Rhode Island Department Of Human Services Ri Dhs-PDF Download

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EXAMPLES OF DOCUMENTS YOU MAY NEED TO PROVIDE FOR YOUR INTERVIEW. OR TO SUBMIT FOR BENEFIT APPROVAL, Note The same document may be used to verify more than one category for example a driver s license can verify identity and address If you. are applying for Medicaid we will verify your information with data sources as much as possible. 1 To verify your identity age date of birth citizenship and or immigration status All Programs. Driver s License Birth Certi cates,School or work Identi cation U S Passport. Immigration and Naturalization Documents e g Green Card Any other documentation requested for citizenship immigration. Hospital birth records status or age may be used for veri cation of identity. 2 To verify your Rhode Island residence All Programs except ACC unless questionable. Rent or mortgage receipts showing address Lease agreement of letter from landlord. Library card showing address Mail received with your home address utility bills bank statements. Voter s registration card,3 To verify your income All Programs. Check stubs showing the last 30 days of income Proof of alimony received. Employer statement showing income before taxes hourly work schedule Proof of receipt of unemployment insurance bene ts temporary. and the number of hours worked for the past four weeks if you get paid in disability bene ts TDI Veteran s Administration VA bene ts. cash or you do not have your check stubs Previous tax returns. Social Security Supplemental Security Income or Veteran s Bene ts Proof of self employment income includes rental income and freelance. award letter work provide tax returns or self employment ledger. Other retirement or disability bene t award letters Child Support court order. 4 To verify your resources RIW GPA EAD LTSS MPP SSP KB CCAP if over 9 500. Documentation of ownership of a trust Vehicle registration including car boat truck motorcycle camper. Proof of rental properties Proof of ownership of other income producing property. Trust documents property Proof of ownership of a burial plot if you own more than one. Stock and or bonds Bank accounts savings accounts credit union statements CD s. Proof of ownership of real property other than your home. 5 To verify your dependent care expenses RIW SNAP, Proof of expenses related to child care or caring for incapacitated adult living in the home receipts showing your out of pocket expenses. 6 To verify your shelter costs SNAP RIW LTSS, Rent lease or mortgage documents Proof of property insurance.
Statement from landlord Receipts or statement from utility company. Property taxes statement Statement from person who shares shelter costs. Statement from U S Department of Housing and Urban Development HUD. 7 To verify your child support expenses SNAP ACC, Child support that you pay income summary if child support is deducted from wages or income Copy of court order. 8 To verify your medical expenses not covered by insurance SNAP EAD. Summary of provided services such as doctor or hospital visits Prescription pill bottles showing cost on label or printout. Receipts showing unreimbursed medical expenses Invoices or receipts for medical equipment including the rental cost. Health insurance policy showing premium amount, 9 To verify relationships among household members RIW CCAP ACC. Adoption papers or records Marriage license tribal marriage certificates. Hospital or public health records of birth or parentage Divorce custody papers. Child support paternity records Guardianship papers or records. 10 To verify your disability or blindness RIW SNAP CCAP GPA EAD LTSS. Proof of receipt of Retirement Survivors and Disability Insurance RSDI or Supplemental Security Income SSI copy of the award letter or similar. documentation from the Social Security Administration and or current nding of eligibility for RSDI or SSI based on blindness. Copy of medical examination report on le at the O ce of Rehabilitation Services ORS Services for the Blind and Visually Impaired. Statement from a medical professional,DHS 2 Rev 09 16 Instructions Page 2 of 4. SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM SNAP, You may file your application immediately as long as we have your name address and the signature of a responsible. household member or your authorized representative on this application If you are determined eligible benefits will be. calculated from the date we receive this form in our office We are required to verify information you provide and take. action on your application within thirty 30 days of the filing date unless you are entitled to expedited service To. determine whether or not you are eligible you must be interviewed The application filing date for pre release applicants is. the date of release from the institution, You will be sent a written request for any verification missing from your application Your application will be denied if the.
