Publications

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• HUSKY Non-Custodial Parent Information Sheet W-39

  HUSKY Non-Custodial Parent Information Sheet.

• HUSKY Non-Custodial Parent Information Sheet W-39S - Versión en Español

  HUSKY Non-Custodial Parent Information Sheet - Versión en Español.

• HUSKY Presumptive Eligibility Application W-1PE

  HUSKY Presumptive Eligibility Application.

• Medicaid Prescription Voucher/Authorization for Payment W-1069

  Medicaid Prescription Voucher/Authorization for Payment.

• Medicaid State Plan Amendments

  Current State Plan Amendments submitted to the Centers for Medicare & Medicaid Services (CMS) within the U.S. Department of Health and Human Services (HHS).

• Medicaid Waiver Applications

  The CT Department of Social Services is the single state agency for the Medicaid program and is responsible for the overall administration of the program, including all federal Medicaid Waivers. This section will provide the notice of the Department of Social Services’ intention to submit a federal Medicaid Waiver application to the Centers on Medicare and Medicaid Services. Medicaid Waiver applications may include a submission for a new Medicaid waiver application, renewal or amendment.

• Medicare Clearance Form W-9

  Medicare Clearance Form.

• Medicare Savings Program Application W-1QMB

  Medicare Savings Program Application.

• Medicare Savings Program Application W-1QMBS - Versión en Español

  Formulario de Renovación de programas de ahorro de Medicare - Versión en Español.

• Medicare Savings Programs Re-determination W-1QMBR

  Medicare Savings Programs Re-determination.

• Medicare Savings Programs Re-determination W-1QMBRS - Versión en Español

  Re-determinación para los Programas de Ahorros de Medicare - Versión en Español.

• Notice of Intent to Amend Medicaid Waivers For Individual and Family Support and Employment and Day Supports

  In accordance with the provisions of section 17b-8(c) of the Connecticut General Statutes, notice is hereby given that the Commissioner of Social Services intends to submit the following two applications to the Centers for Medicare and Medicaid Services (“CMS”).

• Notice of Intent to Amend Personal Care Assistance and Home Care Program for Elders Medicaid Waivers

  In accordance with the provisions of section 17b-8 of the Connecticut General Statutes, notice is hereby given that the Commissioner of the Department of Social Services intends to amend the Personal Care Assistance (PCA) and Home Care Program for Elder Medicaid Waivers to increase the individual cost cap to reflect wage and rate increases for self-directed Personal Care Assistants.

• Patient Liability Change Report W-1696

  Patient Liability Change Report

• Permission to Share Medical Info W-303A

  Permission to Share Medical Information.