231.03 Required Verification: HC-CSD SR 14-04 Dated 01/14

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The individual who signs DFA Form 800, DFA Form 800MA, or New HEIGHTS-generated Form 800HR to apply for Home Care for Children with Severe Disabilities (HC-CSD) on behalf of the child must provide verification of *medical assistance eligibility criteria except for deprivation of parental care and support.

. Require written verification of the child's age.

If a preliminary determination of eligibility, including a manual computation of financial eligibility, indicates the child would be eligible for HC-CSD medical assistance, the Disability Determination Unit (DDU) requires all of the following for the medical eligibility determination:

. A separate DDU Form 900, Authorization for Release of Protected Health Information, for each provider listed on the Form 968;

. DDU Form 940, Cover Memo for Medical Eligibility Information;

. DDU Form 968, Family Information Report; and

. A copy of the child's Individual Education Plan (IEP) or "504" Plan, if available.

DDU is responsible for requesting additional information or verification, if required, to complete the HC-CSD medical eligibility determination.

References: He-W 641.04, RSA 167:3-e, RSA 167:3-f, RSA 167:3-g, 42 CFR 435.225, 42 CFR 435.845(c), 42 USC 1396a, Section 1902(a), (f), & (r) of the Social Security Act [42 USC 1396a]