DHHS Form 3401 Optional State OR Supplementation (OSS) 85 Local eligibility worker DHHS Form 3400 AND - No SSI DHHS Form 3400-B Optional State Supplementation (OSS) 86 Local eligibility worker SSI Recipient Request for SSI recipient for OSS DHHS Form 3400 and (Pickle) 16 eligibility worker DHHS Form 3400-A State Office completes to category to Pass-Along Children ex parte determination 20 which child is being “ex (PAC) when child reaches age parted.”) 18. Qualified Disabled DHHS Form 3400 and Working Individuals 50 CIU DHHS Form 3400-A (QDWI) Qualified Medicare DHHS Form 3400 and 90 Local eligibility worker Beneficiaries (QMB) DHHS Form 3400-A DCEP DHHS Form 3400 and Qualifying Individuals (Eligibility is determined DHHS Form 3400-A 48 (QI) during the limited OR enrollment period) QI Application Refugee Assistance 70 Local eligibility worker DHHS Form 3400 Ribicoff 91 eligibility worker DHHS Form 3400 Specified Low Income DHHS Form 3400 and Medicare Beneficiaries 52 Local eligibility worker DHHS Form 3400-A (SLMB) Supplemental Security 80 N/A N/A Income (SSI) DHHS Form 3400 and TEFRA/Katie Beckett 57 DCEP DHHS Form 3400-A DHHS Form 3401 Waiver Services (WS) OR 15 Local eligibility worker SSI DHHS Form 3400 AND DHHS Form 3400-B Home and Community Based Services for SSI 80 N/A N/A recipient (SSI-WS) DHHS Form 3400 and Working Disabled (WD) 40 CIU DHHS Form 3400-A Former Foster Care 61 Local eligibility worker DHHS Form 3400 (FFC)
Optional State Supplementation (OSS) - No SSI 85 Local eligibility worker DHHS Form 3401 OR DHHS Form 3400 AND DHHS Form 3400-B Optional State Supplementation (OSS) for SSI recipient 86 Local eligibility worker SSI Recipient Request for OSS (Pickle) 16 eligibility worker DHHS Form 3400 and DHHS Form 3400-A Pass-Along Children (PAC) 20 State Office completes ex parte determination when child reaches age 18. to category to which child is being “ex parted.”) Qualified Disabled Working Individuals (QDWI) 50 CIU DHHS Form 3400 and DHHS Form 3400-A Qualified Medicare Beneficiaries (QMB) 90 Local eligibility worker DHHS Form 3400 and DHHS Form 3400-A Qualifying Individuals (QI) 48 DCEP (Eligibility is determined during the limited enrollment period) DHHS Form 3400 and DHHS Form 3400-A OR QI Application Refugee Assistance 70 Local eligibility worker DHHS Form 3400 Ribicoff 91 eligibility worker DHHS Form 3400 Specified Low Income Medicare Beneficiaries (SLMB) 52 Local eligibility worker DHHS Form 3400 and DHHS Form 3400-A Supplemental Security Income (SSI) 80 N/A N/A TEFRA/Katie Beckett 57 DCEP DHHS Form 3400 and DHHS Form 3400-A Waiver Services (WS) SSI 15 Local eligibility worker DHHS Form 3401 OR DHHS Form 3400 AND DHHS Form 3400-B Home and Community Based Services for SSI recipient (SSI-WS) 80 N/A N/A Working Disabled (WD) 40 CIU DHHS Form 3400 and DHHS Form 3400-A Former Foster Care (FFC) 61 Local eligibility worker DHHS Form 3400
Chapter_101.docx