Instructions: This is a number assigned and initially entered by the computer which uniquely identifies this individual. When adding a member who has not previously been included in the case, leave this block blank.

NAME: The name will be entered as it is shown on the HIB Card. If not eligible for Medicare, name should agree with current Social Security Card.

Instructions: Enter person’s last name.

NOTE: The client’s last name will display in other places in FACS, but it can only be entered or changed in this field.

Instructions: Enter person’s first name.

NOTE: Always use client’s legal first name regardless of what the family calls this person. Use the client’s name as shown on their Social Security Card unless different from their Medicare Card. If different, use the Medicare Card name.

Instructions: Enter person’s middle initial.

NOTE: If available, this information can make it easier to distinguish one client from another.

Instructions: Enter appropriate code to show payee or relationship to payee.

C

= Child only – no adults in case – benefit type K, M, or Z only.

G

= Applicant or recipient who has a guardian, conservator or substitute payee.

P

= Applicant, recipient payee or head of household.

R

= Former Payee or Former Spouse. Must be entered when payee changes and former payee’s needs are removed; or in the event of a divorce/separation should be entered on the former spouse.

S

= Spouse of applicant or recipient, or spouse of head of household.

1

= Son or daughter.

2

= Grandchild or great-grandchild.

3

= Niece or nephew.

4

= Brother, sister, half-brother or half sister

5

= Step-child.

6

= Step-brother or step-sister.

7

= Other adult residing in household – benefit type S, C, and E only.

8

= Other child residing in household – benefit type S only.

9

= Cousin.

NOTE: When the payee of the case changes, the computer will update case name in Block A2.

Instructions: Enter one the following codes to indicate the inclusion/exclusion status of the payee and/or spouse and/or parent.

1

= Parent or caretaker relative included in benefit and is a required TANF Work participant.

5

= Step-parent who has the responsibility of a parent not included in benefit.

6

= Parent not included in benefit because of receipt of ABD.

7

= Parent not included in benefit because of SSI (does not receive ABD).

8

= Caretaker relative other than parent not included in benefit.

9

= Parent or caretaker relative not included in the benefit because they are an alien ineligible for benefits.

A

= Adult TANF Pending Reunification

C

= Fleeing Felon

F

= Parent or caretaker not included in grant due to fraud.

I

= Parent or caretaker relative not included in benefit due to positive illegal drug use screening.

M

= Minor parent.

N

= Unemployed parent in two parent household determined to be principal wage earner.

P

= Natural parent of ineligible child not included in benefit.

V

= Parole/Probation Violator

NOTE: Unless there is a C or E benefit for this person, entries will be ignored by computer. The indicator should be for the person listed in the matching Household Member entry. This field is required for all adults who are added to the TANF case.

Instructions: Enter the date of birth of this person. If birthdate is in current century, enter only the last 2 digits of the year. If birthdate is not current century, enter complete year of birth.

Instructions: Enter F or M for sex of this person.

F

= Female

M

= Male

Instructions: Enter the appropriate code to indicate the marital status of any person coded P, S, or G in Block F9.

DV

= Divorced.

LS

= Legally Separated

MC

= (ABD benefit type only) Eligible Individual married and living with ineligible spouse included in TANF case and therefore not included in any A, B, or D case.

ML

= Married and living with spouse.

MP

= Married but involuntarily separated. For example, mental institutions, incarcerated, nursing home, etc.

MS

= Married but separated from spouse without legal action.

SN

= Single.

WD

= Widowed.

Instructions: Enter date person referred to WtW. (MMDDCCYY)

Instructions: Enter WtW acceptance.

N

= No

Y

= Yes

Instructions: Enter the appropriate code to indicate the type benefit(s) to which the individual in F-1 is connected.

A

= State Supplement to the Aged.

B

= State Supplement to the Blind.

C

= Temporary Assistance for Needy Families (TANF).

CK

= Supported Permanency (TANF)

D

= State Supplement to the Disabled.

DA

= Diversion Assistance

K

= Services to adults and families – Child Care, Adult Day Services, and SSI-DCP.

L

= Specified Low Income Medicare Beneficiary (SLMB)

LB

= Qualifying Individuals, Group 1 (QI-1).

M

= Title XIX Medical Assistance.

N

= Energy Assistance.

P

= Qualified Disabled Working Individual (QDWI).

PK

= Phenylketonuria Individual.

Q

= Qualified Medicare Beneficiary Plus (QMB+).

R

= Developmental Disabilities Services.

S

= SNAP food benefits.

T

= Optional TB coverage group.

Z

= Emergency TANF Payment.

ZJ

= Emergency Family Services (Child Welfare).

OBSOLETE CODES:

CT

= Tribal TANF.

CV

= TANF voucher child.

E

= Refugee Assistance

LC

= Qualifying Individuals, Group 2.

MH

= Managed Health Care (computer entered).

U

= Crippled Children’s Program (CCP).

NOTE: Once a client has been added to a benefit type and this field is locked, it cannot be changed. To add a new benefit type, press the insert key on the keyboard while the cursor is in one of the other Benefit fields and a new blank field will be added.

Instructions: Enter the appropriate code from the following list to indicate the status of the corresponding category in F24 for this individual.

NOTE: When a Section changes to denied or closed status, the computer will automatically update an individual to R (removed). This must be updated when the Benefit Type is updated. The status showing is for this individual only, not the whole case. This does not need to be updated if you are closing the section related to this benefit type as the computer will automatically remove from benefits. Every person who is a required household member must have a current status other than “removed from benefits” for that benefit type.

EXCEPTION: When a person is coded O, and reason is 14 or 23 (disqualified), the O will not be updated.

A

= Added to benefit section.

E

= Extended medical coverage.

F

= Foster care only – for C, H, J, and T categories only.

H

= Individual receives food benefits in companion PA case. Computation for food benefits is determined by including this individual and his income.

M

= Special medical.

N

= Not included in benefit. Income and resources are not considered for benefit computation.

O

= Not included in benefit. Income and resources are considered in benefit computation.

R

= Removed from benefit section.

W

= Online Enrollment.

Instructions: Enter the appropriate code from the following list to indicate the reason this individual has one of the following benefit status in F25:

R

= Removed from Benefit Section

O

= Income / Resources are considered in benefit computation – individual not included

N

= Income / Resources are not considered in benefit computation – individual not included

1

= Reached maximum age – TANF and Child Care only.

2

= Marriage.

3

= Committed to an institution.

4

= Death.

5

= Transferred to another type of assistance, certified for TANF or SSP in own name, or added to another benefit or service case.

6

= Divorced/separated/left home

7

= No longer in school – TANF only.

8

= Transferred to foster care – TANF and Medical only.

NOTE: Codes 9 and 9D are for SNAP only.

9

= Failure to comply with Work Registration.

9D

= Voluntary quit employment without good cause.

