STATE OF WASHINGTONDEPARTMENT OF SOCIAL AND HEALTH SERVICESAging and Long-Term Support AdministrationHome and Community Services Division

PO Box 45600, Olympia, WA 98504-5600

HCS MANAGEMENT BULLETIN

H20-103 – Information

December 15, 2020

TO:

Home and Community Services (HCS) Division Regional Administrators

Developmental Disabilities Administration (DDA) Regional Administrators

Area Agency on Aging (AAA) Directors

FROM:

Bea Rector, Director, Home and Community Services Division

Shannon Manion, Director of the Division of Field Services, Developmental Disabilities Administration

SUBJECT:

January 2021 Changes with COLA

PURPOSE:

To notify staff of their responsibilities regarding client payments for services starting January 1, 2021.

BACKGROUND:

Many clients are required to pay toward the cost of their care before the Department pays for services. The Department determines this amount for all long-term care services.

HCS and DDA residential clients, other than Adult Protective Services (APS) residential clients, pay toward their cost of room and board. HCS staff: see Chapter 8 - Residential Services, in the Long-Term Care Manual for details on room and board. DDA staff: see DDA Policy 6.06 Client Responsibility for details on room and board. The client’s total contribution for room and board and the cost of their personal care services is indicated on the provider’s authorization in ProviderOne. Clients receive correspondence from ProviderOne that reflects their social service authorizations and details related to applied client responsibility.

WHAT’S NEW, CHANGED, OR CLARIFIED:

Effective January 1, 2021, the following benefits will increase:

· Social Security Benefits by 1.3%

· Railroad Retirement (RR) and Veteran’s (VA) Benefits by 1.3%

· Some pensions, such as federal civil service pensions by 1.3%

Effective January 1, 2021, the following standards will increase:

· Special Income Level (SIL)

· Categorically Needy Income Level (CNIL)

· Medically Needy Income Level (MNIL)

· Federal Benefit Rate (FBR)

· Maintenance allowance for in-home waiver recipient with community spouse

· Residential room and board standard

· Community spouse maintenance allocation

· Federal spousal resource transfer maximum

· Home Equity Limit

· Medical Institution Personal Needs Allowance (PNA)

· HCS and DDA Waiver Residential PNA

Effective January 1, 2021:

· ACES will:

· Auto update SSA and SSI income amounts for most clients.

· Recalculate client responsibility for January 2021 and generate COLA letters and translations, if necessary, for HCS and DDA waivers, PACE, SSI-related residential MPC, CFC, and Roads to Community Living clients.

· ACES will not:

· Generate a letter for any clients receiving MAGI-based coverage who receive MPC or CFC in a residential setting.

· Generate a letter for any clients active on Medical Care Services (A01/A05) coverage group in a residential setting.

VA and RR benefits must be manually updated in ACES. Clients with cases requiring manual updates will receive a postcard reminder (see attached memo) in early January advising them to report their new income amounts.

The personal needs allowance (PNA) for clients living in medical institutions and residential settings increases from $70.00 to $71.12 per month.

The new room and board amount for all HCS and DDA residential settings is $722.88. This amount is determined by using the following formula of the Federal Benefit Rate: $794 - $71.12 PNA = $722.88. Current residential authorizations with R&B rate of $713 are automatically updated to $722.88 by ProviderOne by January 1, 2021 for clients in the following programs:

· SSI-related residential MPC

· CFC

· HCS and DDA waivers

· PACE

· Roads to Community Living

Service authorizations must be entered before the month of service begins for Client Responsibility to calculate correctly and send the correct letters timely to clients and providers.

