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REV. MAY 3, 2018 NEBRASKA DEPARTMENT OF MEDICAID ELIGIBILITY MANUAL LETTER #43-2018 HEALTH AND HUMAN SERVICES 477-000-004

Secondary Sources 1. Attestation of Social Security number; 2. Signed copy of Form SS-5; 3. Copy of a birth certificate with permission checked to provide Social Security Administration with information for a Social Security card; 4. Form SSA-2853 with the name of the newborn, and a signature and date by an authorized hospital official; 5. Medicare card with a claim number with a suffix "A"; or 6. Dated documentation from SSA that an application for an SSN has been made. Note: A copy of an individual’s Social Security card is NOT required. As a courtesy, a client who does not have a Social Security number but would like to apply for a one may be given a Referral for Social Security Number Application form. I. Non-MAGI Resources Please see 477-000-052 for the Non-MAGI Resource Verification Plan J. Income: Verify income declared by the client or appearing on SEW and evaluate the possibility of additional income. Also consider potential income for which the client may be eligible. 1. Earned Income: Verify the employment status (full time, part time, or temporary), name of the employer, and the gross amount and frequency of the earnings. Primary Sources Federal Data Hub (Tax interface is only applicable to MAGI-based methodology and TALX is applicable for MAGI-based methodology and non-MAGI). Secondary Sources a. Nebraska’s electronic data sources (SEW); b. Paystubs; c. Employer's wage records; or d. A statement from the employer. K. Self-Employment: Verify the amount of income as well as the allowable expenses directly related to producing the goods and services. Primary Source Federal Data Hub (The tax interface is only applicable to MAGI-based methodology).