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CSHCS Home > What's New > Household Income Table > Revised Documentation for Income Verification Revised Documentation for Income Verification

1.800.475.1355
www.statehealth.in.gov

Date: March 20, 2008

To: DFR State Eligibility Managers, DFR Regional Managers, SPOE Supervisors, SC Supervisors, Intake Personnel at Participating Hospitals assisting with CSHCS Enrollment Applications

Thru: Edward M. Bloom, Director Maternal & Children’s Special Health Care Services

From: Judi Johnson, Training Coordinator Children’s Special Health Care Services

Subject: 2008 Income Eligibility Guidelines

Enclosed are the 2008 Income Eligibility Guidelines for the Children’s Special Health Care Services (CSHCS) program, Maternal and Child Health (MCH), Hoosier Healthwise (HHW) and Women, Infants and Children (WIC) programs in Indiana.  These guidelines are based on the Health and Human Services Poverty Income Guidelines that were published in the Federal Register on January 23, 2008.

The CSHCS program revised income eligibility guidelines were implemented as of 1/23/2008.  The other programs’ implementation dates for the revised income eligibility guidelines are listed at the top of the guidelines.  The guidelines are calculated on an annual and a monthly basis for your convenience.  For those clients applying to the CSHCS program on or after January 23, 2008, please utilize the attached updated version exclusively to determine income eligibility and destroy all previously received Income Guideline copies.  For those clients applying for other programs, please continue to utilize the 2007 guidelines until the implementation dates.

Reminder:

The CSHCS program requires supporting documentation be submitted to verify each type of income listed.

    • The most recently filed Federal 1040 for all earned and unearned income; or,
    • The last 3 consecutive pay stubs plus the most recent Federal 1040 when income has drastically changed from previous year’s 1040;
    • Copy (ies) of the yearly award letter and/or a SSA Form 1099 for all Social Security, Social Security Disability and Social Security Supplemental (SS/SSD/SSI) Income.
    • A printout from the Child Support Division or a copy of bank statement for direct deposit of all child support received one month prior to the date of application.
    • Award letter or printout from the county documenting TANF payments.
    • Printout or other documentation (e.g., copy of check stub or leave and earning statement) for Unemployment payment or any type of Military Compensation.
    • Printout or other documentation (e.g., copy of bank statement) for Pensions, Annuities, etc.
    • Written, signed & dated statements for all other non-earned income (e.g., letters that state the amount of rent paid, food purchased, or utilities paid by relatives, trustees, landlords, or others) on behalf of the parent/guardian or the participant.  The letter should state the name of person providing the income and how much and how often the income is provided.

Thank you for your assistance.  If you should need further clarification, please do not hesitate to contact the CSHCS Training Coordinator at (317) 233-5571 or 1 (800) 475-1355, Eligibility Option.  The 2008 CSHCS Income Eligibility Guidelines are also on our web page at www.

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