ACTION:

Action Required by Case Managers:

· Calculate and update client responsibility using the calculator attached below on the financial screen in CARE for clients on the following programs:

· HCS Waivers/MPC/CFC Fast Track

· DDA and HCS MAGI-based coverage groups (N-track) in residential settings

· DDA and HCS Non-citizens on the ABD Cash/HEN programs (A01/A05)– AFH

· DDA and HCS State-funded LTC Program for Non-Citizens if receiving MAGI coverage (N21 and N25 coverage groups) in residential settings

· DDA State Funded Group Homes

· Send the Client Responsibility Notice (DSHS 18-720 for HCS or DSHS 18-692 for DDA) to these clients informing them of the amount they have to pay for room and board.

· If the client is active on basic food or cash, the social service specialist must verify the income by looking at the income verified in ACES.

· If the client is only active on a MAGI-based program, the case manager may use the client’s self-attested income found in ACES online on the client level screen under Health Plan Finder Income.

Action Required by Public Benefit Specialists:

· Manually update cases for clients:

· Who have Veteran’s, Railroad Retirement, or SSA/SSI benefits that were not auto updated by ACES.

· With a community spouse with income that needs to be updated.

Note: Adhoc reports in Barcode can be printed for the Veteran's and Railroad Retirement pensions. A Barcode tickle has been sent for SSA/SSI clients not auto updated by ACES (COL3).

· Update Food Stamp Medical Expense for at-home HCS or DDA waiver clients who pay client responsibility in excess of $35.00 and receive Basic Food.

· Update room and board (R&B) exception to rule (ETR) amounts for a monthly maintenance needs allowance (MMNA), update the spouses unearned income type of AN (MMNA ETR Amount) as well.

RELATED REFERENCES:

ATTACHMENT(S):

January 2021 Medical Income and Resources Standards Chart:

Manual Updates Memo:

Medical Coverage Group Chart:

January 2021 Client Responsibility Calculator

CONTACT(S):

Jennifer Ferguson, Office Chief, LTC Financial Eligibility & Policy

(360) 725-3406

jennifer.ferguson@dshs.wa.gov

Marcell Birdsall, Unit Manager, DDA LTC and Specialty Program Teams

(360) 407-1576

marcell.birdsall@dshs.wa.gov

Graham Zuch, HCS ACES Program Manager

(206) 341-7781

graham.zuch@dshs.wa.gov

Dustin Quinn Campbell, Payment Policy and Systems Unit Manager

(360) 725-2535

dustin.quinncampbell@dshs.wa.gov

Lonnie Keesee, DDA Eligibility and Payment Systems Unit Manager

(360) 407-1547

Lonnie.Keesee@dshs.wa.gov

January 2021 WAH

Income & Resource Standards.pdf

WASHINGTON APPLE HEALTH INCOME AND RESOURCE STANDARDS January 1, 2021 Changes Modified Adjusted Gross Income (MAGI) and SSI-related

PROGRAM STANDARDS (4/1/2020) 1 2 3 4 5 6 7 8 9 10 11+

Family (N01) 511 658 820 972 1127 1284 1471 1631 1792 1951 N/A

133% FPL - New Adult (N05) 1415 1911 2408 2904 3401 3897 4394 4890 5387 5884 497

193% FPL - Pregnancy (N03/N23) N/A 2773 3494 4214 4935 5655 6376 7096 7817 8538 721

210% FPL - Children (N11/N31) 2233 3017 3801 4585 5369 6153 6937 7721 8505 9289 784

260% FPL - Take Charge 2765 3736 4706 5677 6648 7618 8589 9560 10530 11501 971

260% FPL - CHIP T1 (N13/N33) $20 premium 2765 3736 4706 5677 6648 7618 8589 9560 10530 11501 971

312% FPL - CHIP T2 (N13/N33) $30 premium 3318 4483 5648 6812 7977 9142 10307 11472 12636 13801 1165

HWD (S08) No upper income limit

Include an unborn child in the household size for family and pregnancy medical AU’s

