This page is displayed because you told us that a household member pays for adult care.
If someone in your household does not pay for adult care, click the Previous button to navigate back to the Other Bills Survey page to adjust the information entered.
Some items have an asterisk (*) next to them, indicating they are mandatory. You must fill in these items before you can continue to the next page. For Redeterminations and Change Reports, depending on if you indicated that a household member’s bill has changed or ended, you must enter the date in the fields provided.
Provider Information
The Address field can only contain letters, numbers, and the following special characters ‘-‘, ‘#’, and ‘/’. City cannot contain any numbers or special characters. Zip Code must contain only numbers.
Payment Details
When entering Amount paid, only enter two decimal places. Special characters, such as commas, are not allowed (e.g., $1250.00).
Help With Paying
If you answer Yes to the question “Does anyone help pay for this bill?” more fields will display. Answer each question.
If you need do add another Adult Care Expense bill, select Yes. If no, select No.
Click the Print button to print this page for your reference.
Click the Next button to save and continue with the online Redetermination/Change Report/Simplified Report.
Click the Previous button to view the previous page.
Click the Save & Exit button to exit the online Redetermination/Change Report/Simplified Report and save your progress on your Redetermination/Change Report/Simplified Report. The
Redetermination/Change Report/Simplified Report is saved as Incomplete.