Form Mc 176-2-A - Qualified Medicare Beneficiary (Qmb)/specified Low-Income Medicare Beneficiary (Slmb)/qualifying Individual (Qi) Income Eligibility Work Sheet - Couple Or Applicant With An Ineligible Spouse, With Or Without Child(Ren)
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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
COUPLE OR APPLICANT WITH AN INELIGIBLE SPOUSE, WITH OR WITHOUT CHILD(REN)
Case name
County district
County use
Effective eligibility date for this budget
-
-
-
-
Month
Year
New application
Redetermination
Change in income
Correction in circumstances
Case Number
(1) Social Security Number and
Name
Birthdate
(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)
I. INCOME OF POTENTIAL QMB/SLMB/QI INDIVIDUAL; COUPLE APPLYING
II. ALLOCATION TO MINOR CHILD(REN) FROM THE INELIGIBLE SPOUSE. DO
AS AGED, BLIND, OR DISABLED; AND INCOME OF INELIGIBLE SPOUSE
NOT ALLOCATE FROM THE APPLICANT(S). DO NOT INCLUDE QMB/SLMB/QI
WITH(OUT) CHILD(REN).
CHILD(REN), PA OR OTHER PA.
Child
Child
Child
Child
A.
NONEXEMPT UNEARNED
(a) QMB/SLMB/QI
(b) Eligible or
Number
Number
Number
Number
INCOME
Applicant
Ineligible Spouse
One
Two
Three
Four
1. Name
I.
RSDI
2. Standard SSI allocation
2. Net income from property
3. Subtract ineligible minor child(ren) income
(gross). Evaluate for student deduction.
3. Other—itemize
4. Allocation to ineligible child
(2 minus 3)
(a)
(b)
(c)
(d)
5. Total allocation to ineligible children
4.
(add 4(a), (b), (c), and (d))
5. Total
Enter the amount from Section II, line 5, to Section I, Part A, line 6(b), only if the remaining income
(a)
(b)
(add 1 through 4)
of the ineligible spouse exceeds the standard SSI allocation amount. Use Section III to make this
6. Allocation to ineligible child(ren) from
determination.
–
ineligible spouse (Section II, line 5)
(b)
III. INELIGIBLE SPOUSE INCOME EXEMPTION DETERMINATION
(b) (1)
(THIS SECTION USED FOR EVALUATION PURPOSES ONLY.)
7. Remainder (line 5b minus 6b)
(b) (2)
1. Total unearned income (gross)
8. Combine unearned income
(Section I, line 5(b))
)
$
(2))
(add 5(a) and 7(b
2. Total earned income (gross)
(Section I, line 11(b))
$
– 20
9. Any income deduction
3. Total
$
10. Countable unearned income
(add lines 1 and 2)
(8 minus 9)
4. Allocation to children
$
(Section II, line 5)
B.
NONEXEMPT EARNED INCOME
5. Remainder
$
(subtract 4 from 3)
11.
Gross earned income
(a)
(b)
(If line 5 is less than the current standard SSI allocation amount, this income is exempt; do not complete
12. Unused portion of allocation to
Section I, Part A, column (b) or Section I, Part B, column (b).)
ineligible children
(b)
IV. QMB/SLMB/QI ELIGIBILITY DETERMINATION
13. Remainder
--1. Total countable income
(11(b) minus 12(b))
(b)
$
(Section I, Part B, line 20, rounded)
14. Combined earned income
$
--2. List current poverty level for MFBU of ________
(11(a) plus 13(b))
a.--QMB (100%) _______________________
15. Deduct IRWE of potential
$
b. SLMB (120%) ______________________
–
QMB/SLMB/QI applicant(s) only
(If line 1 is less than or equal to line 2a, individual or couple QMB eligible. If line 1 is less than line 2b,
16. Remainder
individual or couple SLMB eligible. If line-1 exceeds line 2a or 2b, go to step 3.)
$
(subtract 15 from 14)
--3. List current poverty level for MFBU of ________
17. $65 earned income deduction plus
a.--QI-1 (135%) _______________________
–
$
$________ of unused $20
b. QI-2 (175%) _______________________
18. Remainder
(If line 1 is less than line 3(a) or 3(b), individual or couple QI-1 or QI-2 eligible. If line-1 exceeds line
$
(17 minus 16)
3(a) or 3(b), deny QMB, SLMB, QI-1, or QI-2 as long as the MC 176-1 QMB/SLMB/QI form has been
19. Countable earned income
completed.)
$
(divide 18 by 2)
NOTE: IF THE INCOME OF THE SPOUSE IS USED, USE THE CURRENT POVERTY LEVEL FOR TWO. IF
20. Total countable income
ONLY THE INCOME OF THE APPLICANT IS USED, USE THE CURRENT POVERTY LEVEL FOR ONE.
(add 10 plus 19) (Enter this amount
$
on Section IV, line-1)
Eligibility Worker signature
Worker number
Computation date
County use
MC 176-2-A QMB/SLMB/QI (09/08) (SSI/SSP Methodology)
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