MNIL STANDARD (1/1/21) 794 794 794 794 858 975 1125 1242 1358 1483 1483

MN RESOURCES 2000 3000 3050 3100 3150 3200 3250 3300 3350 3400 50

INSTITUTIONAL STANDARDS

Amount

Medicaid Special Income Level (SIL) (1/1/21) $2,382

DDA PNA at home (1/1/21) $2,382

Cash PNA ALF $38.84

Cash PNA Medical Institution $41.62

PNA State Veterans Home Maximum $160

All other PNA Med Inst. (1/1/21) $71.12

HCS & DDA Waivers, CFC & MPC PNA in ALF (1/1/21) $71.12

HCS & DDA Waivers, CFC & MPC R&B in ALF (1/1/21) $722.88

HCS Waivers at home PNA with CS (1/1/21) $794

HCS Waivers at home PNA without CS (4/1/20) $1,064

Housing Maintenance Allowance Maximum (4/1/20) $1,064

CS Maintenance Needs Allowance Maximum (1/1/21) $3,260

CS & Dependent Allowance (7/1/20) $2,156

Standard Utility Allowance (10/1/20) $449

CS Excess Shelter (7/1/20) $647

Home Equity Limit (1/1/21) $603,000

TSOA Resources (9/7/17) $53,100

TSOA Resources with CS (7/1/19) $111,175

State Spousal Resources (7/1/19) $58,075

Federal Spousal Resource Maximum (1/1/21) $130,380

Daily Private NF Rate (10/1/20) $346

Monthly Private NF Rate (10/1/20) $10,526

Monthly State NF Rate (10/1/20) $7,149

MEDICARE SAVINGS PROGRAM – Alternate financial eligibility standards 4/1/2020

People in the Household 1 2 3 4 5 6 7 8 9 10 11+

QMB Income – 100% FPL (S03) 1,064 1,437 1,810 2,184 2,557 2,930 3,304 3,677 4,050 4,424 374

SLMB Income – 120% FPL (S05) 1,276 1,724 2,172 2,620 3,068 3,516 3,964 4,412 4,860 5,308 448

QI-1 Income - 135% FPL (S06) 1,436 1,940 2,444 2,948 3,452 3,956 4,460 4,964 5,468 5,972 504

QMB, SLMB, QI-1 Resources 7,860 11,800, if two spouses

QDWI - 200% FPL (S04) 2,172 2,874 3,620 4,367 5,114 5,860 6,607 7,354 8,100 8,847 747

QDWI Resources 4,000 6,000, if two spouses

Note: Internal staff use the charted dollar amounts that reflect net income after deductions allowed under each program. For MAGI programs (N groups), gross income limits are 5% more and maybe higher after allowed deductions. For non-MAGI (classic) programs, gross income is reduced by $20, in addition to other allowed deductions. For example, after adding the $20 to be deducted for MSP, gross income limits are for QMB: $1,084 and $1,457; for SLMB: $1,296 and $1,744; for QI-1: $1,456 and $1,960; and for QDWI: $2,192 and $2,894.

SSI/CNIL STANDARDS (1/1/21)

Single Eligible

Eligible Couple

CNIL INCOME 794 1,191

FBR (SSI Standard) 794 1,191

1/2 FBR 397 --

SHARED LIVING FBR 530 794

SSI RESOURCES 2,000 3,000

MEDICARE SAVINGS PROGRAMS (4/1/2020) People

1 2 QMB Income – 100% FPL (S03) 1,064 1,437

SLMB Income – 120% FPL (S05) 1,276 1,724

QI-1 (ESLMB) Income - 135% FPL (S06) 1,436 1,940

QDWI - 200% FPL (S04) Must be employed for eligibility 2,127 2,874

QMB, SLMB, QI-1 Resources (1/1/20) QDWI Resources

7,860 4,000

11,800 6,000

MEDICARE STANDARDS 1/1/2021 Part A Premium: 40+ work quarters = Free Part A; <40 but >29 work quarters = $259; <30 work quarters = $471

