0105.025.15.10 MAF and MC+

IM-105 August 23, 2002

Provide the client the following leaflets:

  1. HCY
  2. Income Guidelines, MC-4A
  3. Important Information, MC-4
  4. Non-Emergency Medical Transportation
  5. Health Insurance Premium Payment (HIPP) Program

Complete the following forms, at a minimum:

  1. Application and Eligibility Statement, IM-1UA
  2. TPL Form, TPL-1 if needed
  3. Referral for Social Security Number, if needed
  4. Medical Support Referral/Information for Services, CSE-201 if needed
  5. Request for Information, MC-31A if needed
  6. HIPP-1, if applicable

Explain the following eligibility requirements:

  1. Social Security Number
  2. Assistance Grouping
  3. Assignment of Medical Support
  4. Cooperation with DCSE for Medical Support
  5. Residence
  6. Citizenship
  7. Alien Status
  8. Need
  9. Age of child
  10. Prior Quarter Coverage