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COMAR 10.09.24.03
383 State of Maryland Medical Assistance Manual Revised July 2012 DHMH 1159F
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 - _____ Net Monthly Income $_________ less than SSI standard
$_________