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3. MEDICAID

RETROACTIVE DETERMINATION NECESSARY? Y N

RETROACTIVE PERIOD

POTENTIALLY PROTECTED MEMBERS PROTECTED MEMBERS (INCLUDED STATUS)

COMMUNITY SPOUSE?

Y N

4. DOCUMENTATION OF UNIT OR HH MEMBERSHIP, MEDICAID PROTECTED STATUS, VOLUNTARY QUIT, WORK REDUCTION, WORK REQUIREMENT.

5. RESOURCES (EVALUATE SAVINGS OR INVESTMENT ACCOUNT FOR ANY PURPOSE LEADING TO SELF-SUFFICIENCY)

STOCKS/BONDS

PENSION PLANS CASH Y N ACCOUNTS Y N TRUST FUNDS Y N RETIREMENT Y N PROGRAM(S)

MBR

TYPE

AMOUNT

INSTITUTION, ACCT NAME, ACCT# VERIFICATION CALCULATIONS, WITHDRAWLS

COUNTABLE

PROMISSORY NOTES/DEEDS OF TRUST Y N BURIAL Y N PERSONAL PROPERTY Y N REAL PROPERTY Y N

PROGRAM(S)

MBR

TYPE

AMOUNT

ADDITIONAL EXPLANATION, VERIFICATION, CALCULATIONS

COUNTABLE

VEHICLES Y N DMV MATCH NO MATCH DATE

PROGRAM(S)

MBR

YEAR, MAKE, MODEL

USE

FMV

FS LIMIT

EXCESS

LIEN

EQUITY

VERIFICATION, CALCULATIONS

COUNTABLE

HEALTH INSURANCE Y N

MEDICAID: HIPP APPLICATION, MEDICAL QUESTIONNAIRE COMPLETED Y N

MBR TYPE COMPANY POLICY ID# VERIFICATION PREMIUM

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