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  Home >> Eligiblity Policy and Oversight >> Download Applications

 Application Download Page
 Checklist for Required Documentation
 Income Limits for the Specific Program


The information below is based on the selected need for coverage made on a previous page.

This page will provide you with:

  • An Application
  • A Checklist Of Required Documentation
  • Income Limits (if applicable)
For the Medicaid program or other coverage programs managed by DHHS.

Note: Coverage is provided under many categories with different income limits. More than one income table may be presented (if applicable). Not all programs providing coverage are Medicaid programs.

General Hospital, Nursing Home, TEFRA/Katie Beckett and
Home and Community Based (Waiver) Services

(300% of the Federal Benefit Rate-FBR)
January 1, 2009
Family Size Monthly Income Limit
Individual $2,022
Spousal Allocation $2,739


Printable Applications
Applications in Adobe PDF Format Form Link Description
Disabled Children Require the 5 Forms below.
FM 3218-D ME « Disability Report: Mail to Your CEP- TEFRA Coordinator
FM 921 ME « Authorization To Disclose Health Information
FM 3291 ME « TEFRA In-Home Care Certification
FM 3292 ME « ATTN: Parent Considering Applying for TEFRA
FM 3290 ME « Application For TEFRA Medicaid Coverage

What else you will need.
Check List for FM 3290 ME
Then Mail Applications to: ¬
(FM 3290 ME) Mail to Central Eligiblity Office




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