Form MC175-3I.2R "Section 1931(B) Sneede V Kizer Net Nonexempt Income Determination and Mini Budget Unit (Mbu) Determination - Recipient" - California

What Is Form MC175-3I.2R?

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;
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Download Form MC175-3I.2R "Section 1931(B) Sneede V Kizer Net Nonexempt Income Determination and Mini Budget Unit (Mbu) Determination - Recipient" - California

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State of California—Health and Human Services Agency
Department of Health Care Services
SECTION 1931(b) SNEEDE V KIZER NET NONEXEMPT INCOME DETERMINATION
AND MINI BUDGET UNIT (MBU) DETERMINATION—RECIPIENT
Case name
County district
County use
Case number
Effective date
Month:
Year:
CASE TYPE: RECIPIENT (ALTERNATIVE A)
PART 1
NOTE:
The only deduction applicable to the Section 1931(b) program is the deduction for educational expenses, as provided In Section 50547, Title 22,
California Code of Regulations.
Name
Name
Name
Name
Name
ENTER NAME OF EACH MFBU MEMBER
(Do not list unborns)
Child
Child
Child
Person type
Parent A or
Parent A or
Caretaker
Caretaker
Relative
Relative
A.
NONEXEMPT UNEARNED INCOME
(EXCLUDING DISABILITY-BASED INCOME)
1. Source and amount of nonexempt unearned income*
1
2. Net child/spousal support received
2
3. In-kind income (IKI)
4. Income available from PA/other PA
(see MC 175-6, line A.4.)
5. Total nonexempt unearned income
(add lines 1, 2, 3, and 4)
* Sources include: net income from property, social security nondisability payments, etc.
1 Child/Spousal Support Child support is income to the child, not to the parent or caretaker relative.
Payments Received
Divide the $50 per month child/spousal support deduction by the number of persons for whom the income is intended.
Any unused remainder will be prorated among the remaining persons who still have support payments to apply against
the deduction.
2 Unearned IKI
Prorate the unearned IKI among the persons who receive the income. Example: Medi-Cal family budget unit (MFBU) of four
receives free housing. Use IKI for four and each person receives one-fourth of the IKI. Add an unborn’s share of IKI to the
pregnant woman’s share. If the pregnant woman is Public Assistance (PA)/other PA, and not in the MFBU, give the unborn’s
share to the father of the unborn if he is in the MFBU.
Child/Spousal support and/or IKI computations:
B.
DISABILITY-BASED INCOME
6. Source and amount of disability-based income
(continue to line 7, even if no disability income)
7. Section 1931(b) $240 deduction
8. Remaining nonexempt disability-based income
(subtract line 7 from line 6) Enter 0 if negative
9. Unused Section 1931(b) deduction (If line 6 is 0,
enter $240; otherwise, subtract line 6 from line 7.)
Enter 0 if negative.
Page 1 of 4
MC 175-3I.2R (05/07) 1931 Group
State of California—Health and Human Services Agency
Department of Health Care Services
SECTION 1931(b) SNEEDE V KIZER NET NONEXEMPT INCOME DETERMINATION
AND MINI BUDGET UNIT (MBU) DETERMINATION—RECIPIENT
Case name
County district
County use
Case number
Effective date
Month:
Year:
CASE TYPE: RECIPIENT (ALTERNATIVE A)
PART 1
NOTE:
The only deduction applicable to the Section 1931(b) program is the deduction for educational expenses, as provided In Section 50547, Title 22,
California Code of Regulations.
Name
Name
Name
Name
Name
ENTER NAME OF EACH MFBU MEMBER
(Do not list unborns)
Child
Child
Child
Person type
Parent A or
Parent A or
Caretaker
Caretaker
Relative
Relative
A.
NONEXEMPT UNEARNED INCOME
(EXCLUDING DISABILITY-BASED INCOME)
1. Source and amount of nonexempt unearned income*
1
2. Net child/spousal support received
2
3. In-kind income (IKI)
4. Income available from PA/other PA
(see MC 175-6, line A.4.)
5. Total nonexempt unearned income
(add lines 1, 2, 3, and 4)
* Sources include: net income from property, social security nondisability payments, etc.
1 Child/Spousal Support Child support is income to the child, not to the parent or caretaker relative.
Payments Received
Divide the $50 per month child/spousal support deduction by the number of persons for whom the income is intended.
Any unused remainder will be prorated among the remaining persons who still have support payments to apply against
the deduction.
2 Unearned IKI
Prorate the unearned IKI among the persons who receive the income. Example: Medi-Cal family budget unit (MFBU) of four
receives free housing. Use IKI for four and each person receives one-fourth of the IKI. Add an unborn’s share of IKI to the
pregnant woman’s share. If the pregnant woman is Public Assistance (PA)/other PA, and not in the MFBU, give the unborn’s
share to the father of the unborn if he is in the MFBU.
Child/Spousal support and/or IKI computations:
B.
DISABILITY-BASED INCOME
6. Source and amount of disability-based income
(continue to line 7, even if no disability income)
7. Section 1931(b) $240 deduction
8. Remaining nonexempt disability-based income
(subtract line 7 from line 6) Enter 0 if negative
9. Unused Section 1931(b) deduction (If line 6 is 0,
enter $240; otherwise, subtract line 6 from line 7.)
