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________________ ________________ III 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 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 Liquid/non-liquid in spouse's name and/or joint with others - not the customer. $____________ (customer’s Spouse) Liquid/non-liquid in customer’s name and/or joint with others - not the spouse. +____________ Liquid/non-liquid joint between spouses. Day of Admit +____________ ________________ Month/Year $____________ ÷ 2 $____________ II. COMMUNITY SPOUSE RESOURCE ALLOWANCE a. Enter the 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 $____________ Total of I.a. and 1/2 of non-liquid in I.c. f. The amount "considered" available to the community spouse (MAM F-115.2) –____________ g. Community Spouse Resource Allowance $____________ ASSIGNMENT OF RESOURCES AT TIME OF APPLICATION Liquid/non-liquid in spouse's name and/or joint with others - not the customer. a. Community spouse's separate resources $____________ (Customer’s Spouse) Liquid/non-liquid in customer’s name and/or joint with others - not the spouse. b. Customer’s separate resources +____________ Day of Application Month/Year Liquid/non-liquid joint between spouses. c. Joint resources between spouses +____________ Second and ongoing month(s) use low resource balance. *If the amount in item III.f is within Medicaid d. Total Resources $____________ resource limits, then resources up to the amount in item II.g must be transferred to the e. Total amount from Section II, item e above –____________ community spouse within 30 days from the date of the approval notice. $____________ APPENDIX F MAABD BUDGETS *f. Countable resources for customer’s eligibility Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 SPOUSAL IMPOVERISHMENT RESOURCE DETERIMINATION