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Aged, Blind and Disabled Manual Section: Categories of Eligibility Policy Manual Number: 115.030 Chapter: Widow/Widower Categories

March 18, 2019 Division of TennCare 4 In-Kind Support and Maintenance + $ 0.00 Ineligible Spouse’s Deemed Unearned Income + N/A Ineligible Parent’s Deemed Income + N/A General Deduction ($20) - $ 20.00 Child Support Disregard - N/A Widow/Widower Entitlement Disregard - $ 500.00 DAC Entitlement Disregard - N/A COLA Disregard - $ 0.00 Total Net Unearned Income = $ 180.00 Self-Employment Income

$ 0.00 Earned Income + $ 300.00 Irregular Earned Income Disregard - $ 0.00 Student Earned Income Exclusion - N/A Ineligible Spouse’s Deemed Earned Income + N/A Remaining General Deduction - $ 0.00 Earned Income Deduction - $ 65.00 Impairment Related Work Expense - $ 0.00 ½ Deduction - $ 117.50 Blind Work Expense - $ 0.00 Total Net Earned Income = $ 117.50 Total Countable Income (Total Net Unearned Income + Total Net Earned Income) = $ 297.50 Qualified Income Trust - N/A Net Countable Income

$ 297.50 Income Test Limit

$ 735.00 Income Test Result

PASS Patient Liability

N/A The above budget is current as of January 2017.