Form Mc 176-2 B - Qualified Medicare Beneficiary (Qmb)/specified Low-Income Medicare Beneficiary (Slmb)/qualifying Individual (Qi) Income Eligibility Work Sheet Child Applying With Or Without Ineligible Parent(S)
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4State of California–Health and Human Services Agency
Department of Health Care Services
QUALIFIED MEDICARE BENEFICIARY (QMB)/SPECIFIED LOW-INCOME
MEDICARE BENEFICIARY (SLMB)/QUALIFYING INDIVIDUAL (QI)
INCOME ELIGIBILITY WORK SHEET
CHILD APPLYING WITH OR WITHOUT INELIGIBLE PARENT(S)
DO NOT INCLUDE QMB/SLMB/QI PARENT(S), PA, OR OTHER PA
Case name
County district
County use
Effective eligibility date for this budget
r
r
r
r
Month
Year
New application
Redetermination
Change in income
Change in circumstances
Case Number
(1) Social Security Number and
Name
Birth date
(2) Health Insurance Claim Number
Other
Seven-Digit
Person
First, Middle, Last
Sex
or Railroad Retirement Number
Coverage
County
Aid
Serial Number
MFBU
Number
Month/Day/Year
(1)
(2)
(1)
(2)
(1)
(2)
(1)
(2)
(1)
(2)
(1)
(2)
(1)
(2)
II. ALLOCATION TO MINOR CHILD(REN) FROM THE INELIGIBLE PARENT(S) OR
I. INELIGIBLE
PARENT(S)
or
STEPPARENT(S)
INCOME
OF
POTENTIAL
STEPPARENT(S). DO NOT ALLOCATE FROM THE APPLICANT(S). DO NOT
QMB/SLMB/QI CHILD APPLYING AS BLIND OR DISABLED
INCLUDE QMB/SLMB/QI CHILD(REN), PA, OR OTHER PA.
Child
Child
Child
Child
A.
NONEXEMPT UNEARNED
Number
Number
Number
Number
INCOME
Ineligible Parent(s)
One
Two
Three
Four
1. Name
I.
RSDI
2. Standard SSI allocation
3. Subtract ineligible minor child(ren) income.
2. Net income from property
Evaluate for student deduction.
–
–
–
–
4. Remaining allocation to ineligible child(ren)
3. Other—itemize
(line 2 minus line 3)
(a)
(b)
(c)
(d)
5. Total allocation to ineligible child(ren)
4.
(add lines 4(a), (b), (c), and (d)).
5. Total
(Enter amount from Section I, line 5, on line 6.)
$
(add lines 1 through 4)
III. QMB/SLMB/QI CHILD COMPUTATION
6. Allocation to ineligible child(ren)
–
(Section II, line 5)
1. Allocation from parent(s)
$
$
7. Remainder
(a)
(Section I, line 19, rounded)
(line 5 minus line 6)
(b)
$
+$
2. QMB/SLMB/QI child’s own RSDI income
$ –
20
8. Any income deduction
+$
3. Add other unearned income
9. Countable unearned income
4. Total unearned income
(put on line 16 unless negative)
(add lines 1 through 3)
=
B.
NONEXEMPT EARNED INCOME
$
20
5. Subtract any income deduction
–
6. Remainder
10. Gross earned income
(line 4 minus line 5)
=
11. Unused portion of allocation to
+$
7. Child(ren)’s countable earned income
–
ineligible child(ren)
12. $65 earned income deduction plus
8. Subtract IRWE
–
–
$________ of unused $20
9. Subtract $65 earned income deduction
plus $_________ of unused $20
–
$
13. Remainder
10. Remainder
$
(subtract lines 8 and 9 from line 7)
–
14. Divide by 2 and subtract
11. Countable earned income
$
(divide line 10 by 2)
=
$
15. Countable earned income
12. Net nonexempt income
$
16. Add countable unearned income
(add lines 6 and 11)
+$
(line 9)
$
13. Current QMB/SLMB/QI poverty level for one
17. Total countable income
(a) QMB (100%)
_____________
$
(add lines 15 and 16)
(b) SLMB (120%)
_____________
–
(c) QI-1 (135%)
_____________
18. Subtract parent deduction*
(d) QI-2 (175%)
_____________
19. Allocation to QMB/SLMB/QI child
(If line 12 is less than or equal to line 13(a), the child is income eligible for QMB. If
If zero or negative, do not count toward applicant’s income determination.
line 12 is less than line 13(b), (c), or (d), the child is income eligible for SLMB, QI-1 o r
Otherwise, enter this amount on Section III, line 1.
QI- 2.)
*
Individual parent deduction amount if any one parent lives with QMB/SLMB/QI child
(If line 12 exceeds line 13(a), (b), (c), or (d), deny QMB/SLMB/QI - 1/QI-2, as long as
applicant; couple parent deduction amount if both parents live with the child.
the MC 176-1 QMB/SLMB/QI form has been completed.)
Eligibility Worker signature
Worker number
Computation date
County use
MC 176-2 B QMB/SLMB/QI (05/07) (SSI/SSP Methodology)
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