Article 5 Section 10 Pickle Benefits

 

Table of Contents

Title

MPG Cite

Pickle Handbook

5.10.1

Pickle Annual  Stuffers

5.10.2

503 Lead File Reviews

5.10.3

Section 4 Disabled Adult Children Discontinued from SSISSP

5.10.4

Title II and Title XVI Overlapping Payments

5.10.5

Cobra Disabled Widowers

5.10.6

Annual Pickle Stuffer

Appendix A

Discontinuance NOA for Disabled Adult Child – Pickle

Appendix B

Discontinuance NOA for 503 Leads - Pickle

Appendix C

Second Discontinuance NOA - 503 Leads

Appendix D

Pickle Disregard Computation Chart

Appendix E

Pickle Screening Work Sheet DHCS 7020

Appendix F

Pickle Financial Eligibility Work Sheet DHCS 7021

Appendix G

Pickle Disregard Computation Worksheet DHCS 7029

Appendix H

Pickle Resource Worksheet DHCS 7037

Appendix I

Screening Worksheet DW Checklist DHCS 7089

Appendix J

2013 Income Support and Maintenance (ISM) Computing Pickle Eligibility

Appendix K

SSI/SSP Payment Standards  January 1, 2013 Through December 31, 2013

Appendix L

Pickle Handbook Resource Flowcharts

Appendix M

Pickle Handbook Income Flowcharts - Excluded

Appendix N

 

5.10.1 Pickle Handbook

 

A.
General

The purpose of this program guide section is to provide clarification and procedures for eligibility determinations and case maintenance for the Pickle Program. 

 

Under the Pickle Amendment to the Social Security Act, certain ABD/MN eligible’s who receive Title II (RSDI) benefits and who are former Title XVI (SSI/SSP) recipients are entitled to zero SOC Medi-Cal benefits.

 

The Craig v. Bonta court order mandates individuals discontinued from SSI/SSP continue to receive full scope, zero SOC Medi-Cal until the worker performs the eligibility determination.  The only exceptions to the court order are those individual discontinued by SSA due to death or are incarcerated in a correctional facility.

 

 

Individuals discontinued from SSI/SSP due to the annual COLA are placed in Craig v. Bonta aid codes 1E aged, 2E blind and 6E disabled.  These individuals will remain as Exception Eligibles until an eligibility determination has been completed.  When an eligibility determination has not been completed by the second month, MEDS Alert 9548 OVER 2 MONTHS EXTENDED ELIG - MEDI-CAL DETERM OVERDUE will be generated.  The worker must review their MEDS alerts daily and process them within the timelines specified in MPG 20.01.04.  

 

MEM

50247

 

B.
Pickle Handbook
The DHCS issued Pickle Handbook sections are referenced in this program guide section, to include information and instructions necessary to determine Pickle eligibility and comply with the Craig v. Bonta and Lynch v. Rank court orders. 
 
Basic Medi-Cal eligibility requirements are addressed in this program guide section and cover only those eligibility requirements that are different for Pickle eligibles and must be followed when evaluating these eligibility factors. 
 
MPG Ltr# 699 (7/10)

 


5.10.2 Pickle Annual Stuffers

 

A.
Introduction
 

In December of each year, DHCS mails a stuffer notice to individuals who:

currently receive Title II Retirement, Survivor’s and Disability Insurance Social Security Benefits;

have been discontinued from the SSI/SSP program in the last three years;

were determined ineligible during the Pickle screening process.

 

These individuals are aged, blind, and disabled and will be evaluated for Pickle eligibility.  When an individual is determined ineligible for Pickle, the worker will evaluate for all other ABD linked Medi-Cal Programs.

 

The stuffer notice states the criteria for Pickle eligibility If you are aged, blind or disabled, you may be eligible for Medi-Cal benefits without a share of cost if you qualify under the Pickle Amendment”; and advises the beneficiaries to contact the county if they think they may be eligible. 

 

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10-02

 

 

 

 

ACDWL 87-75

95-45

 

 

 

 

B.
Annual Pickle Tickler System

By terms of the Lynch v. Rank court order, the tickler system reviews must be completed during the months of January through March of each year.  Each potentially eligible Pickle individuals must receive a Pickle Medi-Cal notice for three consecutive years.  One year of ineligibles will be purged each year.   When the worker completes the Pickle determination and Submits an HHSA 14-28 MEDS On-Line Request, checking the “Remove Pickle Indicator” box, that individuals name will be removed from the Pickle tickler listing the next year.

 

Persons on the Pickle Tickler system must have their eligibility to Pickle reevaluated each year at the time of the annual Title II COLA.   The individual name will appear on the Pickle Tickler system when a Pickle determination was not completed in the previous year or the individual was not eligible for Pickle.  

 

At the same time, the DHCS sends the Pickle tickler listing to the county; DHCS also mails individual Pickle letters to all persons on the list.  The letter directs beneficiaries to contact their local Welfare office. For San Diego, beneficiaries are advised to call ACCESS at 1-866-252-9881.

 

The Pickle Tickler system list is generated by SPOS Automation and posted in Share Point for FRC’s to access.  The worker will complete the required review described below.

 

When a person brings the NOA in to the FRC or calls ACCESS with questions about the State annual Pickle letter, the worker will screen the client for potential Pickle eligibility and determine if the applicant/ beneficiary has an active Medi-Cal case following the procedures outlined below.

 

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ACWDL

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C.
Review Procedures When FRC Receives Pickle Tickler System
 
 
 
 
 
 
 
 
 
 
 
STEP 1: PICKLE SCREENING PROCEDURES
The worker will clear the names listed on the Pickle Tickler system on MEDS and CalWIN for active Medi-Cal cases.
 

If ...

Then the worker will…

Individual is active on Medi-Cal

Proceed to Step 2.

Individual is not active on Medi-Cal

No further act needed.

 

STEP 2: DETERMINE ELIGIBILITY STATUS

When the individual has an active Medi-Cal case in CalWIN, the worker will complete a Pickle eligibility determination following the procedures outlined below:

 

If …

Then the worker will…

Client is in LTC or receiving IHSS

Submit a HHSA 14-28, checking the “Remove Pickle Indicator” box.

Pickle evaluation has not been completed

Call the individual to screen for Pickle eligibility by asking the question off the DHCS 7020.