Part B Premium

$148.50

Part A Deductible: Inpatient Hospital = $1,484 per benefit period

Part B Deductible $203

Part A coinsurance for Inpatient hospital $371 per day for 61st - 90th day; $742 per day for over 90 days

Part A coinsurance for NF $185.50 per day for 21st - 100th day

Substantial Gainful Activity (SGA) 1/1/21

Non-Blind Blind

$1,310 $2,190

January 1 2021 Cost

of Living Adjustment (COLA) and Requirement for Manual Case Updates.pdf

Page 1Page 2

COLA Attachments A

B.pdf

Page 1Page 2

Medicaid Programs -

LTSS Chart.doc

Desk Aid – Medical Coverage Groups Used in LTSS

Program Category and what agency usually maintains the program

ACES

Description

Scope

HCB Waiver

CFC

MPC

MAC d

TSOA e

NF short stay b

(If not managed care or Medicare days).

Institutional b

30 days or more

SSI and SSI-related

(non-institutional)

Aged/Blind/Disabled (ABD) category

Disability is determined by SSA, or by NGMA referral to DDDS

CSD financial staff manage S track cases unless the client is receiving LTSS through DDA or HCS.

See below for S08/HWD

S01

SSI Recipients Categorically Needy (CN)

CN

a

a

x

x

S02

SSI-related

CN

a

a

x

x

S03

QMB Medicare Savings Program (MSP).

Medicare premiums, copayments, coinsurance, deductibles.

MSP

Pays Medicare co-insurance days as a claim if QMB eligible. No application required for NF if medicare co-insurance days only, on QMB & no other service is needed. No NFLOC is needed to submit a claim for Medicare days in a NF. If on QMB only, must have an application for NF coverage.

S04

Qualified disabled working individual (QDWI).

Medicare Part A premiums.

MSP

S05

Specific low-income Medicare beneficiary (SLMB).

Medicare Part B premiums.

MSP

S06

Qualified individual (QI-1).

Medicare Part B premiums.

MSP

S07

SSI-related Alien Emergency Medical (AEM).

Emergency Related Service Only (ERSO).

ERSO

Hospital, cancer, or end stage renal

S95

SSI-related Medically Needy (MN) no spenddown.

MN

x

S99

SSI-related with spenddown.

MN

If SD met and shows active.

SSI-related

(non-institutional)

Living in an alternate living facility (ALF) - AFH, AL or DDA group home.

G03 Maintained by HCS or DDA LTC staff.

G03

Income under the special income level (SIL) & under state rate x 31 days + $38.84.

Only used for MPC and BHO placements.

CN

a

x

G95

ALF private pay no spenddown.

Income under the SIL, and under the private rate.

MN

x

G99

ALF private pay with spenddown.

Income under the SIL, but over the private rate.

MN

If SD met

SSI-related/ABD

(non-institutional)

Healthcare for Workers with Disabilities (HWD)

Maintained by HCS if on HCS services or DDA LTC team if not on HCS services.

S08

Premium based program. Substantial Gainful Activity (SGA) not a factor in disability determination.

CN

x

x

x

x

x

HCB Waiver (institutional)

SSI or SSI-related 1915(c) waivers authorized by HCS or DDA

Aged/Blind/Disabled (ABD) category

Disability is determined by SSA, or by NGMA referral to DDDS

HCS/DDA LTC financial staff maintain L track cases.

L21

SSI recipients

CN

x

x

x

L22

SSI-related.

DDA – income at or below SIL

HCS – income < effective MNIL (182-515-1508)

CN

x

x

x

L24

Undocumented Alien / Non-Citizen LTC.

Must be preapproved by HCS (Natalie.Lehl@dshs.wa.gov ).

State-funded CN (SFCN) scope.

Community component of SFCN program.

SFCN

State-funded personal care based on NFLOC criteria. Financial Eligibility based on HCB Waiver rules. In home or state funded services in an ALF.

