167 ELIGIBILITY CRITERIA FOR 12-MONTH COVERAGE (MAM)

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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 DFA 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' DFA 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' DFA Form 890 that the parent/caretaker relative was employed in each of the 3 report months.

References: He-W 882.05; RSA 167:82, VI; 42 USC 1396r-6(b); 42 USC 1396u-1(c)(2)