Appendix XVI, Documentation and Verification Guide

Documentation must­ support the eligibility determination and give enough detail so someone unfamiliar with the case will understand computations and eligibility decisions.

Client Statement:

When selecting client statement as a verification source, the information must be on the application, renewal form or imaged documents. Documentation must be in case comments.

Third-Party Contacts by Phone or In Person, including client and authorized representative [AR] contacts:

Phone

Document the following:

• phone number called;
• person called, including title and authority to release information being requested;
• date of call; and
• reported information, including dates, values or balances, descriptions, and source the responder references.

In Person

Document the following:

• date; and
• reported information, including dates, values or balances, descriptions, and source the responder references.

Other Acceptable:

Document the source used to verify the element in case comments if there is no field to enter information on the individual TIERS Logical Unit of Work (LUW) page.

Note: Other forms of verification may be acceptable with proper, complete documentation and program approval. Such as: Kelly Blue Book or savings bond verification.

Blanks on Most Recent Application or Review:

Documentation must address how items left blank on the most recent application or review are cleared.

Note: If an application has only client identifying information and a valid signature, phone contact may be needed to get an explanation of the incomplete items. It is not enough to assume a client has no income or resources or that none of the questions apply and to request only a State Online Query (SOLQ) inquiry.

Only one type of verification is required unless noted otherwise.

Example: If all required information is on the bank statement or available through the Asset Verification System (AVS), Form H1239, Request for Verification of Bank Accounts, is not needed.

When verification is available from both client statement and an electronic data source (ELDS) or other acceptable verification sources, ELDS and the other verification source supersede client statement.

Document the following in case comments:

• The complete name of the person making the comments.
• Any open tickets, including the ticket number, date of ticket and the reason for the ticket.
• The reason for reopening the application, with an explanation of the new file date. Document the reason for denial if a denial was made in error or the previous worker did not clearly document the denial reason. The reviewer, supervisor or worker III must document the reason when approving the reopening of an application with a protected file date.
• The file date chosen and an explanation if there are several dates stamped or written on the application form or if an incorrect file date was used. Image the email if email correspondence is received.
• Document the reason eligibility is denied for the correct program if eligibility cascades to an incorrect program. Case Comment Example: Application for waiver Medicaid denied due to excess income, cascaded to Parent and Caretaker Relative Medicaid (TP 08). Sent to Texas Works for disposal.
• The reason for using the override function.
• The reason the second-party reviewer does not approve whatever is being reviewed.
• The reason a contingency processing method (CPM) is needed due to a defect or because the policy was not programmed into TIERS. If the CPM gives instructions on specific information to include in the explanation, then document the information. Document the CPM number.
• Resolutions to any discrepancies, questionable information or special situations for any eligibility factor.
• The person’s response to clear discrepant Data Broker information, or a notation that the person disagrees with the information.
• The request and use of interpreter services, including when and how the services were provided, and the name of the interpreter.
• Document the date of the call, the phone number and name of the person contacted for any calls made with the applicant, recipient or their AR. Document that person’s relationship to the applicant or recipient and authority to release information.
• The reason for delays in processing an application and the eligibility specialist’s actions, as explained in B-6420, Missing Information Due Dates, subsection titled Delay in Certification.

SOLQ or WTPY

Use and Documentation

SOLQ or Wire Third-Party Query (WTPY) can verify several things about an applicant’s or recipient’s eligibility and co-payment. Examples:

• Name on Social Security Administration (SSA) record
• Date of birth (DOB)
• Citizenship
• Medicare Parts A, B, C and D
• Social Security amounts
• Dual entitlement to Medicare and Medicaid

This list is not all-inclusive.

Use SOLQ as the primary verification tool when possible. To comply with SSA safeguarding requirements, do not print, send for imaging or copy and paste SOLQ data directly into case comments. Document the date or dates SOLQ was viewed in case comments.

Request a WTPY if SOLQ does not provide all needed information. To comply with SSA safeguarding requirements, do not print, send for imaging, or copy and paste WTPY data directly into case comments. Document in case comments the need for a WTPY, the WTPY request number, date viewed, and information verified by WTPY rather than SOLQ.

Use this procedure for community-based programs, including:

• all cost-of-living adjustment (COLA) disregard programs, such as Pickle, Disabled Adult Child (DAC), and Widow or Widower;
• all Medicare Savings Programs; and
• the Community Attendant Services (CAS) program.

