Form Mc 175-4 - Sneede V. Kizer Mini Budget Units And Share Of Cost Determinations / Property Determinations
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1
2State of California—Health and Human Services Agency
Department of Health Care Services
SNEEDE v. KIZER MINI BUDGET UNITS AND:
(CHECK ONLY ONE)
SHARE OF COST DETERMINATIONS
PROPERTY DETERMINATIONS
Case name
Case number
Effective date (month/year)
Instructions:
1. Include unborn in the mother's mini budget unit (MBU) and property limit/maintenance need income level, unless mother is
married and only her separate children want Medi-Cal. If pregnant woman is PA/Other PA, include the unborn in the
spouse's or father's MBU.
2. Do not include an excluded child.
3. Do not list MBU members in more than one MBU.
4. If any MBU has excess property, check to see if Medi-Cal linkage still exists for other family members.
5. Property Determinations: Enter the allocation for each spouse from MC 175-3P, line 18. Enter the net nonexempt property
for each child and/or caretaker relative from MC 175-3P, line 29.
6. Share of Cost Determinations: Enter each person's net nonexempt income from MC 175-3I.
7. If only the separate children of one spouse want Medi-Cal, enter the amounts from lines 13 and 23 of MC 176W.1 for
property determinations and the amounts from lines 26 and 29 or line 28 of the MC 176W.1 for share of cost
determinations.
MBU # _______
MBU # _______
Person Name/Number
Orig Net
Property
Person Name/Number
Orig Net
Property
Aid Nonexempt
Income
Aid Nonexempt
Income
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
6.
6.
7.
7.
8.
8.
9.
9.
10.
10.
TOTAL
TOTAL
MBU's
Property Limit
MBU's
Property Limit
Maintenance Need
Maintenance Need
(Check one)
(Check one)
Excess Property
Excess Property
Share of Cost for
Share of Cost for
(Check one)
(Check one)
property-eligible persons
property-eligible persons
Rounded Share of Cost
Rounded Share of Cost
If SOC, is there an eligible pregnant woman or child under 19 in MBU?
If SOC, is there an eligible pregnant woman or child under 19 in MBU?
No; stop here.
No; stop here.
Yes; go to MC 175-5
Yes; go to MC 175-5
MC 175-4 (05/07)
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