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Medicaid Home & Community-Based Waivers Manual: Appendix C

APPENDIX C: Financial Eligibility

C-1 MA Waiver Eligibility and Cost-Sharing Worksheet (F20919) (PDF, 18 KB)
C-2 Declaration Regarding Transfer of Resources Long Term Care Medicaid Waiver Programs (F20919D) (PDF, 29 KB)
C-3 Model Referral to Economic Support (F21051) (PDF, 15 KB)
C-4 Medical/Remedial Expenses (PDF, 44 KB)
C-5 Sample C.A.R.E.S Screen Printouts from basics
ECSC Community Waivers Cost Share Budget Form
ECED Community Waivers Eligibility Determination Form
(PDF, 1.5 MB)
C-6 Spousal Impoverishment Income Allocation Worksheet (PDF, 34 KB)

Selected References

Medicaid Handbook (Appendix List)

Waiver Wise: Information for Care Managers 09 502 Vol I Issue III

Declaration of Income (F20465) (PDF, 32 KB)

COP Initial and / or Continuing Financial Eligibility Determination Worksheet for a Single Applicant / Participant (F-29316) (PDF, 29 KB)

Uniform Cost Sharing Plan (F-29324) (PDF, 10 KB)

Hardship Policy / Hidden Asset Policy (F-29323) (PDF, 14 KB)

COP Initial Financial Eligibility Determination Worksheet for Married Applicants When One or Both Spouses Apply (F-29317) (PDF, 32 KB)

COP Financial Eligibility Determination Worksheet for Married Participants-Both on COP (F-29318) (PDF, 66 KB)

COP Cost-Share Worksheet (F-29319) (PDF, 26 KB)

COP Cost-Share Worksheet #1 Instructions (F-29320) (PDF, 29 KB)

COP Cost-Share Worksheet #2 (F-29321) (PDF, 17 KB)

COP Cost-Share Worksheet # 3 (F-29322) (PDF, 29 KB)

Instructions: Declaration of Income and Assets and State Residency (F2-9315) (PDF, 136 KB)


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Last Revised: April 23, 2014