General eligibility requirements that apply to all Apple Health programs

General verification

Revised Date: 
April 18, 2017

Purpose: This chapter describes what verification is required and when.

Chart of requirements

Chart of acceptable documents

WAC 182-503-0050 Verification of eligibility factors.

WAC 182-503-0050 Verification of eligibility factors.

Effective March 20, 2017

For the purposes of this section, "we" refers to the medicaid agency or its designee and "you" refers to the applicant for, or recipient of, health care coverage. 

  1. General rules.
    1. We may verify the information we use to determine, redetermine, or terminate your Washington apple health eligibility.
    2. We verify the eligibility factors listed in WAC 182-503-0505(3).
    3. Before we ask you to provide records to verify an eligibility factor, we use information available from state data bases, including data from the department of social and health services and the department of employment security, federal data bases, or commercially available data bases to verify the eligibility factor.
    4. We may require information from third parties, such as employers, landlords, and insurance companies, to verify an eligibility factor if the information we received:
      1. Cannot be verified through available data sources;
      2. Did not verify an eligibility factor; or
      3. Is contradictory, confusing, or outdated.
    5. We do not require you to submit a record unless it is necessary to determine or redetermine your eligibility.
    6. If you can obtain verification within three business days and we determine the verification is sufficient to confirm an eligibility factor, we base our initial eligibility decision upon that record.
    7. If we are unable to verify eligibility as described in (f) of this subsection, then we may consider third-party sources.
    8. If a fee is required to obtain a necessary record, we pay the fee directly to the holder of the record.
    9. We do not deny or delay your application if you failed to provide information to verify an eligibility factor in a particular type or form.
    10. Except for eligibility factors listed in WAC 182-503-0505 (3)(c) and (d), we accept alternative forms of verification. If you give us a reasonable explanation that confirms your eligibility, we may not require additional documentation.
    11. Once we verify an eligibility factor that will not change, we may not require additional verification. Examples include:
      1. U.S. citizenship;
      2. Family relationships by birth;
      3. Social Security numbers; and
      4. Dates of birth, death, marriage, dissolution of marriage, or legal separation.
    12. If we cannot verify your immigration status and you are otherwise eligible for Washington apple health, we approve coverage and give additional time as needed to verify your immigration status.
  2. Submission timelines.
    1. We allow at least ten calendar days for you to submit requested information.
    2. If you request more time to provide information, we allow the time requested.
    3. If the tenth day falls on a weekend or a legal holiday as described in RCW 1.16.050, the due date is the next business day.
    4. We do not deny or terminate your eligibility when we give you more time to provide information.
    5. If we do not receive your information by the due date, we make a determination based on all the information available.
  3. Notice requirements.
    1. When we need more information from you to determine your eligibility for Washington apple health coverage, we send all notices according to the requirements of WAC 182-518-0015.
    2. If we cannot determine you are eligible, we send you a denial or termination notice including information on when we reconsider a denied application under WAC 182-503-0080.
  4. Equal access and limited-English proficiency services. If you are eligible for equal access services under WAC 182-503-0120 or limited-English proficiency services under WAC 182-503-0110, we provide legally sufficient support services.
  5. Eligibility factors for nonmodified adjusted gross income (MAGI)-based programs. If you apply for a non-MAGI program under WAC 182-503-0510(3), we verify the factors in WAC 182-503-0505(3). In addition, we verify:
    1. Household composition, if spousal or dependent deeming under chapter 182-512 WAC or spousal or dependent allowance under chapters 182-513 and 182-515 WAC applies;
    2. Income and income deductions;
    3. Resources, including trusts, annuities, and life estates under chapters 182-512, 182-513, and 182-516 WAC;
    4. Medical expenses required to meet any spenddown liability under WAC 182-519-0110;
    5. All post-eligibility deductions used to determine cost of care for clients eligible for long-term services and supports under chapters 182-513 and 182-515 WAC;
    6. Transfers of assets under chapter 182-513 WAC when the program is subject to transfer of assets limitations;
    7. Shelter costs for long-term care cases where spousal and dependent allowances apply;
    8. Blindness or disability, if you claim either; and
    9. Social Security number for a community spouse if needed when you apply for long-term care.
  6. Verification for MAGI-based programs.
    1. After we approve your coverage based on your self-attestation, we may conduct a post-eligibility review to verify your self-attested information.
    2. When conducting a post-eligibility review, we attempt to verify eligibility factors using your self-attested information available to us through state, federal, and commercially available data sources, or other third parties, before requiring you to provide information.
    3. You may be required to provide additional information if:
      1. We cannot verify an eligibility factor through other data sources listed in subsection (b) of this section; or
      2. The information received from the data source is not reasonably compatible with your self-attestation.
  7. Reapplication following post-eligibility review. If your eligibility for MAGI-based Washington apple health terminates because of a post-eligibility review and you reapply, we may request verification of eligibility factors prior to determining eligibility.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

