with recipient's statement.

Source of verification.

See Section F-7000, Annuities.
 

Verify payments by one or more of the following methods:

• Obtain a letter from the organization providing the payments.
• Contact a representative of the organization, using telephone contact documentation.  
• Obtain a completed Form H1243, Verification of Civil Service Benefit, if the payments are from that source.
• Obtain a completed Form H1297, Request for Information from Teacher Retirement System of Texas, if the applicant/recipient is under that retirement plan.
• Obtain a completed Form H1214, Request for Pension Information, for pensions.
• View or obtain a copy of the applicant's/recipient's award notice.
• View or obtain a copy of the applicant's/recipient's most recent check or direct deposit slip. This method is least desirable because the check may not show gross amount and/or deductions. A follow-up letter should be sent to payor.
• Tape matches such as Employee Retirement System (ERS), Teacher Retirement System (TRS).

Application for Other Benefits

D-6300

If in a Medicaid nursing facility, the administrator of the facility must notify SSA for application for SSI. See MEPD, Section B-7160, Facility Administrator Responsibilities.

Inquire and document the following for potential entitlement to other benefits:

• Military service time for applicant, spouse or child.
• Applicant's employment history.
• Applicant's previous marriages.

Note: If there is an indication of other benefits, the applicant/recipient must apply for the benefits and provide proof of application and/or receipt, that is, apply for VA benefits within 30 days of notice. The caseworker must set special to check if the applicant made application to VA. See MEPD, Section D-6300, Application for Other Benefits Requirement, for monitoring applications for and/or receipt of benefits.

Check with facility administrator and system of record.
 
   
 
Applicant/recipient declaration is acceptable.
 
For complete verification and documentation of potential benefits, refer to appropriate section of guide or the MEPD.
 

Interest and Dividends

E-3330

Document the following;

Name of financial institution, company or other source or interest or dividend income.

Account number, if received from a financial institution.

Policy number, if received from insurance company.

Interest amount and dates paid used for projecting income must be verified at each review, subject to variable income review policy.

Reason for exclusion, if excludable.

Any calculations used to arrive at an average amount, if countable.

Source of verification.

Date of special review, if appropriate.

Sources of verification include: 

• Copy of bank statements.
• Written statement from company or financial institution making the payments.
• Copies of dividend check stubs.
• Completed Form H1239, Request for Verification of Bank Accounts.
• Contact with representative of company or financial institution, using telephone contact documentation.
• Completed Form H1238, Verification of Insurance Policies, if received from insurance company.

Rents

E-3340

Type of rental income, applicant's/recipient's interest in rental income and accessibility of income to applicant/recipient. Document applicant's/recipient's interest in case comments.

Most recent year's income tax return (depreciation is not allowable) for persons who have established rent records.

Note: Income may be projected using the most recent year's income tax return, but a review is required at six months to determine if there is a significant change in the recipient's income.

If the income tax return is not used, the amount of gross income and expenses from the previous six months are used to project the income and expenses for the next six months.

Reason for the difference in income if the amount is anticipated to be different. Document reason in case comments.

Amount of net countable income and calculations used to arrive at countable income. Document, in case comments, type of expense(s) or deduction(s).

Source of verification.

Date of special review, if needed.

Sources for verification include: 

• Income tax return.
• Receipts, payments, bank deposit slips and canceled checks.
• Statements from applicant/recipient and renter.

Royalties (from land resources)

E-3330

Document the following;

Name of payor and reason for payment.

Verification of amounts and dates received used in the calculation.

Reason for exclusion, if excludable.

Calculations used to arrive at an average amount, if countable.

Source of verification.

Use one of the following methods of verification: 

• Copies of check stubs.
• Completed Form H1242. Ensure amounts are reported when received and not when earned.
• Contact with representative of the lease company (must be documented using telephone contact documentation). Automated telephone information is acceptable and a very good source of information, but must be documented using telephone contact documentation.

Gifts, Inheritances, Support and Alimony

E-3320, E-3370

Document the amount of a gift, support, alimony or inheritance.

