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) Page 2
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4QUALIFIED 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
INSTRUCTIONS, MC 176-2 B QMB/SLMB/QI
Form MC 176-2 B QMB/SLMB/QI, Income Eligibility Work Sheet, is used to compute the income (using current Medi-Cal income
methodology and incorporating certain SSI/SSP methodology for QMB/SLMB/QI income criteria which is less restrictive than
Medi-Cal methodology) for allocating income from an ineligible parent(s) for a child who is applying under the QMB/SLMB/QI
program. This form is used if the child does not qualify using Medi-Cal income rules only. This form is completed at the time of
a new application, restoration, reapplication, change in income, or other circumstances affecting the income or correction in the
income.
NOTE: The MC 176-1 QMB/SLMB/QI should be completed prior to completion of the 176-2 B QMB/SLMB/QI to determine if
the child is found to be eligible using Medi-Cal rules.
Identification Section
1. Enter: Case name
2. County district: If the county has districts, identify the district.
3. County use: Make any entries the county department has designated it wants.
4. Check the appropriate box which gives information concerning the reason for the computation. The box “new application”
includes restorations and reapplications.
5. Effective eligibility date for this budget: Enter the month in which eligibility will begin with this budget computation.
6. Case number: For a QMB/SLMB/QI child who is applying as blind or disabled (BD) medically needy (MN), enter the county
code, appropriate aid code, seven-digit number, MFBU number, and the person number. If the county does not use a
seven-digit serial number, enter zeros in front of the serial number until there are seven digits. For the family members
who are not included in the MFBU as eligible members, enter their status under case number.
7. Name: Enter the names of all family members living in the home in accordance with the California Code of Regulations
(CCR), Title 22, Section 50071, and any BD person or spouse of an BD person in LTC or board and care. Enter an unborn
child by listing as the name “unborn” and expected date of birth after “unborn.”
8. Birth date: Enter the birth date of each person listed. Under sex, enter “M” for male or “F” for female for each person listed.
9. Social Security Number: Enter the Social Security number for each person applying as a QMB/SLMB/QI. If a person does
not have a Social Security number, he/she is not eligible as a QMB/SLMB/QI. Enter the Medicare or Railroad Retirement
claim number, if any. See CCR, Section 50187.
10. Other coverage code: Determine the other coverage code in accordance with Section 15, Part A, of the procedural portion
of the Medi-Cal Eligibility Manual.
Section I. Parent(s) or Stepparent(s) Income of Potential QMB/SLMB/QI Child Applying as Blind or Disabled (BD)
In this section, enter all the nonexempt unearned and earned income of the ineligible parent(s) of the child who is applying as
an BD MN under the QMB/SLMB/QI program. NOTE: “Ineligible parent(s)” refers to the parent(s) of the child who is applying
under the QMB/SLMB/QI program. Do not include a parent(s) who is eligible as a QMB/SLMB/QI, PA, or other PA. Only include
the income of an ineligible parent(s).
NOTE: The ownership of the income determination required by Section 50512 should be completed prior to the completion of
this portion of the form if there is a spouse with LTC status who is in a separate MFBU.
Page 1 of 3
MC 176-2 B QMB/SLMB/QI (Instructions) (05/07) (SSI/SSP Methodology)
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