ARTICLE 5

 

                                                               SECTION 17

 


                                               TUBERCULOSIS (TB) PROGRAM

 

1.       GENERAL

 

        Section 13603 of the Omnibus Budget Reconciliation Act of 1993 (OBRA '93) establishes an optional new program for persons infected with tuberculosis whose income and resources do not exceed the maximum amount for a disabled individual.  State law (Chapter 147, Statutes of 1994, (Assembly Bill 2377) specifies that this program be adopted.  Eligibility for this program was effective October 1, 1994.

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        Medi-Cal clinics and providers who serve TB infected persons are encouraged to assist such persons in applying for Medi-Cal.  This is an alternative to the applicant applying directly at the county welfare office.  These providers may help applicants complete all initial Medi-Cal forms used in the application process and may gather applicant verification.  This information will then be forwarded to the county welfare department (CWD) for a Medi-Cal determination. 

 

        Individuals (both adults and children) eligible for the TB program are identified on MEDS under aid code of 7H.

 

2.       ELIGIBILITY REQUIREMENTS

 

        A.     To be eligible for the TB Program, a person must:

 

·         Be infected with TB (This factor links a person to Medi-Cal for the TB Program only).

·         Not be a Medi-Cal beneficiary whose coverage is mandated by federal laws (AFDC, SSI, Other PA or Federal Poverty Level Programs).

·         Be a United States citizen or an alien with satisfactory immigration status who would be eligible for full scope benefits.

·         Have income and resources which do not exceed the maximum amount for a disabled individual under the Supplemental Security Income (SSI) program.  Income cannot exceed an amount referred to as the TB income standard.  (See Income Standards Chart, Appendix 11-1-B.)  Property can be no more than $2,000 for an individual including a child.  When determining a child's property eligibility, if two parents are in the home and neither is eligible to the TB program, the parents are allowed $3,000 as a deduction from their property before it is deemed to the TB child.

·         Meet all other Medi-Cal requirements (i.e., residency, cooperation, verification, etc.).

 

        B.     TB Infected Definition

 

                Infected with TB relates to a condition in which living tubercle bacilli are present in an individual without producing clinically active disease.  A TB infection is active when it produces diseases as demonstrated by clinical, bacteriologic, and/or radiographic evidence.

 

 


                The determination of whether an individual is TB infected shall only be made by a Medi-Cal physician.  The Tuberculosis Application form includes a section for physicians to use to indicate TB infection.

 

 

 

        C.     Medi-Cal Beneficiary With Coverage Mandated by Federal Law

 

                The beneficiary cannot be eligible for Medi-Cal under one of the programs listed below.  These individuals are currently eligible for full scope, zero share-of-cost Medi-Cal benefits which includes TB coverage.  Workers will not be allowed to enter the TB aid code 7H onto the Medi-Cal Eligibility Data Systems (MEDS) if the beneficiary is eligible for one of the programs listed below:

 

 

                1)     California Work Opportunity and Responsibility to Kids (CalWORKS) Program.

                2)     Supplemental Security Income/State Supplementary Program

                3)     Other Public Assistance (Other PA).

                4)     One of the federal poverty level (FPL) programs.

 

 

                In addition, a beneficiary eligible for full scope, zero share-of-cost Medi-Cal under the MN/MI program does not need coverage under the TB program.

 

 

        D.     United States Citizenship or Satisfactory Immigration Status (SIS)

 

                A person applying for the TB program must be a United States citizen or an alien who would be eligible for full scope benefits if he/she were otherwise linked to Medi-Cal.  Workers will follow the usual regulations, procedures and guidelines for determining citizenship-alien status.  Undocumented aliens are ineligible for this program.  Persons who are eligible for restricted Medi-Cal are ineligible for this program.

 

 

        E.     Income and Property Not Exceeding the Maximum Amount for a Disabled Individual

 

                1)     Whose Income and Property is Used

 

                        a)     Unmarried Adult:  If the adult is an unmarried applicant, use only his/her own income and property.

 

                        b)     Married:  If the applicant is married and living with his/her spouse, use only the income received in the applicant's own name.  For property, only use the applicant's separate property and one-half of the community property. 

 

                        c)     Child:  A child is defined as an unmarried person under the age of 18.

 

                                If the applicant is a child, use his or her own income and property and the income and property of any of his or her parent(s) who are not eligible for the TB program.

 

 

If more than one child is applying for the TB program, the parent's allocation to the TB applicant children is divided among the potential TB applicant children.

 



                                Each unmarried person, including a child, applying for the TB program is evaluated separately.  If a married couple is applying, TB eligibility is determined separately.

 

 

3.       SCOPE OF BENEFITS - LIMITED TO TB RELATED SERVICES

 

        The following services are available under the TB program.

 

·         Physician specified clinics,

·         Outpatient hospital services,

·         Clinic services including specified clinics,

·         Federally - qualified health centers services,

·         Case management services, and

·         Services (other than room and board) to monitor prescribed drugs.

 

4.       MEDI-CAL PROVIDER RESPONSIBILITIES

 

 

        A.     Tuberculosis Application Form MC 274 TB (Appendix A)

 

                The Department of Health Services has developed a TB application Part A form which will be available only to county welfare departments (CWDs) and Medi-Cal providers such as physicians and clinics.  This form is entitled the "Application for Medi-Cal Tuberculosis Program."  This form replaces the SAWS 1 only for persons applying for the TB program at a Medi-Cal TB provider site.

 

                On the second page Part B of this application Medi-Cal physicians or their designated staff must certify that the individual is infected with TB (by indicating this person requires preventive therapy for tuberculosis infection or that the person requires treatment for active TB) before submitting the application to the county.

 

                On the third page Part C of the application, the client authorizes the clinic to act as their authorized representative. This is the only acceptable authorized representative (AR) form for the TB program.  No other AR forms may be used.

 

                NOTE:  The effective date of the TB application will be the date the county receives it.

 

        B.     Clinic Activities

 

                1)     Clinics and providers are encouraged to help applicants complete the following forms and submit them to the county: 

 

 

·         Medi-Cal TB Application (MC 274 TB Parts A, B & C)

·         MC 210 Medi-Cal Statement of Facts

·         Statement of Citizenship, Alienage, and Immigration Status.  This can be on the statement of facts, or sworn statement for U.S. Citizens/Nationals.  Non-citizens will need to complete the MC 13.  See MPG 4-2-5 for important requirements regarding citizen/national/alien status declaration.

·         MC 219 Rights and Responsibilities

·         MC 210A Supplement to Statement of Facts for Retroactive Medi-Cal

 

 


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                        Providers will order these forms from the State Department of Health Services' warehouse. 

 

 

                2)     Face-to-Face Interview:  The required Medi-Cal application face-to-face interview can be conducted by the TB clinics or other providers acting on behalf of the CWDs. During the interview, the provider conducting the interview shall complete and explain the contents of the above described forms.

 

                3)     Verification:  In addition, TB clinics and other participating Medi-Cal providers may gather necessary verifications.  For example, providers may copy and forward to the CWD Social Security cards, alien registration cards, and other immigration documents for CWD verification of alien status.  Providers may also forward other items such as copies of wage stubs or bank statements for CWD verification of earned and unearned income and property.

 

5.       DSS RESPONSIBILITIES

 

        Each district will designate a TB Coordinator who will receive the TB applications and forms from Medi-Cal providers.  Upon receipt of the completed application and additional forms, the TB Coordinator will determine eligibility under the TB Medi-Cal program.  If forms received are incomplete and/or additional client information is needed, the clinic/provider may be contacted for this information.  If the information can be obtained by telephone this would be the preferred method.  The worker may have to contact the clinic worker and sometimes participate in a conference call with the clinic worker and the Medi-Cal client.  If the TB clinic/provider is unable or unwilling to assist in providing completed forms and/or verifications, the worker must attempt to contact the client to obtain any forms and/or verifications needed to make an eligibility determination.

