Free Formula to Determine Amount of Income Available to Pay for Room and Board in Substitute Care - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20920 (08/2008)

STATE OF WISCONSIN HFS 1

FORMULA TO DETERMINE AMOUNT OF INCOME AVAILABLE TO PAY FOR ROOM AND BOARD IN SUBSTITUTE CARE
Name ­ Applicant/Participant Today's Date

1. Total income from all sources 2. Discretionary Income (not less than $65) 3. Enter the difference between line 1 and line 2 here 4. Health insurance premium that the person pays out of pocket 5. Enter the difference between line 3 and line 4 here 6. Out of pocket medical/remedial expenses 7. Enter the difference between line 5 and line 6 here 8. Special exempt income 9. Enter the difference between line 7 and 8 here 10. Family Maintenance Allowance 11. Enter the difference between line 9 and line 10 here 12. Spousal income allocation 13. Enter the difference between line 11 and line 12 here 14. Cost Share or Spenddown obligation 15. Enter the difference between line 13 and line 14 here 16. Actual cost of room and board 17. Enter the difference between line 15 and line 16 here

F-20920 (08/2008)

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INSTRUCTIONS

1. Total income from all sources Resident's income from line A-10 of COP-DIA form (F-29314), or For Group A--amount from line 4 of F-20919 For Group B and Group C--from CARES screen ECSC or from Spousal Impoverishment Income Allocation Worksheet, Section C, Line 1 Note: Certain income sources that may have been disregarded in CARES (for example, VA Aid and Attendance) must be added back here under TOTAL Income. 2. Discretionary Income (not less than $65, or more, as defined in the county's COP plan) 3. Difference between line 1 and line 2 4. Health insurance premium (must be out of pocket from this participant's income; i.e., if spouse is paying the premium, do not use this deduction). Includes MAPP premium, if applicable 5. Difference between line 3 and line 4 6. Out of pocket medical/remedial expenses For all Group A For Group B--from line 19 of the Model Referral Form or CARES Screen ECSC For Group C married only--from line 20a of the Model Referral Form or Spousal Income Allocation Worksheet, Section C, Line 10 For Group C single, enter $0.00 7. Difference between line 5 and line 6 8. Special exempt income, if applicable: for Group A, obtain this amount from the participant or ESS; for all Group B and Group C married--from CARES ECSC screen; for Group C single--from CARES ECED screen. 9. Difference between line 7 and 8 For Group A--skip to line 15 and enter this amount on line 15 For Group B and Group C--enter amount here and continue to line 10 10. Family Maintenance Allowance, if applicable--from CARES ECSC screen 11. Difference between line 9 and line 10 12. Spousal income allocation--if applicable, for Group B or Group C, from Spousal Income Allocation Worksheet, Section C, line 4) 13. Difference between line 11 and line 12 14. Cost Share or Spenddown obligation For all Group B from CARES ECSC screen For Group C married only--amount from line 11, Spousal Income Allocation Worksheet For Group C single--Spenddown obligation from CARES ECED 15. Difference between line 13 and line 14 16. Actual cost of room and board in the facility (amount facility charges this resident for room and board). See BALTCR memo dated 5/15/2003 regarding Special Housing Amount for waiver participants. 17. Subtract line 16 from line 15 If amount on line 17 is a positive number, the participant has enough funds to pay for room and board in the facility. The participant pays only the room and board amount and keeps any remaining funds. If the amount on line 17 is a negative number, the participant does not have sufficient funds to pay entire room and board costs. Another, non-waiver, funding source must be used to supplement the participant payment.