 

If …

Then the worker will…

All questions are answered “No”

 

Explain to the individual why they are not eligible.  No NOA is required.

Image DHCS 7020 into case file.

Submit a HHSA 14-28, checking the “Remove Pickle Indicator” box.

All questions are answered “Yes”

Follow the steps outlined in this section.

 

Unable to reach the client by phone

Send the client the DHCS 7020 for completion with a return postage paid envelope.

When form is returned, follow procedures above.

 

Case is active in MEDS not in CalWIN

Determine if case is required to be evaluated for Pickle eligibility.

If yes, follow procedures outlined above.

If no, submit a HHSA 14-28, to terminate MEDS benefits.

 

MPG Ltr #699 (7/10)

ACWDL
10-01

 

 

D.
Review Procedures When Client comes into an FRC
STEP 1: PICKLE SCREENING PROCEDURES
The worker will clear the client on MEDS and CalWIN to determine if the client has an active Medi-Cal case.  The worker will ask the former SSI/SSP recipient to answer the questions on the DHCS 7020.
                   

If ...

Then the worker will…

All questions are answered ‘yes’

Proceed to Step 2.

Any questions are answered ‘no’

1.    Explain to the applicant why they are not eligible.  No NOA is required.

 

If…

Then the worker will….

Applicant does not have a case in CalWIN

Submit HHSA 14-28, checking the “Remove Pickle Indicator” box.

Applicant has an inactive case in CalWIN

Image DHCS 7020 into case file.

Submit HHSA 14-28, checking the “Remove Pickle Indicator” box.

Applicant has an active case in CalWIN

Image DHCS 7020 into case file.

 

STEP 2: Actions  Based on Case Status

When the former SSI/SSP recipient passes the Pickle screening in Step 1, based on the case status, worker will take the following actions.

 

If an active Medi-Cal case …

Then the worker will…

exists

1.    Review CalWIN to determine if client is in LTC or receiving IHSS.

If client 

Then…

is in LTC or receiving IHSS

·         Submit a HHSA 14-28 MEDS, checking the “Remove Pickle Indicator” box.

·         No further action needed.

has eligibility under any other Medi-Cal aid codes

Proceed to Item 2.

 

2.    Review CalWIN to determine if a Pickle evaluation was done.

If a Pickle evaluation…

Then …

was completed

·     Inform client of ineligibility reason.

·     Complete the Pickle denial NOA and hand to client.

·     No further action.

not completed

·     Inform client an evaluation will be completed and he/she will be notified in writing of any changes.

 

does not exist

1. Perform Application Registration in CalWIN.

2.  Provide the following forms to the clients:

  • Copy of SAWS1
  • MC210
  • MC219
  • MC13
  • DHCS 7044

3.    Include a postage paid return envelope.

4.    Inform client that the above forms need to be completed and returned to the FRC so eligibility can be determined.

5.    Image DHCS 7020 into case file.

 

STEP 3: ELIGIBILITY DETERMINATION:

When the applicant’s completed forms are returned to the FRC, the worker will follow the steps outlined in this section.

 

Manual Computations: Once the screening process has been completed, and the adult applicant has been determined to have potential Pickle eligibility, the Financial Eligibility Worksheet DHCS 7021 is used.   

 

The RSDI COLA disregard worksheet computation DHCS 7029 is used to determine the amount of the current RSDI benefit that is to be disregarded for potential Pickle eligibles.   

 

MPG Ltr #699 (7/10)

ACWDL 10-01

 

E.
Review Procedures When Client Calls ACCESS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

When a person calls ACCESS with questions about the State annual Pickle letter, the worker will screen the client for potential Pickle eligibility and determine if the applicant/ beneficiary has an active Medi-Cal case.

              
STEP 1: PICKLE SCREENING PROCEDURES
The worker will clear the client on MEDS and CalWIN to determine if the client has an active Medi-Cal case.  The worker will ask the former SSI/SSP recipient to answer the questions on the DHCS 7020.
 

If ...

Then the worker will…

All questions are answered ‘yes’

Proceed to Step 2.

Any questions are answered ‘no’

Explain to the applicant why they are not eligible.  No NOA is required.

 

If…

Then the worker will….

Applicant does not have a case in CalWIN

Submit HHSA 14-28, checking the “Remove Pickle Indicator” box.

Applicant has an inactive case in CalWIN

Image DHCS 7020 into case file.

Submit HHSA 14-28, checking the “Remove Pickle Indicator” box.

Applicant has an active case in CalWIN

Image DHCS 7020 into case file.

 

STEP 2: Actions based on case status

When the former SSI/SSP recipient passes the Pickle screening in Step 1, based on case status, worker will take the following actions.

 

If an active Medi-Cal case …

Then the worker will…

exists

  1. Review CalWIN to determine if client is in LTC or receiving IHSS.

If client 

Then…

is in LTC or receiving IHSS

·         Submit a HHSA 14-28 MEDS, checking the “Remove Pickle Indicator” box.

·         No further action needed.

has eligibility under any other Medi-Cal aid codes

Proceed to Item 2.

 

  1. Review CalWIN to determine if a Pickle evaluation was done.

If a Pickle evaluation…..

Then …

was completed

·     Inform client of ineligibility reason.

·     Complete the Pickle denial NOA and hand to client.

·     No further action.

not completed

·     Inform client an evaluation will be completed and he/she will be notified in writing of any changes.

·     Send a Share Point to the FRC Change Group requesting that the case be reviewed for Pickle eligibility.

 

does not exist

1. Perform Application Registration in CalWIN.

2.    Mail the following forms to the caller:

  • Copy of SAWS1
  • MC210
  • MC219
  • MC13
  • DHCS 7044

3.    Include a postage paid return envelope of the FRC that will be processing the applications (based on client’s zip code).

4.    Inform client that the above forms need to be completed and returned to the FRC so eligibility can be determined

5.    Image DHCS 7020 into case file.

6.    No SharePoint to FRC.

 

MPG Ltr #699 (7/10)

ACWDL

10-01

 


5.10.3 503 Lead File Reviews

 

A.
DHCS Actions
 

The Lynch v. Rank court order mandates specific requirements for both the DHCS and County of San Diego, Health and Human Services Agency related to identification, main­tenance of lists, and annual notification and review of potential Pickle eligibles.