If in NF 30 days or more, change to L04 program.

WAC 182-507-0125. Natalie Lehl must pre approve the state funded long-term care for non-citizen program. NGMA IS NEEDED IF NOT AGED/BLIND

SSI and SSI-related

(non-institutional) PACE, or Hospice

HCS/DDA LTC financial staff maintain L track cases.

L31

SSI recipient on PACE; or

SSI recipient in institution on hospice (do not change S01 to L31 for hospice outside of an institution).

CN

NF services included in PACE.

Hospice services provided in institutions.

L32

SSI-related PACE or hospice as a program.

PACE is managed care (no CFC or HCB waiver with PACE).

CFC or HCB waiver with hospice only.

Hospice + HCB waiver will trickle to L22 as priority program.

CN

x

x

x hospice only

NF services included in PACE

Hospice services provided in institutions.

SSI and SSI-related Roads to Community Living (RCL)

HCS/DDA LTC financial staff maintain L track cases.

L41

SSI recipient on RCL.

CN

x

L42

SSI-related RCL.

365 day medical upon approval by social services.

Must be receiving Medicaid on day of institutional discharge.

CN

x

SSI and SSI-related Community First Choice (CFC)

HCS/DDA LTC financial staff maintain L track cases.

L51

SSI recipient on CFC or MPC

CN

x

x

x

L52

SSI-related CFC or MPC. L52 includes S02 and G03 eligibility rules with and without spousal impoverishment.

CN

x

x

x

SSI and SSI-related (institutional)

In a medical institution for 30 days or more.

Aged/Blind/Disabled (ABD) category

Disability is determined by SSA, or by NGMA referral to DDDS

HCS/DDA LTC financial staff maintain L track cases.

L01

SSI recipient

CN

x

L02

SSI-related.

Income under the SIL.

CN

x

L04

Undocumented Alien / Non-Citizen LTC.

Must be preapproved by HCS (Natalie.Lehl@dshs.wa.gov )

State-funded CN (SFCN) scope.

Institutional component of SFCN program.

SFCN

x

NGMA IS NEEDED IF NOT AGED/BLIND

L95

SSI-related no spenddown

Income over the SIL, but less than the state rate.

MN

x

L99

SSI-related with spenddown

Income over the state rate, but under the private rate.

Client participation locked to state rate.

MN

Eligible for services, but client pays all cost of care

MAGI (institutional)

Only used for individuals not eligible under non-institutional MAGI through the HPF.

Maintained by HCA

K01

Categorically Needy Family in Medical Institution

CN

x

K03

AEM in Medical Institution.

ERSO

Hospital, cancer or end stage renal.

K95

LTC Medically Needy no Spenddown in Medical Institution

MN

x

K99

LTC Medically Needy with Spenddown in Medical Institution

MN

If SD met

Pregnancy/Family Planning

Maintained by HCA

P02

Pregnant 185% FPL & Postpartum Extension

CN

P04

Undocumented Alien Pregnant Woman

CN

P05

Family Planning (FP) Service

FP

P06

Take Charge

FP

P99

Pregnant Women & Postpartum Extension

MN

If SD met

Refugee Medical Assistance (RMA)

R03

Refugee medical is referred by HCA to CSD if the client is not eligible for a MAGI program due to income

CN

X

X

X

X

Foster Care/JRA

Maintained by HCA

D01

SSI Recipient FC/AS/JRA Categorically Needy

CN

x

x

x

x

D02

FC/AS/JRA Categorically Needy

CN

x*

x

x

x

D26

Title IV-E federal foster care – under 26

CN

x*

x

x

x

MAGI

Maintained by HPF/HCA

N01

Parent / caretaker

CN

x

x

x

Pays as a claim (no award letter). Instructions in NF billing guide.

