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Aged, Blind and Disabled Manual Policy Manual Number: 120.010 Section: Medicare Savings Programs Chapter: Qualified Medicare Beneficiary

January 5, 2026 Division of TennCare 4 Income Budget Calculation

Unearned Income $ 900.00 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 - $ 0.00 DAC Entitlement Disregard - $ 0.00 COLA Deduction - $ 0.00 Total Net Unearned Income = $ 880.00 Self-Employment Income

$ 0.00 Earned Income + $ 0.00 Irregular Earned Income Disregard - $ 0.00 Student Earned Income Exclusion - $ 0.00 Ineligible Spouse’s Deemed Earned Income + $ 0.00 Remaining General Deduction - $ 0.00 Earned Income Deduction - $ 0.00 Impairment Related Work Expense - $ 0.00 ½ Deduction - $ 0.00 Blind Work Expense - $ 0.00 Total Net Earned Income = $ 0.00 Total Countable Income (Total Net Unearned Income + Total Net Earned Income) = $ 880.00 Qualified Income Trust - $ 0.00 Net Countable Income

$ 880.00 Income Test Limit

$ 1,305.00 Income Test Result PASS Patient Liability N/A The above budget is current as of April 2025.

7. QMB and TennCare Medicaid Eligibility Individuals may be eligible for both TennCare Medicaid and QMB, with the exception of TennCare Standard. Only individuals with “grandfathered status” in TennCare Standard may be eligible for both TennCare Standard and QMB because TennCare Standard enrollees, other than those with grandfathered status, are not allowed to have access to third party insurance.

Applicants/enrollees may not receive benefits in more than one MSP.