Form Mc 176 W - Allocation/special Deduction Work Sheet A
ADVERTISEMENT
1
2
3
4Department of Health Care Services
State of California—Health and Human Services Agency
Medi-Cal Program
ALLOCATION/SPECIAL DEDUCTION WORK SHEET A
County Use
Date this form effective
Case name
Case number
Number in MFBU
I. CHILDREN WITH SEPARATE INCOME OR PROPERTY EXCLUDED
FROM THE MFBU—NUMBER: ________________________________
1. Maintenance need for MFBU plus excluded
$
child(ren)
2. Maintenance need for MFBU
$
3. Excluded child(ren)’s share of maintenance need
$
(line 1 minus line 2)
4. Net nonexempt income of excluded child(ren)
$
5. Allocation to excluded child(ren)
$
(line 3 minus line 4)
Enter above amount on MC 176 M, column III, line 5
DO NOT USE PART III FOR LTC PERSONS WITH A COMMUNITY
SPOUSE—GO TO PARTS VII THROUGH X
III. ALLOCATION FROM BOARD AND CARE PERSON TO SPOUSE
AND/OR CHILDREN AT HOME, OR FROM LTC PERSON WITH NO
COMMUNITY SPOUSE TO CHILDREN AT HOME.
1. Maintenance need for spouse and/or children at
home (other than excluded children)
$
2. Total countable income of
spouse and/or nonexcluded
$
children
3. Total allocations/deductions of
II. SSI/SSP OR IHSS RECIPIENT(S) IN FAMILY—INCOME
spouse and/or nonexcluded
AVAILABLE/ALLOCATED
$
children
1. SSI/SSP appropriate payment level
4. Total net nonexempt income of spouse and/or
(plus IHSS authorization for IHSS
$
nonexcluded children (line 2 minus line 3)
$
only)
2. Actual SSI/SSP payment (or IHSS
5. Unmet needs of spouse and/or nonexcluded
children (line 1 minus line 4)
payment)
$
$
3. Net nonexempt income used to
6. Total countable income of
determine grant (or IHSS)
$
person in LTC or board and care $
(line 1 minus line 2)
4. Gross unearned income of SSI/SSP
7. Health insurance for person in
or IHSS recipient (other than grant
$
LTC or board and care
$
or IHSS payment)
5. SSI/SSP unearned income
8. Total net nonexempt income of person in LTC or
deductions and exemptions
$
board and care (line 6 minus line 7)
$
6. Net nonexempt unearned income
9.
(line 4 minus line 5)
$
$
7. Gross earned income of SSI/SSP or
10. Maintenance need for person in
IHSS recipient
$
LTC or board and care
$
8. SSI/SSP earned income deductions
11. Total amount needed for maintenance
and exemptions
$
(add lines 9 and 10)
$
9. Net nonexempt earned income (line
12. Amount available for allocation to spouse and/or
7 minus line 8)
$
children (line 8 minus line 11)
$
10. Total net nonexempt income
13. Allocation to spouse and/or children
(add lines 6 and 9)
$
(line 5 or line 12, whichever is less)
$
11. If line 10 is greater than line 3, the difference is income
available to the MFBU and is entered here and on
A.
For share-of-cost determination of the ABD person or the spouse of
MC 176 M, column I or II, line 3, as “PA recipient
$
the ABD person, enter above amount on MC 176 M, column III, line 3
income available”
12. If line 10 is less than line 3, the difference is the
B.
For share-of-cost determination of spouse and/or children at home,
allocation to the SSI/SSP or IHSS recipient and is
enter above amount on MC 176 M, column II, line 4
$
entered here and on MC 176 M, column III, line 6
Eligibility Worker signature
Worker number
Date of computation
MC 176 W (05/08)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Mc 176 W.1 - Stepparent Computation When Only The Separate Children Of One Spouse Want Medi-cal
Legal
Form Mc 338 - 250 Percent Income Test Work Sheet For The 250 Percent Working Disabled Program-adults
Legal
Instructions For Form Mc 338 - 250 Percent Income Test Work Sheet For The 250 Percent Working Disabled Program-adults
Legal
Form Mc 176 Pa-1 - Property Work Sheet/assessment For Institutionalized Spouses (hoja De Trabajo De Bienes/evaluacion Para Esposo(a) Internado(a) En Una Institucion Medica)
Legal
Form Mc 176-2-a - Qualified Medicare Beneficiary (qmb)/specified Low-income Medicare Beneficiary (slmb)/qualifying Individual (qi) Income Eligibility Work Sheet - Couple Or Applicant With An Ineligible Spouse, With Or Without Child(ren)
Legal
Related Categories
Parent category: Legal