WORKSHEET A – HOUSEHOLD INCOME/ RESPITE ALLOCATION
WORKSHEET A – HOUSEHOLD INCOME/RESPITE ALLOCATION | |
|Completed for all consumers at case opening, annually thereafter, or if financial status change occurs. |
| | | |
|Consumer Name | |ID Number |
|SECTION 1: PAYEE INFORMATION (to be entered in Private Pay Eligibility screen of CMHC, beginning at Field #20) |
| | | |
|First Name |Middle Init |Last Name |
| | | | | |
|Street Address |Apt# |City |State |Zip Code |
| | | |
|Telephone Number (Area Code and Number) | |Relationship To Consumer |
|SECTION 2: ABILITY TO PAY CALCULATION USING STATE INCOME TAX RETURN (preferred method) |
|A. |Total Household Income – Gross Income from Michigan Income Tax Return (enter in Field 6 of Private Pay Eligibility Screen). Fill in|A. | |
| |sources of income below. | | |
|B. |Taxable (Adjusted) Income from Michigan Income Tax Return (read note in column 3 below before recording this amount). Enter the |B. | |
| |number of dependents in E. below. | | |
|C. |Ability to Pay from ATP schedule on back of worksheet based on income listed on line B. above. |C. | |
|SECTION 3: ABILITY TO PAY CALCULATION USING TOTAL GROSS EARNED INCOME FROM LINE 4t, (below) |
|**This method to be used only when Michigan Income Tax Return is not available.** |
| |
|1—ANNUAL HOUSEHOLD INCOME |2—ANNUAL AMOUNT |3 |4—GROSS EARNED INCOME |
|1a. Compensation from employment |2a. | |NOTE: Carry each |4a. | |
| | | |taxable amount listed in Column 2 | | |
| | | |“AMOUNT” | | |
| | | |over to Column 4-“ATP Income” for use | | |
| | | |in computing monthly liability. If | | |
| | | |spouse is not biological or adoptive | | |
| | | |parent of a Dependent Child Consumer, | | |
| | | |do not carry spouse’s income (2b. 2d., | | |
| | | |2f. over to Column 4 as it is not to | | |
| | | |be for purposes of determining monthly | | |
| | | |liability in this Instance. | | |
|1b. Compensation from employment (spouse) |2b. | | |4b. | |
|1c. Unemployment compensation |2c. | | |4c. | |
|1d. Unemployment compensation (spouse) |2d. | | |4d. | |
|1e. Workmen’s compensation |2e. | | |4e. |N/A |
|1f. Workmen’s compensation (spouse) |2f. | | |4f. |N/A |
|1g. Social Security Benefits |2g. | | |4g. |N/A |
|1h. Social Security Benefits (spouse) |2h. | | |4h. |N/A |
|1i. Indian Tribal Income |2i. | | |4i. |N/A |
|1j. Indian Tribal Income (spouse) |2j. | | |4j. |N/A |
|1k. Veterans Benefits |2k. | | |4k. |N/A |
|1l. Veterans Benefits (spouse) |2l. | | |4l. |N/A |
|1m. *Retirement Plans – ONLY if retired |2m. | | |4m. | |
|1n. *Retirement Plans – ONLY if retired (spouse) |2n. | | |4n. | |
|1o. Alimony |2o. | | |4o. | |
|1p. Child Support |2p. | | |4p. |N/A |
|1q. Adoption Subsidy |2q. | | |4q. |N/A |
|1r. Other (DHS Assistance, including Bridge Card) |2r. | | |4r. |N/A |
|Describe: | | | | | |
|1s. Interest Income, Rental Income, etc. |2s. | | |4s. | |
|Total Household Income |2t. | |Total Gross Earned Income |4t. | |
|(Field #6 Private Pay Eligibility) | | |(before exemptions) | | |
|*Retirement & pension benefits may be taxable or non-taxable based on individual’s compensation plan. Consumers must provide documentation to verify type of plan. |
|SECTION 4: ABILITY TO PAY CALCULATION |
|D. Total Annual ATP Income (from 4t above) |D. | |
|E. Number of exemptions claimed on State Income Tax _______ x $3600.00 (Field 4 Private Pay Eligibility) |E. | |
|F. ATP Adjusted Income [Line D minus E. If zero or less than zero, enter -0- on Line F.] (Field 7 Private Pay Eligibility) |F. | |
|G. Ability To Pay from ATP schedule on back of worksheet, based on income listed on Line F. above |G. | |
|SECTION 5: RESPITE ALLOCATION AMOUNT (from table on back of Worksheet) |
| Respite Consumer |Using State Taxable Income (Section 2, Box B or Section 4, Box F) | |
|Respite Only Consumer |Select appropriate allocation from Respite Allocation Schedule on back of form |$ |
|Non-Respite Consumer | | |
VERIFICATION OF INCOME
Copies of documents verifying income amounts listed above are to be attached to completed worksheet. If worksheet is completed
off-site (away from CMHCM clinic) and copies cannot be obtained, CMHCM staff completing worksheet must sign below to verify
that he/she has viewed documentation which supports accuracy of income information presented on this worksheet.