Do not use this procedure when a person is applying for or requesting a transfer to the following programs:

• institutional Medicaid;
• Home and Community-based Services waiver;
• Medicaid Buy-In; or
• Medicaid Buy-In for Children.

Document the reason a more reliable source is not used if Level 1 evidence of citizenship is not used.

If citizenship is verified by sources other than SOLQ:

• Birth Verification System (BVS) — Document the birth certificate number, as TIERS does not automatically keep the certificate number.
• Birth certificate, naturalization papers or other sources used — Ensure the image is available in the portal. If viewing the original document, be sure to send a copy for imaging. Return the original document to the person.

Alien status needs to be verified through Systematic Alien Verification for Entitlements (SAVE) in Data Broker.

Identity verification must also be documented. Copies of documents are acceptable if they are legible and not questionable.

Hint: Ensure copies of alien status cards are legible by adjusting the print quality on the copier.

Excess Resources:

• If excess resources can be designated as burial funds, allow the person the opportunity to do so. Refer to F-4227, Burial Funds.
• If a person is determined ineligible because of excess funds in a joint account, allow the person 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. Refer to F-4121, Joint Bank Accounts.

Excess Income:

Refer to the following:

• B-2500, Explaining Policy vs. Giving Advice
• G-6200, Special Income Limit for the Eligibility Budget
• F-6800, Qualified Income Trust
• Appendix XXXVI, Qualified Income Trusts (QITs) and Medicaid for the Elderly and People with Disabilities (MEPD) Information

Hint: If denial is based on applicant or recipient declaration, both the notification of denial and case comments should include the name and type of contact, date and any other comments to substantiate the decision.

Ensure that the TPR LUW is completed fully and accurately to ensure correct information is submitted to Provider Claims.

State or 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 drafts for premiums for third-party resource (TPR) policies.
• Check employment history or retirement income for possible TPRs.

Verify the names, addresses and policy numbers of insurance policies (assignability).

Sources to verify insurance policies:

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

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

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

Properly determine incurred medical expenses (IMEs) to calculate the co-payment.

• Is the IME being paid by the applicant or recipient?
• Do not allow an IME deduction without proof that the applicant or recipient paid the insurance premium or incurred other medical expenses.
• If someone else has been paying the insurance premium or medical expenses and the applicant or recipient clearly plans to make the payment, schedule a special review to consider the IME deduction.

Request a completed, signed and dated Form H1263-A, Certification of Medical Necessity – Durable Medical Equipment or other IME, or Form H1263-B, Certificate of No Medical Contraindication - Dental, if necessary.


 

Determine if a potential transfer of assets occurred during the look-back period. Do this by reviewing the application, information provided by the applicant, bank statements if available, and information available through AVS.

Document:

• the when, what, and how much was it worth as of 12:01 a.m. on the first day in the month of transfer;
• how much was received;
• who each transfer is from and to; and
  the date of transfer.

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

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

Evaluate the transfer for exceptions. Document applicable exceptions as needed.

Document the value of the resource at the time of transfer and the amount of income being transferred.

Offer an opportunity for rebuttal.

Document the compensation received to offset the value transferred. Document that an opportunity for rebuttal was offered and record the time frames observed. Were the rebuttal notices properly sent? If the person attempts a rebuttal, document the evidence used during the rebuttal process. Document the elements used to determine the validity of the rebuttal.

Document supervisor concurrence of the rebuttal decision.

Bank statements that are provided or requested must be reviewed for possible transfers. If transfers are noted, more bank statements and other verification can be requested to determine and verify if other transfers happened.

Refer to I-3000, Exceptions to the Transfer of Assets.

Refer to:

• F-6500, Irrevocable Trusts
• F-6800, Qualified Income Trust (QIT)
• F-7000, Annuities
• E-4400, Other Annuities, Pensions and Retirement Plans
• E-3320, Alimony and Support Payments
• E-3370, Cash Gifts and Contributions
• E-3372, Effective Date of Receipt of Inheritance; Disclaimers

Sources to verify validity of a transfer:

• Use copies of documents transferring assets. Documentation from viewing documents is okay if one cannot get copies. Document the reason one cannot get a copy.
• Contact with companies or firms, such as a financial institution, that are knowledgeable of the transfer. The contact must be documented using phone contact documentation.
• Verify the fair market value per handbook requirements for the asset transferred.
• A person can request up to 60 months of bank statements or other verification if there was a transfer.

