Twelve-Month Extended Medical Assistance

(b) Acceptable documentation for failure to return a complete quarterly report on time due to a mail delay shall be:

(1) The envelope for the quarterly report form which was post marked prior to the due date; or

(2) The quarterly report form which was date stamped by the department on or before the due date.

(c) Acceptable documentation for failure to return a complete quarterly report on time due to illness shall be the parent’s, caretaker relative's, or physician's signed and dated statement describing:

(1) The duration and nature of the illness; and

(2) How the illness specifically resulted in a late quarterly report.

(d) Acceptable documentation for failure to be employed or to return a complete quarterly report on time due to an emergency shall be the parent’s or caretaker relative's signed and dated statement describing:

(1) The emergency; and

(2) How it specifically resulted in the failure to be employed or in the late submission of the quarterly report.

(e) Acceptable documentation for failure to be employed due to involuntary loss of employment shall be:

(1) A layoff or firing notice;

(2) A signed and dated statement from the employer that indicates that the parent or caretaker relative's termination of employment was involuntary;

(3) Proof of receipt of unemployment benefits or a statement from the department of employment security indicating that the parent or caretaker relative is eligible for unemployment benefits; or

(4) A notarized statement from another individual who has direct knowledge of the circumstances that caused the parent’s or caretaker relative's involuntary loss of employment.

(f) Acceptable documentation for failure to be employed due to illness of a family member shall be the parent’s, caretaker relative's, or physician's signed and dated statement describing:

(1) The duration and nature of the illness; and

(2) How the illness specifically resulted in the parent or caretaker relative's lack of employment.

(g) Acceptable documentation of earned income shall be pay stubs or a statement from the employer that provides the amount and frequency of earnings for each of the 3 months in the quarter.

(h) Acceptable documentation of child care costs shall be a receipt or bill which provides:

(1) The amount and frequency of child care costs for each of the 3 months in the report period; and

(2) A statement from the third party payor indicating the amount subject to third party reimbursement, if applicable.

Source. #13875, eff 2-21-24