CMHCM STAFF SIGNATURE REQUIRED_______________________________________________________________ DATE_______________
CMHCM-801 [White] (Revised-3/26/09)
FINANCIAL LIABILITY SCALE FOR CLINICAL SERVICES
|STATE TAXABLE |ABILITY-TO-PAY |STATE TAXABLE |ABILITY-TO-PAY |
|(ADJUSTED) INCOME |MONTHLY |(ADJUSTED) INCOME |MONTHLY |
|$ 10,000 TO $ 11,000 |$11 |$ 30,001 TO $ 31,000 |$225 |
|$ 11,001 TO $ 12,000 |$ 14 |$ 31,001 TO $ 32,000 |$244 |
|$ 12,001 TO $ 13,000 |$ 18 |$ 32,001 TO $ 33,000 |$ 264 |
|$ 13,001 TO $ 14,000 |$ 22 |$ 33,001 TO $ 34,000 |$ 284 |
|$ 14,001 TO $ 15,000 |$ 27 |$ 34,001 TO $ 35,000 |$ 304 |
|$ 15,001 TO $ 16,000 |$ 32 |$ 35,001 TO $ 36,000 |$ 324 |
|$ 16,001 TO $ 17,000 |$ 38 |$ 36,001 TO $ 37,000 |$ 344 |
|$ 17,001 TO $ 18,000 |$ 45 |$ 37,001 TO $ 38,000 |$ 364 |
|$ 18, 001 TO $ 19,000 |$ 53 |$ 38,001 TO $ 39,000 |$ 384 |
|$ 19,001 TO $ 20,000 |$ 62 |$ 39,001 TO $ 40,000 |$ 405 |
|$ 20,001 TO $ 21,000 |$ 72 |$ 40,001 TO $ 41,000 |$ 426 |
|$ 21,001 TO $ 22,000 |$ 83 |$ 41,001 TO $ 42,000 |$ 447 |
|$ 22,001 TO $ 23,000 |$ 95 |$ 42,001 TO $ 43,000 |$ 468 |
|$ 23,001 TO $ 24,000 |$ 108 |$ 43,001 TO $ 44,000 |$ 489 |
|$ 24,001 TO $ 25,000 |$ 122 |$ 44,001 TO $ 45,000 |$ 510 |
|$ 25,001 TO $ 26,000 |$ 137 |$ 45,001 TO $ 46,000 |$ 531 |
|$ 26,001 TO $ 27,000 |$ 153 |$ 46,001 TO $ 47,000 |$ 552 |
|$ 27,001 TO $ 28,000 |$ 170 |$ 47,001 TO $ 48,000 |$ 573 |
|$ 28,001 TO $ 29,000 |$ 188 |$ 48,001 TO $ 49,000 |$ 594 |
|$ 29,001 TO $ 30,000 |$ 206 |$ 49,001 TO $ 50,000 |$ 615 |
| |
|FOR STATE TAXABLE INCOME OVER $50,000 |
|ABILITY TO PAY SHALL BE .15 OF THAT INCOME |
RESPITE ALLOCATIONS BASED ON INCOME AND MEDICAID ELIGIBILITY
| |Suggested Maximum |
|STATE TAXABLE (ADJUSTED) INCOME |ANNUAL RESPITE ALLOCATION |
|$12,500 … or Medicaid Eligibility |$1000 |
|$12,501 TO $15,000 |$990 |
|$15,001 TO $20,000 |$980 |
|$20,001 TO $23,000 |$970 |
|$23,001 TO $27,000 |$960 |
|$27,001 TO $30,000 |$950 |
|$30,001 TO $35,000 |$940 |
|$35,001 TO $45,000 |$930 |
|$45,001 TO $55,000 |$920 |
|$55,001 TO $65,000 |$910 |
|$65,001 TO $75,000 |$900 |
|$75,001 TO $85,000 |$880 |
|$85,001 TO $100,000 |$860 |
| |
|Annual Respite Allocation may be increased regardless of the consumer/family’s income |
|Based on Medical Necessity of the consumer and documented in the Person Centered Plan |
|Supervisor’s signature is required. Program Director’s signature is required if over $1,000. |
| |
|Supervisor’s Signature:_________________________________Amount:____________Date:__________ |
| |
|Program Director’s Signature:____________________________Amount:____________Date:__________ |
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