Page 68

Effective Date:

Approval Date: 68

This case is being referred to hawk-i because: The children must meet a spenddown under the Medically Needy program. The following children have been voluntarily excluded from the Medicaid eligible group because the child’s income creates Medicaid ineligibility for the remaining household members. Indicate the income of the voluntarily excluded child below in the next section. Also, attach an NOD showing the Medicaid eligibility calculation for the other family members. (Note: Children voluntarily excluded for non-financial reasons are not eligible for hawk-i.)

1.

2.

3.

4.

Income

Family members are employed at the following companies:

Family members have unearned income from the following sources: This case has (check all that apply):

Non-recurring lump sum Income:

Income of voluntarily excluded child: Amount prorated monthly (Standard of Need): $ $ per Last month and year of period of proration:

(week, month, etc)

(MM/YYYY) Income has been verified (attach verification to referral)

Self-employment income: Income has not been verified Amount of depreciation (from Schedule C or $ Comments

(or attach a copy of Schedule C or F)

Unemployment benefits: Name of person(s) receiving UIB: Attachments: Copy of Notice of Decision showing Medicaid ineligibility (Required) REMINDER – Only Refer Children Who Are Over Income For Medicaid Do Not Refer Children to the hawk-i Program Who: Are age 19 or older; or Are ineligible for Medicaid due to a non-cooperation issue. Send via local mail to: Department of Human Services Attn: MAXIMUS/hawk-i Program Division of Financial, Health and Work Supports 1305 E. Walnut Des Moines, IA 50319-0114 OR Fax: 515-457-7701