Allocated Income for Non-MAGI Categories of Medical Assistance

(c) Acceptable verification of (b)(1) through (7) above, shall include the documentation listed below:

(1) A signed and dated statement from the admitting physician, caseworker , hospital social worker, bureau of elderly and adult services social worker, or representative of the institution, which indicates that based on available medical data, the institutionalized individual requires a minimum of 30 days of institutionalization;

(2) Documentation that substantiates the amount and frequency of income, as specified in He-W 806.59;

(3) A marriage certificate, a record of marriage from the town clerk's office, or other document that provides proof of marriage;

(4) Documentation which is no more than 2 months old and which substantiates the community spouse's shelter expenses, such as:

a. Rent receipts that indicate the amount and frequency of payment;

b. A bill or receipt for the mortgage payment;

c. Property taxes;

d. Fire insurance premiums;

e. Manufactured housing lot rent;

f. Utility expenses; or

g. Condominium fees;

(5) Bills or receipts that substantiate that the institutionalized spouse has incurred non-reimbursable medical expenses and the frequency of such expenses;

(6) A copy of the most recent filed internal revenue service income tax return or other documentation that substantiates legal dependency status;

(7) A driver's license, military record, voter registration card, school or hospital record, or any other document that establishes the identity of the dependent;

(8) A birth certificate, baptismal record, marriage certificate, or other documentation which establishes the relationship between the dependent and the spouse who provides support; and

(9) A copy of the court order or other documentation that substantiates that the institutionalized spouse has been ordered to pay support and which indicates the amount and frequency of such support payments.