172i Instructions for Form 172: ABD MAO Individual / Couple / Spouse to Spouse Deeming Budget Sheet

Complete this budget sheet when the A/R resides in LA-A or LA-B and is applying for ABD Medicaid as an individual (Section A only), as an individual with a Medicaid ineligible spouse (Sections A, B and C) or as a couple (Section C only). Do not use Form 172 for a SSI Trial budget for Katie Beckett children. Use the Form 171, ABD Medicaid Parent to Child Deeming Budget Sheet, to test for potential SSI eligibility for a child.

Section A: Use only for individuals or individuals with ineligible spouse.

Unearned Income:

  1. Enter the A/R’s gross unearned income, not allowing for any deductions except those listed in Section 2405 under “Income Not Included in Determining Financial Eligibility”. Consider any In Kind Support and Maintenance (ISM) for the A/R as unearned income. Refer to Section 2430.

  2. Enter the $20 general deduction unless the income is Income Based on Need (IBON). To determine if the income is IBON, refer to Sections 2505, Income Deductions, and 2499, Treatment of Income. If income is IBON, enter 0.

  3. Subtract line 2 from line 1 and enter the result in line 3. This is considered the A/R’s net countable unearned income.

Earned Income:

  1. Enter the A/R’s gross earned income not allowing for any deductions except those listed in Section 2505, Income Deductions.

  2. If all of the $20 general deduction was not used for the Unearned Income budget above, enter the remainder of the $20 in line 5. Otherwise enter 0.

  3. Subtract line 5 from line 4 and enter the result in line 6.

  4. Enter $65 in line 7.

  5. Subtract line 7 from line 6 and enter the result in line 8.

  6. Compute 1/2 of line 8 and enter the result in line 9.

  7. Subtract line 9 from line 8 and enter the result in line 10. This is the net countable earned income for the A/R.

Total Income:

  1. Enter the sum of line 3 and line 10 in line 11.

  2. Enter the individual income limit for the COA for which the A/R is applying. For AMN, enter the individual MNIL. See Appendix A1.

  3. Subtract line 12 from line 11.

    1. If a negative number is the result, the individual with no spouse is eligible for the COA.

    2. If a negative number is the result, and the individual with no spouse has applied for AMN, the individual is defacto eligible.

    3. If the individual with no spouse is applying for QMB, the result may be zero or a negative number to be eligible.

    4. If a positive number is the result, the individual is ineligible for any COA except AMN. Do not proceed to Section B unless applying for AMN.

    5. If a positive number is the result and the individual is applying for AMN, the result is the spendown amount for an individual with no spouse, or the 1st potential spenddown amount for an individual with an ineligible spouse. Proceed to Section B for individual with an ineligible spouse.

    6. If the A/R is applying as an individual with an ineligible spouse and the result was a negative number, proceed to Section B.

Section B: Use only for individuals with an ineligible spouse.

Unearned Income:

  1. Enter the ineligible spouse’s gross unearned income, not allowing for any deductions except those listed in Section 2405 under “Income Not Included in Determining Financial Eligibility”.

  1. If there are child(ren) in the home, enter the child(ren)'s income minus the living allowance for each child. See Appendix A1.

  2. Subtract line 2 from line 1 and enter the result in line 3. This is considered the ineligible spouse’s net countable unearned income.

Earned Income:

  1. Enter the ineligible spouse’s gross earned income, not allowing for any deductions except those listed in Section 2505, Income Deductions.

  2. Enter the amount of any living allowance not subtracted from unearned income. This would have been a negative number in Step 3 above.

  3. Subtract line 5 from line 4 and enter the result in line 6. This is the net countable earned income for the ineligible spouse.

If the individual is potentially AMN and the combined total of the amounts on line B.3 and B.6 is less than or equal to one-half of the MNIL for an individual, discontinue budgeting and use the amount from line A.13 as the AMN spenddown. It will not be necessary to proceed with Section C.

Section C: Use only for individuals with ineligible spouse or for Medicaid couples.

Unearned Income:

  1. If this is a Medicaid couple situation, enter the couple’s gross unearned income, not allowing for any deductions except those listed in Section 2405 under “Income Not Included in Determining Financial Eligibility”.

If this is a Medicaid individual with an ineligible spouse, enter the sum of line A.1 and line B.3.

  1. Enter the $20 general deduction unless the income is Income Based on Need (IBON). To determine if the income is IBON, refer to Sections 2505, Income Deductions, and 2499, Treatment of Income. If income is IBON, enter 0.

  2. Subtract line 2 from line 1 and enter the result in line 3. This is considered the couple’s net countable unearned income or the individual’s net countable unearned income including the income deemed from the ineligible spouse.

Earned Income:

  1. If this is a Medicaid couple situation, enter the couple’s gross earned income not allowing for any deductions except those listed in Section 2505, Income Deductions.

If this is a Medicaid individual with an ineligible spouse, enter the sum of line A.4 and line B.6.

  1. If all of the $20 general deduction was not used for the Unearned Income budget above, enter the remainder of the $20 in line 5. Otherwise enter 0.

  2. Subtract line 5 from line 4 and enter the result in line 6.

  3. Enter $65 in line 7.

  4. Subtract line 7 from line 6 and enter the result in line 8.

  5. Compute 1/2 of line 8 and enter the result in line 9.

  6. Subtract line 9 from line 8 and enter the result in line 10. This is the net countable earned income for the A/R with income deemed from ineligible spouse or the net countable earned income for the Medicaid couple.

  7. Enter the sum of line C. 3 and line C. 10 in line 11.

  8. Enter the couple income limit for the COA for which the individual/couple is applying. For AMN, enter the couple MNIL. See Appendix A1.

  9. Subtract line 12 from line 11.

    1. If a negative number is the result, the individual with ineligible spouse or the couple is eligible for the COA. Exception: If a negative number is the result and the individual with ineligible spouse has applied for Q track, the individual must have been eligible for same or higher level of Q Track in

  10. 13 to be eligible for the Q Track shown in line C. 13. See Note on Form 172.

  11. If a negative number is the result, and the individual with an ineligible spouse or the couple has applied for AMN, the individual/couple is defacto eligible.

  12. If the individual with an ineligible spouse or a couple is applying for QMB, the result may be zero or a negative number to be eligible. See Exception in (a) above.

  13. If a positive number is the result, the individual with an ineligible spouse or the couple is ineligible for any COA except AMN.

  14. If a positive number is the result and the individual with an ineligible spouse is applying for AMN, the result is the spendown amount if it is greater than the amount in A.13. If the amount in A.13 is greater, that is the spenddown amount.

  15. If a positive number is the result and the couple is applying for AMN, the result is the spendown amount.