 

During the month of December each year, the Social Security Administration notifies DHCS of all SSI/SSP recipients scheduled for discontinuance as a result of the COLA.

 

DHCS will initiate extended Medi-Cal benefits for all persons on the listing provided by Social Security in Craig v. Bonta aid codes 1E aged, 2E blind or 6E disabled.   

 

The 503 Lead file report lists those individuals who have been discontinued from SSI/SSP due to the annual COLA.    In addition, these individuals are placed on the Exception Eligibles report and will remain on the Exception Eligibles reports until a Pickle or ABD Medi-Cal Linkage determination has been completed. 

 

During the last two weeks of December, DHCS will send a notice of action and the following forms to each person on the list: 
·         SAWS1
·         MC 210
·         MC 13
·         MC 219
·         MC 239
·         DHCS 7044
 
The notice advises beneficiaries of their extended benefits and when continued Medi-Cal coverage is needed, the forms must be completed within 30 days and mailed to the County ACCESS Center listed at the bottom of the notice. The notice also advises benefi­ciaries that if they have not been contacted by March 15, they should contact their county welfare department.

 

By the first or second week of January, DHCS will mail the 503 Lead file listing of persons discon­tinued from SSI/SSP due to the Title II COLA to the county.   The 503 Lead file report is loaded into SharePoint by SPOS Automation for FRC’s to access.  

 

In April, the fourth month of extended eligibility, DHCS will mail a notice to all persons whose eligibility has not been redetermined by the county.  The individual is advised to contact ACCESS to have an eligibility determination completed.  These individuals will remain as Exception Eligibles until an eligibility determination has been completed. 

 

MPG Ltr # 699 (7/10)

ACWDL

02-05

10-02

 

B.
Review Procedures

Persons on the Pickle 503 Lead report must have their eligibility to Pickle evaluated.  The Pickle Tickler System report is generated by SPOS Automation and loaded into SharePoint for FRC’s to access. The worker will review the report, contact the person and complete an eligibility determination as describe below.

 
When a person contacts San Diego County because their SSI/SSP was discontinued or the worker contacts the person from the Pickle 503 Lead report, the worker will review for Pickle or ABD Linked Medi-Cal Eligibility.  Using the MEDS inquiry process, the worker will review the eligibility status line for the current month. 
 
For potential Pickle individuals, the Pickle 503 Lead Report or the MEDS INQO screen message "SSI-LAST-RECEIVED" can be accepted as verification of the date SSI was last received.  The worker can also use the MEDS INQB screen message, "CUR-BENEFIT-AMT" to verify the individuals current benefit amount.  The following information is for purposes of clarification and to provide specific sup­plemental instructions for case handling.
 
DETERMINE CASE STATUS
 
If …
Then the worker will…
The beneficiary requests a face-to-face interview
Assist the beneficiary with completing the required forms.
The number ‘6’ appears in the third digit of the eligibility status code on MEDS
1.    Perform Application Registration in CalWIN.
2.    Enter application date as the month of the Title II COLA.
3.    Review for Pickle or Medi-Cal eligibility following procedures outlined in MPG 5.10.2.D.
The beneficiary is eligible to Pickle
1.    Grant under the appropriate Pickle aid code beginning with the following month currently on MEDS.
2.    Complete form HHSA 14-28 MEDS On-Line, checking the “Remove Pickle Indicator” box.
The beneficiary is ineligible to Pickle
1.    Mail a Pickle denial NOA.
2.    Complete form HHSA 14-28 MEDS On-Line, checking the ‘Remove Pickle Indicator’ box.
3.    Continue with ABD Linkage Medi-Cal determination.
The beneficiary is eligible to other Medi-Cal
1.    Grant using the beginning date of aid as the first of the following month currently on MEDS.
2.    Complete from HHSA 14-28 MEDS On-Line, checking the ‘Remove Pickle Indicator’ box.
The beneficiary has a SOC
1.    Grant under appropriate aid code allowing timely notification of the change in eligibility benefits to meet 10-day notice requirements.
2.    Mail the Pickle denial NOA and the Medi-Cal granting NOA to meet 10-day notice requirements.
3.    Complete from HHSA 14-28 MEDS On-Line, checking the ‘Remove Pickle Indicator’ box.
The beneficiary is receiving IHSS
1.    Grant under the appropriate Pickle aid code beginning with the following month currently on MEDS.
2.    Complete form HHSA 14-28 MEDS On-Line, to remove the future term date established by DHCS.
3.    Forward a copy of the NOA to the IHSS liaison.
 
 

NOTE:  Once an individual has been determined eligible for Pickle or an other ABD Medi-Cal Linkage program, the worker will submit the HHSA 14-28 to remove the Pickle indicator.  Removing the Pickle indicator in MEDS will cease the individual from appearing in future years on the Pickle Tickler system report.   Only those individuals who have not had a Pickle or continuing eligibility determination completed will appear on future listings.

 
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ACWDL 02-05 10-01

 


5.10.4 Disabled Adult Children Discontinued from SSI/SSP

 

A.
Eligibility Criteria
 
Public Law 99-643 amended the Social Security Act to provide categorical zero SOC Medi-Cal to a limited group of former SSI/SSP recipients who receive Title II benefits as "Disabled Adult Children."  These persons’ eligibility must be determined using Pickle rules. 
 

Exception to Title II COLA Requirement: Persons identified by DHCS as potentially eligible to Pickle under the DAC rules are not required to have received a Title II COLA since their discontinuance from SSI/SSP.

 

To be eligible to Pickle without having received a Title II COLA, DAC persons must meet all of the following additional criteria:

Be over 18 years old;

Previously received SSI/SSP on the basis of blindness or disability which began before the person reached age 22;

Currently receive Title II benefits as a result of the blindness or disability; and discontinued from SSI/SSP as a result of having begun receiving Title II or receiving an increase in the amount of his/her Title II benefits.

 

Note: Beneficiaries who are discontinued from SSI/SSP due to admission to a long-term care facility will not be included in the DAC extended eligibility process. 

