Form Mc 176 D - Medi-Cal Special Treatment Programs-Percentage Obligation Computation

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State of California—Health and Human Services Agency
Department of Health Care Services
Medi-Cal Program
County District
County Use
MEDI-CAL SPECIAL TREATMENT PROGRAMS—PERCENTAGE OBLIGATION COMPUTATION
PART I. IDENTIFICATION
A. Special Treatment Program Application
D. Date of Eligibility
F. Percentage Obligation
Name (first, middle, last)
/
%
(Month)
(Year)
E. Redetermination Date G. Program
Address
(number, street)
/
Dialysis
(city, state, ZIP code)
TPN
(Month)
(Year)
Supplement
B. MN/MI Medi-Cal Case Name:
C.
MN/MI Medi-Cal ID Number
Medi-Cal Special Treatment Program ID Number
Birth Date
Other
(1) SSN
Month/
Cov.
Co.
Aid
7-digit Serial Number
FBU
Pers.
Co.
Aid
7-Digit Serial Number
FBU
Pers.
Day/Year
Sex
Code
(2) HIC or RR Number
PART II. ELIGIBILITY REQUIREMENTS—SUMMARY
SPECIAL TREATMENT—ONLY, PROGRAM
SPECIAL TREATMENT—SUPPLEMENT,
Percentage Obligation Rate—2% per $5,000 Annual Net Worth
PROGRAMS
Dialysis—Only—Aid Code 71
Parenteral Hyperalimentation—Only—
Percentage Obligation Rate1% per $5,000 Annual
Aid Code 73
Net Worth
The applicant must meet all
of the
Dialysis Supplement—Aid Code 71
The applicant must meet all of the following:
following:
1. Needs dialysis and related services
TPN Supplement Aid Code 73
1. Needs parenteral hyperalimentation
2. Ineligible for Medi-Cal under any other
and related services
program due to excess resources
The applicant must meet all of the following:
2. Ineligible for Medi-Cal under any other
3. Meets
Medi-Cal
requirements
of
1. Needs dialysis or TPN and related services
program due to excess resources
citizenship/immigration, residence, institutional
2. Approved as Medi-Cal with a share of cost
3. $250,000 maximum annual net worth
status, linkage, and cooperation
3. Employed or self-employed
4. Be otherwise eligible for Medi-Cal
4. $250,000 maximum annual net worth
4. Earns an individual gross income in excess of the
except that linkage requirements are
5. Ineligible for Medicare if under age 65
(regular) one-person maintenance need
not necessary
5. Meets Medi-Cal requirements of
citizenship/immigration, residence,
institutional status, and cooperation
PART III. ANNUAL NET WORTH COMPUTATIONS
C. Income
A. Real Property
1. Property use as a home:
5. Gross earned income for
12 months
$ __________
(a) Full market value
$ __________
–40,000
(b) Exempted value
$ __________
6. Gross unearned income for
12 months
$ __________
(c) Pro rata encumbrances
$ __________
(d) Excess market value (a–b+c)
$ __________
7. Total gross income
(add lines 5 and 6)
$ __________
2. Property not used as a home:
8. Allowable adjustment deductions
(a) Full market value
$ __________
(per federal tax law)
$ __________
(b) Encumbrances
$ __________
9. Total adjusted gross income
(c) Net market value
$ __________
(line 7 – line 8)
$ __________
Total Real Property (1(d)+2(c))
$ __________
B. Personal Property
D. Percentage Obligation Determination
3. Liquid Assets—Itemize:
10. Annual net worth
_______________________________________________
$ __________
(total of A+B+C rounded down to
_______________________________________________
$ __________
nearest multiple of $5,000)
$ __________
_______________________________________________
$ __________
11. Percentage obligation factor
Total
$ __________
(line 10 divided by $5,000)
$ __________
4. Other—Itemize:
12. Percentage obligation rate
__________ %
_______________________________________________
$ __________
13. Percentage obligation—
_______________________________________________
$ __________
(line 11 multiplied by line 12)
_______________________________________________
$ __________
Enter in Block F, Part I above
__________ %
Total Personal Property (3+4)
$ __________
PART IV. COMMENTS AND SIGNATURE
Medicare effective:
Ineligible Medicare
Discontinued from Aid Code
Effective:
/
/
/
/
Aid Code discontinued because:
Eligibility Worker’s signature
Date
MC 176 D (05/07)

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