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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 6 Student Earned Income Exclusion - $ 0.00 Eligible Spouse’s and Parent’s Deemed Earned Income + $ 0.00 Remaining General Deduction - $ 0.00 Earned Income Deduction - $ 65.00 Impairment Related Work Expense - $ 0.00 ½ Deduction - $ 370.00 Blind Work Expense - $ 0.00 Total Net Earned Income = $ 0.00 Total Countable Income (Total Net Unearned Income + Total Net Earned Income) = $ 1,786.20 Qualified Income Trust - $ 0.00 Net Countable Income

$ 1,786.20 Income Test Limit

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

Note: If the Income Budget Calculation was for Mrs. Moore’s eligibility determination, The COLA Disregard would be calculated using her SSI non-pay date, which was January 2020 of 0.810. Her COLA disregard would be $228 and his COLA disregard would be $190, which means Mrs. Moore’s total COLA Disregard will be $418 in her Income Budget Calculation.