10

= Sufficient resources to meet individual’s needs – do not use for Child Care.

11

= Income sufficient to meet individual’s needs.

12

= Child left home to live with absent parent.

13

= Non-cooperation with child support enforcement – Medical only.

14

= Fraud disqualification – SNAP only.

15

= Other

16

= Automatically closed by computer – State Office use only.

17

= Services completed – Child Care only.

18

= Automatically computer removed due to section closure by county.

19

= Disqualified for failure to meet SSN requirement – SNAP and Medical only.

20

= Ineligible student (higher education) – SNAP only.

21

= Ineligible or undocumented alien.

22

= Food Distribution Program Intentional Program Violation Disqualification – SNAP only.

23

= Refusal to participate in TANF Work.

24

= Child receives SSI.

25

= Computer-removed due to change in Department policy.

26

= Child receives Adoption Subsidy – TANF only.

28

= Refugee Assistance expired after eight months from entry into the US – Medical only.

29

= Failed to provide citizenship verification.

30

= Failed to provide identity verification.

34

= Roomer or Boarder – SNAP Only.

35

= Foster Care or DDS Placement – SNAP Only.

36

= Live in Attendant – SNAP Only.

37

=Other (Purchases and Prepares Food Separately) – SNAP Only.

80

= Able – bodied adult without dependents – SNAP only.

81

= Fleeing Felon – SNAP and / or TANF only.

82

= Probation/Parole Violator – SNAP and/or TANF only.

88

= First positive illegal drug screen result – TANF only.

89

= Second or subsequent illegal drug screen result – TANF only.

99

= State Office use only.

Instructions: Enter the effective date of corresponding status in Block F25 for this individual when necessary.If the person is being added to benefits, enter the date that the person became eligible for benefits.

• If this is a new certification, it will be the certification date.
• If this is a retroactive date on an ongoing case (for instance – adding a newborn to the case), enter the date the person became eligible for the benefits. This date cannot be prior to the certification date for the case.
  • For SSP, TANF, or SNAP Food Benefits, the system will NOT automatically issue supplemental benefits. An F17C or FSSR must be done.
  • For Medical benefits, the system will automatically send retroactive eligibility to the MMIS (EDS) system.

If person is being removed from benefit type ‘K’ (Social Services), the date entered must be the next effective date. If a person is being removed from any other benefit type for any reason other than death, the system will determine the next effective date. If the person is being removed from a benefit type for the reason

“Removed from Benefits” means that the benefit status (F25) of “Added to Benefits is being changed to:

• NOT INCLUDED – INC AND RES.DO NOT COUNT (N)
• NOT INCLUDED-INC AND RES. COUNT (O)
• REMOVED FROM BENEFIT SECTION (R)

“Next Effective Date” means the next date that a negative action can be taken. Please use Appendix B-2 to obtain a schedule of negative action deadlines.

Exceptions: This is automatically updated by the computer when a section is placed in application status, certified, reopened, closed or denied. This is also automatically updated by the computer when an individual is removed from any benefit type other than ‘K’ for a reason other than death. The date must be entered when an individual is added to an open case. If a person is removed or the section is closed or denied and reason code 4, death, is shown, actual date of death must be entered by worker.

Instructions: This field is no longer updatable by the user.  The system retains this field for internal purposes, but it is no longer displayed on any screens:

A

= Asian or Pacific Islander.

B

= Black, not of Hispanic Origin.

I

= American Indian or Alaskan Native.

S

= Hispanic.

W

= White, not of Hispanic Origin.

Note: With I = American Indian or Alaskan Native selected, primary F31 and/or secondary tribe F32, must be entered.

Instructions: If applicable, enter the code for the tribe in which the individual is an enrolled member. See Appendix D-4-A. Use one of the following codes when enrollment status is questionable.

777

= Individual claims to be Indian but tribal records do not substantiate this claim.

888

= Individual claims to be an Indian but tribal records cannot substantiate or disclaim this.

999

= Indian tribe unknown

If non-Indian, leave blank.

Instructions: Enter the secondary Indian Tribe, if applicable for this person according to DHS Appendix D-4-A. If unknown, enter 999. If non-Indian, leave blank.

Instructions: Enter the appropriate code to show whether this individual is a citizen or an alien. If an alien, show what type of alien.Codes are:

A

= Qualified alien – asylee.

C

= Citizen.

D

= Qualified alien – deportation withheld.

E

= Eligible alien.

F

= Qualified alien – refugee.

I

= Special Immigration Status – Iraqi

M

= Qualified alien – veterans/active duty military.

N

= Ineligible alien.

O

= Illegal alien.

Q

= Qualified alien – permanent +40 quarters earnings.

U

= Special Immigration Status – Afghan (SIV, SI SQ PAROLEEE, SI CONDITIONAL RESIDENT)

V

= COMPACT OF FREE ASSOCIATION IMMIGRANT – COFA (MARSHALL ISLANDS, MICRONESIA, PALAU)

W

= AFGHAN HUMANITARIAN PAROLEE

OBSOLETE CODES:

P

= Alien legalized under Section 245A.

R

= Alien legalized under Section 210A.

T

= Alien legalized under Section 902.

See Medical Assistance for Adults and Children: Citizenship/alien requirements 317:35-5-25

See SNAP: Citizenship and alien status 340:50-5-67

See TANF: Citizenship and alien status 340:10-15-1

See Child Care Subsidy: Resources, residence, and citizenship 340:40-7-5

If the client is not a citizen, you must see and copy their alien registration card. If the client cannot provide his/her alien registration card, they are considered undocumented and coded as such.

Instructions: Enter code to indicate individual’s educational status and level. For grade level, show last grade completed. Entry must be alpha digit and 2 numeric digits.

Status

C

= Education being continued.

D

= Education has been discontinued.

N

= No education received.

Level

00

= No education received, preschool or kindergarten.

01 through 12

= Enter appropriate number of last grade completed.

13 through 16

= Enter appropriate number for last year of college completed.

17

= Education above bachelor’s degree.

18

= Special education.

19

= Vocational training.

20

= Unknown – not used for C benefits.

21

= Other – not used for C benefits.

22

= Vocational training after receipt of high school or GED certificate.

23

= Vocational training without receipt of high school or GED certificate. NOTE: Use only for high school dropouts.

24

= Successful completion of GED and receipt of certificate.

Instructions: Enter the appropriate code to indicate this person’s reading level as determined by DHS screening or assessment completed by outside resource. (For C benefit type only).

D1

= Departmental screening – at or below 6^th grade level.

D2

= Departmental screening – at 7^th or 8^th grade level.

D3

= Departmental screening – at 9^th or 10^th grade level.

D4

= Departmental screening – above 10^th grade level.

R1

= Outside resource assessment –at or below 6^th grade level.

R2

= Outside resource assessment – at 7^th or 8^th grade level.

