Patient Responsibility (Single)
Gross Monthly Income
$
Supplemental Health Insurance
(Monthly amount paid)
(Monthly amount paid)
$
Personal Needs Allowance
$
Total Patient Responsibility
$0.00
Patient Responsibility (Married)
Gross Monthly Income
$
Supplemental Health Insurance
(Monthly amount paid)
(Monthly amount paid)
$
Personal Needs Allowance
$
Community Spouse Income Allowance
$
Total Patient Responsibility
$0.00
Medicaid Spousal Diversion Worksheet
Rent or Mortgage Payment:
$
Taxes (prorate monthly amount, if not included in mortgage payment):
$
Homeowner's or Renters Insurance:
$
Condo Maintenance Fee or mandatory homeowners Association Fees:
$
Standard Utility Allowance (10/01/2019)
$361.00
Subtotal
$361.00
Excess Shelter Standard (Updated Each July 1)
$617.00
Excess Shelter Costs (Total)
$-256.00
Minimum Monthly Maintenance Income Allowance:
$2,114.00
Community Spouse Income Allowance:
$1,858.00
Community Spouse's GROSS income from all sources:
$
Community Spouse Income Allowance:
$1,858.00