Application for a §1915 (c) hcbs waiver Submitted by


d-1. Regular Post-Eligibility: 209(b) State



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d-1. Regular Post-Eligibility: 209(b) State. The State uses more restrictive eligibility requirements than SSI and uses the post-eligibility rules at 42 CFR §435.735. Payment for home and community-based waiver services is reduced by the amount remaining after deducting the following amounts and expenses from the waiver participant’s income:


i. Allowance for the needs of the waiver participant (select one):




The following standard included under the State plan (select one)






The following standard under 42 CFR §435.121:




Optional State supplement standard



Medically needy income standard



The special income level for institutionalized persons (select one)








300% of the SSI Federal Benefit Rate (FBR)



%

of the FBR, which is less than 300%



$

which is less than 300% of the FBR



%

of the Federal poverty level



Other (specify):




The following dollar amount:

$

If this amount changes, this item will be revised.



The following formula is used to determine the needs allowance:


ii. Allowance for the spouse only (select one):



The following standard under 42 CFR §435.121




Optional State supplement standard



Medically needy income standard



The following dollar amount:

$

If this amount changes, this item will be revised.



The amount is determined using the following formula:





Not applicable (see instructions)

iii. Allowance for the family (select one)

AFDC need standard




Medically needy income standard




The following dollar amount:

$

The amount specified cannot exceed the higher

of the need standard for a family of the same size used to determine eligibility under the State’s approved AFDC plan or the medically needy income standard established under
42 CFR §435.811 for a family of the same size. If this amount changes, this item will be revised.



The amount is determined using the following formula:





Other (specify):






Not applicable (see instructions)

iv. The State also will deduct medical and remedial care expenses specified in 42 CFR §435.735.

[NOTE: (not part of application) Items B-5-c-2 and B-5-d-2 are for use by states that use spousal eligibility rules and elect to apply the special post eligibility rules.


c-2. Regular Post-Eligibility Treatment of Income: SSI State. The State uses the post-eligibility rules at 42 CFR 435.726 for individuals who do not have a spouse or have a spouse who is not a community spouse as specified in §1924 of the Act. Payment for home and community-based waiver services is reduced by the amount remaining after deducting the following allowances and expenses from the waiver participant’s income:


i. Allowance for the needs of the waiver participant (select one):



The following standard included under the State plan (select one)






SSI standard



Optional State supplement standard



Medically needy income standard



The special income level for institutionalized persons (select one):






300% of the SSI Federal Benefit Rate (FBR)



%

of the FBR, which is less than 300%



$

which is less than 300%.



%

of the Federal poverty level



Other (specify):





The following dollar amount:

$

If this amount changes, this item will be revised.



The following formula is used to determine the needs allowance:



ii. Allowance for the spouse only (select one):



The state provides an allowance for a spouse who does not meet the definition of a community spouse in §1924 of the Act. Describe the circumstances under which this allowance is provided:



Specify the amount of the allowance:



SSI standard



Optional State supplement standard



Medically needy income standard



The following dollar amount:

$

If this amount changes, this item will be revised.



The amount is determined using the following formula:





Not applicable

iii. Allowance for the family (select one):


AFDC need standard



Medically needy income standard



The following dollar amount:

$

The amount specified cannot exceed the higher

of the need standard for a family of the same size used to determine eligibility under the State’s approved AFDC plan or the medically needy income standard established under
42 CFR §435.811 for a family of the same size. If this amount changes, this item will be revised.



The amount is determined using the following formula:





Other (specify):





Not applicable (see instructions)

iv. The State also will deduct medical and remedial care expenses specified in 42 CFR §435.726.

d-2. Regular Post-Eligibility: 209(b) State. The State uses more restrictive eligibility requirements than SSI and uses the post-eligibility rules at 42 CFR 435.735 for individuals who do not have a spouse or have a spouse who is not a community spouse as specified in §1924 of the Act. Payment for home and community-based waiver services is reduced by the amount remaining after deducting the following amounts and expenses from the waiver participant’s income:


i. Allowance for the needs of the waiver participant (select one):






The following standard included under the State plan (select one)









The following standard under 42 CFR §435.121:










Optional State supplement standard






Medically needy income standard






The special income level for institutionalized persons (select one)







300% of the SSI Federal Benefit Rate (FBR)






%

of the FBR, which is less than 300%






$

which is less than 300% of the FBR






%

of the Federal poverty level






Other (specify):










The following dollar amount:

$

If this amount changes, this item will be revised.






The following formula is used to determine the needs allowance:






ii. Allowance for the spouse only (select one):



The state provides an allowance for a spouse who does not meet the definition of a community spouse in §1924 of the Act. Describe the circumstances under which this allowance is provided:



Specify the amount of the allowance:



The following standard under 42 CFR §435.121:





Optional State supplement standard



Medically needy income standard



The following dollar amount:

$

If this amount changes, this item will be revised.


The amount is determined using the following formula:






Not applicable

iii. Allowance for the family (select one)






AFDC need standard






Medically needy income standard







The following dollar amount:

$

The amount specified cannot exceed the higher




of the need standard for a family of the same size used to determine eligibility under the State’s approved AFDC plan or the medically needy income standard established under
42 CFR §435.811 for a family of the same size. If this amount changes, this item will be revised.






The amount is determined using the following formula:









Other (specify):











Not applicable (see instructions)




iv. The State also will deduct medical and remedial care expenses specified in 42 CFR §435.735.





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