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 3
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4of lines 1 through 5.
Educational Expenses
Section 50547
Absent Parent Support
Section 50541
Income for Self-Support
Section 50551.5
Court Ordered Child/Spousal Support
Gibbins v. Rank
--1.
Enter: Social Security income.
--2.
Net income received from property.
3–4. All other unearned income. If applicable, include SSI/SSP, In-Home Supportive Services (IHSS) recipients’ available income and income
allocated from a Pickle eligible spouse or parent.
--5.
Total the amounts in Section I, Part A, lines 1(a) through 4(a). This is the total unearned income of the QMB/SLMB/QI applicant of the MFBU.
Also, total the amounts in Section I, Part A, lines 1(b) through 4(b). This is the total unearned income of the eligible or ineligible spouse of the
QMB/SLMB/QI members of the MFBU.
--6.
Enter the total amount allocated to the minor child(ren), if any, from the ineligible spouse. Enter the figure computed from Section II, line 5,
onto line 6(b). NOTE: Income can only be allocated to a child(ren) from an ineligible spouse.
--7.
Subtract line 6(b) from line 5(b) and enter this amount on line 7(b)(1). If line 7(b)(1) is a minus figure, enter the minus amount on line 12(b)
and enter zero on line 7(b)(2). Otherwise, enter the amount from line 7(b)(1) onto line 7(b)(2).
--8.
This is the combined unearned income of the ABD member(s) of the MFBU and/or spouse who may be a member of the MFBU (either eligible
or ineligible member). (Add line 7(b)(2) and line 5(a).)
--9.
No entry. This shows the $20 any income deduction.
10.
Subtract line 8 from line 7. This is the total countable unearned income. If the countable unearned income is a minus figure, enter zero on
line 10 and enter the minus figure, which is the unused portion of the $20 any income deduction, in the blank provided on line 17.
B.
Nonexempt Earned Income
11.
Enter the gross earned income.
12.
Enter the amount of any allocation for any ineligible minor child(ren) that is not offset by countable unearned income (any minus amount on
line 7(b)(1)). Otherwise, enter zero in Section-I, Part B, line 12(b).
13.
Subtract line 12(b) from line 11(b). Enter the remainder on line 13(b). Exception: enter zero on line-13(b) if line 12(b) is greater or equal to
line-11(b).
14.
Add lines 11a and 13(b). This is the combined nonexempt earned income of the applicant(s) and ineligible spouse if the ineligible spouse’s
income is combined with the applicant’s.
15.
Deduct any impairment related work expenses the potential QMB/SLMB/QI applicant(s) may have.
16.
Subtract line 15 from line 14 and enter this amount on line 16. Exception: enter zero on line 16 if line 15 is greater or equal to line 14.
17.
Enter the $65 of the $65 and one-half deduction plus any unused portion of the $20 any income deduction.
18.
Subtract line 17 from line 16 and enter the difference on line 18. If line 17 is greater or equal to line 16, enter zero.
19.
Divide line 18 by 2. This figure equals the countable earned income.
20.
Add lines 10 and 19. This is the total countable income of the ABD applicant(s) of the MFBU or applicant and his/her spouse who is a member
of the MFBU (either eligible or ineligible). Enter this amount on Section I, Part B, line 20, and on Section-IV, line 1.
SECTION II. ALLOCATION TO MINOR CHILD(REN) FROM THE INELIGIBLE SPOUSE (DO NOT ALLOCATE FROM A
Page 2 of 3
MC 176-2-A QMB/SLMB/QI (Instructions) (09/08) (SSI/SSP Methodology)
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