Effective Dates: 01/23/2013 - Present
TN 11 (09-92)
| Name
|
SSN
|
| Individualized Calculation for Period Beginning |
/ |
| |
(mo) (yr) |
a. Enter appropriate BASE AMOUNT from the threshold chart (SI 02302.200, 3rd column)
|
$ |
| |
|
Recalculate the base amount using the State supplement rate for the individual's actual living arrangement (i.e., FBR + OS x 2 + 85 x 12 months)
|
$ |
| |
|
Enter the higher of a or b.
|
$ |
| |
|
a. Enter the appropriate TITLE XIX amount from the threshold chart (SI 02302.200, 4th column)
|
$ |
| |
|
Enter the individual's estimated Medicaid expenditures for the determination period per SI 02302.050 D.2
|
$ |
| |
|
Enter the higher of a. or b.
|
$ |
| |
|
Enter the annual amount of IRWE the person has
|
$ |
| |
|
Enter the annual amount of BWE the person has
|
$ |
| |
|
Enter the annual amount of income excluded under an approved PASS
|
$ |
| |
|
Enter the value of any publicly funded attendant care the person receives per SI 02302.050D.3
|
$ |
| |
|
Total the amounts for lines 1 - 6
|
$ |
| |
|
Enter the individual's gross earned income for the computation period
|
$ |
| |
|
Compare lines 7 and 8. If the amounts are equal or if 7 is higher, the individual is eligible under the threshold test. If 8 is higher, the individual is not eligible under the threshold test.
KEEP THIS WORKSHEET IN THE INDIVIDUAL'S FILE