JACC COST SHARE WORKSHEET - New Jersey



JACC Cost Share Worksheet Instructions

Purpose: To detail steps required to completion of the JACC Cost Share Worksheet.

|Line |Item |Instruction |

| |Participant |Enter participant name |

| |Participant ID # |Enter 12 digit JACC identification number |

| |Cmgr. Site |Enter the 4 digit case management site number |

| |Cmgr #: |Enter the 7 digit case manager number |

| |Income |Enter amount either in monthly or annual columns. Remaining columns may be used for calculation purposes. |

| |Social Security Retirement |Enter the amount of Social Security Retirement Benefit (net) |

| |Social Security Disability |Enter the gross amount of Social Security Disability Benefit (net) |

| |Pension Benefits |Enter the gross amount of any pension received by the client. These may be from former employment or |

| | |widow/er |

| |Interest Bearing Accounts |Enter the gross amount of interest earned from any source including saving and checking accounts, CD’s IRA’s,|

| | |stock/bonds, etc. |

| |Veteran’s Administration |Enter the gross amount of Veteran’s Benefit. |

| |Benefits | |

| |Alimony |Enter the gross amount of alimony. If payments are not received regularly, average the amount received during|

| | |the previous 3 month period. |

| |Earnings, Salary, Tips |Enter the gross amount of wages, salary, and tips earned. |

| |Worker’s Compensation |Enter the gross amount of worker’s compensation received. |

| |Net Rental Income |Enter net amount of rental income from properties owned by the participant less the costs associated with |

| | |producing the income (except depreciation). |

| |Unemployment benefits |Enter the amount of unemployment compensation received by the participant. |

| |Income of Spouse |Enter the income of the spouse. |

| |Disability Income |Enter any income from disability insurance other than Social Security. |

| |Other Income |Enter amount from all other sources, such as gambling winnings, etc. |

| |Total |Add items 6 through 18 and enter the sum |

JACC Worksheet Instructions, Continued

| |Deductions |Deductions are items that may be subtracted from the total income for the purposes of calculating co-pay. |

| | |Co-pay calculations for a couple include the deductions for both persons. |

| |Supplemental Medical Insurance|Enter the premium of any medical insurance policies held in addition to Medicare A & B, unless using the |

| | |standard deduction. |

| |Prescribed Medical Expenses |Enter the amount paid for services/items prescribed for the client and spouse by his/her physician that were |

| |not reimbursed by insurance |not eligible for reimbursement by Medicare or any supplemental or alternate insurance policy the participant |

| | |holds. A receipt is to be provided for each service/item used as deduction. |

| |CEP Insurance Deduction |Insert the amount paid for the liability and worker’s compensation coverage as required of a participant |

| | |employing a CEP. |

| |Subtotal Deductions |Add items 21 and 22, enter the sum or standard deduction. |

| |Income minus deductions |Subtract line 23 from line 19 and enter the remainder. |

| |Amount of Co-Pay due |Enter the monthly Co-Pay from Co-Pay table. |

| |JACC participant |The participant signs and dates the form. |

| |Case Manager |The case manager signs and dates the form. |

In completing the Co-Pay Worksheet, “Individual” or “Couple”, as appropriate, shall be circled on the co-pay table to make it easier for the worksheet to be reviewed for correctness.

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