Worker Portal Data Collection Screen Inventory Application Details

Worker Portal – Data Collection Screen Inventory Application Details Individual • • Application Information • Individual Interview • Individual • • Representative Summary • Primary Applicant Address • • Individual Address • Contact Information • • Household Status • • Household Composition • • Relationship • • Program Request Summary • Program Details • Living Arrangement • Level of Care • Tax Filing Status • Member Determination • Citizenship • Alien Status • Alien Verification • Alien Sponsor Relationship • Alien Sponsor • Emergency Medical Condition • Residency • Education • Minor Parent • KTAP Ineligibility • Expedited SNAP • LTC Couple Household Questions Pregnancy Information Medicare Details Disability/Incapacity Information Former Foster Care Boarders Caretaker Services Emancipation Community Integration Services • • • • • Resources Income Resource Questions • Liquid Resource • Vehicle • Life Insurance Pre Arranged Funeral • Contract • Burial Plots • Burial Funds • Real Property • Life Estate Annuity • Trust Promissory Note and • Land Contracts • Other Resources Life Time Care • Agreement • Long Term Care Qualified Partnership Insurance Life Settlement Contract Transfer/Sold Resource Summary Resource Assessment Summary Income Questions Earned Income Details Earned Income Verification Education Expenses Earned Income Strike Self Employment Details Self Employment Verification Unearned Income Details Unearned Income Verification Income Summary Monthly Income Amounts Qualified Income Trust No Income Verification Expenses • • • Non Financial Expense Questions • Shelter Expenses • Homeless Shelter • Utility Expenses SUA/BUA/Telephone • Standard • Utility Expenses – Actual • Child Support/Alimony Expenses • Medical Expenses Dependent Care • Expenses Summary • • • • Non Financial Questions • Discontinued or Denied SSI/State supplementation • Pending/Appealed SSI • Out of State Benefits KWP Child Care Availability • • Primary Caregiver Responsibility • Caring for an Incapacitated Individual • Domestic Violence • Conviction Information Chemical Dependency • Program Other Compliance Questions • • Entitled Benefits Third Party Liability Absent Parent Information Exemption Summary KWP Assessment Consent Health Insurance Policy ESI Coverage Details Short Term Needs Qualifying Parent Determination State and Federal Data Sources Medicaid Penalty Warning LTC Resource Transfer Consent LTC Income Statement Post Eligibility Spend Down Details KWP Assessment Absent Parent Referral Information ETP Assessment MRT Individual Referral Accident/Injury Settlement Preferred Payment Details Voter Registration MA/QHP Specific Questions Insurance Agent Kynector Estate Recovery