Free Uniform Cost Sharing Plan - COP Cost-Share Worksheet 2 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-29321 (01/2009)

STATE OF WISCONSIN COP Cost-Share Worksheet 2 Wis. Stats. 46.27

UNIFORM COST SHARING PLAN 2009 COP COST-SHARE WORKSHEET 2
Use COP Cost-Share Worksheet 2 for a married COP participant living AT HOME when the AT-HOME participant's spouse is also on COP and lives in a substitute care facility. INSTRUCTIONS--Do the COP Cost-Share Worksheets in this order: After financial eligibility for COP has been established, first complete Worksheet 3 Parts A - C to determine cost share amount for COP participant in facility; then complete this Worksheet (2) to determine cost share for COP participant at home. Name ­ Applicant 1. 2. Date Completed Reviewed (check one)

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Copy half of the amount of countable assets from line 4 of COP-M/2 or half of the amount from line 2 of COP-M/2 (YR 1+), whichever form was used to determine Eligibility. Subtract an additional $3000 allowance from line 3. If the result is zero or a negative number, enter zero. 1. 2.

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­3,000 = 3. 4. 5. 6 7. 8.

3. 4. 5. 6. 7. 8.

Multiply line 2 by 0.1666 to determine the portion of assets to be added to income each month for six months. Enter AT-HOME-SPOUSE's countable income from line 12 of COP-M/2 or line 10 of COP-M/2 (YR 1+), whichever form was used to determine eligibility. Enter the portion of the amount from Worksheet 3, line 11, that is actually received by the AT-HOME COP recipient. Enter the portion of the amount in Worksheet 3, Line L that is RECEIVED BY persons in the home of the ATHOME COP recipient. Enter income of dependents of the AT-HOME COP recipient who live with the recipient, but are not dependents of the COP recipient in the facility. Find the TOTAL of lines 3 through 7.

SUBTRACTIONS AND COST SHARE AMOUNT 9. Enter the AT-HOME SPOUSE's share of the amount of average monthly medically related expenses from line 14 of COP-M/2 or line 12 of COP-M/2 (YR 1+), whichever form was used to determine eligibility. 10. 11. Budget allowance for AT-HOME SPOUSE. Enter $854 Enter allowance for other dependents who live with the AT-HOME SPOUSE, Count children and other dependents of both the COP participant in the facility and the AT-HOME SPOUSE. The number of dependents is____ x $583.33 Enter court ordered amounts payable by persons in the home. Enter other cost share amounts paid by family members in the home Find the total of lines 9 through 13.

9. 10. $854

11. 12. 13. 14. 15. 16. 17.

12. 13. 14. 15. 16. 17.

Subtract line 14 from line 8 to find monthly resources available for cost sharing allowed by the State. Enter the individual's special NON-medical expenses specified in the county's cost-sharing plan from COP-DIA, Part IV (#4). Medically related expenses entered on line 9 should not be reentered here. Subtract line 16 from line 15. Use this amount as the Maximum Monthly Participant Contribution.

REDETERMINE line 17 at least once a year. If lines 3 and 17 are BOTH more than zero, re-determine in six months.

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