 

 

        When a TB application is received and potential eligibility for full-scope Medi-Cal is identified, the worker must inform the TB applicant.  If the applicant wishes to pursue the determination, he/she must complete a SAWS1 and a face-to-face interview.  If the person is actively infected, a family member may apply for this individual.  If the person has no family member to apply on his/her behalf, the worker will complete a SAWS1 to preserve the application date.  The worker will continue to process the TB application but delay the face-to-face interview until the person can come into the office.  After that interview, the worker can resume the eligibility determination for full-scope Medi-Cal.

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        Beneficiaries will be notified in writing of their Medi-Cal eligibility and of any changes made in their eligibility status.  A Notice of Action will be issued for approvals, denials, or discontinuance of eligibility. Workers will use E-line action and NOA codes 107 for approval, 127 for denial and 077 for discontinuance of eligibility to the TB program.  Timely notice requirements must be met.

 

 


        If the worker determines that the applicant is eligible for the TB program, the worker will grant eligibility under Aid Code 7H. 

 

 


6.       PROPERTY METHODOLOGY

 

        The TB Property Worksheets MC 278 (for an adult) and MC 279 (for a child) must be used.

 

        A.     TB Property Limits

 

                The resource limit for an individual (including a child) is $2,000.  The resource limits do not increase even if the applicant and/or his or her spouse have children living in the home.  When determining a child's property eligibility, if two parents are in the home and neither is eligible to the TB program, the parents are allowed $3,000 as a deduction from their property before it is deemed to the TB child.

 

 

        B.     Determination of Net Nonexempt Property

 

                Resources are determined according to Article 9 and Article 5, Section 14, Sneede v. Kizer.  If the TB applicant is a child, property is deemed to the child as follows:

 

                1)     One parent in the home:

 

                        If there is only one parent living in the home who is not eligible for the TB program, reduce the parent's property by the property limit for one.  The remainder is deemed to the child.

 

 

 

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                2)     Two parents or one parent and a stepparent in the home

 

                        If there are two parents living in the home and neither is eligible for the TB program, reduce the parents' property by the property limit for two.  The remainder is deemed to the child.

 

                        If there is more than one child applying for the TB program, the parent(s)' property is divided among the potential TB applicant children.  However, as soon as a child is determined ineligible for the TB program, the parent(s)' property must be redivided among the remaining children to determine their TB property eligibility, even if their eligibility has already been determined. 

 

 

        C.     Resource Eligibility

 

                Net nonexempt property is compared to the appropriate TB property limit.  If net nonexempt property is less than or equal to the TB limit, the applicant is TB property eligible.

 



7.       INCOME METHODOLOGY

 

        The TB Financial/Income Eligibility Worksheets MC 280 and MC 282 must be used.

 

        A.     TB Income Standard

 

 

                The term "TB income standard" means the maximum amount of income a person may have and still be income eligible for this program. This is the amount against which the applicant's net nonexempt income is tested.  The TB income Standard is located in Appendix 11-1-B.

 

                The TB income standard is not changed by the presence in the home of a spouse or children of the applicant or applicant's spouse.  The TB income standard is based on a computation using the federal benefit rate (FBR) which changes each January.

 

        B.     Determination of Net Nonexempt Income

 

                Net nonexempt income is determined according to Article 10.  The TB applicant is treated as if he/she were a disabled person when determining deductions and exemptions.  Do not deem income to a child from a stepparent.  As in Sneede procedures, use only the parent's income which is in his/her own name.  There are three exceptions to the use of Article 10.

 

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                1)     Parental Allocation to Ineligible Children:

 

                        Instead of the allocation to excluded children a parental allocation as described below will be applied.

 

 

                        a)     Who may have this allocation:

 

                                A parent who is not eligible for the TB program before the parent's income is used to determine the TB income eligibility of his/her child.

 

 

                        b)     Which child the parental allocation is for:

 

                                This allocation is available to any ineligible child.  An ineligible child is defined as a person not applying for the TB program who is (1) unmarried and under age 18 or (2) unmarried, between the ages of 18 and 21 and who is a full time student.

 

 

                        c)     How to determine the amount of the parental allocation:

 

                                (1)    Determine the standard SSI allocation:  This amount will be provided to counties annually, likely in January, and can be found in Appendix 11-1-B.

 

 

 

 

                                (2)    Subtract each ineligible child's own income from the standard SSI allocation.

 



                                Student Deduction:  Each ineligible child is allowed a student deduction for earned income of up to $400 per month, but not to exceed $1,620 per year, if the ineligible child is regularly attending a school, college, university, or a course of vocational training to prepare him for gainful employment.

 

 

                                (3)    The remainder is each ineligible child's parental allocation.

 

                                (4)    Total each ineligible child's parental allocation.  The total is the actual parental allocation.

 

                                (5)    This allocation is applied first to the ineligible parent's unearned income and then to his/her earned income.

 

 

                2)     Parental Deduction

 

                        a)     Who may have this deduction:

 

                                This deduction is available to a parent or parents whose income is being deemed to a child whose income eligibility for the TB program is being determined.

 

 

                        b)     Amount of the Deduction:

 

                                The amount of the deduction is the Federal Benefit Rate (FBR) for one, if only one ineligible parent lives in the home with the child or it is the FBR for a couple if both ineligible parents live in the home with the child.  The FBR income standard is located in Appendix 11-1-B.

 

 

 

 

                3)     No Deeming From the Ineligible Spouse:

 

                        There will be no deeming from the ineligible spouse.

 

 

        C.     Income Eligibility

 

                Compare the applicant's net nonexempt income to the appropriate TB income standard.  If net nonexempt income exceeds the applicable standard, the person is ineligible for the TB program.

 


8.       ANNUAL REDETERMINATION

 

        An annual redetermination is required for the TB program.  Redeterminations are handled similar to the initial application and the face-to-face interview may be completed by the TB provider/clinic.

 

        A new TB certificate Part B would be required to document TB infection and the need for additional TB-related services.  Part A of the MC 274 is not needed for the annual redetermination.  Clinic workers may line out Part A and Part C or indicate “NA” on each.  If the client designates the TB provider/clinic as an authorized representative, Part A can be lined out and completed Part B and Part C forwarded to the county.

 

 

 

 

 

 

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9.       DUAL ELIGIBILITY

 

A.       An AFDC-MN or ABD-MN with a share-of-cost may receive TB services, as well as Dialysis and TPN Supplement beneficiaries.

 

B.       A Qualified Medicare Beneficiary (QMB) or Specified Low Income Medicare Beneficiary (SLMB) may receive TB services.

 

C.       Persons who are TB infected and in long-term care are not dual eligible because they are already receiving care for TB.

 

Workers do not have to discontinue the TB program coverage if a person becomes eligible to zero SOC full scope coverage unless it is one of the following full scope or federally mandated aid codes:

 

 

                03    Adoption Assistance                 10         Aged (SSI/SSP)

                20    Blind (SSI/SSP)                         3A        CAAP CalWORKS-FG

                3C    CAAP CalWORKS-U                  30         CalWORKS-FG

                35    CalWORKS-U                            39         Transitional Medi-Cal

                4C    Voluntary AFDC-FC                   42         AFDC-FC/Federal

                44    200%-Pregnant Citizen               47         200%-Infant Citizen

                48    200%-Pregnant OBRA                5T         Continuing TMC-OBRA

                5W   4-Month Continuing OBRA         5X        2nd year TMC

                5Y    2nd year TMC OBRA                   54         4-Month Continuing

                59    Continuing TMC (6 months)        60         Disability (SSI/SSP)

                69    200%-Infant OBRA                     7A        100%-Citizen Child

                7C    100%-OBRA Child                     72         133%-Citizen Child

                74    133%-OBRA Child                     8N        133%-Excess Prop OBRA

                8P    133%-Excess Prop Child           8R        100%-Excess Prop Child

                8T    100%-Excess Prop OBRA

 

MEDS will generate an alert message indicating these aid codes are INCOMPATIBLE WITH THE TB PROGRAM.

