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)

$

  
  1. 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)

$

  
  1. Enter the higher of a or b.

$

  
  1. a.  Enter the appropriate TITLE XIX amount from the threshold chart (SI 02302.200, 4th column)

$

  
  1. Enter the individual's estimated Medicaid expenditures for the determination period per SI 02302.050 D.2

$

  
  1. Enter the higher of a. or b.

$

  
  1. Enter the annual amount of IRWE the person has

$

  
  1. Enter the annual amount of BWE the person has

$

  
  1. Enter the annual amount of income excluded under an approved PASS

$

  
  1. Enter the value of any publicly funded attendant care the person receives per SI 02302.050D.3

$

  
  1. Total the amounts for lines 1 - 6

$

  
  1. 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