Page 5

Aged, Blind, and Disabled Manual Policy Manual Number: 115.015 Section: Categories of Eligibility Chapter: Institutional Medicaid

January 5, 2026 Division of TennCare 5 If the individual fails the income eligibility determination, then the individual must be provided with the opportunity to establish a QIT. If the individual is able to establish a QIT, her income eligibility will be tested again.

c. Example Budget Mr. Mason was admitted to a nursing home and is applying for medical assistance. He is 64 years old and receives $2,800 in Social Security per month. He also receives $800 per month from a pension. Since his monthly income total is determined to be above the MIC, he must establish a QIT to qualify.

Income Budget Calculation

Unearned Income $ 3600.00 Irregular Unearned Income Disregard + N/A In-Kind Support and Maintenance + N/A Ineligible Spouse’s Deemed Unearned Income + N/A Ineligible Parent’s Deemed Income + N/A General Deduction ($20) - N/A Child Support Disregard - N/A Widow/Widower Entitlement Disregard - N/A DAC Entitlement Disregard - N/A COLA Disregard - N/A Total Net Unearned Income = $ 3600.00 Self-Employment Income

$ 0.00 Earned Income + $ 0.00 Irregular Earned Income Disregard - N/A Student Earned Income Exclusion - N/A Ineligible Spouse’s Deemed Earned Income + N/A Remaining General Deduction - N/A Earned Income Deduction - N/A Impairment Related Work Expense - N/A ½ Deduction - N/A Blind Work Expense - N/A Total Net Earned Income = $ 0.00 Total Countable Income (Total Net Unearned Income + Total Net Earned Income) = $ 3600.00 Qualified Income Trust - $ 2800.00 FPL 250% Disregard N/A Net Countable Income

$ 800.00 Income Test Limit

$ 2313.00 Income Test Result PASS The above budget is current as of February 2019.