DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20919 (08/2008)
STATE OF WISCONSIN Re: 42 CFR 435
MEDICAID WAIVER ELIGIBILITY AND COST SHARING WORKSHEET
Application Check One: Name - Applicant Name - Care Manager Completion of this form meets the requirements of the Federal Regulations 42 CFR 435. Review/Recertification Change Medicaid ID Number Medicaid Eligibility Date Name Income Maintenance Worker (IMW) IMW No. Date
SECTION I FINANCIAL RESOURCES (Complete for all Applicants)
1. Nonexempt Assets 2. Gross Earned Income 3. Total Unearned Income 4. Total Income (2 + 3) $ $ $ $
SECTION IV FOR GROUP C MEDICALLY NEEDY
1. Gross Earned Income (2) 2. $65 and ½ Disregard 3. (1 2) 4. Total Unearned Income (3) 5. (3 + 4) 6. $20 Disregard 7. Balance (5 6) 8. Special Exempt Income 9. Countable Income (7 8) 10. Health Insurance Premium 11. Balance (9 10) 12. Excess Self Employment Expense 13. Balance (11 12) 14. Monthly Medical/Remedial Expenses Obtain this figure from care manager 15. Balance (13 14) 16. Medicaid Card Coverable Services $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Group A (Applicant is currently eligible for Medicaid) Care Manager checks eligible category and completes sections II and V for the following types: SSI Recipient SSI-E 1619a 1619b Katie Beckett Other Medicaid Eligibility: Income Maintenance Worker writes in Type and Category Code: Other Medicaid Type (Specify) ________________________________ CARES Category code (Specify)_____________________________________ NOTE: This form may be used by IMW for a Group B or Group C applicant only if the applicant is institutionalized at the time of application. Group B Special Income Limit (IMW completes Sections III and V) Group C Medically Needy (IMW completes Sections IV and V)
SECTION II SPECIAL DECLARATION REGARDING DIVESTMENT FOR GROUP A WAIVER APPLICANTS WHO RECEIVE SSI, SSI-E, 1619a, 1619b, OR KATIE BECKETT
Care Manager: Ask the applicant both of the following questions: 1. "Have you or your spouse sold, traded, transferred or given away property, land stocks, bonds, cash, vehicles, or anything of value in the past 36 months?" "Have you or your spouse created a trust or added funds to a trust within the last five years?" Yes. Complete F-20919D and Refer applicant to Income Maintenance Worker for investigation and determination. After Income Maintenance Worker makes determination, proceed to Section V. No. Proceed to SECTION V.
17. Balance (15 16) $ If the Balance on line 17 is greater than the current medically needy income limit, the applicant is not eligible for Medicaid Waivers. Proceed to line 18 with all eligible Group C Applicants.
SECTION III COST SHARING/GROUP B UNDER "SPECIAL INCOME LIMIT." When Spousal Impoverishment Protections Apply, Substitute "Income Allocation Worksheet" for Section III
1. 2. Total Income Personal Maintenance Allowance (Compute on Page 2 and Enter Here) Family Maintenance Allowance (Compute on Page 2 and Enter Here) Special Exempt Income Health Insurance Premium Out of Pocket Medical/Remedial Expenses Obtain this figure from care manager. Total Deductions ( 2 + 3 + 4 + 5 + 6) Waiver Cost Share Amount (1 7) The amount on line 8 is monitored and documented by the care manager. Proceed to Section V. $ $
SPENDDOWN DETERMINATION FOR ALL ELIGIBLE GROUP C APPLICANTS
18. Balance (from line 13) 19. Current Medically Needy Income Limit $ $
20. Spenddown Amount (18 19)
4. 5. 6.
$ $ $
The amount on line 20 must be incurred by the applicant on a monthly basis to sustain eligibility. This is monitored and documented by the care manager. Now complete an Income
Allocation Worksheet for all spousal impoverishment cases. Proceed to Section V.
