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 4

QMB/SLMB/QI APPLICANT(S). DO NOT INCLUDE A QMB/SLMB/QI CHILD(REN), PA OR OTHER PA.

--1.

Enter: Name(s) of ineligible child(ren). Do not include QMB/SLMB/QI child(ren), PA or other PA.

--2.

Standard SSI allocation: Enter current year’s allocation amount for each child (see QMB/SLMB/QI poverty level-chart). If no child(ren), enter zero

on line 5, and Section-I, Part A, line 6(b)).

--3.

Income for the ineligible minor child(ren): Enter the income amount for each child, excluding up to $400 per month or $1620 per year if student

income.

--4.

Subtract line 3 from line 2 and enter on line 4.

--5.

Total all columns on line 4. Complete Section III to determine whether this figure is to be entered in Section I, Part-A, line-6(b). If Section-III, line 5

is less than the current SSI allocation, stop and do not complete Section I(b).

SECTION III. INELIGIBLE SPOUSE INCOME EXEMPTION DETERMINATION

--1.

Enter: Total gross unearned income of the spouse (potentially eligible or ineligible) from Section-I, line 5(b).

--2.

Gross Earned Income: Enter the gross earned income of the spouse from Section-I, Part-B, line 11(b).

--3.

Total lines 1 and 2 for combined income of spouse.

--4.

Allocation to child(ren): Enter the figure from Section-II, line 5.

--5.

Remainder: Subtract line 4 from line 3. If line 5 is less than the current SSI allocation amount, this income is exempt. Do not complete Section I(b).

Do not enter the total allocation to ineligible children from Section II, line 5 to Section I, Part-A, line-6(b).

SECTION IV. QMB/SLMB/QI ELIGIBILITY DETERMINATION

--1.

Total Countable Income: This is the total countable income entered on Section-I, Part-B, line 20. This figure was obtained by adding Section I, Part

A, line 10 and Section I, Part-B, line 19.

--2.

List the current poverty level for an MFBU of ______: a. QMB (100%) or b. SLMB (120%). If line 1 is less than or equal to line 2(a), QMB eligible.

If line 1 is less than line 2(b), individual or couple, SLMB eligible. If line 1 exceeds line 2(a) or 2(b), go to step 3.

--3.

List the current poverty level for MFBU of _____: (a) QI-1 (135%) or (b) QI-2 (175%). If line 1 is less than line 3(a) or 3(b), QI-1 or QI-2 eligible.

If line 1 exceeds line 3(a) or 3(b), deny QMB, SLMB, QI-1, or QI-2.

Eligibility Worker signature: The worker enters his/her signature.

Worker number: If the eligibility worker has a county number, enter here.

Date of computation: The eligibility worker completes the box with the date the form was completed.

County use: Optional—to be used in accordance with county policy.

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