Applications for Washington Apple Health (AH) are processed either through Washington Healthplanfinder or the Department of Social and Health Services (DSHS), depending on the client’s eligibility and relatability to a program:

  1. The Washington Healthplanfinder (HPF) is administered by the Health Benefit Exchange (HBE), and eligibility is based on a modified adjusted gross income (MAGI) determination. HPF is the web portal for clients who are:
    • Adults under 65 and not eligible for Medicare;
    • Children age 18 and under;
    • Pregnant women;
    • Family/Caretaker relatives;
    • Blind or disabled who are in the Medicare waiting period; or
    • Clients eligible for Medicare who are pregnant or have dependent children
      ​
      These programs are referred to as MAGI-based AH or non-Classic AH. Clients not eligible for AH may be eligible for a qualified health plan, with or without tax credits, to reduce the monthly premium. 
  2. The Department of Social and Health Services (DSHS) processes applications clients who are:
  • Aged (65+) without minor dependents,
  • Blind,
  • Disabled,
  • Eligible for Medicare,
  • In need of or receiving long-term supports and services; or
  • Over income for MAGI programs (see above) and are disabled.

These programs are referred to as non-MAGI or Classic AH.

Verification – sometimes called proof – is information that confirms a client is eligible.

Eligibility Factors

For all AH programs, the following eligibility factors must be attested to and verified to receive ongoing coverage (see WAC 182-503-0505):

  1. Age
  2. Identity
  3. Citizenship or immigration status
  4. Washington State residency
  5. Social Security number (SSN)
  6. Countable income

Additionally, clients of Classic AH, including long-term care and supports programs, need to verify assets/resources, household composition, and other factors listed in subsection (5) of this WAC. They also may need to fulfill other requirements, such as undergoing a disability determination or level of care assessment. 

Verification of Citizenship/Lawful Presence

Who must verify citizenship/lawful presence and identity

Clients who declare they are U.S citizens, U.S Nationals, or lawfully present are required to verify their citizenship/lawful presence and identity if the HCA or DSHS is unable to verify status through a citizenship/identity interface. By verifying identity, age is also verified.

When applying and renewing in Washington Healthplanfinder, several verification processes take place:

For identity:

  1. For a primary applicant with SSN: a match is made with Experian who returns several questions for the primary applicant to answer. This is called identity proofing. Successfully answering these questions means the client has been successfully ID proofed.
  2. For a primary applicant without SSN or who fails the Experian ID proofing: The client must submit proof of identity to HCA, HBE or to a navigator so they can be manually ID proofed.

For citizenship/lawful presence:

  1. Clients who have an SSN who declare to be a citizen: the system automatically checks the SSN, name and date of birth to confirm identity and citizenship through the federal hub.
  2. Clients who have an SSN who declare to be lawfully present: the system uses the SSN, name, and date of birth to confirm identity and lawful presence with Department of Homeland Security (DHS).
  3. Clients who have an SSN who declare to be a citizen or lawfully present, but it cannot be automatically verified: Verification is requested from the client of the status.

Clients whose SSN does not verify their identity, citizenship, or lawful presence may provide verification proving those factors.

When applying for Classic AH/non-MAGI with DSHS: SSN and citizenship are automatically verified through an interface with the Social Security Administration (SSA). Lawful presence is verified by staff.

Who does not need to verify citizenship/lawful presence

Household members not applying for coverage and clients not lawfully present do not need to verify citizenship or lawful presence.

Coverage while pending verification of citizenship/lawful presence or SSN issuance

Clients who are otherwise eligible for AH are approved for a limited time to obtain and provide verification of their status or SSN. Coverage is approved for 90 days. At the end of the 90 days, verification of the status or verification of the good faith effort to obtain the verification must be provided or coverage may terminate.

Examples of good faith effort includes:

  • Up-to-date documents showing immigration status is pending with DHS/United States Citizenship and Immigration Services (USCIS)
  • Verification of an upcoming appointment with SSA
  • Other verification that reasonably verifies that a good faith effort is being made

See WAC 182-503-0515 for more information on SSN requirements.

Washington State Residency

Self-attestation of residency is accepted unless questionable. Verification may be requested if information shows a client may not be a resident of Washington. Sources include but are not limited to:

  • Return mail with no forwarding address
  • Report from a managed care plan
  • Cross-match with an interstate file showing benefits received in another state
  • A fraud referral

See WACs 182-503-0520 and 182-503-0525 for more information on residency requirements.