Sources to verify the amount of compensation offered:

• Document the formula used to determine the value of the tendered compensation if compensation is other than cash.
• Verification should include a copy of the sales document or agreement. If a verbal agreement was made, get a written statement from the applicant or recipient, and the person who received the transferred asset.
• If more than one source of verification is needed, such as verifying transfer and another to verify compensated value, document the other sources and related information in case comments.

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

The following information must be documented in the case record:

• name of the financial institution;
• complete account number;
• account accessibility by the person;
• account balance as of 12:01 a.m. on the first day of the appropriate month(s); and
• interest paid on account.

Applications:

Explore financial management and potential transfers of assets if bank statements for the month of application and the three prior months are given. If there were transfers, request up to 60 months of bank statements to determine how far back the transfers may go.

Do not request bank statements if balances for the month of application and three prior months are obtained through AVS and:

• no potential transfer of assets is identified; and
• AVS information does not result in potential ineligibility.

Reviews:

Verify resources as of 12:01 a.m. on the first day of:

• the month the renewal form was received;
• the previous 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.

Note:

• Burial Funeral, as reported through AVS, is a type of savings account.
• AVS provides reports on Custodial Other/UGMA/ UTMA and Custodial Retirement.
  • At application, AVS is not a valid verification source because legal review is needed. If needed, request more information to determine if they are a countable resource.
  • At renewal, if there are no changes and no potential transfer of assets exist, AVS can be used as verification.

Sources of verification include:

• AVS response.
• Bank statement
• Completed Form H1239, Request for Verification of Bank Accounts.
• Letter from the financial institution.
• Phone contact with an employee of the financial institution.
• Pursue written follow-up if cannot get information by phone or if the information results in ineligibility.

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

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

Send copies of trusts to regional legal staff for interpretation.

Sources to verify trusts:

• Copy of the trust agreement.
• For special needs trusts, the source of the assets used to fund the trust.
• Copy of the will, if the trust is a testamentary trust.
• For wills, a copy of the Order Probating the Will or a copy of the Letters Testamentary issued when the will was probated. This is needed for any resource type where the person may have inherited an interest in property. For example, a will granting a life estate or other interest in property.
• Statement from the financial institution, trust management company or attorney.
• Legal staff interpretation. Contact with legal staff should occur by designated procedures.

Note: Document the basis for the exemption if the trust is exempt.

Use one of the verification sources listed below:

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

Document the following:

• name of the company;
• number of shares and type of shares;
• calculations of countable value;
• market value as of 12:01 a.m. on the first day of the appropriate month; and
• source of verification.

Use one of the following sources to verify the closing prices of stocks:

• Newspaper
• Statement from a brokerage firm
• Research department of a local library
• Documented contact with the issuing company, using phone 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
• Documented contact with the brokerage firm or issuing company, using phone contact documentation

Document the following:

• name of the issuing company;
• type of bond;
• serial number;
• Market value as of 12:01 a.m. on the first day of the appropriate month; and
• 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 to verify the cash value of municipal, corporate and government bonds:

• Newspaper report of the closing price on the last day of the month before the test month
• Statement from an authorized employee of a savings or banking institution or a brokerage or securities firm
• Research department of a local library
• AVS response, for convertible bonds

Use one of the following sources to verify the cash value of U.S. savings bonds:

• U.S. Department of the Treasury savings bond online calculator
• Table of redemption values for U.S. savings bonds
• Statement from an authorized employee of a savings or banking institution
• Copy of bond

Document the following:

• Ownership of the note.
• Accessibility by the applicant or recipient.
• If the note is negotiable. If non-negotiable, why? Does a transfer of assets exist?
• If the note is an excluded resource.
• If the note is excluded, the reason for exclusion.
• If the note is a countable resource, the current market value of the note.
• Amount of income (interest) generated by the note.
• Source of verification.

State or MEPD Specialist Judgment Call: Document your evaluation of the validity of the appraisal if the appraisal value is $0, based on the reason given by the appraising entity.

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

Send copies of notes, loans and property agreements to legal for interpretation.

