173 ELIGIBILITY CRITERIA FOR 12-MONTH COVERAGE SR 11-30, 07/11 (FAM-A)

The individual is eligible for 12-month extended medical assistance (EMA) for 12 months without completing an application if the assistance group:

• continues to live in New Hampshire;

• continues to have a dependent child residing in the home (one who meets the age and student criteria for *FANF but not necessarily deprivation);

• submits complete and timely Forms 890, Quarterly Extended Medical Assistance Report, by the 21st day of the:

- fourth month verifying information from EMA months 1–3 and used as the income for month 7;

- seventh month verifying information from EMA months 4–6; and

- tenth month verifying information from EMA months 7–9 of the 12-month coverage period;

• indicates on the fourth, seventh, and tenth months’ Forms 890 that the family’s gross monthly earnings minus necessary child care costs are below 185% of the federal poverty income level; and

• indicates on the seventh and tenth months’ Form 890 that the parent/caretaker relative was employed in each of the 3 report months.