 

 

10.    RETROACTIVE BENEFITS

 

        Up to three months of retroactive coverage is available.  The TB Application form asks the provider to indicate whether the applicant was infected three months prior to the date the form was completed.  If the application shows the person was infected at that time and he/she is otherwise eligible, retroactive coverage is appropriate.  Workers are to use the Medi-Cal Application for Retroactive Eligibility form, MC 239D, to approve and deny retroactive eligibility.

 

 



11.    PLASTIC BENEFITS IDENTIFICATION CARD (BIC)

 

        Beneficiaries covered under the TB Program will use the Plastic Benefits Identification Card (BIC) for TB-related services.  The message will be OUTPATIENT TB-RELATED SERVICES ONLY AT NO SHARE OF COST.

 

12.    EXAMPLES - TREATMENT OF INCOME AND PROPERTY

 

        Example 1:

 

        Mr. Smith, age 47 is homeless. He is not disabled.  He receives monthly unemployment insurance benefits (UIB).  On October 15, 1994, Mr. Smith is diagnosed at the county Medi-Cal clinic as being TB infected.  The clinic advises him of the TB program and he agrees to apply.  In October, he will receive $207 UIB and will have no other income.  He has no property.

 

        Provider Activities

 

        The clinic assists Mr. Smith in completing the TB application and the MC 210.  The clinic forwards these forms to the District TB coordinator.

 

        Worker Activities

 

        The worker reviews the TB application.  A SAWS 1 is not used since the TB application form is used for those applying at a provider site.  The worker reviews the MC 210 and needs additional information from Mr. Smith, but Mr. Smith has no address or telephone.  The worker contacts the clinic's TB contact person and the clinic worker agrees to call the worker when Mr. Smith next comes into the clinic. The next day, Mr. Smith comes in for TB treatment at the clinic.  The worker, Mr. Smith and the clinic worker hold a telephone conference call and the worker is satisfied with the information now provided.

 

        Income is determined as if Mr. Smith were disabled.

 

 

        The worker determines TB income eligibility (Appendix B) for October as follows:

 

                  $  207         UIB

                    -   20         any income disregard

                 = $187         net nonexempt income

 

                    $977         TB income standard for one in 1994

       

        Mr. Smith's net nonexempt income does not exceed the TB income standard.  He is income eligible.

 

 

        If the other TB program requirements are met, the worker will find Mr. Smith eligible for the TB program and establish Medi-Cal TB benefits under aid code 7H for October.

 


        Example 2:

 

        On October 15, 1994, Mr. Jones, who lives alone, was determined TB infected at the county Medi-Cal clinic.  The clinic explained about the TB program to him and Mr. Jones agrees to apply.  The clinic informs him that he cannot work until the TB is no longer active.  If Mr. Jones follows the prescribed regimen, his TB should no longer be active by about November 1.  Mr. Jones will be on sick leave from July 16 through the end of July.  He earned $1,205 through October 15 and will earn $1,200 in sick leave pay through the remainder of October.

 

        Provider Activities

 

        The clinic assists Mr. Jones in completing the TB application and MC 210.  Mr. Jones provides the clinic with his October pay stubs.  The clinic forwards the forms and a copy of his pay stubs to the District TB Coordinator.

 

        Worker Activities

 

        The worker reviews Mr. Jones' TB application and needs additional information about Mr. Jones' bank account.  The worker calls Mr. Jones at his home and Mr. Jones supplies his most recent bank statement.  The worker determines Mr. Jones' eligibility.  His property is determined to be less than $2,000 the property limit for one person.

 

        Income is determined (Appendix C) as if Mr. Jones were disabled.  His sick leave pay is earned income.

 

                 $2,405     gross earned income

                  -     20     any income deduction (There is no unearned income to apply this against)

                -  1,225     $65 and 1/2 earned income deduction ($65 + $1160)

          =     $1,160     net nonexempt income

 

                    $977     TB standard for one in 1994

 

 

        The worker compares Mr. Jones' net nonexempt income to $977.00, the TB standard for one.  Mr. Jones is ineligible due to excess income.

 

 

 

        Example 3:

 

        In November, 1994, the county Medi-Cal clinic determines Mr. Brown to be TB infected (active TB).  Mr. Brown is married and lives with his wife.  They have no children.  Mrs. Brown is TB infected (dormant TB) and the clinic will provide her with preventive TB therapy.  Although Mr. Brown cannot work until his TB is no longer active, Mrs. Brown may continue to work since she does not have active TB.  The clinic worker explains about the TB program and they agree to apply.

 

 

        Mr. and Mrs. Brown both work.  In November, Mr. Brown will earn $1,655 gross income and Mrs. Brown will earn $1,001 gross income.  They have one car and have a $2,500 savings account (all community property).  There is no other property.

 

        Provider Activities

 

        The provider may choose to assist with the TB application or may refer Mrs. Brown to the CWD.  If Mrs. Brown is referred to the CWD, the provider will have minimal activities in the TB application process.  Instead of completing the TB Application and MC 210 at the provider site, Mrs. Brown will be referred to the CWD where she will apply for the TB program and be given the regular Medi-Cal application packet.  The provider will complete only Part B (TB Referral Form) of the TB application to confirm the TB infection.  An MC 274 Part B is needed for Mrs. Brown and one for Mr. Brown.  Mrs. Brown will take these forms to the CWD when she applies.

 

        Worker Activities

 

        The worker will process the application according to regular county intake procedures.  The worker will consider Mr. and Mrs. Brown as separate individuals.  Consider each person's separate property and half of the community property (Appendix D1 and D2).

 

        Income is determined (Appendix D3) as if Mr. Brown were disabled.

 

                   $1,655       Total earned income of Mr. and Mrs. Brown

                     -   20       Any income deduction (There is no unearned income to apply this against)

                    -  850       $65 and 1/2 earned income deduction ($65 + 785)

                   =  785       Net nonexempt income

                    $  977               TB income standard in 1994

 

         Mr. Brown is income eligible.

 

        Income is determined as if Mrs. Brown were disabled.

 

                   $1,001       Gross earned income of Mrs. Brown

                      -  20       Any income deduction (There is no unearned income to apply this against.)

                     - 523       $65 and 2 earned income deduction ($65 + 458)

                    = 458       Net nonexempt income

                    $  977               TB income standard in 1994

 

                Mrs. Brown is income eligible.

 

        Mr. and Mrs. Brown each have a property limit of $2,000.  Each has a community property share of $1,250.  Consider each person's separate property and half of community property.  The Browns are resource eligible.

 

        If Mr. and Mrs. Brown meet the other Medi-Cal requirements (i.e. residency, cooperation, etc.) for the TB program, they will be put in aid code 7H).

               

 

        Example 4:

 

        The District TB Coordinator receives a TB application form and an MC 210 from the county Medi-Cal clinic for Mr. and Mrs. Green who are homeless and cannot be contacted. The worker is unable to determine whether the Greens are citizens or have satisfactory immigration status (SIS).  The worker advises the clinic that additional information is needed.  The clinic discusses this with the Greens and the Greens inform the clinic that they are undocumented aliens.   Since the Greens do not meet the citizenship/SIS requirement for the TB program, they are ineligible.  The worker sends a denial notice of action to the Greens via the clinic.   

 

       

 

        Example 5:

 

        John Doe, aged 16, moved back into his parents' home in January, after being a runaway for 8 months.  John and his two brothers are on Medi-Cal with a share of cost.  Mr. and Mrs. Doe are on the County Medical Services Program.  In February, John is diagnosed as TB infected.  No other treatment is prescribed for the remainder of the family.

 

        Mr. and Mrs. Doe are both employed.  Mr. Doe earns $850 gross income per month and Mrs. Doe earns $801 gross income per month.  They have one car and a $2,500 savings account.  Mrs. Doe agrees to request an eligibility determination for the TB program for John.  Since John is already on Medi-Cal, the provider only needs to complete Part B of the TB application form, the Medi-Cal Tuberculosis Program Referral Form which establishes TB infection.  The provider calls the District TB Coordinator and is told to mail the form directly to them. 

