HCBS Income Worksheet Instructions

Refer to MAN 5600, Sections 2025, 2026, 2027 and 2028 for policy and procedure information regarding when to use this form.

Instructions

Completed for: Enter the Name of the Consumer/Client

AIMS ID: Enter the AIMS ID for the consumer named in “completed for”

Part A: Household Information

  • List the person listed above as “completed for”

  • List each individual living with the person listed above as “completed for” and who share resources and/or financial responsibility for the maintenance of the household (Refer to Section 2026)

Part B: Income Information

  • Sources of Monthly Income – Applicant/Recipient’s Statement of Amount

    • List amounts of monthly income for the Household

    • Refer to the Medicaid Manual (MAN 3480), found on ODIS under Family and Children Services, for treatment of Income (inclusion/exclusion, etc.)

  • Total Monthly Income = Add up the amounts on lines 1 – 12 to arrive at the total

  • (MINUS) – Enter the total amount of out of pocket health care, prescriptions, over the counter medications and CCSP cost share here. Itemize these costs, based on the client’s statement, on the reverse side of the Worksheet.

  • (EQUALS) – subtract the (MINUS) line from the Total monthly income line to determine the Adjusted Monthly Household income

Part C: Calculations

  • Step 1: Calculating Annual Income

    • Enter the Adjusted monthly household income from Part B

    • Multiply be 12 to determine the Total Annual Household income

  • Step 2: Determining the Fee

    • After Unit Cost for Service, enter the name of the service (ex: HDM, PSS, etc.)

    • After the $ sign, enter the unit cost for the service

    • After Per: enter the type of unit (ex: hour, day, unit)

  • Step 3: Percent of cost share

    • Enter the % from the current fee scale, found in Appendix K

  • Step 4: Amount of Cost Share

    • After Service, enter the name of the service (ex: HDM, PSS, etc.)

    • After the $ sign, enter the amount of the cost share, which is calculated by multiplying the unit cost for the service (Step 2) by the % from the fee schedule (Step 3)

Completed by: the Signature of the person completing the worksheet is entered here

Date: Enter the date the worksheet was completed

Routing: File a hard copy of this worksheet in the client file. The Client may be given a copy of this worksheet.