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#17-004434-0002
Supplemental Questionnaire

Last Name
First Name

 

**Please note that your answers on the supplemental questionnaire must correspond to the information provided on your application to receive credit. Applications that do not include a completed supplemental questionnaire will be considered incomplete and may be subject to disapproval.**

 


1

Please provide details of your experience in approving, denying or pending eligibility applications for government entitlement and benefit programs.

Please include name of employer, job title, dates of employment, and hours worked
per week, this information must also be reflected in your application. If you do not possess experience in this area, put N/A in the box below.

2

Describe your experience with Maryland Health Connection and HBX.

Please include name of employer, job title, dates of employment, and hours worked
per week, this information must also be reflected in your application. If you do not possess experience in this area, put N/A in the box below.

3

Describe your experience in interpreting and applying Medicaid policies and regulations.

Please include name of employer, job title, dates of employment, and hours worked
per week, this information must also be reflected in your application. If you do not possess experience in this area, put N/A in the box below.

4

From the list below, select all of the Medicaid programs you have experience determining eligibility for:

Families and Children (FAC)
Maryland's Children Health Program (MCHP)
MAGI New Adult Group
Pregnant Women
Home and Community-Based Services Waiver (HCBS)
Aged, Blind and Disabled (ABD)
Long Term Care (LTC)
None of the Above

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