R3

= Outside resource assessment – at 9^th or 10^th grade level.

R4

= Outside resource assessment – above 10^th grade level.

See TANF: Employability planning 340:10-2-3

This field is used for TANF clients only. You must also enter a Literacy Screening Date.

Instructions: Enter the date of the most current literacy screening completed – C benefit type only.

See TANF: Employability planning 340:10-2-3

Instructions: Enter the appropriate code to show the current immunization status of this child (C benefit type only).

Y

= Immunizations current.

N

= Immunizations not current.

P

= Immunizations pending.

G

= Good cause.

See TANF: Immunizations 340-10-14-1

Instructions: Enter the Social Security account number for this individual.See TANF: Social Security Number (SSN) 340:10-12-1

See Child Care Subsidy: Identity and Social Security number 340:40-7-4

See Child Welfare: Social Security number 340:75-13-10

See SNAP: Social Security numbers 340:50-5-68

An entry in this field requires an entry in Verified SSN field.

Instructions: Enter the appropriate code as it pertains to the Social Security account number in F41 for this individual.

M

= Social Security account number has been verified by the social services specialist.

N

 = Social Security account number has not been verified, or no number has been provided.

S

= Person does not have a number and referral to the Social Security Administration (SSA) has been completed

Y

= Social Security account number has been verified by the computer matching the number with SSA files.  This code is entered by the computer only.

NOTE: This block must be updated every time F41 is updated.

Instructions: If this individual is enrolled for Medicare, receiving SSA benefits or receiving Railroad Retirement benefits enter the claim number under which those benefits are being paid (Refer to DHS Appendix T)

DO NOT ENTER SSI IDENTIFICATION NUMBER.

Instructions: (C and K benefit types and M benefit type if categorically related to TANF) Complete only on children and show the deprivation factor that relates to the child’s legal parents. This code must be updated at any time the basis of deprivation changes.

0

= Death.

1

= Incapacitated – Included parent out-of-the-home for medical treatment. Example, Mental Hospital.

2

= Unemployed parent.

3

= Divorced.

4

= Legally separated.

5

= Separated without court decree.

6

= Parents deserted.

7

= Parents not married.

8

= Parent(s) in prison.

9

= Parent(s) absent for other reason. Example, city or county jail.

A

= Absent Parent returned to the home-Adjustment period given (TANF only)

D

= Newborn Deemed Eligible – benefit type M only.

N

= Not deprived of parental support; parent not included in Medicaid benefits; or parent receives CNF or FPW – benefit type M only.

T

= Termination of absent parent’s rights.

U

= Termination of both parent’s rights.

X

= Any single-parent adoption or two-parent Title IV-E adoption of a child under 6 years old.

See TANF: Deprivation of parental support or care by a natural or adoptive parent 340:10-10-1

See Medical Assistance for Adults and Children: Determining categorical relationship 317:35-5-7

This field will cause an edit if entered on an adult. Be sure to document the client’s situation in the Case Notes section. You must enter a deprivation factor for all children included in TANF, Medical and/or child care, but only TANF requires that deprivation exist as a condition of eligibility.

Instructions: Enter Y if this individual is a migrant worker in the work stream. Computer will enter N when Y is not entered.

N

= Migrant farm worker not in the work stream.

Y

= Migrant farm worker in the work stream.

NOTE: Entries will be ignored by the computer for all benefit types except S.

Instructions: Enter the appropriate code to indicate this person’s living arrangement.

AL

= Assisted Living Center

CD

= Dept of Corrections Custody – hospitalization

FH

= Foster Home.

MH

= State Mental Hospital for persons 65 years old and older (M benefit type only).

NC

= Nursing care facility.

OR

= Own residence.

RB

= Room and Board. Do not use if client is in an alcoholic treatment center.

RH

= Relative’s home.

SS

= State School for the mentally retarded; Enid (NORCE) or Pauls Valley (SORC).

XX

= Other.

Instructions: Enter the number of the county in which the individual is receiving services if not living in own home. Code 82 is for out of state.

NOTE: Entries will be ignored by computer for S or Z benefit types.

Instructions: Enter the date the individual was placed in foster care.

NOTE: Entries will be ignored by computer unless individual has a C, K, or M benefit. As long as the child remains in custody even if the placement changes, this date will remain the same. If the child returns to foster care after having custody returned to the parents or being adopted, enter the new date.

Instructions: Enter the date the individual was removed from foster care.

NOTE: Entries will be ignored by computer unless individual has a C, K, M, or U benefit.

Instructions: Enter case numbers or social security claim numbers that relate to this individual. Do not repeat any cross reference numbers that are listed in A49 through A64 or a claim number in F45.

NOTE: These fields are obsolete.

Instructions: Enter case numbers or social security claim numbers that relate to this individual. Do not repeat any cross reference numbers that are listed in A49 through A64 or a claim number in F45.

Instructions: Enter alien registration number.

See Medical Assistance for Adults and Children: Citizenship Requirements 317:35-5-25

See SNAP: Citizenship and alien status 340:50-5-67

See TANF: Citizenship and alien status 340:10-15-1

See Child Care Subsidy: Resource, residence, and citizenship 340:40-7-5

This number is required for all added household members who are not citizens. The Medical Eligibility will not cross to EDS without this number.

Instructions: Military Service indicator. Enter the code that describes the person’s military service. The system will enter a default value of zero for persons under age 17.

0

= None

1

= Active Duty US Military

2

= National Guard / Military Reserve

3

= Former Military

Instructions: Enter gross income from self-employment. If income is received annually, show averaged monthly amount.

NOTE: This block must be updated when F66 is updated. On SNAP cases, determine net self-employment by deducting 50% from gross self-employment. Enter the amount in this field and enter $0 for business expense in F66.

See Medical Assistance for Adults and Children. Categorically related to ABD 317:35-5-42

See Medical Assistance for Adults and Children. Categorically related to TANF 317:35-5-45

See Medical Assistance for Adults and Children: Categorically related to pregnancy-related 317:35-5-46

See Medical Assistance for Adults and Children: Categorically related to Disability for TB 317:35-5-47

See Child Care Subsidy: Sources of income considered 340:40-7-11

See TANF: Determination of earned income 340:10-3-32

If the client has been self-employed for a full tax year and states that their income has not drastically changed, you should use their tax return to determine their monthly income.

Instructions: Leave blank for future use.

Instructions: Enter averaged monthly amount of business expense that is to be deducted or excluded from self-employment (F64). On SNAP cases, determine net self-employment income by deducting 50% from gross self-employment. Enter the amount in F64 and enter $0 for business expense in this field.

NOTE: This block must be updated when F64 is updated.

See TANF: Determination of earned income 340:10-3-32

See SNAP: Self-employed households 340:50-7-30

See Child Care Subsidy: Sources of income considered 340:40-7-11

Instructions: Enter amount of gross earned income. Based on coding of blocks F9, 15, 25, and 35, the computer will use income appropriately to total earnings for the benefit section.