N02

12 month transitional parent / caretaker

CN

x

x

x

N03

Pregnancy

CN

x

x

x

N05

Adult alternative benefits plan (ABP) (age 19-64)

ABP

x

x

x

N10

Newborn medical birth to one year

CN

x

x

N11

Children's (age under 19)

CN

x

x

N13

Children's Health Insurance Program (CHIP) (age under 19)

CN

c

c

N21

AEM parent / caretaker

ERSO

Hospital, cancer or end stage renal

N23

Pregnancy; not lawfully present – CHIP funded. Covers personal care through the end of the pregnancy

CN

***

No

Yes

No

Pays as a claim (no award letter)

N25

AEM (age 19-64)

ERSO

Hospital, cancer or end stage renal

N31

Non-citizen children's (age under 19)

SFCN

x**

x**

Pays as a claim (no award letter)

N33

Non-citizen CHIP (age under 19)

SFCN

x**

x**

Medical Care Services (MCS)

Medical eligibility through eligibility for HEN or ABD Cash

Maintained by CSD unless client is on HCS LTSS. HCS takes over cases when in a NF 30 days or more or if in state funded residential.

A01

ABD legally admitted persons in their 5-year bar or otherwise ineligible due to their immigration status. LTSS include state-funded residential and NF.

MCS

x**

x

x

A05

Incapacitated legally admitted persons in their 5-year bar or otherwise ineligible due to their immigration status. LTSS include state-funded residential and NF.

MCS

x**

x

x

Breast and Cervical Cancer

Program

HCA maintains

S30

Breast and Cervical Cancer (Health Department approval)

CN

x

x

x

X

Tailored Supports for Older Adults (TSOA)

HCS maintains TSOA cases.

T02

Pre-Medicaid benefit for the caregiver of a person 55 or older to support the caregiver. For those not eligible for a CN or ABP Medicaid program and not needing or eligible for other LTSS services because of resources. Must meet NFLOC. No Medicaid service card is issued with TSOA. Program is effective 7/1/2017

x

This is a desk tool used by Aging and Long Term Supports Administration (ALTSA) field staff that has all the medical coverage groups/programs in Washington and what Home and Community Service can be authorized under that medical program if functionally eligible.

x – Service covered under the medical coverage group. Be sure to look at notes and comments.

a – This is provided under L51 for SSI recipients or L52 for SSI-related recipients. S01 and S02 clients are financially eligible for CFC or MPVC; and once financial is notified services have opened under CFC or MPC, the FSS will change the case to a L51 or L52. In addition, G03 rules are built into L52.

b – All NF admissions for skilled or rehabilitation are the responsibility of the managed care entity if enrolled and must be pre-approved by the managed care plan

c – CHIP is Title XXI, and not eligible for Title XIX CFC/MPC, or MAC due to age. There is a CFC/MPC “look-alike” service for Title XXI eligible individuals

d – MAC is Medicaid Alternative Care to provide supports for an unpaid caregiver. The financial requirement of this program are similar to MPC in that the client must be eligible for a CN or ABP medical program. A person cannot get MPC, CFC or HCB Waiver and MAC at the same time. A CN client can be on a MSP and receive MAC. The client must be age 55 or older.

e – Although TSOA is a separate coverage group – “T02” – a person can be MN/non-full scope Medicaid and receive T02. For example, S03 and T02 or S99 and T02. A client on CN or ABP can be considered for MAC if the client is not interested in CFC/MPC. The client must be age 55 or older.

* Must have disability, resource, and income determination for HCB Waiver services. (HCB Waiver services can be used for individuals on cash assistance or foster care as long as a disability determination has been established and the financial worker must keep the assistance unit (AU) as a foster care AU. Until cash assistance is de-linked from the medical assistance, the cash AU must be used in ACES.

** State funded program, not technically CFC/MPC, but does provider similar levels of personal care and services.

*** N23 is a pregnancy medical program paid for under CHIP dollars for the unborn child and currently is not included in the inclusion table for CFC or MAC. 10/2019 clarification from HCA indicates N23 covers MPC but not MAC or CFC.

