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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD Send the Home and Community Based Services Waiver Eligibility Status Form NMO-3010 to DHCFP district office requesting a Katie Beckett determination and, if necessary, a disability determination. If DHCFP disability determination is needed, the Division must obtain Form 2325-Incapacity/Disability Questionnaire, completed by parent(s) of applicant prior to submission of the Home and Community Based Services Waiver Eligibility Status Form NMO-3010 to DHCFP. Do not delay sending the DHCFP disability request while waiting for an SSI decision. The DHCFP decision can be pursued at same time as SSI for Katie Beckett. If the child previously received SSI and was denied for income, use the SSA disability determination. At the same time the Home and Community Based Services Waiver Eligibility Status Form NMO-3010 and if applicable Form 2325-Incapacity/Disability Questionnaire is sent to DHCFP for level of care and/or disability determination, request required verification if needed. Verifications: • Citizenship - Only verify citizenship of the applicant • SSA verification that SSI has been applied for “applicant” • Income – “Applicant” parent’s tax return for the prior year or if no tax return available; all earned and unearned income received for the parent(s) of applicant for the past 3 months • Form 2451 – Authorization for Release of Information for applicant • Form 2325 – Incapacity/Disability Questionnaire for applicant (if applicable) • Form 2525 – Designation of Authorized Representative (if applicable) • Add DHCFP as secondary Designated Authorized Representative Note: Katie Beckett eligibility decision must wait until the Division receives the level of care determination from DHCFP on the Home and Community Based Services Waiver Eligibility Status Form 3010 and if applicable, disability determination. When the Division receives verification that applicant meets the level of care requirement, the Division staff will complete the following steps: 1. Determine financial and non-financial eligibility for Katie Beckett program. 2. Complete section #5 on the Home and Community Based Services Waiver Eligibility Status Form NMO-3010. 3. Send completed the Home and Community Based Services Waiver Eligibility Status Form NMO- 3010 back to DHCFP. 4. If the applicant is determined eligible for Katie Beckett, the Division will calculate monthly parent premium. Calculating Monthly Parental Premiums Based on the applicant parent(s) federal income tax return or gross monthly income, use Form NMO 7011B-Payment Agreement Guide, (Katie Beckett Premium Matrix), to determine family monthly premium amount. The Division will use this matrix to complete Form NMO-7011 Income Review/Premium Payment Agreement. The Division will send completed Form NMO-7011 Income Review/Premium Payment Agreement to parent of applicant to sign and agree to monthly premium payment determination. The parent(s) will be allowed a 10-calendar day timeframe to return Form NMO-7011 Income Review/Premium Payment Agreement. Once the Division receives signed Form NMO-7011 Income Review/Premium Payment Agreement from parent of applicant, the Division will email completed Form NMO-7011 Form to DHCFP at dhcfpkatiebeckett@dhcfp.nv.gov. D-380 MAABD APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25 KATIE BECKETT