Verification Sources and Requests

Verification sources

Prior to requesting verification, staff check third-party sources. Sources include but are not limited to:

  • Social Security Administration
  • Department of Homeland Security’s U.S. Citizenship and Immigration Services (USCIS) SAVE portal
  • Washington State Employment Security Department
  • Lexis Nexis
  • The Work Number
  • Department of Health
  • Landlord, employers, insurance companies, financial institutions

Verification requests and responses

A letter is always sent requesting proof of unverified factors. The letter will meet the requirements in WAC 182-518-0015. The letter may come from:

  1. Washington Healthplanfinder, if coverage is MAGI-based.
  2. DSHS

At least 10 calendar days is provided to respond to the request. If more time is needed, contact the requestor who will allow at least 10 more days.

If verification is not received by the due date, eligibility is based on all information available. This may mean a client is eligible for a different program (including a premium-based program) or higher participation costs. It may also mean eligibility cannot be determined so AH coverage will end or be denied.

If verification is received and eligibility changes or ends, a letter is mailed explaining any changes. 

Providing verification

Letters from HPF have the following logo on the letterhead and envelope:

Washington Healthplangfinder logo

If a letter is mailed from HPF, verification can be provided by:

  • Uploading to the HPF account in the Document Center;
  • Mail to HCA-MEDS, PO Box 45531, Olympia WA 98504;
  • Email to MEDSClientInbox@hca.wa.gov; or
  • Fax to 1-866-720-2892

For questions on requests from HPF pertaining to AH only, call the Health Care Authority Medical Assistance Customer Service Center (MACSC) at 1-800-562-3022.

Letters from DSHS have the following logo on the letterhead and envelope:

Washington Department of Social and Health Services logo

If a letter is mailed from DSHS, verification can be provided by:

For questions on requests from DSHS, call 1-877-501-2233.

Self-Attestation and Post-Eligibility Reviews (PERs)

Self-attestation for MAGI-based AH

For MAGI-based applications processed through HPF, eligibility is based on self-attestation. Verification may be required when the attestation is not compatible with information obtained through cross-matches and the cross-match shows the client may not be eligible. This is called a post-eligibility review (PER). A PER is conducted by HCA staff and is done to confirm income, citizenship, or lawful presence.

For instance:

  1. A client reports his income is $1000 a month from his job, but the Employment Security Department (ESD) shows income to be $1850 a month. Verification of income is requested following a PER.
  2. A client of AH for Adults completes her renewal and her income is $500 a month from her job, but the cross-match with ESD shows it to be $1200. No PER is done because even if the $1200 was verified, she would still be eligible.
  3. A client reports to be a citizen, but it cannot be verified. Coverage is approved and the client is given 90 days to provide verification of citizenship. A PER is done towards the end of the 90 days to verify citizenship.

During a PER, verification is requested when staff cannot verify the attestation. An information request letter is mailed to the client. Once the due date passes, HCA staff look for the verification. If verification is not provided and staff still cannot verify the attestation, eligibility is based on all information available. This may mean a client is eligible for a different program (including a premium-based program) or AH coverage terminates. 

Reapplying following a Post-Eligibility Review (PER)

If a client reapplies following a termination, and the termination was the result of the PER, self-attestation of income, citizenship, or lawful presence might not be accepted. If those three factors are automatically verified through the data bases, coverage is approved. If those factors are not automatically verified, coverage is in pending status.

Pending status means coverage is not approved nor denied, but verification is needed before eligibility is determined. In that case, a letter is sent and at least 10 days is provided to return the verification. Once staff review the verification, the application is processed. 

