Form MC175-5 "Federal Poverty Level (Fpl) Programs for Pregnant Women and Infants (Income Disregard, 200 Percent); Children Ages 1 Through 5 (133 Percent); and Children Ages 6 Through 18 (100 Percent)" - California

What Is Form MC175-5?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2007;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form MC175-5 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form MC175-5 "Federal Poverty Level (Fpl) Programs for Pregnant Women and Infants (Income Disregard, 200 Percent); Children Ages 1 Through 5 (133 Percent); and Children Ages 6 Through 18 (100 Percent)" - California

653 times
Rate (4.7 / 5) 46 votes
Care State of California—Health and Human Services Agency
Department of Health Care Services
SNEEDE V. KIZER
FEDERAL POVERTY LEVEL (FPL) PROGRAMS FOR
PREGNANT WOMEN AND INFANTS (INCOME DISREGARD, 200 PERCENT[%]),
CHILDREN AGES 1 THROUGH 5 (133 PERCENT [%]), AND
CHILDREN AGES 6 THROUGH 18 (100 PERCENT [%])
Case name
Case number
Effective date (month/year)
INSTRUCTIONS:
1. Complete this form for all of the potential percentage program eligibles whose MBU has a share-of-cost.
2. Net Nonexempt Family Income: enter the full net nonexempt income of the percent (%) program eligible and his/her
responsible relatives (i.e., spouse or natural/adoptive parent); do not enter the Sneede allocations.
a. If the potential percent (%) program eligible is:
an unmarried pregnant woman, use only her income;
l
a pregnant minor, do not use her parents’ income, if they are in the home, if it causes her to be ineligible;
l
a married pregnant woman, use her and her spouse’s income;
l
a child, use the child’s and natural/adoptive parents’ income, if they are in the MFBU.
l
b. If the potential percent (%) program eligible and/or his/her responsible relatives are:
AFDC-MN/MI, add lines 20 and 25 from MC 175-3I;
l
ABD-MN, first complete another MC 175-3I (lines 1 through 25), allow only AFDC-MN deductions, and enter the
l
total from lines 20 and 25.
c. When only the separate children of one spouse want Medi-Cal, full net nonexempt parental income does NOT
include income allocations to persons outside of the MFBU. (Use amount from MC 176 W.1, line 30, for
responsible relative net nonexempt income.)
A. NET NONEXEMPT FAMILY INCOME DETERMINATION
1. Name of potential percent (%)
program eligible in MBU with
SOC
2. Name of responsible relative
number 1
3. Name of responsible relative
number 2
4. Full net nonexempt income of
$
$
$
$
$
percent (%) program eligible
5. Full net nonexempt income of
$
$
$
$
$
responsible relative number 1
6. Full net nonexempt income of
$
$
$
$
$
responsible relative number 2
7. Total net nonexempt family
income (add lines 4, 5, and 6
$
$
$
$
$
and enter on B.4.)
(over)
MC 175-5 (05/07)
Care State of California—Health and Human Services Agency
Department of Health Care Services
SNEEDE V. KIZER
FEDERAL POVERTY LEVEL (FPL) PROGRAMS FOR
PREGNANT WOMEN AND INFANTS (INCOME DISREGARD, 200 PERCENT[%]),
CHILDREN AGES 1 THROUGH 5 (133 PERCENT [%]), AND
CHILDREN AGES 6 THROUGH 18 (100 PERCENT [%])
Case name
Case number
Effective date (month/year)
INSTRUCTIONS:
1. Complete this form for all of the potential percentage program eligibles whose MBU has a share-of-cost.
2. Net Nonexempt Family Income: enter the full net nonexempt income of the percent (%) program eligible and his/her
responsible relatives (i.e., spouse or natural/adoptive parent); do not enter the Sneede allocations.
a. If the potential percent (%) program eligible is:
an unmarried pregnant woman, use only her income;
l
a pregnant minor, do not use her parents’ income, if they are in the home, if it causes her to be ineligible;
l
a married pregnant woman, use her and her spouse’s income;
l
a child, use the child’s and natural/adoptive parents’ income, if they are in the MFBU.
l
b. If the potential percent (%) program eligible and/or his/her responsible relatives are:
AFDC-MN/MI, add lines 20 and 25 from MC 175-3I;
l
ABD-MN, first complete another MC 175-3I (lines 1 through 25), allow only AFDC-MN deductions, and enter the
l
total from lines 20 and 25.
c. When only the separate children of one spouse want Medi-Cal, full net nonexempt parental income does NOT
include income allocations to persons outside of the MFBU. (Use amount from MC 176 W.1, line 30, for
responsible relative net nonexempt income.)
A. NET NONEXEMPT FAMILY INCOME DETERMINATION
1. Name of potential percent (%)
program eligible in MBU with
SOC
2. Name of responsible relative
number 1
3. Name of responsible relative
number 2
4. Full net nonexempt income of
$
$
$
$
$
percent (%) program eligible
5. Full net nonexempt income of
$
$
$
$
$
responsible relative number 1
6. Full net nonexempt income of
$
$
$
$
$
responsible relative number 2
7. Total net nonexempt family
income (add lines 4, 5, and 6
$
$
$
$
$
and enter on B.4.)
(over)
MC 175-5 (05/07)
B. ELIGIBILITY DETERMINATION
Number of persons in MFBU ___________
1. Name of potential percent (%)
program eligible
2. Potential percent (%) program
Income disregard
Income disregard
Income disregard
Income disregard
Income disregard
200 percent (%)
200 percent (%)
200 percent (%)
200 percent (%)
200 percent (%)
(check one)
133 percent (%)
133 percent (%)
133 percent (%)
133 percent (%)
133 percent (%)
100 percent (%)
100 percent (%)
100 percent (%)
100 percent (%)
100 percent (%)
3. Enter FPL for percent (%)
$
$
$
$
$
program shown in B.2. based on
the number of persons in MFBU.
4. Enter total net nonexempt
$
$
$
$
$
family income (from A.7.)
5. Is total net nonexempt family
Yes, eligible
Yes, eligible
Yes, eligible
Yes, eligible
Yes, eligible
(continue)
(continue)
(continue)
(continue)
(continue)
income (B.4.) less than or equal
to amount in B.3.?
No, deny FPL
No, deny FPL
No, deny FPL
No, deny FPL
No, deny FPL
Program
Program
Program
Program
Program
6. Person number (optional)
7. Aid code (optional)
8. MBU number (optional)
Eligibility Worker signature
Worker number
Computation date
MC 175-5 (05/07)
Page of 2