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IS LOWER. GO TO STEP II.

. STEP II ELIGIBILITY FOR HELP WITH COST OF CARE A. LTC DEDUCTIONS 1. Enter GROSS INCOME of the b.u. Subtract operational expenses Countable Income 2. Deductions from Countable Income

a. (PNA) Personal Needs $70/$140

b. Court-ordered Guardianship fees

c. Mandatory deductions

d. Work Incentive deduction

e. Spouse/Dependent Allowance

f. (UMN) Unmet medical needs monthly 3. Result (PML)

DMA-5122 COMMUNITY SPOUSE ALLOWANCE WORKSHEET

A. Maximum Income Available for Deeming to CUSP 1. A/B’s countable income from LTC, step II 2. Subtract $70 personal needs allowance 3. Subtract any mandatory deductions 4. Subtract A&A/UME portion of VA payment 5. Difference is the maximum available for deeming 6. Continue to B., if greater than zero.

B. CUSP's Gross Monthly Income 1. Count all, including SSI Special Assistance, & Work First 2. Prorate Work First Based on # in Work First case

C. Is CUSP's GROSS INCOME (from B., above) greater than or equal to Base Allowance 1. [ ] YES. Stop and go to D., below. Docusign Envelope ID: 950E9248-29CC-8930-81BC-BCEC667EB493