Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Page 2

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DHS-2 Rev. 10-14

Instructions Page 2 of 4

Medicare Premium Payment Program (MPP): Eligibility for the Medicare Premium Payment Program (MPP) is based on income and helps adults

over age 65 and disabled adults pay all or some of the costs of Medicare Part A and Part B premiums, deductibles and co-payments. Medicare Part A is

hospital insurance coverage and Medicare Part B is for physician services, durable medical equipment and outpatient services.

RI SSI State Supplemental Payment Program (SSP): The State of Rhode Island supplements the Federal SSI benefit rate for eligible persons.

Supplemental Security Income (SSI) is a federal program that provides monthly benefits to people who are age 65 or older, blind or disabled and who have

low income and limited resources. Authorization of the monthly SSP for current SSI recipients will be completed automatically. New applicants who are

eligible for the Federal SSI will be automatically authorized for the SSP when they apply at the SSA. Applicants for SSP who have been denied through

SSA for excess income will need to meet the income, resource, age and/or disability standards (age 65 or older, disabled or blind). If an applicant is

eligible based on income and is claiming a disability which has not been reviewed or determined by the SSA, the SSP Unit will send a referral to the

Medical Assistance Review Team (MART) for a disability determination.

Katie Beckett: Katie Beckett provides Medicaid/health insurance coverage to children under age 19 who have long-term disabilities or

complex medical needs. Katie Beckett enables children to be cared for at home instead of in an institution. With Katie Beckett, only the child’s income

and resources, not the parents’, are used to determine eligibility. If you are applying for Katie Beckett, you only need to provide information for the

applicant child—you do not need to fill in information about other household members.

This form consists of 38 questions. Except for Question 1, each is followed by a section of boxes used for filling in the required information. Respond to

each question by indicating either YES or NO with a check mark in the box next to the question.

IF the answer is YES [ ]

Supply the requested information by writing in the space available or in the yellow-boxed area beneath the question. Do not write in the blue shaded areas.

You must provide the information asked for EVERY household member whether or not you are requesting assistance for her or him.

IF the answer is NO [ ]

THE QUESTION DOES NOT APPLY TO YOU OR ANYONE IN YOUR HOUSEHOLD. With the exception of Question 38, leave the yellow box blank,

and move on to the next question.

IF you need more space to answer questions

"SEE PAGE 26" if you run out of space. Turn to page 26, where there are boxes to write in additional information. Indicate in one of the boxes,

which question you are referring with its number. You may also attach separate sheets of paper, if necessary.

Read pages 27-30

These pages contain important information about your Rights and Responsibilities.

About the Interview

Page 3 of the instructions has a list of "Things You May Need to Provide for Your Interview or Submit for Benefit Approval".

About the Questions

Question 1.

List yourself on the first line providing all the requested information. Then list all persons who live with you, one person per line. Indicate how each person

is related to you (for example "son", "cousin", etc.) in the "Relationship" block. You must list each person who lives in your home REGARDLESS OF

WHETHER OR NOT YOU ARE SEEKING ASSISTANCE FOR THAT PERSON.

Question 1a. through 13.

Complete the information in the yellow areas for each person requesting assistance. These questions follow the list of household members (Question 1.) and

ask for personal information about everyone listed in Question 1. If the answer to any of these questions is YES [ ] complete the information asked for in the

yellow shaded area. When doing so, write the names of household members exactly as they appear in Question 1.

Question 14. through 19.

These questions ask about the financial assets (such as bank accounts) of all household members. If the answer to any of these questions is YES [ ],

complete the information asked for in the yellow shaded area. When doing so, write the name of household members exactly as they appear in Question 1.

Questions 20. through 28.

These questions ask about the income of all household members. If the answer to any of these questions is YES [ ], complete the information asked for in

the yellow shaded area. When doing so, write the names of household members exactly as they appear in Question 1.

Questions 29. through 38.

These questions ask about shelter and miscellaneous expenses and medical coverage of all household members. If the answer to any of these questions is

YES [ ], complete the information asked for in the yellow shaded area. When doing so, write the name of household members exactly as they appear in

Question 1. If you report and provide proof of your expenses as listed in questions 29 - 38, it may help you get more benefits from SNAP. If you do not

report an expense or provide proof , then we will assume that you do not want this expense to be counted. You can ask for assistance in getting

documentation of the deductions and/or expenses from your DHS worker.

Appointing an Authorized Representative: If you would like to appoint an authorized representative to act on behalf of the household in applying

for program benefits or using the benefits you may do so on pages 1 and/or 29.