Use one of the following sources to verify ownership of a promissory note, loan or property agreement:

• Copy of the instrument, note, mortgage or agreement
• Statement from the purchaser and noteholder

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

• Copy of the instrument that shows if it is negotiable
• Statement from a bank or other financial institution, private investor, or real estate agent

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

• Copy of the instrument
• Amortization schedule

For a 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 the reason
• Date the original instrument was signed
• Interest rate
• Payment schedule

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

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 living in home
• Home is placed for sale
• Life estate or remainder interest, also refer to the Life Estates and Remainder Interests section in this chart
• Intent to return

The primary evidence of an applicant's or recipient's intent to return home is the applicant's or recipient's statement. Document this on a signed Form H1245, Statement of Intent to Return to Home, or a written statement from the applicant's or recipient's spouse or AR.

Document the source of verification.

Remember, a home placed in an irrevocable trust loses its homestead exclusion. A home placed in a revocable trust loses its homestead exclusion, but if it is removed from the trust, it can once again be excluded as a homestead if it meets the exclusion reasons.

Refer to F-3200, The Home and Resources in a Trust, through F-3300, The Home as a Countable Resource.

• Verify the current residence address of the applicant or recipient, and spouse or both, before nursing facility admission. sources to verify the exclusion are as follows:

For a spouse or dependent relative living in the home:

Document the person’s statement establishing the residence as the spouse's or 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 the form in case comments.

For a home placed for sale:

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

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

Use one of the following sources to verify location, ownership and current market value of a home:

• Tax statement with the current assessment, if using 100 percent evaluation
• Copy of the appraisal from the local taxing authority or appraisal district
• Statement from a local knowledgeable source, such as a realtor
• Phone contact with a previously listed source, using phone contact documentation

Use one of the following sources to verify the 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
• Statement from the tax office, if taxes are in arrears

In TIERS, court record or other legal document include:

• a copy of a lien, note or other outstanding debt;
• a statement from the mortgage company; or 
• a copy of the amortization schedule.

Determine the type of resource sold and if the recipient received the current market value. Follow transfer-of-resources policy if the current market value was not received.

Document the following:

• Selling price of the home or other real property.
• Gross amount received from and the expenses involved in the sale of the home or property. Itemize the expenses involved.
• If the applicant or recipient is purchasing a replacement home and the time frame for excluding the proceeds from the sale of the original home. Set a special review to monitor.

Sources to verify the sale and amount received include:

• Copy of the deed
• Real estate contract or agreement
• Statement from the mortgage company or a copy of the amortization schedule
• 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, such as a realtor
• Sales receipt or contract
• Bank deposit slip or copy of check or form of payment

Sources to verify expenses about the sale of a resource include:

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

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 the following:

• CCRC contract date
• CCRC facility name
• CCRC entry date
• Is the resource accessible? Yes or No.
• Does the contract specify that the fee be used to pay for care? Yes or No.
• Is the person eligible for a refund upon termination of the contract or departure from the CCRC? Yes or No
• CCRC entrance fee value
• Amount of entrance fee spent on care
• Refundable amount

Document the following:

• Location and description of the property.
• Ownership interest in the property.
• If the property is excluded and the reason for exclusion.
• Current equity value of the applicant's or recipient's interest in the property.  

Note: Document in case comments the percentage of ownership and the formula used to determine the value of the applicant’s or recipient’s interest if the applicant's or recipient's ownership interest is less than 100 percent.

• Source of verification.

Sources for verification include:

• Ownership interest in the property
• Tax statement with the current assessment, if using 100 percent evaluation
• Copy of the appraisal from the local taxing authority or appraisal district
• Statement from a local knowledgeable source about the value, such as a realtor
• Phone contact with a previously listed source with knowledge of the property in the area, using phone contact documentation
• Copy of the deed or will to verify ownership

State or MEPD Specialist Judgment Call: If the property is inherited by descent and distribution, the recipient's statement on the degree of ownership may be used if no other documentation is available. Get the help of legal staff to determine the degree of ownership.

Sources to verify the equity value of other real property are as follows:

• Copy of a lien, note or other outstanding debt
• Statement from the mortgage company or a copy of the amortization schedule
• Statement from the tax office if taxes are in arrears

In TIERS, court record or other legal document includes:

• a copy of a lien, note or other outstanding debt;
• a statement from the mortgage company; or 
• a copy of the amortization schedule.

Document the location of the life estate property.

Document if the life estate is excluded as a resource, such as a home.

Use life estate as the real property type and document this action in case comments in TIERS, for a remainder interest.

Document the reason for exclusion if the resource is excludable.

Document the current equity value if the resource is countable.

