Free Uniform Cost Sharing Plan - COP Cost-Share Worksheet 3 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-29322 (01/2009)

STATE OF WISCONSIN COP Cost-Share Worksheet 3 Wis. Stats. 46.27

UNIFORM COST SHARING PLAN 2009 COP COST-SHARE WORKSHEET 3
Use COP Cost-Share Worksheet 3 for · Single adult residents of substitute care · Married COP Applicant/Participant who lives in a CBRF or Adult Family Home and other spouse is not on COP · Minors who live in foster homes or group homes. See Collect. Users Manual Unit for parental contribution Note: If both spouses apply and both live in substitute care, use separate worksheets for each. If both spouses apply and only one lives in substitute care, use Worksheet 3 for the spouse who resides in substitute care and Worksheet 2 for the spouse who lives at home. Name ­ Applicant Date Completed Reviewed (check one)

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PART A. ASSESSMENT BASED ON RESIDENT'S INCOME - DHS 1.03(2)-(4) 1. 2. 3. 4. 5. 6. 7. Monthly earned income after income taxes and Social Security. If resident is a minor in school, enter zero. Enter the lesser of the amount in line 1 or $65. Subtract line 2 from line 1. Find HALF of line 3. Enter monthly Unearned Income from COP-DIA. Add lines 4 and 5. 7.

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1. 2. 3. 4. 5. 6.

Enter allowance for UNMET PERSONAL NEED. This is an agency set amount. For COP residents, the total allowances in lines 2 and 7 must be at least $65. Up to $240 may be approved by the county director. Include amounts needed to maintain the home for a planned return. 8. Health insurance and other medically related expenses paid by resident (see financial eligibility determination form--line 15 of COP-S; or line 14 of COP-M/2; or line 12 of COP-M/2 (YR1+). 9. If resident has a spouse, compute the allowance on the reverse side and copy the amount from line E, or enter court ordered spousal support--whichever is higher. If the resident has no spouse, enter ZERO. 10. If resident has children or other legal dependents, compute the allowance on the reverse side and copy amount from Line M or enter court ordered child support-- whichever is higher. If there are no children or other legal dependents, enter ZERO. 11. Other court ordered payments. 12. Total of lines 7 through 11. 13. Subtract line 12 from line 6. This is the assessment from the resident's income.

8.

9.

10. 11. 12. 13.

PART B. ASSETS OVER MEDICAID LIMIT - DHS 1.03(6) 14. Carry forward resident's share of ASSET amount from financial eligibility determination form ­ see line 3 of COP-S; or line 4 of COP-M/2; or line 2 of COP-M/2 (YR 1+). Use half of the asset amount for each spouse when they are both applying or participating. If amount on line 14 is more than zero, re-evaluate monthly. PART C. TOTAL ASSESSMENT. 15. Total lines 13 and 14. This reflects the resident's total assessment. 16. If adult, married resident cannot pay total care costs, complete Part D below. Carry forward spouse's assessment from Part D, line U. 17. Add lines 15 and 16. This is total assessment to apply to cost of care. If cost-share amount on this line exceeds monthly cost of care, the resident ­ though eligible for COP funds ­ must pay the full cost of care until line 17 is less than the cost of care. Minors: If a minor resident cannot pay total care costs, assess for parental support.

14.

15. 16. 17.

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F-29322

COP Cost-Share Worksheet 3

ALLOWANCE FOR RESIDENT'S SPOUSE (if the resident is married, complete this section to fill in line 9) A. Does resident's spouse live in an adult family home, nursing home, CBRF, or other institution? Yes. Enter zero on line E. No. Continue. B. Is resident's spouse any of the following: · A COP participant? Yes No · A Medicaid Waiver Participant? Yes No C. Enter maximum allowance. · If BOTH of the answers on line B are "no," enter $2739. · If EITHER of the answers in line B are "yes," enter $854. D. E. Enter the spouse's total average monthly income (earned and unearned). Subtract line D from line C. If the answer is zero or less, enter zero.

C.

D. E.

ALLOWANCE FOR RESIDENT'S CHILDREN AND OTHER DEPENDENTS (if the resident has children or other legal dependents, complete this section to fill in line 10). F. G. How many legally dependent children does resident have? How many other legal dependents does resident have? (Do not count resident's spouse). F. G. H. ____ x $583.33 = J. K. L. M. I.

H. Add lines F and G. I. J. K. L. M. Multiply the amount in line H by $583.33. Enter the total unearned income of resident's dependent children (Unearned income is defined in the instructions of Form COP-DIA, page 3). Enter all of the income of resident's other dependents. Add lines J and K. Subtract line L from the result in line I. If the answer is zero or less, enter zero.

PART D. SHOULD ADULT RESIDENT'S SPOUSE CONTRIBUTE TO COST-SHARE? N. Is Line D equal to or greater than $2739? (Does spouse have more than "community" spouse maximum allowance?) O. Enter the Total Unearned income of the spouse's dependent children not included in line J or K. (Unearned income is defined on page 3 of the instructions of Form COP-DIA), P. Enter all of the income of the spouse's and other dependents who are not included in line J or K.

O. P. Q. R. S. T. U.

Q. Find the total of lines D, L, O and P. R. Enter court ordered obligations paid by the persons whose income is included in line Q. S. T. Subtract line R from line Q. Enter number of persons in the family. Include spouse, spouse's dependents and resident's dependents.

U. Use the income in line S and family size in line T to find the amount that the spouse should be billed for resident's care. Use Uniform Cost-Sharing Plan (F-29324).

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