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) Page 2
ADVERTISEMENT
1
2
3
4QUALIFIED MEDICARE BENEFICIARY (QMB)/SPECIFIED LOW-INCOME
MEDICARE BENEFICIARY (SLMB)/QUALIFYING INDIVIDUAL (QI)
INCOME ELIGIBILITY WORK SHEET FOR ALL APPLICANTS:
INDIVIDUAL(S); COUPLE(S); AND CHILDREN (LTC INDIVIDUAL IN OWN MFBU)
INSTRUCTIONS, MC 176-1 QMB/SLMB/QI
Form MC 176-1 QMB/SLMB/QI, Income Eligibility Work Sheet, is used to compute the income for all individuals who are
applying under the QMB/SLMB/QI program. This form is completed at the time of a new application, restoration, reapplication,
change in income, or other circumstances affecting the income, or correction in the income.
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 “new application” box
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 applicant and those
included in the MFBU as ineligible members: enter the county code, appropriate aid code, the seven-digit number, MFBU
number, and the person’s number. If the county does not use the 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 the 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. Birth date: Enter the birth date 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 determined prior to the
completion of this portion of the form if there is a spouse with LTC status who is in a separate MFBU.
A.
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 176 W instead of Section I, 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
Page 1 of 3
MC176-1 QMB/SLMB/QI (05/07)
ADVERTISEMENT
0 votes
Related Articles
Related forms
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)
Legal
Form Mc 176-2 B - Qualified Medicare Beneficiary (qmb)/specified Low-income Medicare Beneficiary (slmb)/qualifying Individual (qi) Income Eligibility Work Sheet Child Applying With Or Without Ineligible Parent(s)
Legal
Qualified Medicare Beneficiary (qmb), Specified Low-income Medicare Beneficiary (slmb), And Qualifying Individuals (qi-1) Application
Medical
Form Mc 176 Qdwi - Qualified Disabled Working Individual (qdwi) Income Eligibility Work Sheet Couple Or Applicant With An Ineligible Spouse, With Or Without Child(ren)
Legal
Form Mc 338 B - 250 Percent And Ssi/ssp Income Test Work Sheet For The 250 Percent Working Disabled Program-child Applying With Or Without Ineligible Parent(s)
Legal
Form Mc 280 Tb - Tuberculosis (tb) Program Financial Eligibility Work Sheet-eligible Child With Ineligible Parent Or Parent(s)
Legal
Related Categories
Parent category: Legal