 

        Worker Activities

 

        Because John already is a Medi-Cal beneficiary, all TB requirements are met except for the income and property determination.

 

        Income Determination (Appendix E1):  John is treated as if he were disabled.  Income of the parents is considered, but the parents' income is reduced by any allocation to ineligible children who are the other children who are not applying under the TB program.  Assume the other children each have $100 unearned income.

 

        Determine the allocation to the ineligible children:

 

        1)     The standard SSI allocation to each ineligible child in 1994 is $223.

 

        2)     Subtract each ineligible child's own income.

 

        3)     The remainder is each ineligible child's allocation.

 

        4)     Total each ineligible child's allocation to determine the total allocation to ineligible children.  Reduce the parent's income by this amount after the other unearned and earned deductions.

 

 

                                                                           Brother 1          Brother 2

                Standard SSI allocation                          $223                 $223

                Child's own income                                 -100                  -100

                Each child's allocation                            $123                 $123

 

                Total allocation $246

 

 


                Parental Income Deemed to John:

 

                      $1,651         Mr. and Mrs. Doe's gross earned income

                       -  246         Allocation to ineligible children

                        -   20         Any income deduction (There's no unearned income to apply it against)

                       -  725         $65 and 1/2 earned income deduction ($65 + $660)

                       -  669         Parental Deduction for a couple in 1994 (couple FBR)

                      = $   0         Parental income deemed to John

 

                John's TB Income Determination:

 

                              0         John's own income

                              0         Income from parents

                      =   $ 0         John's total income

 

                    $977.00         TB income standard for one in 1994

               

                John is income eligible.

                Property Determination (Appendix E2)

 

                      $2,500         parents' savings account

                       -3,000         parents' property exclusion

                           $ 0         parents' property deemed to John

 

Since John has no property of his own, he is property eligible. The worker puts John into aid code 7H for February.  He also continues on regular Medi-Cal with a share-of-cost.

 

 

                Example 6:

 

Mr. Samuels is unmarried.  He lives with his 6 year old son Will and the mother of his child.  Mr. Samuels and Will were diagnosed with active TB at the county Medi-Cal clinic in October 1994.  The child's mother needs no TB treatment.  Mr. Samuels agrees to apply for the TB program for himself and Will.  Mr. Samuels will earn $1,535 gross income in October.  The mother will earn $2,000 gross income in October.  Mr. Samuels has a $2,800 savings bond and the mother has a $5,000 savings account.  Will has $100 per month unearned income.

 

 

Eligibility is determined first for Mr. Samuels.  If he is TB eligible, none of his income or property will be deemed to Will when Will's TB eligibility is determined.  If Mr. Samuels is not TB eligible, his income and property will be deemed.

 

 

                Income determination for Mr. Samuels (Appendix F1):

 

 

                Mr. Samuels is unmarried.  For purposes of the TB program, only his income is used and compared to the TB standard for one.

 

 

 

                       $1,535       gross earned income

                          -   20       any income disregard (there is no unearned income to apply it against)

                         -  790       $65 and 1/2 earned income disregard ($65 + $725)

                      =$  725       net nonexempt income

 

                        $  977       TB income standard for one in 1994

 

 

                Mr. Samuels is income eligible.

 

MEM

Proc. 5N

                Property Determination (Appendix F2) for Mr. Samuels:  Mr. Samuels' savings bond is a nonexempt resource.  The savings account of the child's mother is not considered.  Mr. Samuels' net nonexempt property of $2,800 exceeds the $2,000 TB property standard for an individual person.  Mr. Samuels is ineligible for the TB program.

 

 

                Income determination (Appendix F3) for Will:

 

                Determine the income deemed to Will from his unmarried parents:

 

                          $    0        parents' combined unearned income

                       +3,535        parents' combined earned income

                          -   20        any income disregard

                        -1,790        $65 and 1/2 earned income disregard ($65 + 1,725)

                         -  669        parent deduction

                     =$1,056        parental income deemed to Will

       

                Determine Will's income

 

                       $1,056        income from parents

                         +   80        Will's own income ($100 - $20 any income deduction)

                     =$1,136        Will's total income

 

                         $ 977        TB standard for one in 1994

 

                Will is income ineligible for the TB program. 

 

13.    QUESTIONS AND ANSWERS

 

        QUESTION 1:           If the TB clinic sends an application to the county and the county finds this person eligible for full-scope benefits, can the TB application still be used in lieu of the SAWS 1 or would the actual SAWS 1 have to be completed?

 

        ANSWER 1:              The SAWS 1 would be required if the client is applying for full-scope Medi-Cal benefits.  In addition, the face-to-face would also be required when the applicant is applying for full-scope Medi-Cal benefits.  If this individual has infectious active TB, then a family member who is not infected would apply at the county welfare office for this individual.

 

 

        QUESTION 2:           Will the clinics gather all client information and complete an application for each person applying and then forward all completed information to the counties?

 

        ANSWER 2:              Clinics will assist TB applicants in completing the forms AND FORWARDING THEM BY MAIL to the TB Coordinator.  Clinics may also forward verification of income, property, etc.

 

 

        QUESTION 3:           Will a TB application be taken for each individual when families are applying, or will one application suffice?

 

        ANSWER 3:              A TB application (MC 274 TB) must be completed for each individual applying for the TB Program.  If there are more than one family members applying for the TB program, each member of the family must have his/her own TB application completed.

 

        QUESTION 4:           Are family members who are NOT actively infected (Dormant TB) with TB required to go into the county welfare office to apply for the TB program themselves and other active TB infected family members?

 

        ANSWER 4:              Other family members of an TB infected individual may go into the county welfare office and apply for benefits on behalf of this person or the family may apply at the clinic.  However, if the individual or family desires full-scope Medi-Cal benefits, he/she or a family member must go into the county welfare office to apply.  A face-to-face interview would be required.

 

 

        QUESTION 5:           Once the District TB Coordinator receives and reviews the application and determines that additional information is necessary, how will this information be obtained?

 

        ANSWER 5:              If the TB Coordinator receives forms that are incomplete and needs additional client information, they may contact the clinic or provider for this information.  If the information can be obtained by telephone, this would be the preferred method of obtaining this information.  Counties at times may have to contact the clinic worker and sometime participate in a conference call with the clinic worker and the Medi-Cal client.  (Many clients will be homeless and without a phone.)

 

        QUESTION 6:           If an applicant claims to have Satisfactory Immigration Status (SIS) and then the worker finds this to be incorrect, will this individual be discontinued immediately?

 

 

 

 


        ANSWER 6:              The alien verification requirements for the TB program are the same as for the full-scope Medi-Cal program.  When a TB applicant meets all other eligibility requirements, the worker must grant eligibility while SAVE verification is pending.  If the Immigration and Naturalization Service SAVE response indicates this person does not have SIS, the worker should terminate eligibility immediately subject to all notice of action requirements.

 

 

        QUESTION 7:           Will faxes be appropriate to transmit client information from clinics to counties or must they be photocopies?

 

        ANSWER 7:              Workers may accept faxes, however clinics should subsequently forward the original document.

 

        QUESTION 8:           When an applicant is homeless and he is found eligible for the TB Medi-Cal program, where should his card be sent?  Can it be sent to the clinic?

 

 

        ANSWER 8:              The card may be sent wherever the client wishes it to be sent (i.e, the clinic, General Delivery, a shelter, a friend's house).

 

              QUESTION 9:           a.   Can a TB applicant be eligible for the TB program and County Medical Services Program (CMS)?

 

                                        b.   Can a TB applicant be eligible for the TB program and a different Medi-Cal program?

 

          ANSWER 9:              a.  Yes, the beneficiary may have dual eligibility with CMS.

 

                                        b.   Yes, as long as the beneficiary is not covered by a zero share-of-cost Medi-Cal program which covers TB services, such as the ABD-MN or AFDC-MN with zero share of cost or coverage under a federal poverty level program for pregnant women, infants or children.