 

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ACWDL

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B.
DAC Actions

At the time of the SSI/SSP discontinuances, DHCS will provide potential DAC individuals with extended Medi-Cal coverage in Craig v Bonta aid codes 1E aged, 2E blind or 6E disabled. In addition, these individuals are placed on the Exception Eligibles report.  Individuals will remain on the Exception Eligibles report until a Pickle or ABD Medi-Cal Linkage determination has been completed. 

 
DHCS will send the beneficiary a NOA and a set of forms for completion. In the NOA, the beneficiary is instructed to return the completed forms to the County ACCESS Center by the 5th of the following month.
 
Forms sent by DHCS with the NOA are SAWS1, MC 210, and MC 239 C.
 
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ACWDL

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D.
Review Procedures

These individuals will show up monthly on the Exception Eligibles report as SB87-SSI-DAC.  SPOS Automation loads the report into SharePoint for FRC’s to access.  The worker will review the report, contact the person and complete an eligibility determination as described below.     

 

When a person contacts San Diego County because SSI/SSP was discontinued as a result of having begun receiving Title II DAC benefits, the worker will review for Pickle or ABD Linked Medi-Cal Eligibility. The following information is for purposes of clarification and to provide specific instructions for case processing

 

DETERMINE CASE STATUS

 

If …

Then the worker will…

The beneficiary requests a face to face interview

1.    Assist the beneficiary with completing the required forms.

2.    Perform Application Registration in CalWIN.

3.    Use the application date listed on the Exception Eligible listing SB87-SSI-DAC.

4.    Review for Pickle eligibility following procedures outlined in MPG 5.10.2.D

The beneficiary is eligible to Pickle

  1. Grant under DAC eligibility aid code 6A blind and aid code 6C for disabled.
  2. Complete form HHSA 14-28 MEDS on-Line.  Remove Pickle Indicator box.

The beneficiary is ineligible to Pickle

  1. Mail a Pickle denial NOA.
  2. Complete form HHSA 14-28 MRFS On-Line.  Remove Pickle Indicator box.
  3. Continue with ABD Linkage Medi-Cal determination.

 

The beneficiary is eligible to other Medi-Cal

  1. Grant using the beginning date of aid as the first of the following month currently on MEDS
  2. Complete form HHSA 14-28 MRFS On-Line.  Remove Pickle Indicator box.

The beneficiary has a SOC

  1. Grant under appropriate aid code allowing timely notification of the change in eligibility benefits to meet 10-day notice requirements.
  2. Mail the Pickle denial NOA and the Medi-Cal granting NOA to meet 10-day notice requirements
  3. Complete form HHSA 14-28 MRFS On-Line.  Remove Pickle Indicator box.

The beneficiary is receiving IHSS

  1. Grant under the appropriate Pickle aid code beginning with the following month currently on MEDS
  2. Complete form HHSA 14-28 MRFS On-Line.  Remove Pickle Indicator box.
  3. Forward a copy of the NOA to the IHSS liaison.

 

MPG Ltr #699 (7/10)

ACWDL

94-86

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


5.10.5 Title II and Title XVI Overlapping Payments

 

A.
General
 
 
Effective December 1, 1987, a change in rules for overlapping Title II SSA disability and Title XVI (SSI/SSP) payments was made.
 
If the person is granted SSI/SSP first, and Title II benefits are approved several months later retroactively, that person is still potentially Pickle eligible.
 
In these instances the Pickle applicant may have been required to reimburse the SSI/SSP program for any benefits received; however, he/she is still to be considered to have been eligible for and entitled to receive both SSA and SSI/SSP in the same month.
 
This provision does not apply to persons who are determined ineli­gible for SSI/SSP for reasons other than receipt of SSA benefits.
 
Example: Jack Overlap applied for SSI/SSP and SSA disability on June 19, 1990.  The Social Security Administration computed and approved the SSI/SSP grant before computing the SSA payments. Consequently, Jack began receiving SSI/SSP benefits effective June 19, 1990.  His SSA benefits were approved in October 1992 with an effective date of June 1990. It was determined that his SSA payments were marginally more than his SSI/SSP payments.  As a result his SSI/SSP benefits were discontinued effective October 31, 1992, and he was required to pay back the SSI/SSP received.
 
Jack is considered to be potentially Pickle eligible at the time of the January 1993 SSA cost of living increase and a Pickle eligibility determination must be completed by the worker.
 
MPG Ltr #699 (7/10)
ACWDL 93-73

 


5.10.6 Cobra Disabled Widows (DW)

 

A.
Cobra 1985

The Consolidated Omnibus Reconciliation Act of 1985 (COBRA '85) established criteria to be used in restoring and continuing Medi‑Cal eligibility for disabled widows if their 1983 RSDI COLA resulted in a loss of their eligibility for SSI/SSP pay­ments.

 

Persons who met the criteria for zero SOC Medi-Cal under COBRA '85 provisions were given a deadline of July 1, 1988 to apply at their local welfare department.  Although no COBRA applications were received in San Diego County, there is the possibility that a COBRA '85 Medi-Cal beneficiary could move to San Diego County and request transfer of his/her case.  In this event, Pickle Handbook, Section 5 specifies information which must be provided from the original county of responsibility to San Diego County.

ACWDL

87-5

 

B.
OBRA 1987

The Omnibus Reconciliation Act of 1987 (OBRA '87) amended the Social Security Act to extend Medi-Cal coverage to a new group of disabled widow(er) s. The amendment allows DW between the ages of 60 and 64 who lose SSI/SSP benefits as a result of becoming entitled to or receiving an increase in Title II benefits to continue their Medi-Cal eligibility until they become eligible for Part A Medicare benefits.  Eligibility under this provision was effective July 1, 1988.

 

Unlike COBRA '85 legislation, OBRA '87 does not establish an application deadline for potential eligibles.  Potential OBRA '87 eligible DW are notified in their SSI/SSP discontinuance notice of their potential eligibility and are advised to apply at their local welfare department.

 

Individuals are deemed to be SSI recipients for purposes of Medi-Cal under this provision if they meet the following conditions:

Are between the ages of 60 and 64;

Are eligible for and receiving early widows benefits;

Are not entitled to Medicare Part A; and

Are ineligible for SSI/SSP benefits because of receipt of Title II SSA benefits.

 

These individuals are deemed to be SSI recipients for Medi-Cal purposes as long as they would continue to be eligible for SSI/SSP in the absence of the widow’s benefits.

