Free Uniform Cost Sharing Plan Instructions, COP Cost-Share Worksheet 1 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-29320 (01/2009)

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

UNIFORM COST SHARING PLAN INSTRUCTIONS COP COST-SHARE WORKSHEET 1
COMMUNITY OPTIONS PROGRAM (COP)
Use COP-WORKSHEET 1: · For all adult clients living in their own homes (single or married), OR · For a married couple, when both apply and both live at home (complete separate worksheets for each) · For a married couple, when the spouse who lives at home applies or participates in COP and the other spouse is institutionalized Lines 1 through 3 If the amount copied onto line 1 is a positive number, subtract an additional allowance of $3000 at line 2. For any amount remaining after the additional disregard, count one-sixth (1/6) of the remainder as an add-on to monthly income. Amount on line one is copied from the applicable Financial Eligibility Determination Form. See line 3 of COP-S; or line 4 of COP-M/2 (if both spouses apply, use half for each spouse); or half of the amount on line 2 of COP-M/2 (Yr 1+). - 3,000 1. SUBTRACT an additional $3000 allowance from line 1 and enter amount on line 2. If result is less than zero, enter zero. 2. MULTIPLY result on line 2 by 0.1666 to determine portion of assets to be added to income each month for six (6) months.

Lines 4a through 4d. These lines pull together all the countable income of the participant and of the adult participant's family. Enter only the income amounts that are requested. 4a. COPY NET COUNTABLE INCOME of the applicant/participant from the last line of Calculation # 3 of the Financial Eligibility Determination Worksheet used to determine eligibility for this applicant/participant and ENTER here. ENTER all gross income of spouse who lives in the home (If the spouse is institutionalized, enter zero). If the spouse is not on a Medicaid Waiver, enter gross income before reductions for taxes and/or Medicare. If the spouse is on a Medicaid Waiver, reduce gross income by the out-of-pocket amount of medical/remedial expenses listed on CARES. A "dependent child" is any child under the age of 18 OR a child over the age of 18 who is a student and who depends on parents for at least half of his or her support. A dependent child should be counted if in the home or away at school. Enter only the UNEARNED INCOME of dependent children. See unearned income list on page 2 and 3 of the Instructions for the Declaration of Income and Assets and State Residency (COP-DIA-Instr.) "Other dependents" are relatives who: · are related to either spouse by being one of the following: child, stepchild, parent, stepparent, grandparent, brother, stepbrother, sister, stepsister, grandchild, mother-in-law, or, if related by blood, uncle, aunt, nephew, niece, and · depend on the person for at least half of his or her support, and · have income of less than $2000 per year (not including public assistance benefits or non-taxable Social Security). Note: An "other dependent" need not live in the household. Enter ALL income, earned and unearned of these "other dependents."

4b.

4c.

4d.

Line 5. 5. ADD lines 3 and 4 to determine monthly combined assets/income Lines 6a through 6e 6a. SELECT the appropriate allowance from the list provided at 6a. The larger allowance is an attempt to gain consistency with the Spousal Impoverishment Allowances of the Medicaid program. 6b. 6c. Follow instruction given in COP Cost-Share Worksheet 1. Each child and/or other dependent receives an allowance based on spousal impoverishment provisions. Do not enter an allowance for the participant's spouse here. Follow instruction given in COP Cost-Share Worksheet 1. If family is paying a cost share to another program, such as the Family Support Program or another Uniform Fee System service, enter those cost share amounts on this line. Do not enter medically related expenses reported elsewhere. Total of lines 6a through 6e. Page 1 of 2

6d. 6e.

6.

F-29320

COP Cost-Share Worksheet 1 ­ INSTR.

Lines 7 through 9. 7. SUBTRACT line 6 from line 5 to find monthly resources available for cost-sharing allowed by the State. 8. This line is provided as an optional allowance for expenses that the county permits under its local decision # 1 of the COP CostSharing Plan. See the Declaration of Income and Assets (COP-DIA), Part 4. These are expenses that are needed to help a person remain in the community. These expenses must be non-medical and non-work related. If both spouses are applying, allow half of these deductions for each spouse, unless the expense relates specifically to one spouse (e.g., special clothing needs). Some examples include: · Life insurance premiums · Property Taxes · Specialized non-work/non-medically related transportation · Special high rent situations (accessible housing, or energy efficient housing, etc.) · Energy Assistance (needed to maintain a special temperature in the house) Special telephone equipment or service · · Special clothing needs This is a partial list. IRWEs deducted from income or medically related expenses should be entered under Calculation 3 of the Financial Eligibility Determination Worksheet used to determine eligibility and should not be repeated on line 8. 9. Subtract the amount on line 8 from line 7. Enter the result on line 9. This is the Maximum Monthly Participant Contribution (costshare). The county cannot charge the participant or his/her family to contribute more than this amount toward the cost of care.

See policy on Adjustment to Prevent Hardship (attached) if the cost-share does not take into account unusual expenses for the client or the family.

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