Instructions For Form Dhcs 7021 - California Financial Eligibility Work Sheet - Health And Human Services Agency

ADVERTISEMENT

State of California—Health and Human Services Agency
D epartment of Health Care Services
INSTRUCTIONS
FINANCIAL ELIGIBILITY WORK SHEET (DHCS 7021)
(Individual or Couple, Applicant With an Ineligible Spouse)
A.
APPLICANT’S TOTAL COUNTABLE INCOME
Enter the applicant’s total countable income. This is to be obtained by using only the applicant’s earned and unearned
income. If, after subtracting any applicable Title II COLAs, the applicant’s income is still above the current SSI/SSP
payment level for an individual, the applicant is not eligible as a Pickle person and no further action is necessary. In that
case do not proceed to Part B. If the total countable income is below the payment level and the applicant has an ineligible
spouse, complete Parts B through F. In completing this section for a potentially eligible couple (both pass screening test),
it is necessary to compute countable income using the income and disregard amounts for both. If this countable income
exceeds the maximum allowance, this section must then be completed for each person using only his/her income and
disregard amounts.
B.
INELIGIBLE SPOUSE’S UNEARNED INCOME
Do not include any public assistance income.
Line B.1.
Enter the ineligible spouse’s unearned income.
Line B.2.
If ineligible spouse has Title II income, subtract all TItle II cost-of-living increases received since the applicant was
discontinued from SSI/SSP. Use amount from Disregard Computation Work Sheet (DHCS 7029, line C.3.).
Line B.3.
Subtract line B.2. from line B.1. and enter the difference.
Line B.4. (If there are no children, enter zero on line 4.c.)
Enter each Pickle ineligible child’s first name in boxes provided. On line 4.a., enter the allocations for any ineligible
child(ren) not on public assistance. On line 4.b., enter any income for each of the children, excluding $1,620 per year of
student income. Enter the remainder for each child and total the allocation for each child on line 4.c. Do not make any
entry in this part for a Pickle-eligible child.
Line B.5.
Subtract line B.4.c. from line B.3. (countable unearned income) and enter the difference. This is the remaining unearned
income amount unless there is no remaining unearned income because the allocation amount (line B.4.c.) exceeds
line B.3. (countable unearned income). In the latter case, the negative figure on line B.5. is carried over to line C.2. (unused
portion of allocation).
C.
INELIGIBLE SPOUSE’S EARNED INCOME
Line C.1.
Enter the ineligible spouse’s earned income.
Line C.2.
Enter the amount of any allocation for ineligible children that is not offset by countable unearned income (there is a negative
figure on line B.5.). If all the allocation for ineligible children was offset by countable unearned income (line B.3. is equal
to or more than line B.4.c.), enter zero in line C.2.
Line C.3.
Subtract the allocation amount on line C.2. from line C.1. (gross earned income) and enter the difference; however, if
negative, enter zero.
D.
INELIGIBLE SPOUSE’S TOTAL INCOME AFTER ALLOCATIONS
If line B.5. is negative, the ineligible spouse’s total income after allocations is the amount from line C.3.; otherwise, add the
amounts in lines B.5. and C.3. to determine the total income after allocations.
NOTE: If, at this point (after the allocation for ineligible children and the Title II Disregard) the total income amount, earned
or unearned, is less than the difference between the FBR for a couple and the FBR for an individual, there is no income
available for deeming to the applicant. In this case, use only the applicant’s income in Part E and the current SSI/SSP
payment level for an individual in Part F. If there is earned and/or unearned income remaining in excess of the difference
between the FBR for a couple and the FBR for an individual, use the amounts from lines B.5. and C.3. in Part E and the
current SSI/SSP payment level for a couple in Part F.
Page 1 of 2
DHCS 7021 Instructions (06/07)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2