Patient Responsibility (Single)

Gross Monthly Income
$
Supplemental Health Insurance
(Monthly amount paid)
$
Personal Needs Allowance
$
Total Patient Responsibility

$0.00

Patient Responsibility (Married)

Gross Monthly Income
$
Supplemental Health Insurance
(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