Cost Share
Section 1. Spousal Information
Section 2. Monthly Income (Amounts auto-fill from Financials - Income, Financial - Expenses, and Cost Share and Medicaid Thresholds and Schedules)
| Monthly Income Source | Client (A) | Spouse (B) | Couple/Total (C) |
|---|---|---|---|
| 1A. Total Social Security. | |||
| 2A1. Medicare Part A Premium (Columns A & B auto-fill); Column C = A + B) | |||
| 2A2. Medicare Part B Premium (Columns A & B auto-fill); Column C = A + B) | |||
| 2A3. Net Social Security (Row 2A – Row 2A1 – Row 2A2); Note Part D Premium is not subtracted | |||
| 2B. Pension/Retirement: (Columns A & B auto-fill); Column C = A + B) | |||
| 2C. Interest: (Columns A & B auto-fill); Column C = A + B) | |||
| 2D. Dividends: (Columns A & B auto-fill); Column C = A + B) | |||
| 2E. Other Income (Columns A & B auto-fill); Column C = Sum of Rental Income, Salary/Wages, Self-employment, Other Income from Financials – Income form) | |||
| 2F. Total Monthly Income (Sum of Row 2A3 thru Row 2E) | |||
| 2G. Non-applicable spouse's income unavailable for mutual needs: (Auto-fill) | |||
| 2H. Total Monthly Income for Cost Share (Row 2F – Row 2G) | |||
| 2I. Cost Share Monthly Income Threshold (Auto-fill); If Row 2H is less than Row 2I, the Fee Rate is 0% |
Section 3. Housing (Auto-fill amounts are from Financial - Expenses)
| Monthly Housing Expenses | Total Amount ($) |
|---|---|
| 3A. Rent: (Auto-fill) | |
| 3B. Mortgage: (Auto-fill) | |
| 3C. Maintenance/Common Charges: (Auto-fill) | |
| 3D. Electricity: (Auto-fill) | |
| 3E. Gas: (Auto-fill) | |
| 3F. Oil: (Auto-fill) | |
| 3G. Water/Sewage: (Auto-fill) | |
| 3H. Telephone: Basic phone service only. No Internet or data plans. Must choose cell or landline, not both. If no phone, enter $0 | |
| 3I. Property Taxes (in NYC school taxes are part of property tax) | |
| 3J. Other: Keep house home physically habitable such as snow/garbage removal, yard cleaning, etc. If no other expenses, enter $0 | |
| 3K. Monthly Housing Total: (Average Total) (Sum of Rows 3A thru 3J) |
Section 4. Housing Adjustment (Auto-fill amounts are from Cost Share and Medicaid Thresholds and Schedules)
| Housing Adjustment | Client (A) |
|---|---|
| 4A. Housing Adjustment Threshold: (Auto-fill) | |
| 4B. Excess Housing Expenses: (Row 3K – Row 4A). If the Housing Adj. Threshold (Row 4A) is greater than the Monthly Housing Exp. (Row 3K), client is not eligible for a housing adj. | |
| 4C. Net Monthly Income: (Row 2H) (Auto-fill) | |
| 4D. Housing Adjusted Amount: (Either Row 4A or 4B, whichever is less) | |
| 4E. Net Monthly Income Minus Excess Housing Expenses (Row 4C – Row 4D) | |
| 4F. Monthly Income Threshold: (Auto-fill) | |
| 4G. Adjusted Monthly Income (Maximum Monthly Fee): (Row 4E – Row 4F) |
Section 5. Cost Share
5A. Authorized Monthly Services (Auto-fill amounts are from client's care plan/service plan)
| Service Type * | Auth. Weekly Units * | Estimated Monthly Units | Unit Cost | Monthly Cost |
|---|---|---|---|---|
| Monthly Cost Calculation | Total Amount ($) |
|---|---|
| 5B. Total Monthly Cost for Authorized Services: (Row 5A, Column E) (Auto-fill) | |
| 5C. Fee Rate % | % |
| 5D. Monthly Fee: (Row 5B × Row 5C) | |
| 5E. Maximum Monthly Fee: (Row 5B) | |
| 5F. Monthly Cost Share: (Either Row 5D or 5E, whichever is less; also if last amount is negative, then it will be converted to Zero) |
Section 6. Monthly Contribution – A contribution is requested ONLY from clients who do not pay a cost share.
| Requested Monthly Contribution (Per Hr. Home Care Rate × Estimated Monthly Units) |
Any apply client's household?
Section 1. Resources (Amounts auto-fill from Financial – Income and Cost Share and Medicaid Thresholds and Schedules)
| Resources | Client (A) | Spouse (B) | Couple (C) |
|---|---|---|---|
| 1A. Checking Accounts: (Auto-fill) | |||
| 1B. Savings Accounts: (Auto-fill) | |||
| 1C. Stocks, Bonds, Mutual Funds: (Auto-fill) | |||
| 1D. Other Cash and Liquid Assets: (Auto-fill) | |||
| 1E. Total Liquid Assets: Sum of Row 1A thru Row 1E | |||
| 1F. Real Property: (Auto-fill) Market value of second home, land, or rental property. Exclude primary home and one automobile | |||
| 1G. Burial Fund:(Auto-fill) | |||
| 1H. Face Value of Life Insurance: (Auto-fill) Enter amount only if the face value of all policies is LESS than $1500 per person | |||
| 1I. Cash Value of Life Insurance: (Auto-fill) Enter only if the cash value of all policies is GREATER than $1500 | |||
| 1J. Total Adjusted Liquid Assets: (Row 1E + Sum of Rows 1F thru Row 1I) Term life insurance is excluded from this calculation and does not count as a resource | |||
| 1K. Medicaid Allowable Resources Limit: (Auto-fill) If amount in Row 1J is greater than Row 1K, client appears ineligible for Community Medicaid |
Section 2. Income (Amounts auto-fill from EIGEP Cost Share, Financial – Expenses and Cost Share and Medicaid Thresholds and Schedules)
| Income | Client (A) | Spouse (B) | Total (C) |
|---|---|---|---|
| 2A. Monthly Income: (Auto-fill from EIGEP Cost Share – Row 2F) | |||
| 2B. Income Exclusion – (Auto-fill) Amount is the same regardless of number of persons in the household | |||
| 2C. Health Insurance Premium – Auto-fill. Do not include Medicare Part A or B | |||
| 2D. Monthly Prescription Insurance Premium – Auto-fill. Includes ERC, etc. | |||
| 2E. Other Insurance Premiums – Auto-fill: Dental, Vision, Long term care. Do not include Medicare Part A and B Premiums | |||
| 2F. Monthly Income (Net): (Row 2A – Sum of Rows 2B thru 2E) | |||
| 2G. Monthly Medicaid Income Level: (Auto-fill) | |||
| 2H. Excess Income: (Row 2F – Row 2G) |
Section 3. (Amounts auto-fill from EIGEP Cost Share, Financial – Expenses)
| Monthly Medical Expenses | Client (A) | Spouse (B) | Total (C) |
|---|---|---|---|
| 3A. Monthly Cost of Medicable Reimbursable Services: (Auto-fill) | |||
| 3B. Other Medical Expenses – Auto-fill: Includes recurring medical expenses such as medical equipment rental, co-pay, prescriptions, etc. | |||
| 3C. Total Medical Expenses: Row 3A + Row 3B | |||
| 3D. Difference between Excess Income (Row 2H) and Total Medical Expenses (Row 3C) |