Form Mc 338 - 250 Percent Income Test Work Sheet For The 250 Percent Working Disabled Program-Adults

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State of California—Health and Human Services Agency
Department of Health Care Services
250 PERCENT INCOME TEST WORK SHEET FOR THE
250 PERCENT WORKING DISABLED PROGRAM—ADULTS
Case name
Case number
Applicant(s) name(s)
I. Income of Potential 250 Percent Individual or Couple and Income From the Ineligible Spouse With or
Without Children
(a)
(b)
A. Nonexempt Unearned Income
Individual or Couple Applicant(s)
Ineligible Spouse
1. Applicant’s retirement and survivor’s social
security. Do not include social security
disability income.
2. Social Security (RSDI) ineligible spouse.
3. Net income from property.
4. Other—itemize. Exempt any other disability
income of applicant(s).
5. Add lines 1 through 4 to get subtotal(s).
STOP HERE and complete Sections II and III for the ineligible spouse. Then complete the remainder of this section for the
applicant(s) and, if spousal deeming applies, complete the remainder for the ineligible spouse.
6. Allocation to ineligible children from
ineligible spouse (Section II, line 5).
7. Subtract line 6(b) from line 5(b). If minus,
enter amount, without the minus sign, on
line 12(b) and zero (0) on line 7(b).
Otherwise, enter amount on line 7(b).
8. Add unearned income from line 5(a) and, if
spousal deeming applies, from line 7(b).
-$20
9. Any income deduction.
10. Subtract line 9 from line 8 to get countable
unearned income. If minus amount, enter
amount, without minus sign, in instruction
box on line 17.
B. Nonexempt Earned Income
11. Enter gross earned income of applicant(s)
and, if deeming applies, from ineligible
spouse.
12. Per line 7(b), unused portion of allocation to
ineligible children.
13. Subtract line 12(b) from line 11(b). If minus,
enter zero.
14. Add line 11(a) and line 13(b) to get
combined earned income.
15. Enter any IRWE of potential 250 percent
applicant(s).
16. Subtract line 15 from line 14.
17. Enter $65 earned income deduction plus
$_____ of unused $20.
18. Subtract line 17 from line 16.
19. Divide line 18 by 2 to get countable earned
income.
20. Add line 10 and line 19 to get total countable
income.
Also enter this amount on
Section IV, line 1.
MC 338 (05/07)
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