Document if the income will be treated as a lump sum payment, infrequent or irregular income or regular and predictable income.

Source of the income.

Frequency the income is received.

Expected continuation.

Verify a gift, an inheritance or support and alimony payments by one or more of the following methods:

• Obtain a statement from the person or organization providing the item. Use “other acceptable” in TIERS and document in case comments.
• View or obtain copies of the court order, court records, or will. If terms and/or conditions of the agreement do not clearly identify income, obtain the assistance of legal staff.
• Obtain a fair market value of gift items from a knowledgeable source or through newspaper advertisement.
• Use other appropriate methods, depending on the nature of the item.

Notes and Mortgages

E-1750, E-3331, F-4150

Document the following:

Name of the person making note payments and whether income is accessible to applicant/recipient. Document name of person making note payments in case comments.

Amount of payment and frequency of payments. Whether or not the note is negotiable.

Whether or not payments are countable as income and, if so, portion of payment that must be considered as income.

Source of verification.

See MEPD, Section I-6200, Purchase of a Promissory Note, Loan or Mortgage.

Sources of verification include: 

• Amortization schedule.
• Copy of contract.
• Copy of note or mortgage document giving terms of repayment. If terms and/or conditions of the agreement do not clearly identify income, obtain the assistance of legal staff.
• Statements from the applicant/recipient and the person who makes payments. Use “purchaser/note holder” in TIERS.
• Contact with bank, using telephone contact documentation.

Prizes and Awards

E-3360

Document type of prize or award in the case comments.

Name of awarding company. Document name in case comments.

Document, on expense screen or in case comments, any legal or medical expenses involved in obtaining award.

Value of prize or award.
 

Verify prizes and awards by one or more of the following methods: 

• Obtain a copy of the applicant's/recipient's notice of the prize or award.
• Contact a representative of the organization, using telephone contact documentation.
• View or obtain a copy of the applicant’s/recipient's check.
• Obtain estimates of the value if the prize or award is not cash.
• Obtain proof of any legal or medical expenses involved in obtaining an award.

Medical Necessity (MN)/Level of Care (LOC) Determination for Applications

B-7420

Document MN/LOC. For MN/LOC, document only that there is an approved or denied MN/LOC. Purpose codes or MN effective dates are not required for eligibility. For TIERS this is auto-populated via interface.

Use one of the following methods for verification:

• LTSS Summary screen in TIERS populated by interface.
• Telephone contact with TMHP documenting name of person, date and time.

Thirty Consecutive Day Stay Rule

E-6300, B-7400, G-6000, G-6200

Documentation that an applicant/recipient has met the 30 consecutive days. Enter documentation, including verification and sources, in case comments.
 
The person must be admitted to a Medicaid-approved long term care facility (Medicare-SNF, NF or ICF/MR) for the 30 consecutive day time frame to begin if the person is eligible only because of the special income limit.

Verify the applicant's/recipient's stay using one of the following methods: 

• Contact with facility staff no sooner than the 31st day of the applicant's/recipient's stay, using telephone contact documentation.
• Copy of Form H3618 showing discharge due to death.
• Copy of an admission Form H3618 with no discharge Form H3618.
• Contact with TMHP, using telephone contact documentation.
• Contact with providers, using telephone contact documentation.
• Contact with waiver staff, using telephone contact documentation.

Special Review Requirement

B-8200, B-8430

Monitor eligibility at least every three months if the applicant’s/recipient's total countable income is within $10 of the income limit.

Monitor eligibility at least every three months if the applicant’s/recipient's countable resources are within $100 of the resources limit.
 
The following information must be included in the case record documentation:

• whether a special review is needed,
• the specific details of the special review,
• months and source of verification, and
• date special review will be conducted.

 
All special reviews must be entered on Form H1000-A/Form H1000-B or entered into TIERS.
 
In SAVERR, special reviews for resource or income elements must be monitored through entry on Form H1000-A/Form H1000-B, items 139 and 140.

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