Free Uniform Cost Sharing Plan - COP Cost-Share Worksheet - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-29319 (01/2009)

STATE OF WISCONSIN COP Cost-Share Worksheet 1 Wis. Stats. 46.27

UNIFORM COST SHARING PLAN 2009 COP COST-SHARE WORKSHEET 1
Use COP Cost-Share Worksheet 1 for: · All adult clients living in their own homes--Single or Married, or · A married couple, when both apply and both live at home (complete separate worksheets for each applicant/participant), or · A married couple, when only the spouse who lives at home applies and the other lives in an institution Name ­ Applicant Date of Application 1. 2. 3. 4. COPY the amount of countable assets from the financial eligibility determination form used to determine eligibility (line 3 of COP-S; or line 4 of COP-M/2; or half of the amount on line 2 of COP-M/2 (Yr 1+). SUBTRACT an additional $3000 allowance from line 1. Enter amount on line 2. If result is less than zero, enter zero. MULTIPLY amount on line 2 by 0.1666 to determine portion of assets to be added to income each month for 6 months. ENTER income amounts (refer to this Worksheet's instructions): a) COPY NET COUNTABLE INCOME of this applicant/participant from the last line of 4a. Calculation 3 of the Financial Eligibility Determination b) ENTER all income (gross) of the spouse living in the home. · If the spouse is institutionalized, enter zero. · If spouse is on Medicaid Waiver, deduct medical/remedial expenses from CARES 4b. screen from gross income. c) d) ENTER all unearned income of dependent children that comes into the home. ENTER all income of all other dependents, earned and unearned 4c. 4d. 4. 5.

1. - 3,000 2. 3.

TOTAL 4a through 4d and ENTER on line 4 5. 6 ADD lines 3 and 4 to determine MONTHLY COMBINED ASSETS/INCOME ENTER allowances for persons in the home that will be deducted from monthly combined assets and income: a) Choose one of the following allowances and ENTER it on line 6a. · Single participant, or if married and spouse is institutionalized, ENTER $854 · If married but spouse is not on COP or not on Medicaid Waiver, ENTER $2739 · If married and spouse is on COP, or is applying for COP, or is on Medicaid Waiver, or is applying for Medicaid Waiver, ENTER $1738 If amount on 6a is $2739, ENTER child support paid by client's spouse if any, on line 6b Allowance for children and other dependents*. The number of dependents ____ x $583.33 = ENTER court ordered amounts paid by persons in line 6c ENTER cost-share amounts paid by family members (see instructions)

6a. 6b. 6c. 6d. 6e. 6. 7. 8. 9.

b) c) d) e)

TOTAL 6a through 6e and ENTER on line 6 7. 8. SUBTRACT line 6 from line 5 to find monthly resources available for cost-sharing allowed by the State. ENTER special NON-MEDICAL expenses specified in the county's COP Cost-Sharing Plan--see COP-DIA, Part IV (#4). Medically related expenses or IRWEs deducted from income to determine eligibility should not be re-entered here. See instructions. SUBTRACT line 8 from line 7. Use this amount as the MAXIMUM MONTHLY PARTICIPANT CONTRIBUTION (Cost-share).

9.

* See instructions for definition of "dependent." REDETERMINE LINE 9 AT LEAST ONCE A YEAR, or when reportable changes occur. If line 2 and line 9 are BOTH more than ZERO, REDETERMINE IN SIX MONTHS.

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