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Aged, Blind and Disabled Manual Policy Manual Number: 115.020 Section: Categories of Eligibility Chapter: Pickle Passalong

January 05, 2026 Division of TennCare 5 Total Countable Income (Total Net Unearned Income + Total Net Earned Income) = $ 1,003.26 Qualified Income Trust - $ 0.00 Net Countable Income

$ 1,003.26 Income Test Limit

$ 1,450.00 Income Test Result PASS Patient Liability N/A The above budget is current as of October 2025.

Mr. Moore was an SSI and OASDI benefit recipient until December 2021, when his SSI eligibility ended due to an OASDI COLA. He and his wife live together with no children. Mrs. Moore was also an SSI and OASDI benefit recipient until January 2020, when her SSI eligibility ended due to an OASDI COLA. Mr. Moore has $1,000 in OASDI benefits. Mrs. Moore has $1,200 in OASDI benefits. Mr. Moore applies for medical assistance on August 1, 2025.

The COLA disregard for Mr. Moore’s Income Budget will use his SSI non-pay date. This means the December 2021 conversion factor of 0.821 will be used to determine how much can be disregarded from both Mr. Moore’s and Mrs. Moore’s Social Security income. His COLA disregard is $179 and her COLA disregard is $214.80, which means Mr. Moore’s total COLA Disregard will be $393.80 in his Income Budget Calculation. Mr. Moore’s net countable income of $1,786.20 is greater than the current SSI-FBR for a household of 2, $1,450. So, he is not income eligible for the Pickle Passalong category.

Income Budget Calculation

Unearned Income $ 2,200.00 Irregular Unearned Income Disregard - $ 0.00 In-Kind Support and Maintenance + $ 0.00 Ineligible Spouse’s Deemed Unearned Income + $ 0.00 Ineligible Parent’s Deemed Income + $ 0.00 General Deduction ($20) - $ 20.00 Child Support Disregard - $ 0.00 Widow/Widower Entitlement Disregard - N/A DAC Entitlement Disregard - N/A COLA Disregard

- $ 393.80

Total Net Unearned Income = $ 1,786.20 Self-Employment Income

$ 0.00 Applicant’s Earned Income + $ 0.00 Irregular Earned Income Disregard - $ 0.00