Form Mc 176 W.1 - Stepparent Computation When Only The Separate Children Of One Spouse Want Medi-Cal Page 4
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4III. SHARE-OF-COST DETERMINATION (continued)
Name:
Name:
Name:
Name:
D.
TOTAL COUNTABLE INCOME:
AFDC-MN/MI and/or ABD-MN
15. Countable unearned income
(from line 9)
16. Countable earned income
(from line 13 or 14)
17. Total countable income (add lines 15 and
16)
E.
OTHER DEDUCTIONS:
AFDC-MN/MI and/or ABD-MN
18. Health insurance
19. Child support/alimony paid
20.
21.
22. Total allocation/deductions
(add 18 through 21)
23. Total net countable income less in-kind
income (line 17 minus line 4 and 22) Enter
this on MC 175-4 if no parent in MFBU;
otherwise continue.
PARENTAL ALLOCATION:
Enter net countable income (line 23)
F.
AFDC-MN/MI and/or ABD-MN
–$600
(Skip if no parent in MFBU
Less Parental Needs Deduction
24. Parent’s total net nonexempt income LESS
P/S Needs (line 23 minus $600)
25. Number of persons for whom parent is
responsible (see section I.D.) DO NOT
INCLUDE PARENT
26. Parent’s allocation to separate children who
want Medi-Cal (divide line 24 by line 25)
(enter in each applicable box)
27. Enter child’s net nonexempt income
(from line 23)
28. Child’s total net nonexempt income
(add lines 26 and 27)
29. Parental Needs Deduction (the lesser of
$600 or the amount on line 23, plus line 4)
30. Total net nonexempt income of the parent
Note: This line establishes the parent’s net nonexempt income.
(add all totals from lines 26 and 29)
31. Total net nonexempt income for MFBU
(add all totals from lines 27 and 30)
32. Maintenance needs for MFBU
33. Share-of-cost (line 31 minus line 32)
34. Underpayment adjustment
35. Rounded share-of-cost
If SOC and separate children have own income, Sneede case exists. Next, complete MC 175-4 and establish separate mini budget unit for
parent and his/her children who have no (or exempt) income of their own. Enter amounts from line 26 (for each child in parent’s MBU) and
the amount from line 29 (for the parent). Establish a separate mini budget unit for each child with own nonexempt income. Enter amount
from line 28 as child’s total net income.
If SOC and separate children are under 6, or age 6 through 18, and do not have separate income (i.e., not a Sneede case), consider
Federal Poverty Level Programs (100 percent, 133 percent, 200 percent). Use parent’s income after allocations to persons outside of the
MFBU (i.e., only consider income which is used in determining the share-of-cost) (line 30).
Eligibility Worker signature
Worker number
Date of computation
Page 4 of 4
MC 176 W.1 (05/07)
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