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) Page 2

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)

INSTRUCTIONS, MC 176-2 A QMB/SLMB/QI

Form MC 176-2 A 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 which are less restrictive than Medi-Cal methodology) for allocating income from a spouse (eligible or ineligible)

with or without a child(ren) to either the applicant and/or a child(ren) who does not qualify using Medi-Cal income rules only. This form is completed at the

time of a new application, restoration, application, 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 A QMB/SLMB/QI to determine if the applicant(s)/beneficiary(ies)

are 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 family members who are applying as an ABD medically needy (MN) QMB/SLMB/QI application and those included in the MFBU

as ineligible members: enter the county code, appropriate aid code, and 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 ABD person or spouse of an ABD 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.

Birthdate: Enter the birthdate 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.A. of the procedural portion of the Medi-Cal Eligibility

Manual.

SECTION I. INCOME OF POTENTIAL QMB/SLMB/QI COMPOSITION

In this section enter all the nonexempt unearned and earned income of the QMB/SLMB/QI applicant(s); and ineligible spouse, if any, who is applying as

ABD in Section I(a) and (b), providing the spouse or parent is a member of the MFBU (either an eligible or ineligible member). Do not list income which is

exempt in accordance with CCR, Sections 50523 through 50544.

NOTE: The ownership of the income determination required by CCR, 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.

Nonexempt Unearned Income

When any of the following deductions apply to a person’s income which will be listed in Section I, complete Section-VI, Part-A. of the MC 176W instead

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MC 176-2-A QMB/SLMB/QI (Instructions) (09/08) (SSI/SSP Methodology)