Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-29316 (01/2009)

STATE OF WISCONSIN COP-S Wis. Stats. 46.27

INITIAL AND/OR CONTINUING FINANCIAL ELIGIBILITY DETERMINATION WORKSHEET FOR A `SINGLE' APPLICANT/PARTICIPANT Community Options Program (COP)
This Worksheet should be used for each "Single" applicant/participant. The definition of "Single" includes: 1) an individual who is unmarried, separated (with or without legal documentation), divorced or widowed, or 2) an individual whose spouse resides in an institution, or 3) an individual who is on COP for one year or longer and whose spouse is not on COP or COP-W. Waiver Mandate applies if the Applicant/Participant is currently eligible or would be found eligible for Medicaid. Consult with your Income Maintenance Agency about potential Medicaid eligibility. If the individual is eligible for Medicaid and the waiver mandate applies, process as a waiver case only. If the individual is not eligible for Medicaid and/or if the waiver mandate does not apply, continue. Name ­ Applicant / Participant Date of Application

ELIGIBILITY BASED ON SIX-MONTH RESOURCE ESTIMATE If the waiver mandate does not apply, and the individual is categorically eligible for Medicaid, the individual has no cost-share. Enter zero on line 20 below and on line 9 of COP Cost-Share Worksheet # 1. Exception: for individuals who live in substitute care, determine cost-share using appropriate worksheet (see COP Financial Eligibility Forms Guide). Categorical eligibility means that the person is eligible for one of the following: SSI and/or SSI State Supplement, SSI-related programs, SSI-E or any other full benefit Medicaid (except MAPP, BADGERCARE and Family related Medicaid, e.g., AFDC or AFDC related). SSI-related cases include those situations such as "503", DAC, and Widow Widower cases. Check with Income Maintenance Worker to determine if the person is covered by any of these programs. The person is also categorically eligible if his/her income and assets are low enough to meet eligibility criteria for any full benefit Medicaid program but they do not currently participate. CALCULATION 1: COUNTABLE ASSETS Enter Total Assets from Declaration of Income & Assets and State Residency (COP-DIA). Deduct $2000 Asset Allowance for a Single Individual. Enter result. This is the amount of countable assets. CALCULATION 2: COUNTABLE INCOME Enter monthly Gross Earned Income from COP-DIA. Subtract $65 from amount on line 4. Enter result . Divide amount on line 6 in half. Enter result. Enter monthly Unearned Income from COP-DIA. Add line 7 and 8. Enter result. Enter total out-of-pocket impairment related work expenses from COP-DIA (Part IV).

1 2 3 4 5 6 7 8 9 10

Minus =

2,000

Minus = + =

65

11 Subtract amount on line 10 from amount on line 9. Enter result. = 12 If participant receives a spousal income allocation, enter it on this line. If there is no spousal income allocation, enter zero (0). 13 Add line 11 and line 12. Enter result. This is the COUNTABLE INCOME. = CALCULATION 3: DEDUCTIONS FROM COUNTABLE INCOME TO DETERMINE NET COUNTABLE INCOME (Information for lines 14 and 15 comes from Part IV of Form COP-DIA) 14 Enter participant's total court-ordered expenses. 15 Enter participant's total amount of out of pocket average for medically related expenses. + 16 Add lines 14 and 15. Enter result. = 17 Subtract amount on line 16 from amount on line 13. Enter result. THIS IS NET COUNTABLE INCOME. CALCULATION 4: AMOUNT OF COUNTABLE RESOURCES 18 Multiply number on line 17 by 6. Enter result. X6= 19 Enter amount of countable assets from line 3 + 20 Add lines 18 and 19. This is the amount of COUNTABLE RESOURCES. =

Now determine if applicant/participant is eligible. See question on page 2.
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F-29316 For each adult applicant/participant, is the amount on line 20 equal or less than $39,554 (until June 30, 2009)? For each child applicant/participant, is the amount on line 20 equal to or less than $162,607 (until December 31, 2009)? Yes--The applicant/participant is eligible for COP. If the applicant is eligible for COP, determine the cost- share liability by choosing the appropriate COP Worksheet (see Financial Eligibility Forms Guide ­ first attachment after memo). No--The applicant/participant is not eligible for COP

COP-S

Note: If the applicant is not eligible for COP, the agency may be aware of other factors that might make the person eligible for Medicaid in six months because of exceptional expenses in a nursing home (i.e., costly private pay rate, therapy, medications). The relevant factors must be documented in the individual's file.

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