- Verification of income and unpaid medical bills for the three months prior coverage.
- Medical insurance other than Medicaid.
- Method of income computation.
- Eligibility for transitional Medicaid.
- Reason for assigning less than the maximum transitional Medicaid coverage.
- Denial of TP 20 because spousal support payments stopped.
- Reason for action on a Medicaid EDG.
- Gross earnings and the dates the person received the earnings.
- Cost of health insurance premium for the child(ren) before certifying for CHIP.
- Name and phone number of state hospital employee.
If the household requests continuation of Medicaid for children aging out of TP 44, follow policy in A-825, Medicaid Termination, and document that the child:
- is hospitalized on their 19th birthday;
- remains hospitalized through the end of their eligibility period; and
- meets all other criteria according to A-825 .
If providing prior coverage for more than three months, follow policy in A-831.2.1, Reopening Three Months Prior Applications, and document that:
- there was an application on file to cover any of the prior months; and
- the file date on the application was used to cover these months.
Document the pregnancy verification method and the anticipated delivery date.