NOTE: Use MICAL to figure income and enter the countable monthly amount of gross earned income for the person.

See TANF: General provisions regarding income 340:10-3-26

See SNAP: Income inclusions 340:50-7-29

See SNAP: Income exclusions 340:50-7-22

See Medical Assistance for Adults and Children: Categorically related to ABD 317:35-5-42

See Medical Assistance for Adults and Children: Categorically related to TANF 317:35-5-45

See Medical Assistance for Adults and Children: Categorically related to pregnancy-related 317:35-5-46

See Medical Assistance for Adults and Children: Categorically related to Disability for TB 317:35-5-47

Income is auto-filled through MICAL

Instructions: Enter code to describe how hourly wage this individual receives relates to the federal minimum wage or if the person is a striker.

A

= Earns above federal minimum wage.

B

= Earns below federal minimum wage.

S

= Earnings just prior to strike.

Y

= Earns actual federal minimum wage.

Instructions: Enter the number of hours per week the client is participating in a TANF employment activity if the ETE authorization is work full time, work part time or on-the-job training.If the client has a child under age 6, they are required to participate at least 20 hours.

If the client does not have a child under age 6, they must participate at least 30 hours.

If the client does not participate the required hours (20 or 30) or more, leave the block blank or delete the information.

See TANF: Individual earned income exemptions / work related expenses 340:10-3-33(1)

The number of hours entered in this field determines the amount of work related expense deduction applied to the income for this person.

Instructions: Enter the work related expense for ABD and M benefit types. The computer will enter the amount of allowable deduction for expenses connected with earned income shown in F64-F66 and F68 for C, E, or Z benefit types.

NOTE: Entries will be ignored by computer for all benefits except A, B, D, and M.

See Medical Assistance for Adults and Children: Categorically related to ABD 317:35-5-42

See Medical Assistance for Adults and Children: Categorically related to TANF 317:35-5-45

See Medical Assistance for Adults and Children: Categorically related to pregnancy-related 317:35-5-46

See Medical Assistance for Adults and Children: Categorically related to Disability for TB 317-35-5-47

See TANF: Individual earned income exemptions / work related expenses 340:10-3-33(1)

Instructions: For benefit types C, E, M (categorically related to TANF) or S, enter the actual cost for the care of a child or other dependent when necessary for a household member to seek, accept, or continue employment or to attend training or education preparatory for employment.

NOTE: Entries will be ignored by computer for Z category.

See SNAP: Deductions 340:50-7-31(4)

This amount could be a co-payment on subsidized child care or a private pay amount. If more than one child is in child care, divide the copay equally among all children in care.

Instructions: (“C” Benefit Type Only). The computer will enter the amount of exempt earned income (1/2 remainder).

NOTE: Entries will be ignored by computer for all other benefit types.

Instructions: Enter the general income exclusion for ABD-related medical assistance.

The GIE can be deducted from earned income only for the following benefit types:

• Aid to the Aged – SSP
• Aid to the Blind – SSP
• Aid to the Disabled – SSP
• ABD-related medical
• Optional TB coverage group
• Nursing home assistance or assisted living

The GIE can be deducted from either earned or unearned income (NOT BOTH) for the following benefit types:

• Qualified Disabled Working Individual
• Qualified Medicare Beneficiary Plus
• Specified Low Income Medicare Beneficiary
• Qualified Individuals Group 1

Many cases have more than one benefit type related to ABD. To know how to correctly apply the GIE correctly, follow these steps:

1. Does the case have A or B or D or T benefits or is the client in a nursing home or assisted living center?

Yes = Use A or B or D or T or NC/AL Rules

No = Go to Step #2

2. Does the case have a Q or L or LB or P Benefit?

Yes = Use Q or L or LB or P Rules

No = Go to Step #3

3. Does the case have an M benefit related to ABD?

Yes = Use M rules

No = The case is ineligible for the GIE

Instructions: Enter amount of Retirement, Survivors, and Disability Insurance entitlement for this individual.

NOTE: The amount entered is the gross amount before recoupment. Medicare premium, etc.

See TANF: Retirement, disability, and unemployment benefits 340:10-3-39(h)

See SNAP: Income inclusions 340:50-7-29(c)(2)

See SNAP: Income exclusions 340:50-7-22

Instructions: Enter the amount of Supplemental Security Income entitlement for this individual. NOTE: The amount entered is the gross amount before recoupment, Medicare premium, etc.

See SNAP: Income exclusions 340:50-7-22

Instructions: Enter the amount of any VA entitlement for this individual.
NOTE: The amount entered is the gross amount before recoupment, Medicare premium, etc.

Instructions: Enter the code to indicate type of VA benefit for this individual.

C

= Compensation

P

= Pension

R

= Reduced Pension (due to veteran or surviving spouse residing in a Medicaid – approved nursing facility)

Instructions: On TANF cases, enter the total amount of child support received for this child. On Aid to the Blind or Disabled cases, enter only countable child support. For a C benefit type, child support is shown only for the months it is applied against the benefit and when the case is closed.

NOTE: If this child has the same AP as another child and the household is receiving one payment for several children, divide the total child support by the number of children and code that amount on each child.

Instructions: Enter the total amount of Tribal TANF received from programs administrated by Indian tribes.

See TANF: Special considerations 340:10-3-57(c)

See SNAP: Income exclusions: 340:50-7-22

See Medical Assistance for Adults and Children: Categorically related to ABD 317:35-5-42

See Medical Assistance for Adults and Children: Categorically related to TANF 317:35-5-45

See Medical Assistance for Adult and Children: Categorically related to pregnancy-related 317:35-5-46

See Medical Assistance for Adult and Children: Categorically related to Disability for TB 317:35-5-47

Instructions: Enter any countable income from any source not shown in blocks F64 through F95.

NOTE: In addition to coding unearned income not counted elsewhere, this field should be used for the income diverted from SSP companion cases.

See TANF: General provisions regarding income 340:10-3-26.

See SNAP: Income inclusions 340:50-7-29

See SNAP: Income exclusions 340:50-7-22

See Medical Assistance for Adults and Children: Categorically related to ABD 317:35-5-42

See Medical Assistance for Adults and Children: Categorically related to TANF 317:35-5-45

See Medical Assistance for Adults and Children: Categorically related to pregnancy-related 317:35-5-46

See Medical Assistance for Adults and Children: Categorically related to Disability for TB 317:35-5-47

Income is auto-filled through MICAL

Instructions: Enter code to indicate type of income shown in F98 and/or F103.

A

= Alimony

B

= Income deemed from parents to disabled child.

C

= Contribution from persons not included in this household.

D

= Dividends, interest, and royalties.

E

= Subsidized employment

F

= Adoption Subsidy or Foster care payments.

