Free Initial Financial Eligibility Determination Worksheet for Married Applicants when One or Both Spouses Apply (COP) - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-29317 (01/2009)

STATE OF WISCONSIN COP-M/2 Wis. Stats. 46.27

INITIAL FINANCIAL ELIGIBILITY DETERMINATION WORKSHEET FOR MARRIED APPLICANTS WHEN ONE OR BOTH SPOUSES APPLY
Community Options Program (COP)
In order to comply with the waiver mandate, when a married individual or when both members or a couple apply for COP 100% State funding, they should be referred to the Income Maintenance Agency for determination of Medicaid eligibility. If they are not eligible for Medicaid, or if the waiver mandate does not apply, this Worksheet should be used when: · This is an initial application or an initial six-month review and only one spouse applies for COP and the other spouse is NOT institutionalized. When only one spouse applies, complete calculation 1 as instructed. Complete only one column (Spouse 1) in calculation 2, 3 and 4. After 12 months and thereafter use Form COP-S if only one spouse continues to be on COP, OR · This is an initial application or an initial six-month review and both spouses apply for COP. When both spouses apply, complete calculation 1 as instructed. Complete both columns (Spouse 1 and Spouse 2) in calculations 2, 3 and 4. After 12 months and thereafter use Form COP-M/2 (YR 1+) if both spouses continue participation in COP. Name ­ Spouse 1 Date of Application Name ­ Spouse 2 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 (0) on line 19 and on line 9 of COP Cost-Share Worksheet # 1. EXCEPTION: for individuals who live in substitute care, you must 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 (except MAPP and/or BadgerCare) but they do not currently participate. 2009 TABLE FOR COMMUNITY SPOUSE RESOURCE ALLOWANCE (CSRA) (Use this table to enter appropriate amount on line 2 of Calculation 1) If the total Asset Amount on the Declaration of Income and Assets and State Residency is: Community Spouse Asset Allowance (CSRA)
$ 0 - $ 50,000 $ 50,001 - $ 100,000 $100,001 - $ 219,120 Over $ 219,120 All $ 50,000 ½ of Combined Assets $ 109,560

1. 2. 3. 4.

CALCULATION 1: DETERMINE THE CSRA AND THE INDIVIDUAL ASSET ALLOWANCE Enter total asset amount listed on the Declaration of Income and Assets and State Residency (COP-DIA, line B-10) here. From the table above, choose the appropriate community spouse asset allowance (CSAA) Subtract line 2 from line 1. Enter result here. If result is zero, enter zero on this line and on line 4. Subtract $2,000 from the amount on line 3. This is the individual asset allowance for the applicant. If the result is a negative number, enter zero. (Note: If both spouses are applying, each spouse is allocated half of this amount on line 18) CALCULATION 2: COUNTABLE INCOME ENTER INCOME OF COP APPLICANT(S) ONLY Spouse 1 Enter monthly Gross Earned Income from COP-DIA, here. Deduct $65. If both spouses have income, each can claim the deduction. Divide amount on line 6 in half. Enter here. Enter monthly unearned income from COP-DIA Add lines 7 and 8. Enter here + + Page 1 of 2 Minus 65____ = Minus 65____ = Minus = Minus $2,000 =

Spouse 2

5. 6. 7. 8. 9.

F-29317 10. Bring forward amount from line 9. 11. Enter total out-of-pocket impairment related expenses from COP-DIA, Part IV. 12. Subtract line 11 from line 10. Enter result. This is the countable income. + +

COP-M/2

= = CALCULATION 3: DEDUCTIONS FROM COUNTABLE INCOME TO DETERMINE NET COUNTABLE INCOME (Obtain court ordered and medically related expenses from COP-DIA, Part IV) Spouse 1 Spouse 2

13. Enter applicant(s) total court ordered expenses, if applicable. 14. Enter applicant(s) total amount of out of pocket average for medically related expenses 15. Add lines 13 and 14. Enter result here. 16. Subtract amount(s) on line 15 from line 12. Enter result. This is the NET COUNTABLE INCOME CALCULATION 4: AMOUNT OF COUNTABLE RESOURCES Spouse 1 X6 17. Multiply number on line 16 by six. Enter result. 18. When both spouses apply, enter ½ of countable assets from line 4 for each applicant spouse. Otherwise enter the entire amount from line 4. 19 Add lines 17 and 18. Enter result. This is the amount of COUNTABLE RESOURCES used to determine if each spouse is eligible. For each spouse, is the amount on line 19 equal to or less than $39,554 (until June 30, 2009? Spouse 1: Spouse 2: Yes--Applicant is eligible for COP. Yes--Applicant is eligible for COP. No--Applicant is not eligible for COP. No--Applicant is not eligible for COP. = + = + Spouse 2 X6 + = + =

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If the applicant(s) are not eligible for COP, the agency may be aware of other factors that might make the person(s) eligible for Medicaid in six months if in the nursing home (i.e., private pay rate, therapies, medications). The relevant factors must be documented in the case file.

If the applicant(s) are eligible for COP, determine the cost-share liability by choosing the appropriate COP Cost-share Worksheet (See Financial Eligibility and Cost-Share Worksheets Guide).

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