Acronym

Definition

ABP

Alternative Benefits Plan – Scope of care for the N05/Expanded adult group

AH

Apple Health. Washington Apple Health. General term for all medical coverage including MAGI, Classic Medicaid, MCS, Institutional and HCB Waiver medical

Classic

Medicaid programs that are not determined by the Health Benefit Exchange. These programs did not change with the Affordable Care Act (ACA). Classic programs are those who are age 65 or older and those under age 65 who are disabled or blind and not on Medicare. It also includes foster care medical, institutional, Home and Community Based (HCB) Waiver and state funded Medical Care Services (MCS).

CN

Categorically Needy

ERSO

Emergency Related Services Only for Alien Emergency Medical (AEM)

FP

Family planning service

MAC

Medicaid Alternative Care Provide for unpaid caregivers who support a person on CN or ABP medicaid eligible but who do not currently access traditional LTSS services, (like MPC or CFC). Although the financial eligibility is the same as MPC, a person can’t get both MPC and MAC at the same time. There is no state funded caregiver support program in ACES like there is for in P1/CARE for MPC. For someone who is not eligible for TSOA or MAC, refer to the AAA offices for the state funded program. The state funded caregiver support program is not in ACES or CARE. This program is effective 7/1/2017

MAGI

Modified Adjusted Gross Income. This is a methodology used by the Health Benefit Exchange

MCO

Managed Care Organization

MCS

Medical Care Services (state-funded medical assistance)

MN

Medically Needy

MPC

Medicaid Personal Care

MSP

Medicare Savings Program

NF

Nursing Facility

RMA

Refugee Medical Assistance

SD

Spenddown

SF

State-funded

SFCN

State-funded with state funded CN scope of care

TSOA

Tailored supports for older adults. This is a pre-medicaid CN/ABP medicaid benefit. A person cannot be on CN/ABP medicaid and get TSOA (we could considered MAC for those on CN/ABP). Medicaid coverage is not included in the TSOA medicaid package, although a person could be on a MSP or MN program and receive TSOA benefits. If not financially eligible for TSOA, there is a state funded program through the AAA offices. This program is effective 7/1/2017

Revision 5/2020

The current version of this chart is on the financial eligibility and policy (FEP) SharePoint under “for the field” https://teamshare.dshs.wa.gov/sites/hcs/FP/SitePages/default.aspx

5/2020

MAGI & A01-A05

Client Responsibility Calculator 2021.xlsx

MAGICLIENT RESPONSIBILITYMAGI

Enter Data in the Shaded Cells

Client NameMonthCase Manager Name

Full Month

Earned Income$0.00Allowable DeductionsUnearned IncomePayee$0.00Balance$0.00Guardianship fees$0.00PNA (Standard)$71.12Court Costs$0.00Balance$0.00Medical Expenses$0.00Deductions$0.00Total$0.00Balance$0.00Room & Board$0.00Total Client Responsibility$0.00

Partial Month - Pro-Rated

Participation Paid$0.00Room & Board Paid$0.00Total Client Responsibility Paid$0.00Number of days in facility0Daily Room & Board Rate$23.43Total Pro-Rated Cost$0.00Pro-Rated Client Responsibility$0.00Amount Reimbursed to the client$0.00NOTES

ABD CashCLIENT RESPONSIBILITYGO3 CALCULATOR

Enter Data in the Shaded Cells

Client NameMonthCase Manager Name

Full MonthAllowable DeductionsPayee$0.00Earned Income$0.00Guardianship fees$0.00Unearned Income$197.00Court Costs$0.00Balance$197.00Total$0.00PNA ($62.79)$38.84Balance$158.16Participation$0.00Room and Board rate$672.21Deductions$0.00Room and Board payment$158.16Total Client Responsibility$158.16