Refer to Appendix X, Life Estate and Remainder Interest Tables, for information about calculating life estate and remainder interest values.

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

Document the source used to verify the value.

Note: Clearance of a life estate is required for later reviews if the recipient is over the resource limit and older than when the value was initially determined.

Record if:

• the applicant or recipient chooses to rebut the value;
• the basis of the rebuttal; the value from a knowledgeable source used for the rebuttal; and 
• the verification used to support the rebuttal.
  
  For the purchase of a life estate, refer to I-6100, Purchase of a Life Estate.
  
  Refer to F-3800, The Home and Transfer of Assets.

Sources to verify 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 or recipient was granted a life estate or remainder interest. If the terms of the will, court record or other legal document are difficult to understand, get the help of legal staff.

Sources to verify the current market value of a life estate or remainder interest:

• If a statement from a 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 to verify 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 rebuttals, written verification from a knowledgeable source

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

For the life insurance policy, document the following:

• Name of the life insurance company, the policy number and the face value
• Date the life insurance policy was converted to a life settlement contract

For the life settlement contract, legal review is required. Document the following:

• Name of the life settlement company
• Amount of proceeds from the life settlement contract
• Irrevocable or revocable assignment
• Name of the financial institution
• Account number
• Any allowable disbursements, as shown in the account agreement
• Amount of funds reserved for the death benefit

Send an encrypted email to the HHSC OES MEPD IC Mailbox After certification. Document the date the email was sent in case comments.

Title the email LIFE SETTLEMENT in all caps.

In the body of the email, include all the following:

• Case name
• Case number
• Document Control Number (DCN) for the life settlement contract and supporting documentation
• Disposition date
• Result of the disposition, certified or denied
• Total proceeds of the life settlement contract

Sources of verification include:

• Copy of a contract or written agreement from the life settlement company
• Copy of the account agreement from the bank
• Bank account statement showing deposits and withdrawals
• Written statement from the life insurance company showing change of ownership

Document the following:

• Name of the insurance company, the policy number and the face value.
• Type of insurance coverage.

If the insurance is excluded or not as a resource.

If the insurance is excluded, the reason for exclusion.

If the insurance is a participating policy or not. If an applicant or recipient has a participating policy, determine and document if the dividends are used to:

• Purchase more insurance — Treat as other life insurance policy.
• Increase the value of existing insurance policy coverage — Verify if the face value or cash value is increased.
• Apply toward the payment of premiums — Disregard the dividends as income or resources.
• Pay cash to the policyholders — Verify how often cash is paid, the amount of the payment and how the cash is used.

Balance of any dividend accumulation and interest.

Add the countable value of the dividends to the cash value of the policy for TIERS if dividends are accumulating and are considered in eligibility. Enter this total in the cash value section of the life insurance screen. Use case comments to document the actual value of the policy and the value of the dividends separately. Do not use the interest or dividend field on the life insurance screen.

Use the current cash value if the insurance is a countable resource.

Source used to verify the value.

Casework Hints:

• Check the bank drafts for life insurance premiums.
• Check the insurance policy for an Application for Life Insurance page for indicators of other life insurance policies.

Sources of verification include:

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

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

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

Accept the person’s statement as verification if the burial spaces are not an investment.

If the burial spaces are an investment, sources to verify the location and number of spaces include:

• Applicant's or recipient's statement
• Cemetery association
• Funeral home if associated with a particular cemetery or if it sells plots

Review the purchase contract for the burial spaces.

Document the type of resource being designated.

Document the total amount of assets being designated.

Document the amount of the asset that is excludable under the designated burial fund exclusion.

Get a written statement from the applicant or recipient, or their AR designating the assets for burial unless the designated resource is a prepaid burial contract or a bank account styled for burial. Verbal designation is acceptable when the applicant, recipient, or AR is designating life insurance insuring the applicant or recipient, or spouse and the case is due. The recipient or AR must follow up with a written statement, to keep getting the burial fund designation.

For preneed contracts, document:

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

May substitute another source of verification.

Refer to Appendix XXXIV, Burial Resources, for information about calculating the countable amount of a preneed.

Burial spaces can be excluded for anyone. However, only allow the designated burial fund exclusion for the person and the person’s spouse.

