Form Mc 176 M-Ltc - Share Of Cost Determination - Mfbus With Ltc Person Included - Ltc

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State of California --- Health and Human Services Agency
Department of Health Care Services
SHARE OF COST DETERMINATION – MFBUs WITH LTC PERSON INCLUDED - LTC
Case Name
County District
County Use
Effective Eligibility Date for this Budget
New Application
Redetermination
Change
Retroactive Eligibility
Correction
Mo.
Yr.
State Number
(1) Social Security No. and
Birthdate
Other
(2) Health Ins Claim No. or
Pers.
Name – First, Middle, Last
Mo.
Day
Yr.
Sex
Railroad Retirement No
Coverage
Co.
Aid
7 Digit Serial No. MFBU
No.
(1)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(2)
(1) _ _ _ _ _ _ _ _ _ _ _ _ _ _
_
(2)
(1) _ _ _ _ _ _ _ _ _ _ _ _ _ _
_
(2)
(1) _ _ _ _ _ _ _ _ _ _ _ _ _ _
_
(2)
(1) _ _ _ _ _ _ _ _ _ _ _ _ _ _
_
(2)
(1) _ _ _ _ _ _ _ _ _ _ _ _ _ _
_
(2)
(1) _ _ _ _ _ _ _ _ _ _ _ _ _ _
_
(2)
I. Income of MFBU members applying as aged,
II. Income of MFBU members not listed in I.
III. Share of Cost Computation
blind, or disabled plus income of spouse or
(except PA or other PA)
parent (except PA or other PA)
A. NONEXEMPT UNEARNED INCOME
A. NONEXEMPT UNEARNED INCOME
1. Countable Income from I. 18
a. ABD-MN
b. Spouse or
1. Social Security
2. Countable Income from II. 11
Parent
2. Net Income From
3. Total countable eligibility income
1. Social Security
Property
(add 1 and 2)
2. Net Income From
3. Other - Itemize
DEDUCTIONS ADDED BACK FOR LTC SOC
Property
4. ABD income deductions
+$20
3. Other - Itemize
(e.g. any income deduction)
4.
4.
5. Other income deductions
5. Total
6. Total deductions added back
(add 1 thru 4)
(add 4 and 5)
5. Total unearned income
7. Total countable income
6. Deductions
(add 1 thru 4)
(add 3 and 6)
7. Remainder
a.
b.
6. Deductions
ALLOCATIONS AND DEDUCTIONS
(5 minus 6)
8. Allocation from LTC/B&C
8. Combined unearned income
7. Countable unearned inc.
Income (176W, Part III)
(add 7a and 7b)
(5 minus 6)
- $20
9. Allocation to excluded children
9. Any income deduction
B. NONEXEMPT EARNED INCOME
(176W, Part I)
10. Countable unearned
8. Net earned income
10. Income to determine PA
income (8 minus 9)
(MC 176W, Part IV, Line 11
Eligibility
9. Subtotal countable
B. NONEXEMPT EARNED INCOME
11. Health Insurance
Income (add 7 and 8)
11. Gross Earned
a.
b.
10. Child Support/
12. Total allocations/deduction
Income
Alimony Paid.
(add 8 through 11)
11. Total countable income
13. Total net nonexempt income
12. Deductions
(9 minus 10)
(7 minus 12)
13. Remainder
a.
b.
14. Total net nonexempt income
(11 minus 12)
rounded
14. Combined earned inc.
15. Maintenance Need
(add 13a and 13b)
15. $65 earned inc deduction
a. MFBU members not in LTC
plus $___ unused $20
No.
16. Remainder
b. MFBU members in LTC
• Personal Needs
(14 minus 15)
• Upkeep of home
17. Countable earned inc.
• Needs of disabled dependents
(divide 16 by 2)
18. Total countable inc.
c. Total maintenance need
(add 10 and 17)
(15a + 15b)
IV. EXEMPT INCOME
16. Share of cost
(14 minus 15)
17. Underpayment adjustment
Eligibility Worker Signature/Computation Date
Worker Number
County Use
18. Adjusted Share of Cost
(17 minus 18)
MC 176 M-LTC (11/07)

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