zz – Obsolete

Obsolete per IM-126 September 15, 2022

IM-44 September 4, 2014, IM-105 August 23, 2002

Give copies of the following leaflets:

1. Medicaid and You; IM-4 Medicaid
2. Non-Emergency Medical Transportation;
3. Medical Assistance Benefits; IM-4 MA
4. Medical Assistance Spenddown, if needed; IM-4 SPDN
5. Hearing Rights; IM-4 Hearings
6. HCY, if applicant under 21
7. Personal Care; IM-4 PC
8. Health Insurance Premium Payment (HIPP) Program

Complete the following forms, at a minimum:

1. Application and Eligibility Statement; IM-1MA
2. Request for Direct Deposit; (if dual eligibility for GR) IM-4DD
3. Insurance form, IM-9, if needed;
4. Referral for Social Security Number, SSN-1 if needed;
5. If applying based on disability and a Medical Review Team (MRT) decision will be required, complete and submit all documents necessary in the MRT-Processing Center Packet:
   • MRT Checklist
   • Authorization for Disclosure of Consumer Medical/Health Information (MO-650-2616) (requires applicant’s signature)
   • Social Information Summary (IM61)
   • Disability Questionnaire (IM61B)
   • Work History (IM61C)
   • Facility/Doctors List (IM61D)
   • Visual Disability Examination Report (if application includes a determination based upon blindness) (IM68)
6. Home and Community Based Referral (if applying for HCBS); IM-54A
7. Request for Information, if needed; IM-31A
8. Third Party Liability, if needed; TPL-1
9. HIPP-1, if applicable

Explain the following:

1. How spenddown works (if spenddown)
2. December 1973 eligibility requirements (see 0105.020.15.60)
3. Lack of a cash grant
4. Need
5. Division of assets (if institutionalized or HCB and there is a community spouse)
6. Special Eligibility Groups (MACC, QMB, SLMB, QDWI, MADC, MOCDD, 1619)
7. Prior quarter coverage
8. Medicare Buy-in
9. SSN
10. Available services and how to access them