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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD NEVADA STATE DIVISION OF SOCIAL SERVICES PATIENT LIABILITY (P/L) BUDGET ─ SPOUSAL IMPOVERISHMENT Case Name Case Number Date Worker MAINTENANCE ALLOWANCE PARTIAL MONTH PRORATION COMMUNITY SPOUSE MONTHLY INCOME ALLOWANCE Full Month Patient Liability................................. Number of Days in the Month ............................ Daily Rate…. Number of Days Institutionalized ....................... Patient Liability for _______________ ............... REMARKS/DOCUMENTATION $ ________ + ________ = ________ x ________ = $ ________ 1. Housing Costs ......................................... $________ 2. Standard Utility Allowance (SUA) ........... +________ 3. Shelter Costs........................................... ________ 4. Maximum Shelter (30% of 150% of 2-Person Poverty)...... -________ 5. Excess Shelter Allowance........................ ________ 6. 150% of 2-Person Poverty ...................... $________ Excess Shelter Allowance........................ +________ 7. Monthly Maintenance Allowance ............................................... ________ ▲ COMPARE ▼ 8. Federal Maximum Monthly Maintenance Allowance ..................... $________ 9. Lessor of #7 or #8 $________ _______ 10. Community Spouse Gross Income…… - _______ 11. Community Spouse Monthly Income Allowance .............................. $________ FAMILY ALLOWANCE Repeat this calculation for each family member: -1­ -2­ 1. 150% of 2-Person Poverty.................. $________ $________ 2. Family Member Total......................... -________ -________ 3. Net Difference $________ $________ ÷ 3 ÷ 3 4. Family Member Allowance $________ $________ 5. Total All Family Member Allowances (1+2)................................ $________ PATIENT LIABILITY INCOME MONTH: ___________________ FOR: ______________ (MONTH) TOTAL GROSS MONTHLY INCOME.................................. $ _______ Less Involuntary Mandatory Deductions ........................ $-_______ Less Income Excluded from P/L ...................................... $-_______ TOTAL PATIENT LIABILITY INCOME ................................. $ _______ LESS: 1. Personal Needs Allowance ................. -________ $ _______ (SUBTOTAL) 2. Community Spouse Income Allowance .......................................... -________ 3. Family Allowance ............................... -________ 4. Payments for Health Insurance.......... -________ 5. Incurred Medical Expense.................. -________ TOTAL DEDUCTIONS (#s 2- 5) ......................................... $ _______ PATIENT LIABILITY (Full Month) ...................................... $ _______ APPENDIX F MAABD BUDGETS Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 PATIENT LIABILITY (P/L) BUDGET ─ SPOUSAL IMPOVERISHMENT