TN 11 (09-92)

SI 02302.300 Individualized Threshold Calculation Worksheet - Exhibit

Name                         SSN        
Individualized Calculation for Period Beginning      /
(mo)  (yr)
  1. 1. 

    a.  Enter appropriate BASE AMOUNT from the threshold chart (SI 02302.200, 3rd column)

$

 
  1. 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)

$

 
  1. c. 

    Enter the higher of a or b.

$

 
  1. 2. 

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

$

 
  1. b. 

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

$

 
  1. c. 

    Enter the higher of a. or b.

$

 
  1. 3. 

    Enter the annual amount of IRWE the person has

$

 
  1. 4. 

    Enter the annual amount of BWE the person has

$

 
  1. 5. 

    Enter the annual amount of income excluded under an approved PASS

$

 
  1. 6. 

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

$

 
  1. 7. 

    Total the amounts for lines 1 - 6

$

 
  1. 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