 

MPG Ltr #699 (7/10)

ACWDL

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C.
OBRA 1990
The Omnibus Budget Reconciliation Act of 1990 (OBRA-90) created a new group of Medi-Cal eligibles.  Section 5103 of OBRA-90 extended Medi-Cal coverage to disabled widows age 50-59 that become ineligible to SSI/SSP benefits because of entitlement to or an increase in certain Title II widows insurance benefits.  OBRA-90 mandated zero SOC Medi-Cal coverage for this group of disabled widows until Medicare begins for them.
ACWDL
93-02
 
 
 
 
 

 

D.
Eligibility Determination

The eligibility determination is the same as DW ages 60-64.

 

At the time of the SSI/SSP discontinuance, DHCS will provide potential DWs aged 50 to 64 with extended zero SOC Medi-Cal eligibility.  When DHCS is notified of the SSI/SSP discontinuance, these individuals will also be sent a DW NOA, a SAWS1, MC 13, MC 210, MC 219, and MC 239.  The NOA will tell these individuals that because they are not receiving an SSI/SSP check, they will not receive an SSI/SSP Medi-Cal card.  However, they will be granted extended Medi-Cal eligibility.   If they want to continue their Medi-Cal coverage after that, they must contact their local county welfare department.
 
Form DHCS 7089 (Screening Worksheet) is used when evaluating whether an individual is potentially eligible for the DW program.
 
The worker shall determine whether the individual would meet the DW program criteria and send an Approval or Denial NOA as appropriate.  The following are DW NOA’s to be used:

Disabled  Widow(er) Approval Notice MC 239 DW1

Disabled  Widow(er) Denial Notice   MC 239 DW2

 
ALERT MESSAGES
 
DWs become eligible for Medicare Part A two years after the onset of disability.  At that time, they become ineligible for the DW program.  Beginning in December, 1994, the DHCS Data System Branch will be sending counties MEDS alert messages concerning DW individuals who need to be terminated in two months from the DW program because of the impending receipt of Medicare Part A.  These individuals shall be re-evaluated under another Medi-Cal program.  The alert message will read, "Medicare Part A in Two Months:  Re-evaluate for other category."
 
MPG Ltr #699 (7/10)

 


Appendix A Annual Pickle Stuffer

 

 

PICKLE AMENDMENT

IMPORTANT NOTICE

REGARDING YOUR MEDI-CAL

ELIGIBILITY

 

If you are aged, blind or disabled, you may be eligible for Medi-Cal benefits without a share of cost if you qualify under the Pickle Amendment.  To qualify, ALL of the following must apply to you.

 

1.         You currently receive Social Security Title II (RSDI) benefits; and

 

2.         You received and were entitled to receive both RSDI and Title XVI, Supplemental Security Income/State Supplementary Payment (SSI/SSPP) benefits simultaneously in any month since April 1977; and

 

3.         You no longer receive SSI/SSP benefits; and

 

4.         Your countable income and property are within Pickle Amendment limits.

 

If you would like an evaluation for the Pickle Amendment, you should contact your county welfare department eligibility worker.  If you do not currently receive Medi-Cal, you will need to fill out some forms at your county welfare department to apply for Medi-Cal under the Pickle Amendment.

ENMIENDA PICKLE

AVISO IMPORTANTE

SOBRE SU ELEGIBILIDAD

PARA MEDI-CAL

 

Usted es anciano(a), ciego o incapacitado, y si cumple con los requisitos de la Enmienda Pickle, es posible que sea elegible para recibir beneficios de Medi-Cal sin parte del costo.  Para cumplir con los requesitos, TODAS las siguientes deben corresponderle:

 

1.         Está recibiendo beneficios del Titulo II (RSDI) del Seguro Social; y

 

2.         Recibió y tuvo derecho a recibir simultáneamente en cualquir mes desde abril de 1977 beneficios de RSDI y  Titulo XVI, Seguridad de Ingreso Supplemental/Programa Suplementario del Estado (SSI/SSP); y

 

3.         Ha dejado de recibir SSI/SSP; y

 

4.         Su ingreso contable y propiedades están dentro de los límites de la Enmienda Pickle.

 

Si desea obtener una evaluación para la Enmienda Pickle, deberá ponerse en contacto con el trabajador a cargo de elegibilidad del departamento de bienestar público de su condado.  Si no está recibiendo Medi-Cal actualmente, necesitará llenar varios formularios en el departamento de bienestar público de su condado para solicitar Medi-Cal bajo la Enmienda Pickle.

 


Appendix B Discontinuance NOA for Disabled Adult Child – Pickle

 

State of California – Health and Welfare Agency                                           NOTICE TYPE 10

Department of Health Services                                                            NOTICE PREPARATION DATE:

Medical Assistance                                                                              December 16, 1993

 

                                                                        DISCONTINUANCE OF SSI/SSP  MEDI-CAL

MEDI-CAL                                                    EXTENDED MEDI-CAL ELIGIBILITY

            NOTICE OF ACTION                                        (Disabled Adult Child – Pickle)

 

                                                EMOOOO1

 

SMITH                         JOHN                                                              Social Security Number:

JOHN SMITH                                                                                      111-22-3333

 

1111 MAIN ST                                                                                                Beneficiary ID Number:

ANYWHERE CA                    91212                                                  01-60-9111223-33

 

The Social Security Administration (SSA) has notified us that you are no longer eligible to receive a Supplemental Security Income/State Supplementary Payment (SSI/SSP) check.  Because SSA informed us that you are not receiving an SSI/SSP check now, you will not receive an SSI/SSP Medi-Cal card after December 31, 1993.

 

The regulations which require this action are California Administrative Code, Title 22, Sections 50227 and 50703.