 

 

        QUESTION 10:          Can persons under age 21 living away from their parent's home apply on their own?

 

        ANSWER 10:            This would have to be determined according to the living situation of the individual.  The living situation of the individual would be looked at to determine whether their status is as an adult or child.

 

 

        QUESTION 11:          a.    Is a TB application needed when a Medi-Cal beneficiary with a share-of-cost becomes TB infected and wishes to apply for the TB Program

 

b.    What then would be the date of application for the TB Program?

                                        c.   Could there be a retro period?

 

        ANSWER 11:            a.   Only the certification (MC 274 TB Part B) is needed.

 

                                        b.   The date the person asks for coverage.

 

                                        c.   Yes.

 

 

        QUESTION 12:          Will a physician's stamp be acceptable under this program?

 

        ANSWER 12:            Yes.  A physician's stamp is acceptable.  Other staff members using the stamp should countersign with their own initials.

 

        QUESTION 13:          Do deductions for guardian/conservatorship fees and educational expenses apply to the TB program?  At this time there is no place for these deductions on the Eligibility worksheets (MC 280 TB 9/94) or (MC 281 9/94).  If allowed, how shall these be recorded?

 

 

 

 

 

ACWD

95-12

 

        ANSWER 13:            Yes.  These deductions would apply.  To accommodate these deductions until the forms are corrected, we suggest pen and ink changes to the MC 280 and the MC 281 and their related instructions.   

 

        QUESTION 14:          Does the ineligibility child mean an ineligible child living with his or her parents?

 

        ANSWER 14:            Yes.

 

        QUESTION 15:          If the TB clinic/provider is to act on behalf of the applicant/beneficiary, would the TB granting/denial Notice of Action (NOA) be sent to the TB clinic or provider?

 

        ANSWER 15:            The choice is the client's.  It may be sent to the clinic or to any address the applicant/beneficiary chooses.

 

        QUESTION 16:          When working with homeless applicants via a TB clinic or provider, are workers required to meet the promptness requirements for determining eligibility for the TB program?

 

        ANSWER 16:            Yes.

 

        QUESTION 17:          If the TB applicant has other family members who want RESTRICTED Medi-Cal benefits, will the clinic/provider refer the family to the county welfare office to apply for Medi-Cal?

 

        ANSWER 17:            Yes.  This referral is made anytime family members want Medi-Cal other than the Medi-Cal TB program, unless the family member who will go to the county has active TB.

        QUESTION 18:          Does the client provider check the restricted box for TB on the MC 13?

 

        ANSWER 18:           No.  They need to check the box labeled “other” and write in ATB@ in the space next to that box.

 

        QUESTION 19:          When determining income eligibility, is the actual income used or is weekly/biweekly converted to a monthly amount?

 

        ANSWER 19:            Actual income is used.

 

        QUESTION 20:          If the clinic conducts the face-to-face interview, who should sign the MC 219 on behalf of the ET?

 

        ANSWER 20:            The clinic staff person or provider who initially goes over the form with the client should sign the MC 219.

 

        QUESTION 21:          Can the county hold a TB application for at least a month while verification of actual income is pending?

 

        ANSWER 21:            Applications are not “held”, but there must be verification before eligibility can be approved.  Workers must verify in the same manner that is used for any other Medi-Cal case according to the promptness requirement.

 

        QUESTION 22:          Under the TB program, what is the definition of family member?

 

        ANSWER 22:            Family member means the following persons living in the home:

 

                                        (1)  A child or sibling children

                                        (2)  The parents married or unmarried of the sibling children

                                        (3)      The stepparents of the sibling children

                                        (4)      The separate children of family member means a single person of a married couple.

 

        QUESTION 23:          Can a TB case be transferred to another county?

 

        ANSWER 23:            This case would be transferred the same as any other Medi-Cal case.

 


5-17-A1

TB Application - Part A

 

State of California - Health and Welfare Agency                                                                                                                                                                                    Department of Health Services

MEDI-CAL TUBERCULOSIS PROGRAM

APPLICATION

If you are applying only for the Medi-Cal Tuberculosis Program, please complete this form.

NOTE: You must be a U.S. citizen or have satisfactory immigration status to receive benefits under this program.

 

 

1.  PATIENT/APPLICANT NAME

COUNTY USE ONLY

 

2.  MAILING ADDRESS - Number/Street

 

 

City

 

 

ZIP Code

 

 

Case Name:

 

3.  IF NO PERMANENT ADDRESS, TELL US WHERE YOU CAN BE REACHED

 

 

 

4.  TELEPHONE NUMBER(S) - Home

     (          )

Work

   (          )

Message

   (          )

Case Number:

 

5.  DATE OF BIRTH

                                       /            /           

                            Month      Day      Year

6.  SOCIAL SECURITY NUMBER

__                __

 

7.  THE LAW SAYS WE MUST GET YOUR ETHNIC GROUP AND PRIMARY LANGUAGE. IF YOU DO NOT WANT TO

     COMPLETE THESE ITEMS, THE COUNTY WILL DO IT FOR YOU. THIS WILL NOT AFFECT YOUR ELIGIBILITY.

County of Application:

 

     a. Ethnic Group: q White                    q Black              q Hispanic          q Filipino        q Chinese

q Hawaiian               q Asian Indian     q Laotian            q Cambodian  q Japanese

q American Indian      q Korean            q Guamanian      q Samoan      q Vietnamese

or Alaskan Native   q Other Pacific Islander (specify):                                                  

County of Residence:

q  CWD Records

        Cleared

Ethnic Group:

 

 

     b. Language:      q English                  q Cantonese       q Lao                 q Tagalog      q  Spanish

                             q Cambodian            q Vietnamese     q American Sign  q Other (specify):                   

Primary Language:

If Applicant is Under 18 Years of Age, Parent/Spouse information:

 

NAME

 

 

ADDRESS - Street/Number

 

 

City

 

 

ZIP Code

 

 

CERTIFICATION AND PERJURY STATEMENT

I certify that I understand and agree that I have to comply with eligibility rules. I understand that the statements I have made on this form may be checked and verified.

I declare under penalty of perjury under the laws of the United States of America and the State of California that the information I have given on this form is true, correct, and complete.

 

SIGNATURE (OR MARK) OF APPLICANT OR AUTHORIZED REPRESENTATIVE

DATE SIGNED

 

SIGNATURE OF INTERPRETER OR WITNESS TO APPLICANT’S MARK

ORIGINAL - County Welfare Department               COPY - Provider               COPY - Patient

MC 274 TB (8/94) Part A - Application

 


5-17-A2

TB Application - Part B

 

State of California - Health and Welfare Agency                                                                                                                                                                                    Department of Health Services

 

MEDI-CAL TUBERCULOSIS PROGRAM

REFERRAL

COUNTY USE ONLY

         EW Name                                         

               EW No                                         

            Case No                                         

       Case Name                                         

 

This form must be completed in order to determine the person’s eligibility

for the Medi-Cal Tuberculosis Program.

Please Print Clearly.

PATIENT NAME

 

 

DATE OF BIRTH - Month/Day/Year

 

 

SOCIAL SECURITY NUMBER

               __           __

PATIENT CONSENT:

I consent to this information being forwarded to the County Welfare office.

Signature of Patient or Parent/Guardian (If Patient is Under 18 Years of Age)

PROVIDER USE ONLY:

If either question is answered “Yes,” the patient,                                                                          , is Tuberculosis infected.

1.     Requires Preventive Therapy for Tuberculosis Infection.

                        q Yes                                                                                                              q No

2.     Requires Treatment for Active Tuberculosis.

                        q Yes                                                                                                              q No

RETROACTIVE ELIGIBILITY

This person has been under therapy for Tuberculosis within the past three months prior to application.

                   q   Yes - Date Tuberculosis therapy began:                   

                   q   No

Provider or Clinic Staff - please complete the MC 210A if the above question is “Yes” and patient believes he/she is eligible for retroactive benefits.

