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To compute income eligibility for the Medical Programs and, if applicable, the spend down amount for the Medically Needy Program.
When to Prepare
Use as an addendum to Form H1101, TANF Worksheet, or Form H1102, TANF Worksheet for Special Reviews and Denials, for each application. Do not use page 3 of Form H1101 or page 2 of Form H1102 for the Medical Programs determinations.
Number of Copies
Complete an original in ink.
File with Form H1101.
See the Texas Works Manager's Guide.
STEP 1 — Earned/Unearned Income
Line 1 – Names — Enter the first and last name initials of each client with countable earned income.
Lines 2-18 — Enter the countable amounts of income.
Line 2 – Tot. Earnings —Enter the gross earned income amounts for each client listed on line 1. Also enter each client's amount in Item 42 of Form H1000-A, Notice of Application, or Form H1000-B, Record of Case Action. Enter the total amount in the far right box.
Line 3 – RSDI —Enter any Retirement, Survivors and Disability Insurance (RSDI) received. Each client's RSDI amount must be entered in Item 43 of Form H1000-A or Form H-1000-B. Total the RSDI amounts and enter the total in the last box.
Line 4 – Pensions, VA, Unemployment Benefits —Enter any pensions, Veterans Affairs (VA) or Unemployment benefits received. Each client's benefits must be entered in Item 44 of Form H1000-A or Form H1000-B. Total the benefits and enter the total in the last box.
Line 5 – RR Retirement —Enter any railroad (RR) retirement benefits received. Total the RR retirement benefits and enter the total in the last box. The total amount must be entered in Item 55 of Form H1000-A or Form H1000-B.
Line 6 – Subtotal — Enter the totals of lines 3, 4, and 5.
Lines 7-15 – (Other Listed Unearned Income) — Self-explanatory.
Line 16 – Other Income — If a client has unearned income (other than the types in lines 3-15), enter the amount received (examples: union benefits, interest income, stock dividends, alimony).
Line 17 – Subtotal — Enter the totals of lines 7-16.
Line 18 – Total Unearned Income — Enter totals of B and C.
STEP 2 — Income Deductions
Enter deductions for all members of the budget group.
Line 1 – Names — Enter the first and last name of each certified member with allowable deductions.
Lines 2 and 3 – Work Expense Standard and Child/Incap. Care Cost — Cannot exceed the member's earned income.
Lines 4, 5 and 6 — Farm Loss from Form H1049, Client’s Statement of Self-Employment Income, pg. 3, line D, Payments to Deps. Outside Home and Alimony and Child Support Payments — Combined with lines 2 and 3. Cannot exceed the member's total income.
Line 7 – Total — (Line 4 + Line 5 + Line 6).
Line 8 – Child Support Disregard — Enter the amount of child support disregard up to $50 per month. This amount cannot exceed the amount of monthly child support income.
Line 9 – Extra Needs for Legal Parent (TP 47 only) — Enter the difference between Temporary Assistance for Needy Families (TANF) recognizable and budgetary needs for a caretaker who has income.
Line 10 – Total — Enter the totals of lines 8 and 9.
STEP 3 — Recognizable Needs or FPIL/MNIL
Use to determine eligibility for TPs 40, 43, 44, 47, 48, 55 and 30. Follow instructions on the form.
On line 1, enter the:
- TANF Recognizable Needs if determining eligibility for TP 47.
- 185% federal poverty income limits (FPIL) if determining eligibility for
- TP 40 for pregnant women,
- TP 43, or
- TP 30 for pregnant women and children under age one.
- 133% FPIL if determining eligibility for
- TP 48, or
- TP 30 for children ages one to six.
- 100% FPIL if determining eligibility for
- TP 44, or
- TP 30 for children ages 6-18.
- Medically Needy Income Limits (MNIL) for TPs 55 or 30.
If the income amount on line 9 exceeds the recognizable needs or FPIL on line 1, deny the TP 40, 43, 44, 47 or 48 application. If the income amount on line 9 exceeds the MNIL on line 1, go to Step 4.
STEP 4 — Determining Spend Down Amount (MN)
Subtract the MNIL from the adjusted gross income. Round down by dropping cents.