G

= Grants for education or scholarships.

H

= Income considered only on Medical calculations

I

= Indian.

J

= TRICARE Payment (formerly known as Champus)

K

= Aid and Attendance (VA).

L

= Loans for education (Deferred Payment).

M

= Military allotment.

N

= Income received from another household member.

P

= Pension or annuities (other than RSDI and VA).

R

= Rental income.

S

= Striker’s benefits.

U

= Unemployment compensation.

V

= Public assistance grants.

W

= Worker’s compensation.

X

= Insurance or legal settlement.

Y

= Lump sum.

Z

= Other counted unearned income not described above.

Instructions: Income entered in this field will be diverted from the Medical (Section D) and Financial Assistance (Section B) of the case.

To divert income from the Social Services (Section E of the case), go to the Eligibility Notebook/Child Care tab and use the “Total Diverted Income” (E47) field.

Enter income diverted to legal dependents. This includes amounts deemed from parents to disabled children. Income cannot be diverted between active cases with a C benefit type and active cases with an A, B, or D benefit type.

NOTE: When this person enters a nursing facility after the first day of the month and the first’s month’s vendor payment would be zero, show all income for that month as diverted.

Entries will be ignored by computer for G, S and Z categories.

Refer to ABD: How to Code for Eligible Couple (State Supplemental Payment)

See TANF: Step-parents income 340:10-3-57(e)

See TANF: Parent(s) of a minor parent 340:10-3-57(e)(5)

See State Supplemental Payment: Deeming of Income 340:15-1-6(b)(1)

This field diverts income from the B section only.

Instructions: Enter the total amount being recouped by the Social Security and/or Veterans Administrations to repay overpayments.

Instructions: Enter code which specifies what benefits are being recouped.

A

= RSDI, SSI and Veteran’s benefits.

O

= RSDI only.

S

= SSI only.

V

= Veteran’s benefit only.

X

= RSDI and SSI.

Y

= RSDI and Veteran’s benefit.

Z

= SSI and Veteran’s benefit.

NOTE: When recoupment indicator (F109) is updated, recoupment amount (F108) must also be updated.

Instructions: Enter the amount of the resource.

See TANF: Personal Property 340:10-3-5

See Medical Assistance for Adults and Children: Categorically related to ABD 317:35-5-42

See Medical Assistance for Adults and Children: Categorically related to TANF 317:35-5-45

See Medical Assistance for Adults and Children: Categorically related to pregnancy-related 317:35-5-46

See Medical Assistance for Adults and Children: Categorically related to Disability for TB 317:35-5-47

See Child Care Subsidy: Resources, residence, and citizenship 340:40-7-5(a)

Instructions: Enter the code to indicate type of resource.

A

= Automobile or other motorized vehicle.

B

= Small business equipment.

C

= Savings which include cash, bank accounts, bonds, stocks, etc.

E

= Farm Equipment.

F

= Exempt Burial Funds, including those made irrevocable.

I

= Restricted Indian property.

L

= Life Estate that is not home property.

M

= Mineral rights.

N

= Insurance. Include burial policies, and show $0 as the value.

P

= Prepaid burial funds.

R

= Real property.

S

= Livestock.

T

= Exempt trust.

X

= Other countable resources not described above.

Z

= Included in estate recovery only, such as personal property, jewelry, paintings, etc.

Instructions: If applicable, enter appropriate code to show current type of voluntary consent, protective arrangement, court request, or court action.

01

= Voluntary consent for foster care – K benefit type only.

02

= Guardianship, conservator – not assigned to DHS.

03

  = Substitute payee – not assigned to DHS

04

= Substitute payee.

05

= Temporary legal custody, Child Welfare.

06

= Permanent legal custody, Child Welfare.

07

= Temporary legal custody, OJA.

08

= Permanent legal custody, OJA.

09

= Adult emergency guardianship assigned to DHS (72 hours).

10

= Adult emergency guardianship assigned to DHS (10 hours).

11

= Adult guardianship assigned to DHS (6 months).

12

= Temporary Custody – Tribal.

13

= Permanent Custody – Tribal.

14

= Designated IV-E Foster Care or IV-E Adoption Subsidy.

15

= Voluntary Placement – Child Welfare.

16

= Voluntary Placement – OJA.

17

= Voluntary Placement – Tribal.

44

= Non IV-E Foster Care or non IV-E Adoption Subsidy.

50

= Child included in open TANF or Title XIX case but remains in DHS custody and resides in his/her own home.

51

= Child included in open TANF or Title XIX case, but remains in OJA custody and resides in his/her own home.

52

= Child included in open TANF or Title XIX case, but remains in tribal custody and resides in his/her own home.

98

= Child is no longer in custody of State or Tribal Child Welfare agency.

99

= State Office use only.

NOTE: This field should be updated when the child’s custody status changes such as moving into a TANF household or a TANF household being certified for foster care payments.

Instructions: Enter the date of the protective or court action entered in Block F130.

Instructions: Enter the number of the county of jurisdiction of the action described in Block F130. If out-of-state, enter code 82.

NOTE: Whenever any one of the three custody Blocks (F130 – F132) is updated, the other blocks must also be updated. Entries will be ignored by the computer for S and Z benefit types. Once entered, information can be changed, but not deleted, by the user.

Instructions: Enter date of entry for refugee/alien as indicated by official documents from the Immigration and Customs Enforcement (ICE).

NOTE: Entries will be ignored by computer for Z category.

This date is required on all clients who are not citizens. This date determines the beginning of the 5 year waiting period. Eligibility for medical services will not cross to EDS without this date.

See Refugee Resettlement Program (RRP): 340:60-1-3.

Instructions: Enter code to show result of EPSDT. Physical Screen Offer.

A

= Accepted offer and no support services requested.

B

= Accepted offer and support services were requested.

D

= Declined offer.

Instructions: Enter date EPSDT physical screen offered.

Instructions: Computer enters code from Medical Claims payment tape.

C

= Completed; no follow-up required.

F

= Completed; follow-up required.

When follow-up is required, worker enters code listed below to show need for support services.

N= No support services were requested.Y= Support Services were requested (F146 equals F on files).Z= Support services requested before notice received from claims processing.

Instructions: Computer enters date from medical claims payment tape to show date of service. When follow-up is recommended, social services specialist enters date follow-up support services were offered. This should be entered when F146, EPSDT physical screen result, is equal to N or Y.

Instructions: Enter code to show result of EPSDT dental screen offer.

A

= Accepted offer and no support service requested.

B

= Accepted offer and support services were requested.

C

= Computer entered.

D

= Declined offer.

When the dental screen is completed, the computer updates this field to C.

NOTE: This screening is only for children over 3 years of age. When the dental screen is completed, the computer updates this field to C.

Instructions: Enter date EPSDT dental screen was offered.