 

 

IF THIS PERSON IS TUBERCULOSIS INFECTED, PLEASE MAIL PART A, B, AND C OF THE MC 274 TB FORM TO THE LOCAL COUNTY WELFARE OFFICE FOR A MEDI-CAL DETERMINATION UNDER THE TUBERCULOSIS PROGRAM.

 

PHYSICIAN NAME (Please Stamp, Print, or Type)

 

TELEPHONE NO.

  (         )

PHYSICIAN TITLE

 

MEDI-CAL PROVIDER NO.

 

DATE

 

PROVIDER ADDRESS - Number/Street

 

CITY

 

ZIP Code

 

AUTHORIZED PROVIDER SIGNATURE

 

 

 

ORIGINAL - County Welfare Department               COPY - Provider               COPY - Patient

 

MC 274 TB (8/94) Part B - Referral

5-17-A3

TB Application - Part C

 

State of California - Health and Welfare Agency                                                                                                                                                                                    Department of Health Services

 

 

MEDI-CAL TUBERCULOSIS PROGRAM

AUTHORIZATION FOR CLINIC ASSISTANCE

 

I hereby designate any staff member, authorized by the clinic, to perform intake and/or treatment functions, to assist me in my application for Tuberculosis Program benefits at no cost to me.

 

This assignment enables the authorized staff of the clinic to:

 

·                     Submit requested verifications to the county welfare department;

 

·                     Assist me in the completion of the “Application for Medi-Cal Tuberculosis Program” and the MC 210 Statement of Facts forms; and

 

·                     Obtain information from the county welfare department regarding the status of my application.

 

 

I understand that I do not have to apply for Medi-Cal benefits under this program and that I will not be denied treatment if I choose not to apply. I also understand that I have the responsibility to complete and sign the Statement of Facts and to provide all requested verifications before my Medi-Cal eligibility can be determined.

 

I hereby state that I make this assignment voluntarily and that I may revoke it at any time by notifying my Medi-Cal eligibility worker and the clinic.

 

 

                                                                                                                                         

                               Signature of Applicant                                                                                            Signature of Authorized Clinic Staff Assistant

 

 

                                                                                                                                               

                                      Date                                                                                                                                    Name of Clinic

 

 

                                                                                                                                               

                                                                                                            Clinic Address

 

 

                                                                                    (              )                                           

                                                                                                       Clinic Telephone Number                                                                                                                                                                                                                                                                                                                                                             

 

 

 

                                                                                                                                                                                                                                                                       

 

ORIGINAL - County Welfare Department               COPY - Provider               COPY - Patient

 

MC 274 TB (8/94) Part C - Clinic Assistant Assignment


5-17-B

 

 

State of California - Health and Welfare Agency                                                                                                                                                                                    Department of Health Services

Example 1

Using 1994

Income Standards

 

TUBERCULOSIS (TB) PROGRAM
INCOME ELIGIBILITY WORK SHEET

 

 

Use this form for an individual or applicant with spouse where both may be eligible for the TB Program. If one individual is found to be ineligible, then this process completes the determination for the ineligible spouse.

 

CASE NAME

                            Mr. Smith

CASE NUMBER

 

APPLICANT’S NAME

                     Mr. Smith

TB INDIVIDUAL’S TOTAL COUNTABLE INCOME

 

a.  TB APPLICANT

b.  TB SPOUSE

PART A.  UNEARNED INCOME

 

1.

Applicant’s Gross Unearned Income:

              207

                                            

 

2.

Subtract General Income Exclusion:

              - 20

 

 

3.

Subtract Other Unearned Income Deductions:

               187

 

 

4.

Total Countable Unearned Income:

 

 

PART B.  EARNED INCOME

 

5.

Applicant’s Earned Income:

 

 

6.

Subtract Balance of General Exclusion:

[If Not Offset by Unearned Income (Line 2)]

 

 

7.

Remaining Earned Income:

 

 

8.

Subtract Work Expense Exclusion:

 

 

9.

Subtract Other Earned Income Deductions:

 

 

10.

Remaining Earned Income:

 

 

11.

Subtract One-Half (½) Remaining Earned Income:

 

 

12.

Total Countable Earned Income:

 

 

13.

Total Countable Income (add lines 4 and 12):

               187

 

PART C.  TB ELIGIBILITY CALCULATION

 

14.

Current TB Income Standard for Individual:

              977

 

 

15.

Enter Total Countable Income (line 13):

               187

TB Income Eligible

(If line C.15 is less than or equal to line C.14, the Applicant is TB Income eligible.)

Eligibility Worker Signature

Worker Number

 

Computation Date

 

County Use Only

 

 

MC 282 TB (7/95)



5-17-C

 

 

State of California - Health and Welfare Agency                                                                                                                                                                                    Department of Health Services

Example 2

Using 1994

Income Standards

 

TUBERCULOSIS (TB) PROGRAM
INCOME ELIGIBILITY WORK SHEET

 

 

Use this form for an individual or applicant with spouse where both may be eligible for the TB Program. If one individual is found to be ineligible, then this process completes the determination for the ineligible spouse.

 

CASE NAME

                            Mr. Jones

CASE NUMBER

 

APPLICANT’S NAME

                     Mr. Jones

TB INDIVIDUAL’S TOTAL COUNTABLE INCOME

 

a.  TB APPLICANT

b.  TB SPOUSE

PART A.  UNEARNED INCOME

 

1.

Applicant’s Gross Unearned Income:

 

                                            

 

2.

Subtract General Income Exclusion:

 

 

 

3.

Subtract Other Unearned Income Deductions:

 

 

 

4.

Total Countable Unearned Income:

 

 

PART B.  EARNED INCOME

 

5.

Applicant’s Earned Income:

             2405

 

 

6.

Subtract Balance of General Exclusion:

[If Not Offset by Unearned Income (Line 2)]

               - 20

 

 

7.

Remaining Earned Income:

             2385

 

 

8.

Subtract Work Expense Exclusion:

               - 65

 

 

9.

Subtract Other Earned Income Deductions:

 

 

10.

Remaining Earned Income:

             2320

 

 

11.

Subtract One-Half (½) Remaining Earned Income:

              1160

 

 

12.

Total Countable Earned Income:

              1160

 

 

13.

Total Countable Income (add lines 4 and 12):

              1160

 

PART C.  TB ELIGIBILITY CALCULATION

 

14.

Current TB Income Standard for Individual:

               977

 

 

15.

Enter Total Countable Income (line 13):

              1160

TB Income Ineligible

(If line C.15 is less than or equal to line C.14, the Applicant is TB Income eligible.)

Eligibility Worker Signature

Worker Number

 

Computation Date

 

County Use Only

 

 

MC 282 TB (7/95)


5-17-D1

 

State of California - Health and Welfare Agency                                                                                                                                                                                    Department of Health Services

 

Example 3

TUBERCULOSIS (TB) PROGRAM
PROPERTY WORKSHEET

ADULT

(18 Years of Age and Older or Married)

 

 

NAME

              Mrs. Brown

CASE NUMBER

 

MONTH

 

STEP I

Determine net nonexempt property in accordance with Article 9.

 

One-half of

Community Property

STEP II

A.     Only consider the net nonexempt property of the TB applicant;

do not consider the property of any other family members in the home.

B.     Net nonexempt property of TB applicant:..................................................................      $           1250     

C.    Property limit for one person:.....................................................................................      $        2000     

 

D.    Is line II.B. less than or equal to line II.C.?

        Yes, TB property requirement met.

TB Property Eligible

        No, ineligible due to excess property.

 

 

 

 

 

 

 

 

 

                                                                                                                                                        

                                                                Eligibility Worker Signature                                                                                                                               Worker Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MC 278 TB (7/95)


5-17-D2

 

State of California - Health and Welfare Agency                                                                                                                                                                                    Department of Health Services

 

Example 3

TUBERCULOSIS (TB) PROGRAM
PROPERTY WORKSHEET

ADULT

(18 Years of Age and Older or Married)

 

 

NAME

              Mr. Brown

CASE NUMBER

 

MONTH

 

STEP I

Determine net nonexempt property in accordance with Article 9.