 

‘IF YOU HAVE CONTACTED SSA AND HAVE BEEN TOLD THAT YOU WILL ONCE AGAIN RECEIVE AN SSI/SSP CHECK, PLEASE DISREGARD THIS NOTICE.  SSA WILL NOTIFY THE DEPARTMENT OF HEALTH SERVICES TO RESUME ISSUANCE OF YOUR MEDI-CAL CARD.  THIS REINSTATEMENT PROCESS NORMALLY TAKES 4 T0 6 WEEKS.  IF YOU HAVE A MEDICAL EMERGENCY AND NEED YOUR MEDI-CAL CARD BEFORE THE REINSTATEMENT PROCESS HAS BEEN COMPLETED, CONTACT YOUR LOCAL SSA OFFICE AND THEY WILL ISSUE YOU AN ELIGIBILITY REFERRAL FORM WHICH YOU CAN TAKE TO THE LOCAL COUNTY WELFARE DEPARTMENT AND OBTAIN ANY MEDI-CAL CARDS TO WHICH YOU ARE ENTITLED”

 

Even though you will not receive an SSI/SSP Medi-Cal card after December 31, 1993, YOU HAVE BEEN GRANTED ONE MONTH OF EXTENDED MEDI-CAL ELIGIBILITY.  YOU WILL RECEIVE AN EXTENDED ELIGIBILITY MEDI-CAL CARD ONLY FOR THE MONTH OF January 1994.

 

IF YOU WANT TO COMTINUE YOUR MEDI-CAL COVERAGE AFTER THAT, you must take the Following actions:  COMPLETE THE ENCLOSED APPLICATION AND THE STATEMENT OF FACTS.  MAIL THEM NO LATER THAN January 5, 1994 to:

Pickle Coordinator

San Diego County

Social Service Agency

7947 Mission Center Ct

San Diego, CA 92108

(866-292-9881

 

 

The county will review your application and determine your continuing Medi-Cal eligibility immediately, IF YOU COMPLETE AND RETURN THESE FORMS BY January 5, 1994.  Later, the county will set up an appointment for your required interview with your county worker.

 

HAS THE STATE BEEN PAYING YOUR MEDICARE PART B PREMIUMS?

The State IS CONTINUING TO PAY YOUR PART B PREMIUMS UNTIL THE END OF January 31, 1994.

 

If you wish the state to continue paying your Part B premiums AFTER January 31, 1994, you should SEND IN YOUR APPLICATION FORMS IMMEDIATELY.  Once the County approves your continuing Medi-Cal, the State will continue to pay your Part B premiums.

 

If you do not follow these instructions, you Extended Medi-Cal Eligibility will end January 31, 1994.  If you want Medi-Cal again, you will have to apply at the county welfare department.

 

Keep this letter to show the county welfare department.  It will help them to determine your Medi-Cal status.

 

(07/93)                         PLEASE READ THE ENCLOSED REQUEST FOR A FAIR HEARING

 

 


Appendix C     Discontinuance NOA for 503 Leads - Pickle

 

State of California – Health and Welfare Agency                                            NOTICE TYPE 51

Department of Health Services                                                            NOTICE PREPARATION DATE:

Medical Assistance                                                                              December 12, 2000

 

                                                                                                DISCONTINUANCE OF SSI/SSP MEDI-CAL

MEDI-CAL NOTICE                                                   EXTENDED MEDI-CAL ELIGIBILITY

                                                                                                            (503 Leads – Pickle)

                                                PN00026

 

NOTICE TYPE                        FIFTYTWO V

FIFTYTWO V NOTICE TYPE

 

TO:      Medi-Cal Beneficiaries Discontinued

            From SSI/SSP on January 1, 2000

 

RE:      CONTINUED MEDI-CAL BENEFITS AND FOOD STAMPS

 

You were recently told by the Social Security Administration (SSA) that your Supplemental Security Income/State Supplementary Payment (SSI/SSP) benefits have stopped.  That notice also instructed you to contact your county welfare department within 30 days of that notice if you wanted your Medi-Cal benefits to continue. 

You should ignore the information included in the notice that related to your Medi-Cal Benefits.

 

The reason your SSI/SSP checks were stopped is that you received an increase in your Social Security benefits.  Although this increase makes you ineligible for the SSI/SSP check, you will continue to receive Medi-Cal benefits under the federal law called the Pickle Amendment until the county evaluates your eligibility.  Those who are Pickle eligible will continue to receive Medi-Cal without a share of cost.

 

If you want Medi-Cal coverage, please complete the enclosed forms:

 

·         The Application for Medical Assistance/Food Stamps

·         Statement of Facts

·         Statement of Citizenship, Alienage, and Immigration Status

·         Important Information for Persons Requesting Medi-Cal

·         Statement of Living Arrangements, In-Kind Support, etc.

 

Within 30 days of the date of this notice, mail the forms to the office listed below.  If you do not hear from the county by March 15, be sure to contact a worker at your local county welfare department.

 

You may also be eligible for food stamps.  Food stamps are coupons that can be used to pay for food.  Your local county welfare office will tell you more about food stamps and whether you are eligible to receive them and even help you apply.

 

If you are receiving SSI/SSP benefits, please ignore this notice.

 

If you need help in completing the forms or have questions about Medi-Cal, contact the county welfare department at the phone number listed here:               Pickle Coordinator

                                                            San Diego County Social Service Agency

                                                            7947 Mission Center Ct., San Diego  CA 92108 (866) 262-9881

ACWDL 99-51

 


Appendix D Second Discontinuance NOA - 503 Leads

 

State of California – Health and Welfare Agency                                                                                      Department of Health Services

 

NOTICE OF ACTION

COUNTY INFORMATION

 

SECOND NOTICE

(503 LEADS NOTICE OF ACTION

DATE:

 

TO:                 Medi-Cal Beneficiaries Discontinued

                        From SSI/SSP in January 1

 

FROM:           County Welfare Department

 

RE:                  Your Medi-Cal Benefits Will End

 

               

You were notified by the Social Security Administration (SSA) in December that your SSI/SSP was discontinued as of January 1 of this year.  The reason your SSI/SSP checks were stopped is because you received an increase in your Social Security benefits.  Although this increase made you ineligible for your SSI/SSP checks, you also were notified by the State Department of Health Services that you would continue to receive Medi-Cal until the county welfare department determines whether you will be able to get a zero share of cost Medi-Cal card under the Pickle Amendment.  The county must evaluate your Pickle eligibility for Medi-Cal.

 

However, you have not responded to the State Department’s notice and we were unable to reach you by telephone.  Therefore, your Medi-Cal will automatically be discontinued on April 30.  You will not receive a May Medi-Cal Card.

 

If you have information that you would like to be considered, please contact your county eligibility worker immediately.

