Form Mc 176 Ad - Aged And Disabled Federal Poverty Level Program Financial Eligibility Form

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State of California—Health and Human Services Agency
Department of Health Care Services
AGED AND DISABLED FEDERAL POVERTY LEVEL PROGRAM
FINANCIAL ELIGIBILITY FORM
Case name
County district
COUNTY USE
Applicant’s name (if different from above)
Case number
Effective eligibility date for this budget
Month:
Year:
Name of additional MFBU member (spouse)
Name of additional MFBU member (child)
Other coverage
New applicant
Redetermination
Change
Retroactive eligibility
Correction
PART A
Is the applicant(s)/beneficiary(ies) aged or disabled per Title 22, Sections 50221, 50223, and 50167:
Yes, then go to Part B
No: Do not complete this form; if not aged, refer for disability determination.
PART B INCOME ELIGIBILITY DETERMINATION
I.
UNEARNED INCOME
Eligible
Ineligible
Ineligible
Eligible Individual
Spouse/Child/Parent
Family Member #1
Family Member #2
1. OASDI
$
$
$
$
2. PROPERTY NET INCOME
$
$
$
$
3. IN-KIND INCOME
$
$
$
$
$
$
$
$
4. OTHER INCOME
(Include source of other income) Source:
Source:
Source:
Source:
$
$
$
$
5. OTHER INCOME
(Include source of other income) Source:
Source:
Source:
Source:
6. TOTAL INCOME INDIVIDUAL
Total of above boxes:
Total of above boxes:
Total of above boxes:
Total of above boxes:
UNEARNED INCOME
(Add 1 through 5 in each column) $
$
$
$
7. COMBINED UNEARNED INCOME (Add totals from Row 6)
TOTAL:
$
–20
8. SUBTRACT $20 (Any income deduction)
$
9. REMAINING UNEARNED INCOME
$
II. EARNED INCOME
Eligible
Ineligible
Ineligible
Eligible Individual
Spouse/Child/Parent
Family Member #1
Family Member #2
10. GROSS EARNED INCOME
$
$
$
$
11. COMBINED EARNED INCOME (Add amounts in Row 10)
$
12. $65 EARNED INCOME DEDUCTION PLUS $_____ FROM
UNUSED $20 DEDUCTION
– $
13. REMAINING EARNED INCOME
(Subtract line 12 from line 11)
=
14. 50% EARNED INCOME DEDUCTION (Divide line 13 by 2)
$
III.
NET NONEXEMPT INCOME AND ELIGIBILITY DETERMINATION
15. TOTAL EARNED AND UNEARNED INCOME
(Add lines 9 and 14)
$
16. DISREGARD FOR QUALIFIED INDIVIDUALS OR QUALIFIED
COUPLES
– $
17. HEALTH INSURANCE PREMIUMS
– $
18. AGED AND DISABLED MEDICALLY NEEDY DEDUCTIONS
Specify:
– $
19. DEDUCTION FOR ALLOCATION TO INELIGIBLE FAMILY
MEMBERS (=MNL for number of ineligible family members)
– $
20. NET NONEXEMPT INCOME (Line 15 – lines 16 through 19)
=
21. PROGRAM INCOME LIMIT (100% FPL for number of individuals
being evaluated for eligibility)
$
22. ELIGIBLE IF LINE 20 IS LESS THAN OR EQUAL TO LINE 21
Eligible
Not eligible
23. NOTE: IF INELIGIBLE, ASSESS FOR ELIGIBILITY FOR OTHER MEDI-CAL PROGRAMS
MC 176 AD (06/12) Aged/Disabled FPL Group

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