Partial Month - Pro-Rated

Client Responsibility Paid$158.16Number of days in facility0Client Daily Rate$0.00Total Pro-Rated Cost$0.00Pro-Rated Client Responsibility$0.00Amount Reimbursed to the client$158.16NOTES

AO1-AO5CLIENT RESPONSIBILITYABD Income CALCULATOR

Enter Data in the Shaded Cells

Client NameMonthCase Manager Name

Full MonthEarned Income$0.00Allowable DeductionsUnearned Income$0.00Payee$0.00Balance$0.00Guardianship Fees$0.00PNA$38.84Court Costs$0.00Balance$0.00Medical Expenses$0.00Deductions$0.00Total$0.00Balance$0.00Room & Board Pmt$0.00Balance$0.00 $0.00$0.00Participation Pmt$0.00Total Client Responsibility$0.00

Partial Month - Pro-Rated

Participation Paid$0.00Room & Board Paid$0.00Total Client Responsibility Paid$0.00Number of days in facility0Client Daily Rate$0.00Total Pro-Rated Cost$0.00Pro-Rated Client Responsibility$0.00Amount Reimbursed to the client$0.00NOTES

Change logClient Responsibility Worksheet (for Program Manager use only)Step 1Unearned IncomeAmountSSASSDIDACVAOtherTotalStep 2DeductionsAmountPNA + $20 (starting 1/1/20 increase total PNA to $70.00 w/ no $20)70Payee/GuardianUncovered MedicalOther Guardianship CostsTotalStep 3Countable Unearned IncomeAmountSubtract Step 2 from Step 1Step 4Earned IncomeAmountTotalSubtract$65BalanceDivide Balance by 2Step 5Retained IncomeSubtract the calculated amount from the total income. This is the Retained Income

Room and Board CalculationCountable Unearned Income (from Step 3)Earned Income (total)Step 6Income Available for R&B (sum of Earned and Countable Unearned)Room and BoardAmountEnter Monthly R&B rate713if Income Available is greater than the monthly R&B rate, client pays total R&B to the providerIf Income Available is less than the monthly R&B rate, client pays Income Available to the providerParticipation CalculationStep 7Total IncomeAmountEarned IncomeUnearned IncomeTotalMinus DeductionsBalanceMinus R&B PaidBalanceMinus Retained IncomeBalanceIf this amount is 0 or less, no participation is due. If this amount is greater than 0, this amount is paid to the provider for participation (in addition to the Room and Board amount.)

Step 8Total Client Responsibility (Room & Board and Participation)

2008 Changes and Corrections - 11/20/07SSI = 637HCS PNA = 60.78R&B = 576.22Corrected SSI worksheet to allow $20 disregard for both earned or unearned - linked to total income over SSI standard.2008 Changes - 7/1/2008HCS PNA = 62.78R&B = 574.22DDD PNA = 41.44GO3 PNA = 41.44 + 202009 Changes - 1/1/2009SSI increase to $674HCS PNA = 62.79R&B = 611.21DDD PNA (combined w/ $20 to match HCS) = 62.79GO3 PNA = 62.79NOTES box expands to allow needed comments2012 Changes - 1/1/2012SSI increase to $698R&B = 635.212013 Changes - 1/1/2013SSI increase to $710R&B = 647.212014 Changes - 1/1/2014SSI increase to $721R&B = 658.21corrected G03 calculator2015 Changes - 1/1/2015BKSSI increase to $733R&B = 670.212017 Changes - 1/1/2017BKSSI increase to $735R&B = 672.212018 Changes - 1/1/2018BKSSI increase to $750R&B = 685.952019 Changes - 1/1/2019BKSSI increase to $771R&B = 701.002019 Changes - 12/19/18Updated calculator for current rulesLK2020 Changes 12/9/2019AASSI increase to $783R&B = 713.002021 Changes 12/1/2020AASSI increase to $794R&B=722.88PNA= 71.12