Enter 0 if negative.
Page 1 of 4
MC 175-3I.2R (05/07) 1931 Group
C.
NONEXEMPT EARNED INCOME
10. Source and amount of nonexempt earned income
(include TWC, SDI and earned IKI)
11. Section 1931(b) deduction from line 9
12. Remaining nonexempt earned income
(subtract line 11 from line 10)
13. 50% earned income deduction (one-half of line 12)
14. Child care deduction
15. Other deductions
16. Total deductions (add lines 13, 14, and 15)
17. Total net nonexempt earned income
(subtract line 16 from line 12)
D.
TOTAL COUNTABLE INCOME
18. Total countable nonexempt unearned income (line 5)
19. Total countable disability-based income (line 8)
20. Total countable nonexempt earned income (line 17)
21. Income allocated from LTC/B&C person to family
members at home (from MC 176W, Part B, or
from MC 175-7, line C.2)
22. Total countable income (add lines 18, 19, 20, and 21)
E.
TOTAL NET COUNTABLE INCOME
AFTER OTHER DEDUCTIONS
23. Court-ordered child support or alimony
24. Income used to determine PA eligibility
(see MC 175-6, Section B)
25. Other deductions:
26. Total deductions (add lines 23, 24, and 25)
27. Total net countable income (subtract line 26
from line 22) Enter this amount in Part 2 if
no parent in MFBU. If parent in MFBU, continue.
F.
PARENTAL/SPOUSAL (P/S) ALLOCATION
COMPUTATION (Skip if no parent in MFBU)
28. P/S (subtract $1 from MBSAC for one person or $1
from MBSAC for 2 or more if pregnant)
29. Total unearned in-kind income, income from PA, or
income allocated from LTC/B&C spouse
(add lines 3, 4, and 21)
30. Parent’s total net nonexempt income
(subtract line 29 from line 27)
31. Parent’s net nonexempt income less P/S own needs
(subtract line 28 from line 30); if negative, enter 0
32. Number of persons for whom Parent A is responsible
(MC 175-2, Section A) DO NOT COUNT PARENT A
33. Number of persons for whom Parent B is responsible
(MC 175-2, Section B) DO NOT COUNT PARENT B
34. Child’s natural/adoptive parent—check if Parent A
and/or B (see MC 175-2)
A
B
A
B
A
B
Page 2 of 4
MC 175-3I.2R (05/07) 1931 Group
35. Parent A’s allocation to spouse (if any) and
natural/adopted children (divide Parent A’s line 31 by
line 32 and enter in applicable box) Do not enter
under Parent B if unmarried.
36. Parent B’s allocation to spouse (if any) and
natural/adopted children (divide Parent B’s line 31 by
line 33 and enter in applicable box) Do not enter
under Parent A if unmarried.
37. Enter the lesser of either line 28 or 30
38. Parent’s total net nonexempt income
(add lines 29, 37, and 35 or 36)
39. Child’s total net nonexempt income
(add lines 27, 35, and 36); enter in Part 2
PART 2
SECTION 1931(b) MBU DETERMINATION—PROPERTY AND INCOME
Section 1931(b) MBSAC Income Test
Section 1931(b) Property Determination
Instructions:
1.
Include unborn in the mother’s MBU and property limit/MBSAC income level unless mother is married, and only her separate children want Medi-Cal.
If the pregnant woman is PA/other PA, include the unborn in the spouse’s or father’s MBU.
2.
Do not include an excluded child.
3.
Do not list MBU members in more than one MBU.
4.
If any MBU has excess property, check to see if Medi-Cal linkage still exists for other family members.
5.
Property determinations: enter the allocation for each spouse from MC 324, line 29.
6.
Enter each person’s net nonexempt income from lines 38 or 39.
MBU NUMBER _______
MBU NUMBER _______
Person name/number
Net nonexempt
Person name/number
Net nonexempt
Property
Income
Property
Income
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
6.
6.
TOTAL
TOTAL
MBUs
Property limit
MBUs
Property limit
MBSAC
MBSAC
Check one:
Check one:
Excess property—FAIL
Excess property—FAIL
Income ineligibility—at/exceeds MBSAC—Property eligible—FAIL
Income ineligibility—at/exceeds MBSAC—Property eligible—FAIL
Income eligible—below MBSAC—Property eligible—PASS
Income eligible—below MBSAC—Property eligible—PASS
Page 3 of 4
MC 175-3I.2R (05/07) 1931 Group
MBU NUMBER _______
MBU NUMBER _______
Person name/number
Net nonexempt
Person name/number
Net nonexempt
Property
Income
Property
Income
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
6.
6.
TOTAL
TOTAL
MBUs
Property limit
MBUs
Property limit
MBSAC
MBSAC
Check one:
Check one:
Excess property—FAIL
Excess property—FAIL
Income ineligibility—at/exceeds MBSAC—Property eligible—FAIL
Income ineligibility—at/exceeds MBSAC—Property eligible—FAIL
Income eligible—below MBSAC—Property eligible—PASS
Income eligible—below MBSAC—Property eligible—PASS
MBU NUMBER _______
MBU NUMBER _______
Person name/number
Net nonexempt
Person name/number
Net nonexempt
Property
Income
Property
Income
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
6.
6.
TOTAL
TOTAL
MBUs
Property limit
MBUs
Property limit
MBSAC
MBSAC
Check one:
Check one:
Excess property—FAIL
Excess property—FAIL
Income ineligibility—at/exceeds MBSAC—Property eligible—FAIL
Income ineligibility—at/exceeds MBSAC—Property eligible—FAIL
Income eligible—below MBSAC—Property eligible—PASS
Income eligible—below MBSAC—Property eligible—PASS
Page 4 of 4
MC 175-3I.2R (05/07) 1931 Group
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