When the dental screen is completed, the computer updates with the date the dental screen occurred.

Instructions: Enter code to show service request.

Y

= Family Planning requested

NOTE: This service is available to any household member who needs it. Small children should not need this service.

See Medical Assistance for Adults and Children: Certification for the Family Planning Waiver Program 317:35-7-60.1

Instructions: Enter date to shown when Family Planning services were requested.

Instructions: For persons included in a C benefit enter one of the following codes to show current TANF Work participation status.

Participation Status:

RR

= Required participant.

WS

= Participant in Work Supplementation

EU

= Single custodial parent with a child under the age of four months.

EC

= Child under 19 years of age attending school and preschool age children.

MP

= Minor Parent Head of household under 19 years of age.

Sanction Status

N9

= Sanctioned – Required Participant.

Instructions: Enter date the TANF Work Status in F154 began or changed.

NOTE: This date should be reentered anytime a new assessment of the client’s ET&E status is done. For instance, if the client has a baby and becomes exempt, enter the new status as Exempt, and the new date (the baby’s DOB).

Instructions: Enter an appropriate two digit code as described below for a person who is a TANF Work participant.

The first digit describes a participant’s needs as they relate to employment or what is currently being received. Code J is used when no other need exists. If more than one of codes T, S, or E apply, use the code describing what the client is most in need of or is receiving.

J

= Job Referral or Job Search.

T

= Training (vo-tech, trade school, OJT, etc.).

S

= Services.

E

= Education (high school, literacy, GED, etc.).

The second digit describes the participant’s occupation skill and or/ experience. If more than one code applies, the one in which the person has the most skill or experience is used. Secondary occupations should be recorded on TW-2.

O

= Other (to be used only with S code).

1

= Professional, technical, managerial, doctors, lawyers, managers, data processing, nursing, etc.

2

= Clerical and sales occupation.

3

= Service occupations (housekeeping, child care, laundry, maintenance, grooming, food service, etc.).

4

= Agricultural, fishery, forestry, and related occupations.

5

= Processing occupations (refining, mixing, compounding, chemical treatment, heat treatment).

6

= Machine trades (operation of machines that cut, bore, mill, abrade, print such materials as metal, paper, wood, plastics and stone).

7

= Bench work (assemble or repair small products such as jewelry, radios, tires, shoes, pottery and garments).

8

= Structural work (assembling, erecting, installing, paving, painting and repairing buildings, roads, bridges, motor vehicles, engines, etc.).

Instructions: (ABDM Only) Enter the following codes to indicate eligibility or ineligibility for Title XIX medical services for any adult included or whose income and resources count for a State Supplemental Payment.

A

= Ineligible on citizenship and alienage.

S

= Ineligible spouse.

Y

= Yes, eligible. Use this code for ABD recipients and essential spouse who were grandfathered into the SSI program.

For M benefit the following codes are used.

For Catastrophic illness use:

B

= Blood and blood fractions.

D

= Drugs.

W

= Blood and drugs.

Enter the number of births expected if pregnancy related.

NOTE: Entries will be ignored by computer for S benefit type.

Instructions: Enter expected month and year of birth (MM/YY) when entering F162, Medical indicator, for pregnancy.

Instructions: This field is obsolete.

Instructions: This field is used to show funding eligibility for expanded medical coverage. The codes are entered by the computer.

E

= Income exceeds Appendix C-1 standards in effect 4-15-97

P

= Income within Appendix C-1 standards in effect 4-15-97

M

= Expanded Medical Coverage Group – Has Medicare

Q

= Expanded Medical Coverage Group – Does Not Have Medicare

Instructions: (S Benefit Only) Enter the appropriate code to indicate Oklahoma Food benefit work status.

R

= Registered member of household

A

= Younger than 16 or 60 years of age or older

B

= Person 16 or 17 years of age not head of household or attending school or an employment and training program

C

= Caretaker of a child under six years ago or an incapacitated person

E

= Employed 30 hours or minimum wage equivalent per week or contracted migrant or seasonal farm worker

I

= Physically or mentally incapacitated

P

= TANF Work Registrant

S

= Student enrolled at least half time

T

= Alcohol/drug treatment program

U

= Unemployment compensation applicant/recipient

Instructions: Enter the month, day and year or work status.

Instructions: (S Benefit Only) Enter the appropriate code to indicate Oklahoma SNAP work status in relation to requirements for Able-Bodied Adults without Dependents.

ABAWD Coding:

K

= Initial ABAWD not meeting work rule (countable).

M

= Regained eligibility – maintaining 20 hours per week employment or service (not countable).

W

= Initial ABAWD meeting work rule (not countable).

Y

= Regained eligibility for three continuous months. (countable)

P

= Initial ABAWD not meeting work rule when the benefit is prorated (not countable).  NOTE: This code is system-entered and is visible only on the BNP and ABWI screens.

ABAWD Exemptions:

C

= Living in a household with minor children.

E

= Exempt from Work Registration (system-entered based on the entry in F170 SNAP Work Registration Status)

1

= Younger than 18 or 50 years of age or older.

2

= Certified physically or mentally unfit for employment or is destitute homeless.

4

= Pregnant.

H

= Homeless.

V

= Veteran.

F

= Individual aged 24 or younger in foster care on their 18th birthday .

X

= 12% state exemption (State Office Use Only) NOTE: This code is visible only on the ABWI screen.

Instructions: Enter the month, day and year of work status.

Instructions: Enter date E & T Classification in Block F174 started.

NOTE: This block is obsolete.

Instructions: Enter the client’s classification in relation to the SNAP Employment and Training Program.

NOTE: This block is obsolete.

R

= Referred

P

= Participating

N

= Not Participating

Instructions: This must be updated when F174 is updated with E.

Note: This block is obsolete.

1

= Residence is an unreasonable distance from the county office or potential employer. A distance is considered unreasonable if the round trip exceeds two hours by public or private transportation.

2

= Registrant is a migrant or seasonal farmworker away from their home base and following the work stream.

3

= Registrant lack of child care.

4

= Registrant physical and/or mental problems.

5

= Registrant is fifty-five years old or older and working under Title V of the Older American Act.

6

= Registrant is homeless.

Instructions: Enter result of E & T Component. C, D, O and R are entered by the Job Developer. The numbers 1, 2, or 3 is entered by computer if F Comply action is not canceled.

Note: This block is obsolete.

C

= Complied but no job found.

D

= Job obtained from DHS referral.

O

= Job obtained on own.

R

= Reported for non-compliance.

1

= First non-compliance – benefits terminated for one month.

2

= Second non-compliance – benefits terminated for three months.

3

= Third or subsequent non-compliance – benefits terminated for six months.

Instructions: Enter effective date for codes C, D, O and R in Block F179. Computer updates to reflect date for codes 1, 2 and 3 in F179.

Note: this block is obsolete.

