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-- Customer do not have to request the maintenance allowance for their spouse/dependents. The case manager will automatically request the information necessary to determine the maintenance allowance when there is a spouse or dependents at home. 3. Family Allowance (Spousal Impoverishment) Family members must be a dependent child, dependent parent(s) or dependent sibling(s). The child, parent or sibling must be residing in the home of the community spouse and claimed by the community spouse or institutionalized spouse as dependent(s) for federal income tax purposes. The amount determined to be the family allowance is deducted from the institutionalized spouse's countable income effective with the first month in which the continuous period of institutionalization is met, or if this deduction was not previously allowed, the deduction will be allowed effective the first month following the month in which the change is reported. The family allowance deduction need not be determined if the $154 personal needs allowance, in combination with the community spouse monthly income allowance, makes the patient liability zero. Obtain verification of each family member's gross income. a Subtract the family member's gross income from minimum needs allowance (150% of poverty). b Divide the amount from above by three. This is one family member's allowance. Repeat this calculation for each family member. If there is more than one family member, add each family member's allowance to determine the total family allowance deduction. 4. Dependent Allowance (Non-Spousal Impoverishment) The dependent allowance is a monthly income allowance for each dependent family member living in the institutionalized individual’s home with no community spouse living in the home. Determine the dependent allowance by subtracting the dependent's total income from the Need Standard (100% Need Standard) for the household size. 5. Expenses Incurred For Health Insurance Premiums, Deductibles and Co– Insurance Charges Deduct health insurance premiums, deductibles and co–insurance expenses incurred by the customer. Customers/Representatives must advise the agency of medical insurance and provide proof of expenses. These expenses must not be paid or subject to payment by a third party. F-120.5 LONG TERM CARE SERVICES Patient Liability Budgeting Procedures – Form2220 EM/A Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25