Page 102

COMAR 10.09.24.03

401 State of Maryland Medical Assistance Manual Revised July 2012

Worksheet - Pickle Eligibility

A person is eligible under the Pickle Amendment if all factors are met.

If the response to any statement is “No”, do not continue worksheet; the person is determined ineligible under the Pickle Amendment.

Yes

No

I. Terminated from SSI after April, 1977

Received both SSI and SSB prior to termination

Currently receives Social Security Benefits

II. Aged, Blind or Disabled

Citizenship, residency, etc.

III. Resources of $

less than or equal to SSI standard of $

IV. Income Calculation:

Gross Monthly Income $

COLA Deduction ˉ

Net Monthly Income $

less than

SSI standard $