Instructions: Enter code Y to indicate program violation.

See TANF: School attendance 340-10-13-1

A 25% sanction is applied to the TANF for each program violation.

Instructions: Enter code Y to indicate program violation.

See TANF: Requirement for assignment of support rights and cooperation 340:10-10-5

A 25% sanction is applied to the TANF for each program violation.

Instructions: Enter code Y to indicate program violation.

NOTE: The fraud sanction is applied by the Benefit Integrity and Recovery Section (BIRS). They are the ones who will enter the checkmark to start the penalty. The county worker is responsible for tracking and removing the checkmark when the penalty is finished. You will receive a notice from BIRS.

Instructions: Enter code Y to indicate program violation.

See TANF: Immunizations 340:10-14-1

A 25% penalty is applied to the TANF for each program violation.

Instructions: Enter code Y to indicate program violation.

See TANF: Social Security Number 340:10-12-1

A 25% sanction is applied to the TANF for each program violation.

Instructions: On certifications for medical services where Financial Assistance is not also approved, enter the appropriate categorical relationship for each member whose Benefit status, F25, is coded A. Enter the appropriate categorical relationship from the list below. Further information about special benefit groups is outlined below.

Qualified Medicare Beneficiary Plus. If the individual is determined eligible for the Qualified Medicare Beneficiary Plus (QMBP) program, enter the category to which the person is related.

CNA

= Categorically Related to Aged

CNB

= Categorically Related to Blind

CND

= Categorically Related to Disabled

CNC

  = Categorically Related to AFDC

CNF

= Pregnancy Related Services

CNM

= Transitional Medical

Cuban/Haitian Entrants and Refugees. Enter CNR to indicate categorical relationship.

CNR

= Cuban/Haitian Entrants over 18 and Refugees with Benefit Types A, B, C, D or M.

CNT

= Continued Medical – TANF

CNW

= Independent Living

Family Planning Waiver.

If the individual is eligible for only Family Planning services, then enter the categorical relationship as FPW.

PKU Program:

If the client is not eligible for Title XIX Medical Services, but financial and medical eligibility has been determined through the PKU Program, use the following code: PKU

PKU Program

child diagnosed with Phenylketonuria and has medical necessity for food supplements. Family income and resources are not considered for PKU children.

TEFRA

On all TEFRA certifications enter one of the following TEFRA categorical relationships as indicated on MEDATS.

TFI

= TEFRA T1 – ICF/MR

TFN

= TEFRA T2 Nursing Facility

TFH

= TEFRA T3 Acute Care Hospital

TFC

= TEFRA T4 Sub-Acute Care Hospital

Optional TB Coverage Group.

If the individual is not eligible for Title XIX medical services, but financial eligibility has been determined using the Optional TB Coverage Group policy, enter the TB category to which the person is related.

TBA

= Categorically Related to Aged w/Diagnosis of TB

TBB

= Categorically Related to Blind w/Diagnosis of TB

TBD

= Categorically Related to Disabled w/Diagnosis of TB

Program of All-Inclusive Care for the Elderly (PACE). If the individual is participating in the PACE pilot project, enter one of the following codes according to Medicare status and categorical relationship. The PACE pilot project is limited to persons residing in certain zip code areas. For a listing, enter M PACEZIP in IMS.

PMA

= PACE – Medicare –Aged

PNA

= PACE – Non-Medicare – Aged

PMB

= PACE – Medicare – Blind

PNB

= PACE – Non-Medicare – Blind

PMD

= PACE – Medicare – Disabled

PND

= PACE – Non-Medicare – Disabled

OBSOLETE CODES:

BCC

= Breast and Cervical Cancer

CNP

= Presumptive Eligibility – Pregnancy Related

MN* categorical relationships.

The Medically Needy (MN) programs were discontinued by OHCA and may still show within the system on old cases that have not been updated recently. These codes are no longer in use.

Instructions: This will be computer determined.

Instructions: This field is computer-entered from the Health Care Authority information to indicate why an individual is not included in Managed Health Care.

D

= SED (severe emotional disturbance).

M

= SMI (serious mental illness).

O

= Other health related condition.

(computer entered)

Instructions: The Department administers four waivers that provide certain services outside normal Title XIX scope to recipients who are approved for HCBW services.

The first waiver (ICF/MR) is available to recipients who require ICF/MR care. If recipient has been approved for HCBW Services enter the code from the list below identified on MDL (MEDATS) that identifies where recipient received care prior to HCBW approval. These codes are:

W1

= Intermediate care facility.

W2

= Skilled nursing facility.

W3

= State School for the Mentally Retarded.

W4

= Private ICF/MR Facility.

W5

= Community – not one of the above.

The second waiver (ADP) is available only to recipients in nursing facilities identified by (Pre-Admission Screening and Annual Resident Review (PASARR) as inappropriately placed and is only used for the Alternative Disposition Plan (ADP) waiver. This waiver is also noted on MDL.

W6

= Nursing facility – Use only for those NF residents identified by PASARR and have been determined eligible for ADP by the PASARR.

The third waiver is available to recipients approved for the Long-Term Care ADvantage Program.

W7

= Diverted from a nursing facility.

W8

= De-institutionalized from a nursing facility.

W9

= Development Disabled without cognitive impairment.

When the client is no longer approved for any of the above waivered services, update as follows:

WN

= Client is no longer eligible for DDSD or ADvantage Waivered Services.

The fourth waiver is available to recipients approved for the Living Choice Program funded through the Money Follows the Person (MFP) Rebalancing Demonstration.

P1

= MFP Living Choice – Elderly

P2

= MFP Living Choice – MR/MFP Living Choice – PRTF effective 08/28/17

P3

= MFP Living Choice – Disabled

PN

= MFP Living Choice Participation Ended

S1

= Self-Directed Living Choice – Disabled

S2

= Self-Directed Living Choice – Elderly

SN

= Self-Directed Living Choice Participation Ended

DDS waivered codes:

H1

= Individual served through the In-Home Supports waiver who live in the family home, is Developmental Disabled with mental retardation, 18 years of age and younger.

H2

= Individual served through the In-Home Supports waiver who live in the family home, is Developmentally Disabled with mental retardation, over 18 years of age.

H3

= Individual served through the In-Home Supports waiver who previously lived in an ICF/MR, is developmentally

H4

= Individual served through the In-Home Supports waiver who previously lived in an ICF/MR, is Developmental Disabled with mental retardation, over 18 years of age.

HN

= Individual is no longer eligible for in-home supports waiver.

Homeward Bound Class Waivers

C1

= Member of the Homeward Bound Class who entered the waiver from an institution.

C2

= Member of the Homeward Bound Class who entered the waiver from the community.

CN

= Member of the Homeward Bound Class who is no longer eligible for the Waiver.

Instructions: Enter the date indicating certification beginning date or certification ending date for waivered services.

