Page 42

Medical Services - Appendix I, Application Form Chart Appendix I (01/23) Page 1 of 2 Eligibility Group Families and Individuals (MAGI) Groups ARKids A X * X ARKids B X * X Newborns X * X Parents & Caretakers X X Pregnant Women Low Income X X Unborn Child X X Former Foster Care X X Adult Expansion Group X X Aid to Aged, Blind or Disabled Long Term Services and Supports Nursing Facility X * * X X * * * X * * X ● ● ● Assisted Living Facility X * X X * * * X * * X ● ● ● X ARChoices Waiver X * X * * * X * * X ● ● ● X PACE X * X * * * X * * X ● ● ● X DDS Waiver X * * X * * * X * * X ● ● ● X Medicare Savings Program ARSeniors X X QMB X X SMB X X QI-1 X X QDWI X X A green X signifies this form will be needed for an application. A red dot ● signifies this form will be needed for an application if a disability determination from MRT is needed. A blue asterisk * signifies this form may be needed, depending on the circumstances. (e.g. DCO-0090 when there is an absent parent)