Form Mc176-1 - Qualified Medicare Beneficiary (Qmb)/specified Low-Income Medicare Beneficiary (Slmb)/qualifying Individual (Qi) Eligibility Work Sheet For All Applicants: Individual(S), Couple(S), And Child(Ren) (Ltc Individual In Own Mfbu)
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4Department of Health Care Services
State of California—Health and Human Services Agency
QUALIFIED MEDICARE BENEFICIARY (QMB)/SPECIFIED LOW-INCOME
MEDICARE BENEFICIARY (SLMB)/QUALIFYING INDIVIDUAL (QI)
ELIGIBILITY WORK SHEET FOR ALL APPLICANTS:
INDIVIDUAL(S), COUPLE(S), AND CHILD(REN) (LTC INDIVIDUAL IN OWN MFBU)
Case name
County district
County use
Effective eligibility date for this budget
New application
Redetermination
Change
Correction
Month
Year
Case Number
Birthdate
(1) Social Security Number and
Name
(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 MFBU MEMBERS APPLYING AS AGED,
BLIND, OR DISABLED PLUS INCOME OF SPOUSE
II. INCOME OF MFBU MEMBERS NOT LISTED IN I.
OR PARENT (EXCEPT PA OR OTHER PA)
(EXCEPT PA OR OTHER PA)
III. QMB/SLMB/QI ELIGIBILITY COMPUTATION
A. Nonexempt Unearned Income
A. Nonexempt Unearned Income
1. Countable income from Section I, line 16.
(a)
(b)
2. Countable income from Section II, line 9.
1. RSDI
QMB/SLMB/QI Spouse
3. Combined countable income
QMB/SLMB/QI
(or) Parent/Ineligible
$
2. Net income from property
(add 1 and 2, rounded)
Applicant
Spouse or Parent(s)
3. Other—itemize
4. List current FPL for MFBU of
________________
1. RSDI
a. QMB (100%)
________________
2. Net income
from property
b. SLMB (120%)
________________
If line 3 is less than or equal to line 4(a), QMB eligible.
3. Other—itemize
If line 3 is less than line 4(b), SLMB eligible.
4.
4.
5. Total
5. Total unearned income
If line 3 exceeds lines 4(a) or 4(b) and there is an ineligible spouse
$
(add 1 through 4) (a)
(b)
(add 1 through 4)
or applicant child, complete MC 176-2 A QMB/SLMB/QI or
MC 176-2 B QMB/SLMB/QI. If no ineligible spouse or applicant child,
6. Combined unearned income
B. Nonexempt Earned Income
go to step 5.
(add 5(a) and 5(b))
6. Total net earned income
5. List current FPL for MFBU of
7. Any income deduction
________________
$
–
20
$
(MC 176 W, Part IV, Line 11)
a. QI-1 (135%)
________________
8. Countable unearned income
C. Total Countable Income
$
b. QI-2 (175%)
________________
(6 minus 7)
7. Subtotal
If line 3 is less than lines 5(a) or 5(b), QI-1 or QI-2 eligible. If line 3
B. Nonexempt Earned Income
$
(add 5 and 6)
exceeds lines 5(a) or 5(b), deny QMB, SLMB, QI-1, or QI-2.
9. Gross earned
8. Child support/alimony paid
income
(a)
(b)
10. Combined earned income
9. Total countable income
$
(add 9(a) and 9(b))
(7 minus 8)
11. Deduct IRWE of potential
NOTE: If there is income from which educational expenses are
–
deducted (Section 50547), show calculations here. Enter net amount
QMB/SLMB/QI applicant(s) only
on line 3 or 4.
12. Remainder
$
(subtract 11 from 10)
Total income for educational purpose
________________
13. $65 Earned income deduction
Less total education expenses
________________
–
plus $_____________ unused $20
Net countable income
________________
14. Remainder
$
(subtract 13 from 12)
If any of the following deductions apply, complete MC 176 W, part VI,
before completing Column I:
15. Countable earned income
$
(divide 14 by 2)
Educational Expenses
Section 50547
16. Total countable income
$
Absent Parent Support
Section 50541
(add 8 and 15)
Student Deduction
Section 50551
$30 Plus 1/3
Section 50551.1
Work Expenses for the Blind
Section 50551.4
Income for Self-support
Section 50551.5
IV. EXEMPT INCOME
Note: Do not allow a deduction for health insurance.
Eligibility Worker signature
Worker number
Computation date
County use
➤
MC176-1 QMB/SLMB/QI (05/07)
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