226i Instructions for Form 226: Medicaid and IV-E Redetermination Form | Medicaid

Notification from the MES to the SSCM that a redetermination is due and information is needed.

The top section or header information which includes the name, date of birth, date child entered care, current placement, child’s AU number, child’s SUCCESS Medicaid number, and the month review is due should be completed by the MES before the form is sent to the SSCM.

Questions 1 thru 5, and 8 are self explanatory, and should be answered by the SSCM.

Question 6: If disabled/incapacitated is circled and the parent(s) is not receiving SSI or RSDI, then updated medical information may be required.
If unemployed is circled and/or the previous determination was based on unemployed parent criteria, current information should be made available by the SSCM concerning the employment of the parent(s). This information would include monthly gross income and place of employment.

Question 7: List any income that is received by the foster child (examples: RSDI and child support). This includes any income that belongs to the child.

Question 8: If current placement is different from the placement information in the top section, please give new placement information. Also, indicate if placement is in approval status. If the current placement is different from the placement appearing at the top of Form 226, have there been placements that occurred between the placement listed at the top and the current placement? If the answer is yes, the name and address of each placement(s), the dates of placement, and whether or not the placement was an approved placement should be listed.

The form should be signed by the JPPS/SSCM with a printed name and current telephone number. The original form should be retained in the social services case record and a copy should be faxed to the MES at the appropriate Revenue Maximization Regional Office.

Revision Date: 07/05