Form Faa-1097t - Young Adult Transitional Insurance (Yati) Tribal Referral Page 3
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3Completion Instructions for the FAA-1097T
FAA-1097T FORFF (9-17)
Page 3 of 3
YOUNG ADULT TRANSITIONAL (YATI) TRIBAL REFERRAL
I.
Purpose. This form is used to send updated information to DBME/FAA on children aging out of foster care for an eligibility
redetermination. It is also used to communicate the results of the determination to Tribal Social Services.
II.
Completion. Complete all items as follows (items not listed are self-explanatory):
FROM
Social Services: Tribal Social Services staff enters the Tribe name in the “From field, then enters his or her
name, phone and fax numbers and the date the form is sent to FAA.
TO FAA: The Tribal Social Services staff checks the box.
TO
Social Services: The FAA Eligibility Interviewer checks the box and enters the Tribe name, the Tribal Social
Services staff member’s name, phone and fax numbers and the date the form is routed to FAA.
INFORMATION ABOUT YATI CUSTOMER
Customer’s Name: Enter YATI Customer’s last name, first name and middle name.
WHERE WILL THE CUSTOMER BE LIVING?
Address: Enter the Customer’s anticipated residential address once he or she ages out of foster care. Include mailing address
if different) and any telephone contact numbers. If the anticipated address is not known, enter the last known address if there is a
reasonable expectation that the Customer will reside at that address, and note as “LKA”. If there is no anticipated residential address
or LKA appropriate for use and the DCS Specialist has reason to believe the Customer is residing in the state, enter the following
general delivery address:
FAMILY MEMBERS THAT WILL BE LIVING WITH THE CUSTOMER:
Enter name, Social Security number, sex, and date of birth of the Customer on the first row. Then list the same information for any
of the following family members with whom the Customer will be living after aging out of foster care:
Parent, step-parent, spouse, sibling, and Customer’s own child(ren). If a family member’s Social Security Number or exact date
of birth is not available, enter “unknown”.
INFORMATION FOR ELIGIBILITY:
Item A: Enter pregnancy information (proof of pregnancy is not required).
Item B: Enter U.S. Citizenship/Qualified Non-citizen status information. Qualified Non-citizen statuses are:
•
Cuban-Haitian Entrant
•
Afghan and Iraqi Special Immigrant Visa
•
Hmong or Laotian Highlander
•
Deportation withheld or removal withheld
•
Lawful Permanent Resident (LPR)
•
Amerasian Refugee
•
Parolee for at least one year
•
Asylee
•
Refugee
•
Battered Non-citizen
•
Victim of trafficking
•
Conditional Entrant
Item C through F: Enter the information for each applicable factor, and attach copies of any available proof. If the proof is not
available from the Customer’s file or through a collateral contact, do not delay submitting the form to collect proof. Some proof may
be available electronically through HEAplus’ data hubs. If more proof is needed, the eligibility worker will contact you.
Item G: Enter the Customer’s choice of AHCC CS health plan. If not ready to make a choice, enter “no choice made”.
Item H: Explain electronic notifications and enter Customer’s decision, and if applicable, the email or phone number. The Tribal
Social Services staff member prints and signs his/her name.
Item I: Enter the Customer’s choice for authorized representatives, and if applicable, the name and contact information of the
authorized representative.
FAA DETERMINATION: The FAA worker checks the applicable determination: Approved, Denied or Stopped.
Approved: Enter the Medical Assistance Category, effective date, and the date notice was sent to the Customer.
Denied: Enter the reason, the effective date, and the date notice was sent to the Customer.
Stopped: Enter the reason, the effective date, and the date notice was sent to the Customer.
III. Routing: (fax or secure e-mail)
•
Tribal Social Services keeps a copy for their case file and routes the original to FAA.
•
FAA returns completed original to Tribal Social Services, and keeps a copy in the FAA case file.
ACCEPTABLE PROOF DOCUMENTS (Examples)
CITIZENSHIP [List of document(s)]
QUALIFIED NON-CITIZEN STATUS
•
U.S. passport or passport card
•
Immigration documents
•
Naturalization certificate, form N-550 or N-570
•
Court documents
•
Certificate of U.S. Citizenship, form N-560 or N-561
Income
•
Document issued by a federally recognized Indian Tribe
•
Paystubs
•
Certified birth documents
•
Documented collateral contact by social worker
•
Church records
•
Written statement from employer
•
Baptismal certificates issued prior to child’s fifth birthday
•
Award letters
•
Hospital records
•
Current tax returns for self-employment
•
Court documents/minute entries
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