$ $ DATE NEXT MA REVIEW DUE - Reviews must be completed every 12 months
F-20919 Page 2
SECTION V STATEMENT OF ELIGIBILITY. COMPLETE FOR ALL MA WAIVER APPLICANTS. (Check One) Applicant is eligible as a Group A. Applicant is not eligible for waiver services as a Group A for ____ months due to Divestment. Applicant is eligible as a Group B with no cost share. Applicant is eligible as a Group B with a monthly cost share of $__________. Applicant is eligible as a Group B married, spousal impoverishment rules apply, with a monthly cost share of $_________ (from Spousal Income Allocation Worksheet). Applicant is eligible as a Group C with no spenddown. Applicant is eligible as a Group C with a monthly spenddown liability of $__________ (Line 20). Applicant is eligible as a Group C married, spousal impoverishment rules apply, by incurring a monthly spenddown of $________ (Line 20) and monthly cost share of $__________ (from Spousal Income Allocation Worksheet) Applicant is not eligible under Group C not medically needy.
ALLOWANCE DETERMINATIONS FOR SECTION III
PERSONAL MAINTENANCE ALLOWANCE CALCULATION Add the amounts in a, b, and c. Enter the total personal maintenance allowance on page 1, Section III, line 2. This total must not exceed $___________ (figure adjusts annually). a. Basic Needs Allowance Everyone is allowed the basic needs allowance $_________ FAMILY MAINTENANCE ALLOWANCE CALCULATION Calculate the family maintenance allowance and enter it on page 1, Section III, line 3, using formula a or b. a. For AFDC-related households in which the waiver participant is the custodial parent of minor child(ren) living in the household and there is no spouse in the household: $_________ $_________
b. Earned Income Disregard $_________ People who have earned income are allowed an additional $65 & half of the remaining income. c. Special Housing Amount $_________ [Reference Medicaid Handbook 184.108.40.206.1(3)] The special housing amount is an amount of the person's income set aside to help pay certain high housing costs. If the housing costs listed below are over $350 per month, the waiver applicant may be eligible for the special housing amount. Special Housing costs include only the following: a. Rent b. Insurance c. Mortgage d. Property Tax (includes special assessments) e. Utilities (heat, water, sewer, electricity) f. Rent in an Adult Family Home, CBRF, or RCAC.
(1) Minor children's gross earned income (2) Enter $65 & half of gross earned income (Reference Medicaid Handbook 220.127.116.11) (3) Subtract (2) from (1) (4) Minor children's total unearned income (5) Add (3) and (4)
$_________ $_________ $_________
$_________ $_________ $_________ $_________ $_________ $_________
(6) Enter AFDC related medically needy income limit $_________ (Reference Medicaid Handbook 8.1.4) (Group size is the number of minor children in the household. Do not include the waiver applicant.) (7) If (5) is greater than (6), there is no family maintenance allowance. If (5) is less than (6), the family maintenance allowance is the difference between (5) and (6). b. For households in which there are no minor children living in the household and there is a spouse in the household but spousal impoverishment policies do not apply. $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________
Add together all housing costs. If the amount is more than $350 per month, the special housing amount equals monthly housing costs minus $350. If both members of a couple are applying and both have income, and they reside together in the same residence, divide the housing amount equally between them. If only one spouse of a couple has income and both are applying, and they reside together in the same residence, allocate the full housing amount to the spouse with income. Note: The special housing amount does not apply to waiver participants under the age of 18 years.
(1) Spouse's gross earned income (2) Enter the first $65 & ½ of total gross earned income (3) Subtract (2) from (1) (4) Spouse's total unearned income (5) Add (3) and (4) (6) Enter $20 disregard (7) Subtract (6) from (5) (8) Enter the SSI-E payment level for 1 person (figure adjusts annually)
If (7) is greater than (8) there is no family maintenance allowance. If (7) is less than (8) the family maintenance allowance is the difference between (7) and (8).