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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD D-385.5 Responsibilities of Eligibility Staff The staff: • Requests completion of Form 2069–EM "Parent Income and Household Information" and verification of income, court-ordered child support/alimony, medical expenses and health insurance coverage at application and redetermination. • Determines the monthly reimbursement amount based on the family size, annual income, child support/alimony, home care credit, medical expenses and medical insurance using Form 2028- EE, "Parental Reimbursement Worksheet." Notify the parents of their monthly reimbursement amount using Form 2849-EM. • If the monthly reimbursement is greater than zero (0), send copies of the parent questionnaire and copy of Form 2849-EM with the recovery referral form to I&R in their service area. • If a parent's whereabouts is unknown, the staff will refer eligibility information to I&R for parent locate services using Form 2683–EE "Investigation Referral Form." • If eligibility for the child terminates, the staff will notify I&R on Form 6009-AG. Example computation: A family of four (4) has an annual gross income of $150,000. $150,000 - 1,200 Child Support $148,800 -64,300 Annual Family Deduction $84,500 Net Annual Gross Income a. $50,000 of net annual gross income is multiplied by 10% or 15% (5% Insurance Penalty) • $50,000 X 10% = $5,000 or 15% = $7,500 b. The net annual gross income is also between $50,000 - $60,000, multiply $10,000 by 13% or 18% (5% Insurance Penalty) • $10,000 X 13% = $1,300 or 18% = $1,800 c. The net annual gross income is also between $60,000 - $75,000, multiply $15,000 by 16% or 21% (5% Insurance Penalty) • $15,000 X 16% = $2,400 or 21% = $3,150 d. The net annual gross income is also OVER $75,000, multiply the amount which is over $75,000 by 19% or 24% (5% Insurance Penalty) • $9,500 X 19% = $1,805 or 24% = $2,280 Add the results of a, b, c and d, then divide by 12 for the monthly reimbursement amount. D-385.5 MAABD APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25 Responsibilities of Eligibility Staff