Page 62

State of Maryland Medical Assistance Manual Revised April 2014

Spend-Down

Available income is greater than cost of care. Ineligible for cost of care.

Consideration Period

to

Income:

Total Monthly Income $

x

= $

Allowances:

Personal Needs $

x

= $

Spousal/Dependent

x

=

Residential

x

=

Total Allowances -

Available Income $

Cost of Care:

Private Per Diem $

Days in period x

Projected Cost of Care -__________

Excess Available Income $ __________

Medical Expenses:

Date

Amount $

 Spend-down met on __________. Eligible for MA card only. Complete 1159C, LIEN WORKSHEET, if the institutional person has home property.

 Application preserved for the period ________ to __________.

_________________ ___________

Case Manager Date

DHMH 1159D 7/13 (LTC) (2 of 2)