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of this Title) or full benefits if they meet certain clinical/functional and financial eligibility criteria. The State uses information known about the beneficiary when determining eligibility for LTSS for current Medicaid beneficiaries to the full extent feasible. The additional information required, as out-lined below, may be provided by completing the applicable sections of the DHS-2 form, or designated supplemental form, or by updating an on-line account as appropriate: Basis of Eligibility Supplemental Information Required from Existing Beneficiaries Seeking LTSS

Preventive LTSS Clinical/function (See Part 40-05-1 of this Title) Functional/clinical Level of Need (See Part 5 of this Subchapter) Financial Eligibility – Allocation of resources and transfer of assets – Part 40-00-3 of this Title and Part 6 of this Subchapter) Post-eligibility Treatment of Income (See Part 8 of this Subchapter) 1.SSI Documentation from health provider Documentation from health provider Limited to current information on spouse and dependents as related to spousal impoverishment and transfer of assets Applies – information related to allowances including income and expenses of spouse and dependents 2. EAD Documentation from health provider Documentation from health provider Limited to sixty (60) months pre-application of information on spouse and dependents as related to spousal impoverishment and transfer of assets Applies – information related to allowances income and expenses of spouse and dependents 3. ACA Expansion Adults Not applicable Documentation from health provider Limited sixty (60) months of pre- application information on resources of self, spouse and dependents as related to transfer of assets only Not applicable