Form H1042, Modified Adjusted Gross Income (MAGI) Worksheet

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Effective Date: 9/2019


Updated: 9/2019


To calculate monthly income for an individual under the MAGI rules.


Follow the five steps outlined below. Complete this form only for the people in the individual’s MAGI household who are applying for benefits. Each member of the household applying for benefits requires a separate MAGI worksheet, and the steps must be completed in numerical order.


Step 1: Determine an individual’s household composition.
Follow policy in A-240, Medical Programs, for determining the ;MAGI household composition.

Step 2: Calculate income for each person listed in step 1 in the individual’s MAGI household.
Fill in all applicable income and expenses for each person included in the individual’s MAGI household identified in Step 1, line 1.

Step 3: Determine if any person’s income is exempt.
Within an individual’s MAGI household, identify whether any person is a child (natural, adopted or step), regardless of age whose parent is included in the child’s MAGI household or whose MAGI household includes a parent (Part 1). List the names of those individuals.

Within an individual’s MAGI household, identify whether any person is a tax dependent included in the MAGI household of the taxpayer that claims the person (Part 2). List the names of those individuals.

If an individual meets the criteria for both Part 1 and Part 2, only include the individual in Part 1. If there are no individuals who meet the criteria for Part 1 or Part 2, proceed to Step 4 on page 7. If the identified individuals do not have any income, proceed to Step 4 on page 7.

If any individual in Part 1 has Social Security Benefits (SSBs), which includes RSDI or Railroad Retirement or any individual on Part 2 has SSBs and the taxpayer claiming the tax dependent is applying for medical assistance for themselves, use Table 3 to calculate the countable SSBs.

For each person identified in Part 1 and Part 2, complete Parts 7 to 11. Use a separate page for each individual.

Step 4: Determine the individual’s MAGI household income.
For each person in the individual’s MAGI household, calculate MAGI household income using Steps 2 and 3 on pages 1 to 6. Do not complete Step 4 for any individuals whose income does not count (as determined in Step 3).

  1. Add total income, self-employment income and disbursements.
  2. Subtract overpayments.
  3. Subtract expenses.
  4. Add together each person’s MAGI individual income to determine the total Eligibility Determination Group (EDG) MAGI income.
  5. Subtract the standard MAGI disregard (found in the standard MAGI disregard table) to obtain the MAGI household income.

Step 5: Determine MAGI financial eligibility.
Compare the MAGI household income to the income limit based on the applicable MAGI household size. MAGI household income must be less than or equal to the income limit of the applicable Medicaid program or Children’s Health Insurance Program (CHIP) for the applicable MAGI household composition size.

If the individual may be eligible for Medically Needy with Spend Down, determine the spend down amount. Only include income from the individual eligible for Medically Needy with Spend Down, and the individual’s parents or spouse if in the applicant’s MAGI household and their incomes have not been determined exempt.