Instructions: Enter the medical diagnosis code determined by LOCEU. This information is shown on the MDL Inquiry (MEDATS).

Instructions: Enter the medical diagnosis code determined by LOCEU. This information is shown on the MDL Inquiry (MEDATS).

Instructions: Enter code to indicate lien status.

Y

= Lien filed.

S

= Lien not filed – surviving spouse.

M

= Lien not filed – child 20 years old or less.

D

= Lien not filed – disabled child (any age).

B

= Lien not filed – sibling with equity interest resides in home.

U

= Lien not filed – undue hardship (State Office use only).

R

= No lien, client intends to return home.

N

= Intent to file lien.

V

= Lien dissolved (State Office use only).

X

= Lien satisfied (State Office use only).

See Medical Assistance for Adults and Children: Medicaid recovery 317:35-19-4

See Medical Assistance for Adults and Children: Overview of Long Term Care Services 317:35-9-1

Instructions: Enter eight digit date, when intent to file lien was determined, the decision was made not to file, or the date the lien was released.

Instructions: Enter code to indicate estate recovery status.

Y

= Yes, a recovery should be done.

S

= No, there is a surviving spouse.

M

= No, there is a child age 20 or less.

D

= No, there is a disabled child.

U

= No, undue hardship (State Office use only).

X

= Recovery completed (State Office use only).

See Medical Assistance for Adults and Children: Medicaid recovery 317:35-19-4

See Medical Assistance for Adults and Children: Overview of Long Term Care Services 317:35-9-1

Instructions: Enter eight digit date to indicate when the family composition was determined most recently (it may be a date after the client’s date of death).

Instructions: Enter eight digit date to indicate when recipient entered a nursing home, whether or not certified for Title XIX. (Works in conjunction with Blocks F205 and F207).

Instructions: Enter ‘Y’ or ‘N’ (in FACS – check box to indicate ‘Y’) to indicate if person has declared Hispanic/Latino Ethnicity.

This filed is required for all persons who are “added to benefits” for any benefit type.

Instructions: Enter ‘Y’ or ‘N’ (in FACS – check box to indicate ‘Y’)

A value of ‘Y’ (checked) indicates Asian

A value of ‘N’ (not checked) indicates not Asian

Instructions: Enter ‘Y’ or ‘N’ (in FACS – check box to indicate ‘Y’)

A value of ‘Y’ (checked) indicates Black

A value of ‘N’ (not checked) indicates not Black

Instructions: Enter ‘Y’ or ‘N’ (in FACS – check box to indicate ‘Y’)

A value of ‘Y’ (checked) indicates White

A value of ‘N’ (not checked) indicates not White

Instructions: Enter ‘Y’ or ‘N’ (in FACS – check box to indicate ‘Y’)

A value of ‘Y’ (checked) indicates Hawaiian or Pacific Islander

A value of ‘N’ (not checked) indicates not Hawaiian or Pacific Islander

Instructions: Enter ‘Y’ or ‘N’ (in FACS – check box to indicate ‘Y’)

A value of ‘Y’ (checked) indicates American Indian

A value of ‘N’ (not checked) indicates not American Indian

If this field is marked as ‘Y’ (Yes), then the Primary Indian Tribe field must be list the primary Indian tribe of this person.

Instructions: This field is currently only required only for persons whose Citizenship Status Field indicates that they are a citizen and who are ‘added to benefits’ for a Medicaid benefit type.

Use the appropriate code to indicate how citizenship was verified or waived:

BC

= Birth Certificate

CC

= Certificate of US Citizenship from USCIS

CK

= Child in OKDHS Custody

CZ

= US Citizen ID Card Issued by USCIS

HD

= ODH Verified Citizenship

MB

= Medicaid Paid Birth

MC

= Medicare Record Shows Citizenship

MR

= Official Military Record of Service US

NC

= Naturalization Certificate

OT

= Other

PS

= Passport – United States Passport

SS

= SSI Record Shows Citizenship

W1

= Waived for One Year (Newborn)

W2

= Waived for 60 Days

W3

= Waived for 120 Days

See Medical Assistance for Adults and Children: Citizenship/alien status and identity verification requirements 317:35-5-25.

Be sure to review policy to determine if this field is required. This field can be updated only if the Citizen/Alien Status of this person is “Citizen”. If citizenship verification is waived, the Citizenship Verification Status and the Citizenship Verification Status Date should be updated in a way to give the maximum waiver possible. For instance if the person is a child under age 1, but is 11 months old, then it would be more benefit to set the Citizenship Verification Status to “Waived for 60 days” then it would to set it to “Waived for one year”.

Instructions: If the citizenship verification was waived (W1 or W2), enter the date it was waived.

If a person is a newborn, enter the date of birth.

Except for newborns, do not enter a date more than 30 days old.

See Medical Assistance for Adults and Children: Citizenship/alien status and identity verification requirements 317:35-5-25

Be sure to review policy to determine if this field is required. This field can be updated only if the Citizen/Alien Status of this person is “Citizen”. If citizenship verification is waived, the Citizenship Verification Status and the Citizenship Verification Status Date should be updated in a way to give the maximum waiver possible. For instance, if the person is a child under age one, but is 11 months old then it would be more benefit to set the Citizenship Verification Status to “Waived for 60 days” then it would to set it to “Waived for one year”.

Instructions: This field is currently required for the payee on the case and for persons whose Citizenship Status Field indicates that they are a citizen and who are ‘added to benefits’ for a Medicaid benefit type.

Use the appropriate code to indicate how identity was verified or waived:

AV

= Affidavit

CC

= US Citizenship Issued by USCIS

DC

= Day Care or Nursery Record

DL

= Driver’s License

GV

= Government Issued Id

ML

= US Military Id

MM

= US Coast Guard Merchant Mariner Card

NC

= Naturalization Certificate

PS

= US Passport

RC

= School Record or Report Card

SC

= School Id

TB

= Tribal Id

WV

= Child Under One Year – Waived

See Medical Assistance for Adults and Children: Citizenship/alien status and identity verification requirements 317:35-5-25

See Child Care Subsidy: Identity and Social Security number 340:40-7-4

See SNAP: Citizenship and alien status 340:50-5-67

Instructions: Enter appropriate code for each household member to show his/her relationship to the spouse of the payee.

1

= Son or Daughter

2

= Grandchild or Great-Grandchild

3

= Niece or Nephew

4

= Brother, Sister, Half-Brother or Half-Sister

5

= Step-Child

6

= Step-Brother or Step-Sister

8

= Other Child Residing in Household

9

= Cousin

NOTE: This field is left blank for both the payee and the spouse.

Instructions: Ask the client to name the SNAP head-of-household. Make sure to explain the head-of-household responsibilities, such as disqualification and/or sanctions.

See SNAP: Application Process 340:50-3-1(b)(2)