Free Continuing Financial Eligibility Determination Worksheet for Married Participants - Both on COP - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-29318 (01/2009)

STATE OF WISCONSIN COP-M/2 (YR 1+) Wis. Stats. 46.27

CONTINUING FINANCIAL ELIGIBILITY DETERMINATION WORKSHEET FOR MARRIED PARTICIPANTS ­ BOTH ON COP
Community Options Program (COP)
In order to comply with the Waiver mandate, COP 100% State funded married applicants/participants should be screened yearly for Medicaid eligibility (unless the waiver mandate does not apply). If the married participants are not eligible for Medicaid, or if the waiver mandate does not apply, this Worksheet should be used when this is a yearly review and both spouses are participating in COP. Name ­ Spouse 1 Name ­ Spouse 2 Date of Application Date of Application

ELIGIBILITY BASED ON SIX-MONTH RESOURCE ESTIMATE If the individual is categorically eligible for Medicaid, the individual has no cost-share. Enter zero on line 18 and on line 9 of COP CostShare 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 (except MAPP and/or BadgerCare) but they do not currently participate. CALCULATION 1: DETERMINE ASSET ALLOWANCE FOR SPOUSES Enter total asset amount listed on the Declaration of Income and Assets and State Residency (COP-DIA, line B-10). Subtract $4000 (= 2000 individual allowance for each participant spouse) from amount on line 1. Enter result here (if the result is a negative number enter zero). This is the amount of total countable assets for the participants. On line 17, each spouse is allocated half of this amount. CALCULATION 2: COUNTABLE INCOME Spouse 1 3. 4. 5. 6. 7. 8. 9. Enter monthly Gross Earned Income from COP-DIA. Enter $65. If both spouses have earned income, each spouse can claim the deduction. Subtract line 4 from line 3. Enter result. Divide amount on line 5 in half. Enter here. Enter monthly Unearned Income from COP-DIA. Add line 6 and line 7. Enter result. Enter out-of-pocket impairment related work expenses from COP-DIA. = = = = Minus 65 = Minus 65 = Spouse 2

1. 2.

Minus =

4000.00

10. Subtract line 9 from line 8. Enter result. This is the countable income.

CALCULATION 3: DEDUCTIONS FROM COUNTABLE INCOME TO DETERMINE NET COUNTABLE INCOME (Obtain court-ordered and medically related expenses from Form COP-DIA, Part IV) Spouse 1 Spouse 2 11. Enter participant(s) total court ordered expenses. 12. Enter amount of out of pocket average for medically related expenses. 13. Add lines 11 and 12. Enter result. = 14. Subtract amount on line 13 from amount on line 10. This is the NET COUNTABLE INCOME. = + +

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F-29318

COP-M/2 (YR 1+)

CALCULATION 4: AMOUNT OF COUNTABLE RESOURCES TO DETERMINE ELIGIBILITY Spouse 1 15. Bring forward amount from line 14. x6 16. Multiply number on line 15 by 6. Enter result. 17. Enter ½ of countable assets from line 2 for each applicant spouse. 18. Add lines 16 and 17. Enter result. This is the amount of COUNTABLE RESOURCES used to determine if each spouse is eligible. = + = + x6

Spouse 2

=

=

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.

If the participants 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., costly private pay rate, therapies, medications, etc.) The relevant factors must be documented in the case file.

If the participants 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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