Use one of the following sources to verify the designation of burial funds:

• Form H1252, Designation of Burial Funds.
• A written statement from the applicant, recipient or their representative having the same information requested on Form H1252.
• For a life insurance designation, use a verbal statement from the applicant, recipient, or their AR with the same information requested on Form H1252. This is to certify a case on a timely basis when a written statement or a completed Form H1252 is not received before the certification deadline. The case also must reflect a special review to follow up for the written statement of designation. If the written verification is not received by the due date, redetermine eligibility based on the resource not being designated.
• Copy of the ownership papers or the financial institution's record showing the burial fund designation.

Get a copy of the burial trust or agreement. Document if the designated burial funds are in the form of an irrevocable trust or arrangement.

Note: Burial space items are not excludable on insurance-funded burial contracts. However, if the insurance-funded burial contract is irrevocable and fully paid, the value of the burial space item is disregarded when determining the amount of the irrevocable arrangement that reduces the burial fund designation.

Exception: If the irrevocable burial contract is owned by someone other than the applicant or recipient, do not make a deduction for the burial space items whether the contract is paid in full or not. Reduce the burial fund designation by the face value of the contract.

For preneed contract verification, request one of the following:

• Completed Form H1238-A, Verification of Pre-Need Information
• Copy of the contract or a letter from the funeral home, or document verbal contact with a funeral home representative using phone contact documentation

Although contact with a funeral home representative can be used to complete a case near the delinquency deadline, immediately follow up with verification by getting a copy of the contract or a letter from the funeral home.

For insurance-funded preneeds, verification such as irrevocable assignment, must come from the insurance company, not the funeral home.

Document the 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 other household member requires another vehicle for transportation to and from work, exclude the other vehicle for that member for work transportation.
• For households of more than one person with another household member who requires handicap-accessible transportation, exclude the other vehicle if it is specially equipped for that other member of the household.

For all other vehicles, use the current market value.

If the applicant or recipient still owes on the vehicle, consider the current market value and equity value. Document the formula used to determine the countable value if the equity value is less than the market value. Show the source used to verify the current market value and equity value.

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

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

Sources to verify the value of a vehicle include:

• Kelley Blue Book or NADA guidebook, trade-in wholesale value
• Hearst Corporation Black Book
• Statement from an automobile dealer
• Newspaper ads
• A source with knowledge 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.

Document the following:

• Location or address of the property - document in case comments.
• Percentage of ownership interest in the land resources - document in case comments.
• Applicant’s or recipient’s accessibility to the interest in the land resources.
• If the land resources are excluded as a resource.
• If the land resources are excluded, the reason for exclusion.
• If the land resources are not excluded, the current equity value of the applicant's or recipient's interest in the land resources. Document in case comments the calculation of countable equity value.
• Clearance of value is not required for subsequent reviews unless circumstances occur that may change the countability or value.
• If the mineral rights are non-producing, assign a $100 default value. Document in case comments the reason for the $100 default value.
• If the default value negatively impacts eligibility, verify a specific value.

Source of verification.

Notes:

• Clearance of value is not required for subsequent reviews unless circumstances occur that may change the countability or value.
• If the mineral rights are non-producing, assign a $100 default value. Document in case comments the reason for the $100 default value.
• If the default value negatively impacts eligibility, verify a specific value.

Sources to verify the value of land resources:

• Tax statement, if assessed.
• Contact with a knowledgeable source in the community, using phone contact documentation. Sources include oil and gas producers, tax assessors or collectors, and petroleum lease agents or landmen.
• Form H1242, Verification of Mineral Rights, completed by an authorized employee of the producing company.
• Internal Revenue Service formula to assess the value of mineral rights for inheritance purposes — 40 times the average monthly payout. Use this only when no other source is available. In TIERS, use other acceptable and document this 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, get the help of legal staff.
• Copy of royalty statement.
• Division order, if the mineral rights are producing.
• Statement from the applicant or recipient about the amount of interest (ownership).
• Completed Form H1242.

Document the following:

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

• Source of earnings.
• Calculations used to determine average earned income, if appropriate.
• Amount of the protected earned income allowance, if appropriate.
• Source of verification.
• Date of special review, if appropriate.

Amount of mandatory payroll deductions. Identify these payroll deductions on the expenses screen in TIERS, using case comments.