missing verification is not received within ten 10 days of the written request. FINANCIAL ASSISTANCE RIW GPA CCAP SSP, If you are applying for RIW GPA CCAP or SSP and are determined eligible for benefits those benefits will be determined from. the date the signed application is received,MEDICAID LTSS EAD. Retroactive Medicaid coverage for certain health expenses may be provided to applicants eligible through the LTSS and EAD pathways for up. to three 3 months prior to the date we receive a signed application provided all factors of eligibility are met for each month There is no. retroactive coverage available for ACC Medicaid beneficiaries. Applicants may qualify for Medicaid through more than one eligibility pathway If you are uncertain which pathway best suits the needs of. the applicants in your household contact 1 855 MYRIDHS 1 855 697 4347. ABOUT THE PROGRAMS, Again the letter boxes next to each program below are used through this application to identify questions you need to answer to be. considered for specific programs Answer only those questions for the programs you want to apply for For example if you want to. apply for all programs answer all the questions If you are applying for only RIW and ACC you must answer a question with a RIW or. ACC box above it and can leave the other questions blank. RIW RI Works RIW Cash Assistance The RIW Program gives cash assistance for a limited number of months to families in need of. support as well as those who are unable to work or in training or looking for a job Applicants for RIW must be responsible for the support and. care of a child under age 18 or between ages 18 and 19 if enrolled full time in and expected to complete secondary school prior to their 19th. birthday A pregnant woman with no other children can qualify for assistance if she is in her third trimester of pregnancy RIW requires. an interview with an eligibility worker and a meeting with a Social Caseworker to complete an employment plan. SNAP Supplemental Nutrition Assistance Program SNAP SNAP formerly known as food stamps helps low income households buy. the food needed to stay healthy Your income minus certain allowable expenses will determine if you are eligible for SNAP benefits You will. need to participate in an interview over the telephone or in the office before you can be granted SNAP benefits. CCAP Child Care Assistance Program CCAP Child Care Assistance is available to families with earnings up to 180 of the federal. poverty level and is only available to cover hours of employment or short term training Families may be required to pay a co payment based on. their family size income level and number of children Families that participate in RIW automatically meet the income requirements for CCAP. Prior to enrollment RIW applicants or participants who are not employed must discuss child care options with a Social Worker as part of the. assessment process and the development of the employment plan For families not participating in the RIW Program eligibility for CCAP is. based on working at least 20 hours per week at or above Rhode Island s minimum wage. GPA General Public Assistance GPA Program GPA is available for adults ages 18 64 who have very limited income and resources. and have a chronic or disabling illness or condition that keeps them from working Adults who have a current pending application for. Supplemental Security Income SSI may be determined eligible for GPA benefits A determination for ACC Medicaid health care coverage must. be completed prior to a determination of eligibility based on a disabling condition GPA applicants can apply for ACC Medicaid healthcare. coverage by completing the ACC questions on this application or by applying online at www healthyrhode ri gov. DHS 2 Rev 09 16 Instructions Page 3 of 4, SSP RI SSI State Supplemental Payment Program SSP The State of Rhode Island supplements the Federal Supplemental Security. Income SSI benefit rate for eligible persons Authorization of the monthly SSP for current SSI recipients will be completed automatically when. they apply at SSA Applicants for SSP who have been denied through SSA for excess income will need to meet the income resource age. and or disability standards age 65 or older disabled or blind established for Medicaid for low income persons who are aged or living with a. disability If an applicant is eligible based on income and is claiming a disability which has not been reviewed or determined by the SSA the. SSP Unit will send a referral to the Medicaid Review Team MART for a disability determination. ACC Affordable Care Coverage Medicaid and Private Health Insurance with Financial Help ACC Medicaid is available for. parents caretakers with income up to 136 of the Federal Poverty Level FPL children with income up to 261 of the FPL pregnant women. with income up to 253 of the FPL and adults age 19 to 64 with income up to 133 of the FPL who are otherwise ineligible for Medicaid and not. eligible for or enrolled in Medicare through this eligibility pathway Adults who are awaiting a determination of disability by a government. agency have resources above the limits for EAD eligibility and or do not meet the criteria for disability determination may apply for Medicaid. affordable care coverage through this pathway Families and individuals not eligible for Medicaid with income below 400 of the FPL may be. eligible for a tax credit from the federal government to help pay the costs of coverage through a private a health plan You can also apply for. coverage online at www healthyrhode ri gov or over the phone by calling the HSRI Contact Center at 1 855 840 4774. LTSS Medicaid Long Term Services and Supports LTSS LTSS are available for individuals who meet the necessary level of need. and financial requirements and for individuals with disabilities You must meet both the financial and clinical level of care requirements to. qualify for LTSS For people who qualify Medicaid LTSS may be provided in a health institution like a nursing home at home or in certain. pre approved community settings including some assisted living residences The range of long term services Medicaid covers includes but. is not limited to homemaker certified nursing assistant CNA services environmental modifications case management self directed care. respite minor home modifications and shared living RIte at Home The range of services and the choice of service settings depends on an. individual s care needs, EAD Medicaid Health Coverage for Low Income Elders and Persons with Disabilities and Working Adults with.
Disabilities Sherlock Plan EAD To qualify for Medicaid for low income elders and persons with disabilities an individual or member of a. couple must be age 65 years or older or living with a disability Persons who are blind also qualify for coverage in this category Income must be. at or below 100 of the FPL and resources cannot exceed 4 000 for a single person and 6 000 for a couple In addition a person under age. 65 must be determined to have a disability by the Medicaid Review Team MART that prevents gainful activity including work for a minimum of. one year Some applicants who have income and or resources above these amounts may qualify for Medicaid through the medically needy. pathway if they have high medical expenses each month You will be given more information about this pathway if you do not meet the EAD. income and resource standards People who receive Supplemental Security Income SSI based on age or disability are automatically eligible for. Medicaid and do not need to complete this application People who receive Social Security Disability Insurance SSDI must apply but do not. have to undergo a disability review by the MART, Medicaid for Working People with Disabilities Program Sherlock Plan People eligible under this category are entitled to the full. scope of Medicaid benefits home and community based services and services needed to gain and or maintain employment To be found. eligible for this program a person must be at least eighteen 18 years of age meet the Medicaid requirements for eligibility based on a disability. have proof of active paid employment have income at or below 250 of the FPL and meet special resource standards. MPP Medicare Premium Payment Program MPP Eligibility for the MPP is based on income and helps adults over age 65 and adults. with disabilities pay all or some of the costs of Medicare Part A and Part B premiums deductibles and co payments Medicare Part A is hospital. insurance coverage and Medicare Part B is for physician services durable medical equipment and outpatient services People with income up to. DHS 2 Rev 09 16 InstructionsPage1 of 4 RHODE ISLAND DEPARTMENT OF HUMAN SERVICES APPLICATION FOR ASSISTANCE DHS 2 Getting Help with this Application

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