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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

a. An income tax return; b. Self-employment bookkeeping records; c. Sales and expenditure records; d. State income tax bureau; or e. Business expense receipts. Source of Third Level Documentation A Statement from the client of estimated earnings. L. Unearned Income: Explore all potential sources of unearned income. When the client states s/he does not receive a benefit, evaluate this in terms of the client's background, marital history, past work history, and present circumstances. For example, a review of the client's employment history may indicate a possible eligibility for unemployment compensation, a company retirement pension, or benefits from past union membership.

1. RSDI Benefits: Verify the amount of RSDI benefits and evaluate the existence of RSDI as potential income. A routine check should be made in all cases where a child is deprived of parental support because of death or incapacity, or when a client is retired, disabled, widowed, or divorced. Primary Sources Federal Data Hub, BDE, or SDX file. Secondary Sources a. RSDI benefit payment check; b. Recent RSDI award letter or other correspondence from SSA; or c. Contact with SSA. 2. Veteran's Income: Verify the amount and type of VA income and evaluate the existence of VA as potential income. Explore the client's and spouse's background and past military service record. Primary Sources a. VA check; b. VA award letter or other written correspondence; c. VA Form 21-0172, Certificate of Permanent and Total Disability; d. IRS Form 1099-R (May be issued to a veteran by the Defense Finance and Accounting Services which reflects the taxable portion of compensation received.) e. A release from active duty showing disability; f. Other contact from VA; or g. SDX financial file. NOTE: Income alerts from interfaces such as PARIS regarding Veterans/Military income are to be treated as leads only.