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 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
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 . 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, 2012
Family Size Monthly Income Limit
Individual $2,094
Spousal Allocation $2,841


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