 

One-half of

Community Property

STEP II

A.     Only consider the net nonexempt property of the TB applicant;

do not consider the property of any other family members in the home.

B.     Net nonexempt property of TB applicant:..................................................................      $           1250     

C.     Property limit for one person:.....................................................................................      $        2000     

 

D.     Is line II.B. less than or equal to line II.C.?

        Yes, TB property requirement met.

TB Property Eligible

        No, ineligible due to excess property.

 

 

 

 

 

 

 

 

 

                                                                                                                                                        

                                                                Eligibility Worker Signature                                                                                                                               Worker Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MC 278 TB (7/95)


5-17-D3

 

State of California - Health and Welfare Agency                                                                                                                                                                                    Department of Health Services

Example 3

Using 1994

Income Standards

 

TUBERCULOSIS (TB) PROGRAM
INCOME ELIGIBILITY WORK SHEET

 

 

Use this form for an individual or applicant with spouse where both may be eligible for the TB Program. If one individual is found to be ineligible, then this process completes the determination for the ineligible spouse.

 

CASE NAME

          Mr. Brown

CASE NUMBER

 

APPLICANT’S NAME

        Mr. Brown

    Mrs. Brown  TB INDIVIDUAL’S TOTAL COUNTABLE INCOME

 

a.  TB APPLICANT

b.  TB SPOUSE

PART A.  UNEARNED INCOME                                                                        Mr. Brown                  Mrs. Brown

 

1.

Applicant’s Gross Unearned Income:

 

                                            

 

2.

Subtract General Income Exclusion:

 

 

 

3.

Subtract Other Unearned Income Deductions:

 

 

 

4.

Total Countable Unearned Income:

 

 

PART B.  EARNED INCOME

 

5.

Applicant’s Earned Income:

              1655

             1001

 

6.

Subtract Balance of General Exclusion:

[If Not Offset by Unearned Income (Line 2)]

                  20

                 20

 

7.

Remaining Earned Income:

              1635

               981

 

8.

Subtract Work Expense Exclusion:

                  65

                 65

 

9.

Subtract Other Earned Income Deductions:

 

10.

Remaining Earned Income:

              1570

               916

 

11.

Subtract One-Half (½) Remaining Earned Income:

               785 

              458

 

12.

Total Countable Earned Income:

               785

              458

 

13.

Total Countable Income (add lines 4 and 12):

               785

              458

PART C.  TB ELIGIBILITY CALCULATION

 

14.

Current TB Income Standard for Individual:

               977

               977

 

15.

Enter Total Countable Income (line 13):

               785

              458

(If line C.15 is less than or equal to line C.14, the Applicant is TB Income eligible.)               Both are TB Income Eligible.

Eligibility Worker Signature

Worker Number

 

Computation Date

 

County Use Only

 

MC 282 TB (7/95)

 


5-17-E1

State of California - Health and Welfare Agency                                                                                                                                                                                    Department of Health Services

TUBERCULOSIS (TB) PROGRAM

Using 1994

Income Standards

Example 5

FINANCIAL ELIGIBILITY WORK SHEET - ELIGIBLE CHILD

WITH INELIGIBLE PARENT OR PARENT(S)

 

CASE NAME

                      John Doe

CASE NUMBER

APPLICANT’S NAME

                      John Doe

PART I.  INELIGIBLE PARENT’S UNEARNED INCOME

1.    Parent’s unearned income - do not include public assistance (PA), other PA, or TB parent’s income.

       Do not include parent’s income if spouse is PA, other PA, or TB:                                                         $             0   

2.    Allocation for ineligible children  (if no children, enter zero in Part I.2.c.). Do not include TB applicant or

              TB-eligible children.

CHILD #1

CHILD #2

CHILD #3

CHILD #4

 

 

Name

Name

Name

Name

 

              a.   Standard SSI allocation (Federal Benefit Rate

                    (FBR) for a couple minus FBR for an individual):

   223

   223

 

 

 

              b.   Minus child’s income:

  -100

  -100

-

-

 

              c.   Total allocation:

   123

+   123

+

+      

=    $       246   

3.  Remaining unearned income (subtract line I.2.c. from line I.1.):                                                              $       246       

PART II.  INELIGIBLE PARENT’S EARNED INCOME

1.  Parent’s gross earned income:...............................................................................................................     $     1651   

2.  Unused portion of allocation for ineligible child(ren):.........................................................................     $       246   

3.  Remaining earned income (subtract II.2. from II.1.):..............................................................................     $     1405   

IF THERE IS NO INCOME REMAINING AND I.3. AND II.3. ARE BOTH ZERO, DO NOT DEEM, GO TO PART IV.

IF THERE IS INCOME, PROCEED WITH PART III.

PART III.  COMBINED INCOMES - Ineligible Parents

PART IV.  TB ELIGIBILITY CALCULATION

 

Unearned Income

 

1.

Deemed income from Part III.15.

    0

1.

Remaining unearned income (after allocation) or zero (from I.3.)

               

2.

Eligible child’s own OASDI income

    0

2.

A.  Subtract general income exclusion

- 20

3.

Other unearned income

    0

 

B.  Subtract other unearned income deductions

 

4.

A.  Subtract general income exclusion

- 20

3.

Countable unearned income (to III.11.)

 

 

B.  Subtract other unearned income deductions

    0

 

Earned Income

 

5.

Countable unearned income (IV.1. + IV.2. + IV.3. - $20)

    0

4.

Remaining earned income (from II.3.)

1405

6.

A.  Child’s countable earned income (subtract $65 + ½ remainder)

    0

5.

Subtract balance of general income exclusion

   20

 

B.  Subtract other earned income deductions

    0

6.

Remainder

1385

7.

Total countable income

    0

7.

A.  Subtract work expense exclusion

-65

8.

Current TB income standard

977

 

B.  Subtract other earned income deductions

     -

If line IV.7. is less than or equal to line IV.8., this person is income eligible.

8.

Remainder

1320

 

 

 

9.

Subtract ½ remainder

660

 

 

TB Income Eligible

10.

Countable earned income (to III.12.)

660

 

 

 

Deemed Income

 

 

 

 

11.

Countable unearned income (from III.3.)

     -

 

 

 

12.

Add countable earned income (from III.10.)

660

 

 

 

13.

Total countable income (from III.11. + III.12.)

660

 

 

 

14.

Subtract parent deduction*

-669

 

 

 

15.

Deemed income. Enter on Line IV.1.

     0

 

 

 

* Individual FBR if one ineligible parent lives with child; couple FBR if both ineligible parents live with child.

 

MC 280 TB (4/95)


5-17-E2

 

State of California - Health and Welfare Agency                                                                                                                                                                                    Department of Health Services

TUBERCULOSIS (TB) PROGRAM

Example 5

PROPERTY WORKSHEET

CHILD

 

NAME

                      John Doe

CASE NUMBER

 

MONTH

STEP I

A.     There is no allocation of property from an ineligible parent(s) if one or both parents is public assistance (PA), other PA, or eligible for the TB program.

B.     Determine net nonexempt property in accordance with Article 9.           (1) car exempt

 

STEP II

Ineligible Parental Allocation

Only consider the net nonexempt property of the parent(s) in the home; do not consider

the property of any other family members.

Parent(s)’ net nonexempt property:...........................................................................................       $       2500      

Property limit for one person (if two parents, enter property limit for two persons).............       $       3000      

Subtract line A.2. from line A.1. (enter 0 if negative). Total Allocation:...................................       $                0      

Divide line A.3. by the number of TB children in the home.

