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________________ ________________ MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD NEVADA STATE DIVISION OF SOCIAL SERVICES SPOUSAL IMPOVERISHMENT RESOURCE DETERMINATION Case Name Case Number Date Worker I. SPOUSAL SHARE OF RESOURCES AT TIME OF INSTITUTIONALIZATION/HOME BASED WAIVER SERVICES Month/Year a. Community spouse's separate resources b. Customer’s separate resources c. Joint resources between spouses d. Total Resources e. Total resources divided equally f. A spousal share $____________ +____________ +____________ (Customer’s Spouse) $____________ ÷ 2 $____________ II. COMMUNITY SPOUSE RESOURCE ALLOWANCE a. Enter State Medicaid Maximum Resource Share from Appendix C $____________ b. Enter the spousal share up to the Federal Maximum from Appendix C $____________ c. Enter the amount established based on a hearing decision $____________ d. Enter the amount established in a court order $____________ e. Enter the greatest of a, b, c or d above $____________ f. The amount "considered" available to the community spouse (MAM F-115.2) −____________ g. Community Spouse Resource Allowance $____________ III. ASSIGNMENT OF RESOURCES AT TIME OF APPLICATION a. Community spouse's separate resources $____________ b. Customer’s separate resources +____________ c. Joint resources between spouses +____________ d. Total Resources e. Total amount from Section II, item e above *f. Countable resources for Customer’s eligibility (Customer’s Spouse) $____________ –____________ Month/Year $____________ *If the amount in item III.f is within Medicaid resource limits, then resources up to the amount in item II.g must be transferred to the community spouse within 30 days from the date of the approval notice. APPENDIX F MAABD BUDGETS SPOUSAL IMPOVERISHMENT DETERIMINATION Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25