Form Mc 175-I - Sneede V. Kizer Income Screening Questions printable pdf download

Form Mc 175-I - Sneede V. Kizer Income Screening Questions

State of California—Health and Human Services Agency

Department of Health Care Services

SNEEDE V. KIZER

INCOME SCREENING QUESTIONS

If the MFBU has a share-of-cost and includes child(ren), complete the following:

Case name

Case number

Effective date (month/year)

New application

Redetermination

Change

Retroactive eligibility

Correction

DOES THE MFBU INCLUDE:

Yes

a. A stepparent?

Yes

b. An unmarried couple with mutual child(ren)?

Yes

c. A child with his/her own nonexempt income (including unearned in-kind income

provided by someone outside of the MFBU) and there are other persons in the MFBU?

Yes

d. A nonparent caretaker relative in the same MFBU with the child(ren) for whom care is

provided and the caretaker wants Medi-Cal?

If “No” to all of the above, determine if eligibility exists for pregnant woman or infant under 1 (Income Disregard

Program), child under 6 (133 percent), or child, age 6 through 18 (100 percent).

If “Yes” to any of the above and:

1. the MFBU includes a parent, complete MC 175-2, MC 175-3I, and MC 175-4.

2. the MFBU does not include a parent, complete MC 175-3I and MC 175-4.

Eligibility worker signature

Worker number

Date

MC 175-I (05/07)

Form Mc 175-I - Sneede V. Kizer Income Screening Questions