 

IF YOU DISAGREE WITH THIS ACTION AND YOU WANT TO APPEAL THE DISCONTINUANCE, YOU MAY REQUEST A STATE HEARING BY FOLLOWING THE INSTRUCTIONS ON THE BACK OF THIS NOTICE.

 

NOTE:            THIS NOTICE WILL NOT AFFECT ANY MEDI-CAL BENEFITS YOU MAY ALREADY BE RECEIVING UNDER ANOTHER MEDI-CAL PROGRAM.

 

If your SSI/SSP checks have been started again since January 1 of this year, please ignore this letter.

 

This notice is a result of a court decision in the case of Lynch v. Rank, U.S. District Court, Northern District of California, No. C-83-2340 WHO.

 

For additional information contact:

 

DHS 7025 (1/92)

 

 

Appendix E Pickle DHCS Disregard Computation Chart

 

2014

Pickle Persons Title II Disregard Computation Chart

 

Date of Last SSI

Cost of Living Amount

Multiplier

1/13 through 12/13

1.015

0.0148

1/12 through 12/12

1.017

0.0312

1/11 through 12/11

1.036

0.0649

1/10 through 12/10

1.000

0.0649

1/09 through 12/09

1.000

0.0649

1/08 through 12/08

1.058

0.1162

1/07 through 12/07

1.023

0.1360

1/06 through 12/06

1.033

0.1636

1/05 through 12/05

1.041

0.1966

1/04 through 12/04

1.027

0.2177

1/03 through 12/03

1.021

0.2338

1/02 through 12/02

1.014

0.2444

1/01 through 12/01

1.026

0.2635

1/00 through 12/00

1.035

0.2884

1/99 through 12/99

1.024

0.3051

1/98 through 12/98

1.013

0.3140

1/97 through 12/97

1.021

0.3281

1/96 through 12/96

1.029

0.3471

1/95 through 12/95

1.026

0.3636

1/94 through 12/94

1.028

0.3809

1/93 through 12/93

1.026

0.3966

1/92 through 12/92

1.030

0.4142

1/91 through 12/91

1.037

0.4351

1/90 through 12/90

1.054

0.4641

1/89 through 12/89

1.047

0.4881

1/88 through 12/88

1.040

0.5078

1/87 through 12/87

1.042

0.5276

1/86 through 12/86

1.013

0.5337

1/85 through 12/85

1.031

0.5477

1/84 through 12/84

1.035

0.5630

7/82 through 12/83

1.035

0.5778

7/81 through 06/82

1.074

0.6069

7/80 through 06/81

1.112

0.6465

7/79 through 06/80

1.143

0.6907

7/78 through 06/79

1.099

0.7186

7/77through 06/78

1.065

0.7357

4/77 through 06/77

1.059

0.7505

                                       

 

                               Instructions for Current Year Title II Disregard Computation Chart

 

This chart replaces and supersedes all previous Title II Disregard Computation charts.  The steps to be taken to use this chart are outlined below.

 

1.     Determine the current benefit amount.

2.     Determine when the last SSI/SSP check was received.

3.     Multiply the current benefit amount by the multiplier for the time period the last SSI/SSP check was received.

4.     The result is the amount to be disregarded.

                                                                             

 

 

Appendix F Pickle Screening Work Sheet DHCS 7020

 

 

 

 

 

Appendix G Pickle Financial Eligibility Work Sheet DHCS 7021

 

 

 

 

 

Appendix H Pickle Disregard Computation Worksheet DHCS 7029

 

 

 

 

Appendix I Pickle Resource Worksheet DHCS 7037

 


 

 

 

 

Appendix J Screening Worksheet DW Checklist DHCS 7089

 

 

 

 

Appendix K 2014 Income Support and Maintenance (ISM) Computing Pickle Eligibility

 

                          Individual                                                    Couple

                          VTR    (not rebuttable)                                 $240.33                $360.67

                          PMV   (rebuttable)                                       $260.33                $380.67

 

        The VTR is the payment level to be used in situations 1, 2 and 3 below.

        The PMV is the unearned income amount to be added in other situations.

The following chart provides the method that must be used for determining Pickle eligibility for individuals and couples in various living arrangements.

 

                        HOUSEHOLD SITUATION

                        (LIVING ARRANGEMENT)

 

                        Principle

 

1.     Living in household of another through­out a month and receiving both food and shelter from someone in the household.

Reduce the applicable payment level by one-third the Federal Benefit Rate (FBR).  Use the VTR

 

2.       Living in household of another who is providing both food and shelter and also receiving ISM from a third party.

 

3.     Living with a responsible relative (deemor) who lives in the household of another and the householder is not a responsible relative but is supplying both food and shelter

Reduce the FBR payment level by one-third (VTR).  Exclude third party ISM.

 

Add VTR from the Householder to deemed income from the responsible relative and add to other unearned income

 

4.     Living in own household (ownership or rental liability) and receiving ISM from someone outside the household.

Add Presumed Maximum Value (PMV) to other unearned income.

 

5.     Living in non-institutional *care situation or group home and receiving ISM from someone outside the household.

Add PMV to other unearned income.

 

           *           All non-medical institutions including those for education or

                     Vocational training.  Also, see page 3 of ISM section.

 

6.     Living with a responsible relative (deemor) who lives in the household of another and the householder is not a responsible relative but is supplying food or shelter.

Add PMV from the householder to deemed income from the responsible relative and add to other unearned income.

 

7.     Living in household of another and sharing partial or total household expenses

If prorata share is contributed we use the SSI/SSP payment level for a person in an "Independent Living Arrange­ment". If prorate share is not contributed add PMV.

 

8.     One member of an eligible couple lives in the household of another and receives both food and shelter from the house­holder while the second member lives in his/her home or a non-medical institution.

1/6 of the FBR for a couple for the person living in his/her own household.  (VTR) not rebuttable.

 

1/6 of the FBR for a couple plus $10.

 

9.     If the non-institutionalized spouse lives in any other situation.

1/6 of the FBR for a couple plus $10.