Use one of the following sources to verify the gross earned-income for the immediate past six months or less, depending on the review schedule:

• Statement from the employer about wages - signed and dated
• Copies of check stubs - for the entire period if there is fluctuating earned income
• The Work Number (TWN) earned income and employment information provided through the Federal Data Services Hub (FDSH)
• Written statement furnished by the ICF or IID provider, only if cannot get verification from the employer
• Completed and signed Form H1028, Employment Verification

Sources of verification include:

• Statement from the owner as to the current market rental value
• Statements from the applicant or recipient and the head of household or AR.  Use statement from Form H1200, Application for Assistance — Your Texas Benefits, if reasonable
• Copies of checks for payments made by the applicant or recipient
• Copies of household bills such as utilities, and rent

Verify gross annual income and expenses, as appropriate.

Verify that the income is at least six percent of the equity value to ensure the farmland is exempt if the farmland is not part of the applicant's or recipient's homestead.

Note: If the farm qualifies as the applicant's or recipient's business, it can be excluded whatever the value or the rate of return. Refer to F-4300, Resources Essential to Self-Support.

Sources of verification include:

• Income tax return
• Receipts, payments and statements from other knowledgeable sources such as a county agent or a co-op

Document the following:

• type of self-employment income;
• most recent income tax return; and
• 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.

Identify if the earnings are anticipated to change significantly if staff determines earnings using the applicant's or recipient's tax return. 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.

If staff determines earnings using the applicant's or recipient's IRS Schedule C form, staff is directed to the Schedule C page in TIERS to enter the applicable fields from the applicant's or recipient's IRS Schedule C form. TIERS calculates the monthly expense amount automatically.

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

Explain the reason if the amount of income is expected to change. Document this information in case comments.

Document in case comments the amount of net countable income and the calculations used to arrive at countable income if not using a tax return, an IRS Schedule C form, or an IRS Schedule F form.

Document the source of verification.

Set a six-month special review for variable earnings income.

Verify gross earnings and expenses for the past six months. Refer to E-5000, Variable Income, and E-6000, Self-Employment Income, for the averaging of earned income every six months. Refer to G-2200, Variable Income for treatment in the eligibility budget. Refer to H-3400, How to Budget at Reviews for treatment in the co-payment budget. Note the income tax return exception.

Sources for verification include:

• most recent year's income tax return;
• IRS Schedule C, Form 1040- Profit or Loss from Business;
• IRS Schedule F, Form 1040- Profit or Loss from Farming; and  
• receipts maintained by the applicant or recipient.

Note: Reconciliation must be done when a new tax return, an IRS Schedule C form, or an IRS Schedule F form 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 or recipient cannot provide income records or  income tax receipts, have the applicant or 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 to the applicant or recipient the information needed to establish the applicant's or recipient's true income. Set a one-month special review to get the necessary information. Use the information gathered at the special review to project the applicant’s or recipient's earnings for six months.

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

• View or get a copy of the applicant's or recipient's award notice (letter) from the SSA.
• Get an SOLQ or WTPY report.
• Contact a representative of the Social Security Administration, using phone contact documentation.
• View or get a copy of the applicant’s or recipient's most recent benefit check or direct deposit slip. This method is least desirable, because the check or direct deposit slip may not show the gross benefit amount.
• At review, use the conversion amount in the system of record if there is no indication that the RSDI benefit is different from the converted amount.

Document the gross benefit amount and, if appropriate, the SMIB premium amount.

Document deductions on the expenses screen and utilize case comments in TIERS to explain the deductions.

Check the deductions for potential life or health insurance. Pursue verifying and documenting the insurance policy if a deduction is for health or life insurance. Refer to the Third-Party Resources and Life Insurance sections of this chart.

Document the railroad retirement claim number.

Document the source of verification.

Document the date of the special review If a special review is needed for an annual cost-of-living increase, not automated or an anticipated change in the health insurance premium.

Verification sources include:

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

• Document the gross benefit amount and, if appropriate, the amount of any VA allowance not considered in the eligibility and co-payment budgets such as aid and attendance [A&A], housebound benefits, or reimbursements for unusual or continuing medical expenses.

Make two entries for VA income in TIERS, if the pension is not full A&A: one entry for the VA pension and the other entry for A&A.

Document the VA claim number.

Document the source of verification.

Note: If the recipient's VA compensation is capped at $90, there is no need to reverify it at the recipient's review or at the COLA review. There is no need to reverify old-law benefits at the review if the recipient or AR indicates there has been no change.

If a special review is needed for an annual cost-of-living increase, not automated, document the date of the special review.