Worker Responsibilities

  1. Before requesting verification:
    1. Look in the case record (HPF document center, Barcode ECR, WebAx, case notes) and third party sources to verify the information.
    2. Only request verification needed to verify the eligibility factor.
    3. Do not request verification to be in a particular type or form. For instance, do not ask for a bank statement to verify resources. Instead, request “proof of resources, such as a bank statement for the month of March 2017.”
    4. Use alternative methods, such as telephone calls, as the primary method to verify the client’s circumstances. Request paper verification only when there are no other methods readily available.
  2. When verification is needed:
    1. Verification may be needed when the information received is questionable. Consider the information questionable when it:
      1. Contradicts or conflicts with other statements made by the client;
      2. Is received from a third-party source that contradicts or conflicts with other statements made by the client; or
      3. Calls into question the accuracy of the information provided by the client.
    2. Ask for documents the client can easily get. If it will take the client more than three business days to get the verification, such as immigration documents, offer to help get it. Do not deny or terminate AH if the client is responding to verification requests by reporting they need more time.
    3. If the client has a disability or needs equal access services, offer to help get the information.
    4. If the verification will cost money (such as out-of-state birth, death, or marriage certificates, medical information, copies of bank statements, etc.), explore alternate verifications before offering to purchase the items.
  3. Processing verification received:
    1. Accept reasonable explanations. Use the prudent person concept and document this.
    2. When a client provides partial verification, send another request letter asking for more information and allow more time. The exception is when the provided verification confirms the client is not eligible. For example: a worker requests proof of income and citizenship, but only receives the income verification. The income verification shows the client is over income. It is not necessary to repend for the citizenship verification. AH can be terminated for over income.
    3. Use the following criteria to evaluate verification and verbal/written statements used for verification:
      1. Does it verify the eligibility factor? (For example, a child's birth certificate verifies age and citizenship, but not residency.)
      2. Is the document/statement the most reliable available evidence?
      3. Was the document/statement prepared near the time the event took place?
      4. Is the document/statement signed and dated?
      5. Has the time period the document/statement covers expired?
      6. Does the document appear to be altered?
      7. After evaluating a document on the above criteria, determine if you have enough information to establish eligibility. If not, document the reason and request further verification.

Certain eligibility factors do not change and do not require another check in the future, including:

  1. US citizenship (unless extremely rare circumstances);
  2. Family relationships by birth, marriage, and divorce; and
  3. Social Security Numbers (unless in the rare circumstance the client has more than one).

Documentation:

  1. When requiring additional verification, document why additional verification is needed.
  2. What to document for each case:
    1. What verification you requested;
    2. Why you requested verification/additional verification;
    3. What verification you received;
    4. When you received the verification;
    5. What action you took, if any, to help the client get the verification;
    6. Whether the client has a disability that would make it hard or impossible to get the verification, and/or whether the client is a victim of domestic violence and failed to get the verification due to the domestic violence;
    7. Whether the client has been designated as Equal Access (EA) and if so, whether you followed the EA Plan.
    8. What decision or action you took.
  3. In the letter to the client, explain what information was requested and that it was not received or explain it was received but did not verify eligibility. 

Verification of citizenship/identity for Classic AH/non-MAGI and some MAGI-based cases can be found in ACES:

Citizen valid value identity valid value
T1, T2, EW or FV V, E or F

Clients who match with the SSA interface for citizenship/identity will automatically be updated by ACES with "FV" valid value for citizenship and "F" valid value for identity.

If it is determined the interface is in error and the federally verified codes need to be changed, call or email:

Kevin Cornell 360 725-1423 kevin.cornell@hca.wa.gov

Chris Stehr 360-725-1304 chris.stehr@hca.wa.gov

For MAGI-based AH through HPF, citizenship and lawful presence is found in ACES Online on the Client >> Demographic screen.

Example of a client’s citizenship attestation that was verified through the federal hub:

Screenshot of citizenship attestation

Example of a client’s lawful presence attestation that was verified through the federal hub:

Screenshot of lawful presence attestation

Survivors of domestic violence/ACP Participants

If a client is a victim of domestic violence:

  • Have the client write a statement that explains what proof or way of getting proof would put the client and/or children at risk of harm, if any.
  • Help the client get proof that will not put them at risk.
  • For a victim of domestic violence who is also an immigrant, consider a referral to an immigration attorney or to the Northwest Immigrant Rights Project.

Example: A woman and her two children apply for coverage. They are living at the local domestic violence shelter and the father of the children lives in the family home. Do not call the family home to verify any information. Do not require the victim to return to the home to get any verification.

When a client presents an ACP authorization card:

  1. Enter the ACP address into HPF or ACES. Only call the ACP at 360-753-2972 to verify that the client is currently certified in the program if return mail is received.
  2. If the client is currently certified in the ACP:
    1. In HPF, enter PO Box 257. This triggers a popup to enter the post mail box (PMB). Enter the PMB and Olympia, WA 98507.
    2. In ACES, enter the ACP mailing address and participant code number as shown on the card in place of the client's physical address on the ACES ADDR screen.
  3. Mail all letters to the substitute address.
  4. Do not ask the client to provide their actual address.  Do not record the client's physical address in any case notes or retain copies of any documents that list the client's physical address.
  5. If information is found or entered that could be used to locate an ACP client, notify your supervisor to redact information from ACES and/or HPF.
  6. When verifying residency, household composition, or shelter costs, do not ask the client to provide documents that state their physical address.  Accept any document that lists the ACP address and reasonably verifies the eligibility factor. 
  7. If the client provides a document that lists the physical address, work with a supervisor to contact ACES, Barcode and/or HPF to remove any reference to the address. 

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