 

10.    Paying less than current market rental value for shelter.

Add PMV unless criteria for earned/ unearned income are met.  (See ISM)

 

(Pickle Handbook Revised 2/21/2012)

 



Appendix L SSI/SSP Payment Standards Effective January 1, 2014

 

 

 

 

Independent Living

Arrangement

Household of Another

With In-Kind Room and Board

Independent Living

Arrangement Without

Cooking Facilities (RMA)1

Nonmedical Board and Care

Licensed Facility/Household of Relative Without In-Kind

Room & Board

 

Total

SSI

(FBR)

SSP

TOTAL

SSI

(FBR)

SSP

TOTAL

SSI

(FBR)

SSP

TOTAL

SSI

(FBR)

SSP

INDIVIDUAL:

-Aged or

 Disabled

-Blind

-Disabled

 Minor*

-NMOHC2

                

 

    877.40

    935.00

                

    784.40

              

 

721.00 

 

              

  721.00

 

 

  156.40

 

 

     63.40

 

                  

       658.67

       739.67

 

       547.50

       887.67

 

                  

                  

 

 

      480.67

      480.67

 

                  

                  

 

 

         66.83

      407.00

 

 

      961.40

              

 

  674.00

 

              

  280.00

 

 

   1,133.00

   1,133.00

 

   1,133.00

                  

 

      720.00

      720.00

                  

      720.00

              

 

  412.00

  412.00

              

  412.00

COUPLE:

Both are:

Aged or Disabled -

Per Couple

                

 

 

1,524.00

              

 

 

              

              

 

 

              

                  

 

 

   1,233.33

 

 

                  

 

 

    1692.00

 

 

                  

 

 

   2,266.00

                  

 

 

   1,082.00

              

 

 

1,184.00

BLIND:

Couple-Both are Blind -

Per Couple

                

 

1,751.00

 

 

                  

 

   1,460.00

 

 

 

 

 

                  

 

   2,244.00

                  

 

   1,082.00

              

 

1,184.00

BLIND/AGED OR DISABLED:

Couple One is Blind, the Other

is Aged or

Disabled -

Per Couple

                

 

 

 

1,666.00

 

 

                  

 

 

 

   1,374.00

 

 

 

 

 

                  

 

 

 

   2,244.00

                  

 

 

 

   1,082.00

              

 

 

 

1,184.00

NMOHC2

Per Couple

 

 

 

 

 

   1,767.00

 

      721.34

 

   1,045.66

 

 

 

 

 

 

NONMEDICAL BOARD AND CARE                                                                              FEDERAL BENEFIT RATE (FBR)

                                                                                                                                                 

                                                             Minimum                 Maximum                                      INDIVIDUAL:                                        $721.00

TOTAL:                                               $1,133.00                $1,133.00                                      Aged, Blind, or Disabled

Board and Room                              $487.00                   $487.00

Care and Supervision                     $417.00                   $516.00                                                                                                        

Personal and Incidental Needs     $130.00                   $229.00                                         COUPLE:                                              $1,082.00

                                                                                                                                                       Aged, Blind, Or Disabled

Title XIX Medical Facility – Individual $50.00 Couple $100.00

*         Independent living arrangement for a disabled minor means living in the home of his/her parents.  Household of another is used if both the disabled minor and his/her parents live in the household of someone else, i.e., grandparents, etc.

 

1 RMA - Restaurant Meals Allowance -  $84 Individual; $168 Couple

2 NMOHC2 - Nonmedical out-of-home care living in household of relative or guardian with In-Kind Room and Board.

PICKLE HANDBOOK Revised 12/15/09 (16-1a)

MPG LTR#805 (3/2014)

 


Appendix M Pickle Handbook Resource Flowcharts

 

SECTION 9 – RESOURCE FLOWCHARTS

SOURCE

TREATMENT

REQUIRED VERIFICATION

Keogh, IRA, pension accounts, time deposits

Counted.  Deduct penalty for early withdrawal. If verified that funds cannot under any circumstances be withdrawn, the funds are excluded until maturity.

Examine the time deposit certificate or statement from financial institution.

Child – IRA’s, Keoghs, and pensions of an ineligible parent.

Exclude from potentially eligible Pickle child, the IRAs, Keoghs, and pensions of ineligible parent.

None

 

Loans which require repayment.

Counted, if funds are retained more than 30 days from date of receipt.  Exempt first 30 days.

Copy of loan documents.

 

Nonrecurring lump sum.

 

Ref:  SI 01130.600

Excluded the month of receipt.  Retroactive SSI/SSP and RSDI payments are excluded for nine months (following the month of receipt), with the exception of the periods listed below.

If received between October 1, 1989 through March 1, 2004, or prior to October 1, 1987, the excluded period is six months.

Applicant’s/beneficiary’s signed statement.

Replacement of lost, stolen, destroyed, or damaged property (previously excluded property only).

If property was previously excluded, exclude payment for nine months from date of receipt.  An additional nine month extension may be granted for circumstances beyond applicant’s/beneficiary’s control.

Copy of written evidence showing the source, amount, date, and intended purpose.  If written evidence is unavailable, use applicant’s/beneficiary’s statement under penalty of perjury.

Income tax refunds.

Counted as a resource the first day of the month following the month of receipt.  (Excluded as income the month of receipt.)

Copy of tax return.  (Obtain a copy of bank statement if in a financial institution).

 

PICKLE HANDBOOK REV.  04/02 (Page Amended 12/09).

 

 


Appendix N Pickle Handbook Income Flowcharts – Excluded

 

SECTION 13- INCOME FLOWCHARTS – EXCLUDED

 

SOURCE

TREATMENT

REQUIRED VERIFICATION

Infrequent or irregular income

Excluded up to $20 per month of unearned income; 410 per month of earned income

Applicant’s/beneficiary’s statement

 

 

Nonrecurring lump sum

Ref: SI 01130.600

Excluded the month or receipt.  Retroactive SSI/SSP and RSDI payments are excluded for nine months (following the month of receipt), with the exception of the periods listed below.

If received between October 1, 1989 through March 1, 2004, or prior to October 1, 1987, the excluded period is six months.

Applicant’s/beneficiary’s signed statement

Older Americans Assistance Act of 1965 payments (other than wages, free meals, or reduction in price of meals).

Excluded.  Wages are considered income, free meals or a reduction in the price of meals is considered unearned income.

Pay stubs, statement from agency.

 

 

PICKLE HANDBOOK REV. 04/02 (Page Amended 12/09)                                                                                     13-5