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

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

Verify payments by one or more of the following methods:

• Get a letter from the organization providing the payments.
• Contact a representative of the organization, using phone contact documentation.
• Get a completed Form H1243, Verification of Civil Services Benefits, if the payments are from that source.
• Get a completed Form H1297, Request for Information from Teacher Retirement System of Texas, if the payments are from that source.
• Get a completed Form H1214, Request for Pension Information, for other types of pensions.
• View or get a copy of the applicant's or recipient's award notice.
• View or get a copy of the applicant's or recipient's most recent check or direct deposit slip. This method is least desirable, because the check or direct deposit slip may not show the gross benefit amount and or deductions. Send a follow-up letter to the payor.
• View tape matches, such as ERS or TRS.

Document the following:

• Name of the financial institution, company or other source of interest or dividend income.
  
  If the income is received from a financial institution, the account number.

If the income is received from an insurance company, the policy number.

The information used for projecting income, including the interest amount and dates paid, must be verified at each review subject to variable income review policy.

If the income is excludable, the reason for exclusion.

If the income is countable, any calculations used to arrive at an average amount.

Source of verification.

If a special review is needed, the date of the special review.

Sources of verification include:

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

Sources for verification include:

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

Document the following:

• Name of the payor and the reason for payment.
• Verification of the amounts and receipt dates used in the calculation of average income.
• If the royalties are excludable, the reason for exclusion.
• If the royalties are countable, the calculations used to arrive at an average amount.
• Source of verification.

If a special review is needed, the date of the special review.

Use one of the following methods of verification:

• Copies of check stubs.
• Completed Form H1242, Verification of Mineral Rights. Ensure the reported payments reflect when royalties were received and not when they were earned.
• Contact with a representative of the lease company must be documented using phone contact documentation. Automated phone information is acceptable and a very good source of information, but it must be documented using phone contact documentation.

Document the following:

• Amount of the gift, support, alimony or inheritance.
• 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.
• if the income is expected to continue.

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

• Get a statement from the person or organization providing the item. Use other acceptable in TIERS and document in case comments.
• View or get copies of the court order, court records or will. If the terms or conditions of the agreement do not clearly identify income, get the help of legal staff.
• Get 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.

Document the following:

• Name of the person making the note payments and if the income is accessible to the applicant or recipient.
• Amount of the note payment and the frequency of payments.
• If the note is negotiable, or not.
• If payments are countable as income or not and, if so, the portion of the note payment that must be considered as income.
• Source of verification.
• If a special review is needed, the date of the special review.

Refer to 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 the terms of repayment. If the terms or conditions of the agreement do not clearly identify income, get the help of legal staff.
• Statements from the applicant or recipient and the person who makes the payments. Use purchaser or noteholder in TIERS.
• Contact with the bank, using phone contact documentation.

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

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

Use one of the following methods for verification:

• Long-term Services and Supports (LTSS) summary screen in TIERS, populated by the interface
• Phone contact with TMHP or the NF, documenting the name of the person and the date and time of contact

Document in case comments that an applicant or recipient has met the 30-consecutive-days requirement, including verification and sources.

If the person is eligible only because of the special income limit, the person must be admitted to a Medicaid-approved long-term care facility such as Medicare-SNF, NF or ICF or IID for the 30-consecutive-day time frame to begin.

Note: A full or regular Medicaid recipient who enters a Medicaid-approved long-term care facility does not have to meet the 30-consecutive-day time frame.

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

• Contact with facility staff no sooner than the 31st day of the applicant's or recipient's stay, using phone contact documentation
• Proof of admission or discharge due to death by the LTSS summary screen interface
• Contact with TMHP, using phone contact documentation
• Contact with providers, using phone contact documentation
• Contact with waiver staff, using phone contact documentation

Hint: This list is not all-inclusive. Special reviews are set for many reasons depending on the information needed.

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

Monitor eligibility at least every three months if the applicant’s or recipient's countable resources are within $100 of the resources limit.

Special reviews are needed every six months for the following:

• All IMEs
• Variable income

Other situations requiring a special review include the following:

Known changes, such as an increase in income or TPR amount or loss of benefits.

Enter in case comments the following information:

• Date of the special review
• Why a special review is being set
• What information needs to be requested to complete the special review

Include the following information in the case record documentation:

• If a special review is needed
• Specific details about the special review
• Months and source of verification related to the special review
• Date the special review will be conducted

Enter all special reviews into TIERS.