TN 11 (09-92)

# SI 02302.300 Individualized Threshold Calculation Worksheet - Exhibit

 Name SSN Individualized Calculation for Period Beginning / ​ (mo)  (yr) 1.  a.  Enter appropriate BASE AMOUNT from the threshold chart (SI 02302.200, 3rd column) \$ b.  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) \$ c.  Enter the higher of a or b. \$ 2.  a.  Enter the appropriate TITLE XIX amount from the threshold chart (SI 02302.200, 4th column) \$ b.  Enter the individual's estimated Medicaid expenditures for the determination period per SI 02302.050 D.2 \$ c.  Enter the higher of a. or b. \$ 3.  Enter the annual amount of IRWE the person has \$ 4.  Enter the annual amount of BWE the person has \$ 5.  Enter the annual amount of income excluded under an approved PASS \$ 6.  Enter the value of any publicly funded attendant care the person receives per SI 02302.050D.3 \$ 7.  Total the amounts for lines 1 - 6 \$ 8.  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

 To Link to this section - Use this URL: http://policy.ssa.gov/poms.nsf/lnx/0502302300 SI 02302.300 - Individualized Threshold Calculation Worksheet - Exhibit - 05/20/1999 Batch run: 04/14/2014 Rev:05/20/1999