                                                                                         TB Child’s Share: ...............................       $                0      

 

TB Child’s and Parent(s)’ Resources

Child’s own net nonexempt property (as determined under Article 9): .................................       $                0      

Enter child’s share of property from parent(s) (line A.4.) .......................................................       $                0      

Add line B.1. and B.2.: ................................................................................................................       $                0      

Enter the TB property limit for one person:...............................................................................       $       2000      

TB Property Eligible

Is line B.3. less than or equal to line B.4.?

                 Yes, TB property requirement met.

                 No, ineligible due to excess property. If more than one TB child in the home,

                      proceed to Section C.

 

More Than One TB Child in the Home

 

Follow these steps if the child in Section B above is ineligible for any reason, e.g., attainment of age 18 or due to excess property because the parental allocation when combined with the TB child’s own net nonexempt property exceeds the TB property limit for one person.

 

Take the amount of property deemed from the parent(s) (line A.3.) and re-divide it among the remaining number of TB children in the home (line A.4.).

 

Repeat Section B for each of the remaining TB children in the home to determine if the combined amount of the child’s share of parental net nonexempt property and the child’s own net nonexempt property (line B.3.) is within the allowable TB property limit (line B.4.).

 

 

                                                                                                                                                       

                                Eligibility Worker Signature                                                                        Worker Number

 

MC 279 TB (3/95)


5-17-F1

 

State of California - Health and Welfare Agency                                                                                                                                                                                    Department of Health Services

 

Example 6

TUBERCULOSIS (TB) PROGRAM
INCOME ELIGIBILITY WORK SHEET

 

 

Use this form for an individual or applicant with spouse where both may be eligible for the TB Program. If one individual is found to be ineligible, then this process completes the determination for the ineligible spouse.

 

CASE NAME

                            Mr. Samuels

CASE NUMBER

 

APPLICANT’S NAME

                     Mr. Samuels

TB INDIVIDUAL’S TOTAL COUNTABLE INCOME

 

a.  TB APPLICANT

b.  TB SPOUSE

PART A.  UNEARNED INCOME

 

1.

Applicant’s Gross Unearned Income:

 

                                            

 

2.

Subtract General Income Exclusion:

 

 

 

3.

Subtract Other Unearned Income Deductions:

 

 

 

4.

Total Countable Unearned Income:

 

 

PART B.  EARNED INCOME

 

5.

Applicant’s Earned Income:

              1535

 

 

6.

Subtract Balance of General Exclusion:

[If Not Offset by Unearned Income (Line 2)]

                  20

 

 

7.

Remaining Earned Income:

              1515

 

 

8.

Subtract Work Expense Exclusion:

                  65

 

 

9.

Subtract Other Earned Income Deductions:

 

 

10.

Remaining Earned Income:

              1450

 

 

11.

Subtract One-Half (½) Remaining Earned Income:

               725

 

 

12.

Total Countable Earned Income:

               725

 

 

13.

Total Countable Income (add lines 4 and 12):

               725

 

PART C.  TB ELIGIBILITY CALCULATION

 

14.

Current TB Income Standard for Individual:

               977

 

 

15.

Enter Total Countable Income (line 13):

               725

 

(If line C.15 is less than or equal to line C.14, the Applicant is TB Income eligible.)                           TB Income Eligible

Eligibility Worker Signature

Worker Number

 

Computation Date

 

County Use Only

 

 

MC 282 TB (7/95)



5-17-F2

 

State of California - Health and Welfare Agency                                                                                                                                                                                    Department of Health Services

 

Example 6

TUBERCULOSIS (TB) PROGRAM
PROPERTY WORKSHEET

ADULT

(18 Years of Age and Older or Married)

 

 

NAME

              Mr. Samuels

CASE NUMBER

 

MONTH

 

STEP I

Determine net nonexempt property in accordance with Article 9.

 

STEP II

E.     Only consider the net nonexempt property of the TB applicant;

do not consider the property of any other family members in the home.

F.     Net nonexempt property of TB applicant:..................................................................      $          2,800    

G.    Property limit for one person:.....................................................................................      $        2,000    

 

H.    Is line II.B. less than or equal to line II.C.?

        Yes, TB property requirement met.

TB Property Ineligible

        No, ineligible due to excess property.

 

 

 

 

 

 

 

 

 

                                                                                                                                                        

                                                                Eligibility Worker Signature                                                                                                                               Worker Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MC 278 TB (7/95)

 


5-17-F3

State of California - Health and Welfare Agency                                                                                                                                                                                    Department of Health Services

TUBERCULOSIS (TB) PROGRAM

Using 1994

Income Standards

Example 6

FINANCIAL ELIGIBILITY WORK SHEET - ELIGIBLE CHILD

WITH INELIGIBLE PARENT OR PARENT(S)

 

CASE NAME

                      Mr. Samuels

CASE NUMBER

APPLICANT’S NAME

                      Will Samuels

PART I.  INELIGIBLE PARENT’S UNEARNED INCOME

4.    Parent’s unearned income - do not include public assistance (PA), other PA, or TB parent’s income.

       Do not include parent’s income if spouse is PA, other PA, or TB:                                                         $                   

5.    Allocation for ineligible children  (if no children, enter zero in Part I.2.c.). Do not include TB applicant or

              TB-eligible children.

CHILD #1

CHILD #2

CHILD #3

CHILD #4

 

 

Name

Name

Name

Name

 

              a.   Standard SSI allocation (Federal Benefit Rate

                    (FBR) for a couple minus FBR for an individual):

         

         

 

 

 

              b.   Minus child’s income:

-

-

-

-

 

              c.   Total allocation:

         

+         

+

+      

=    $                   

6.  Remaining unearned income (subtract line I.2.c. from line I.1.):                                                              $             0       

PART II.  INELIGIBLE PARENT’S EARNED INCOME

4.  Parent’s gross earned income:...............................................................................................................     $    3535  

5.  Unused portion of allocation for ineligible child(ren):.........................................................................     $             0  

6.  Remaining earned income (subtract II.2. from II.1.):..............................................................................     $    3535  

IF THERE IS NO INCOME REMAINING AND I.3. AND II.3. ARE BOTH ZERO, DO NOT DEEM, GO TO PART IV.

IF THERE IS INCOME, PROCEED WITH PART III.

PART III.  COMBINED INCOMES - Ineligible Parents

PART IV.  TB ELIGIBILITY CALCULATION

 

Unearned Income

 

1.

Deemed income from Part III.15.

1056

1.

Remaining unearned income (after allocation) or zero (from I.3.)

               

2.

Eligible child’s own OASDI income

      0

2.

A.  Subtract general income exclusion

- 20

3.

Other unearned income

  100

 

B.  Subtract other unearned income deductions

 

4.

A.  Subtract general income exclusion

  - 20

3.

Countable unearned income (to III.11.)

 

 

B.  Subtract other unearned income deductions

       0

 

Earned Income

 

5.

Countable unearned income (IV.1. + IV.2. + IV.3. - $20)

   1136

4.

Remaining earned income (from II.3.)

  3535

6.

A.  Child’s countable earned income (subtract $65 + ½ remainder)

        0

5.

Subtract balance of general income exclusion

      20

 

B.  Subtract other earned income deductions

        0

6.

Remainder

   3515

7.

Total countable income

   1136

7.

A.  Subtract work expense exclusion

     -65

8.

Current TB income standard

    977

 

B.  Subtract other earned income deductions

        0

If line IV.7. is less than or equal to line IV.8., this person is income eligible.

8.

Remainder

  3450

 

 

 

9.

Subtract ½ remainder

   1725

 

 

TB Income Ineligible

10.

Countable earned income (to III.12.)

   1725

 

 

 

Deemed Income

 

 

 

 

11.

Countable unearned income (from III.3.)

        0

 

 

 

12.

Add countable earned income (from III.10.)

   1725

 

 

 

13.

Total countable income (from III.11. + III.12.)

   1725

 

 

 

14.

Subtract parent deduction*

   -669

 

 

 

15.

Deemed income. Enter on Line IV.1.

1056

 

 

 

* Individual FBR if one ineligible parent lives with child; couple FBR if both ineligible parents live with child.

 

MC 280 TB (4/95)