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FINANCIAL ELIGIBILITY AND COST-SHARE WORKSHEETS GUIDE

COP (100% State Funded)

Guide for COP Forms (PDF, 35 KB)

FORMS/WORKSHEETS INSTRUCTIONS

STEP ONE:  COLLECT FINANCIAL INFORMATION

Declaration of Income and Assets and State Residency

Form COP-DIA F-29314 (PDF, 28 KB)

Care managers use Form COP-DIA to collect financial and other information needed to complete the financial eligibility determination and cost-share worksheets at application and/or at each review.  The declaration must be signed by the applicant/participant, or by the authorized representative at application and/or at each review. 

Instructions for the Declaration of Income and Assets and State Residency Form

Form COP-DIA-Instr. F-29315 (PDF, 133 KB)

Care Managers:  REVIEW Form COP-DIA-Instr. to complete Form COP-DIA. 

STEP TWO:  ESTABLISH ELIGIBILITY

Initial or Continuing Financial Eligibility Determination Worksheet for a Single Applicant or Participant

Form COP-S F-29316 (PDF, 28 KB)

IMPORTANT:  Information to complete the Financial Eligibility Determination Worksheets comes from the Declaration of Income and Assets and State Residency.  If you have questions about income, assets, and/or medical/remedial expenses, see Instructions for the Declaration (Form COP-DIA-Instr. F-29315) (PDF, 133 KB).

Use Form COP-S to determine financial eligibility when the applicant/participant is "single".  A "single" individual includes:
  1. An individual who is unmarried, separated (legally or otherwise), divorced or widowed, OR
  2. An individual whose spouse resides in an institution, OR
  3. An individual who is on COP for one year or longer and whose spouse is not on COP or COP-W.
Initial Financial Eligibility Determination Worksheet for Married Applicants

Form COP-M/2 F-29317 (PDF, 31 KB)

Use Form COP-M/2 to determine financial eligibility when this is an initial COP application or an initial six-month review, and:
  1. Only one spouse applies for COP.  After 12 months and thereafter, use Form COP-S if only one spouse continues to be on COP, OR
  2. Both spouses apply for COP.  After 12 months and thereafter use Form COP-M/2 Yr (1+) if both spouses continue to be on COP.
Continuing Financial Eligibility Determination Worksheet for Married Applicants

Form COP-M/2 (Yr 1+) F-29318 (PDF, 65 KB)

Use Form COP-M/2 (Yr 1+) to determine financial eligibility when this is a one year review and each year thereafter and both spouses are on COP.

STEP THREE:  DETERMINE THE COST SHARE

Cost-Share Determination for All Adults at Home

COP Worksheet #1 F-29319 (PDF, 25 KB)

Use COP Worksheet #1 to determine the cost-share for adults who live in their own home, whether single or married, OR
For a married couple, when both apply and both live at home (complete separate worksheets for each), OR
For a married couple, when one applies and lives at home and the other spouse is in an institution.

Instructions for COP Worksheet #1 F-29320 (PDF, 28 KB)
Cost-Share Determination for Adults at Home When Spouse Lives in a CBRF or AFH (both on COP)

COP Worksheet #2 F-29321 (PDF, 16 KB)

Use COP Worksheet #2 to determine the cost-share for a married adult, when both spouses apply and one lives in a CBRF or in an Adult Family Home and the other lives at home.  Use COP Worksheet #2 for the spouse who resides at home.  For the spouse who resides in the CBRF or in the Adult Family Home use Worksheet #3.

Cost-Share Determination for Adults in CBRF or AFH, and for Couples When One or Both Live in a CBRF or in an AFH

COP Worksheet #3 F-29322 (PDF, 28 KB)

Use COP Worksheet #3 to determine the cost-share for:
  1. Single adults who live in a CBRF or in an Adult Family Home (see definition of "single" at Step 2 above), OR
  2. For married adults, when one lives in the CBRF and is on COP and the other lives at home and is not on COP, OR
  3. For married adults, both living in a CBRF or in and Adult Family Home, both on COP (complete separate worksheets for each).
Cost-share Determination for Minors who Live in Foster Homes or Group Homes.

COP Worksheet #3 F-29322 (PDF, 28 KB)

For a minor (someone under 18 years of age) who lives in a foster home or in a group home, COP Worksheet #3 is used to calculate the minor's contribution.  Refer to the substitute care unit of the Collection User's Manual to calculate the parents' cost of care contribution.  The manual is available through the county's fiscal unit.

Parental Cost-share for Minors who Live at Home With Their Parents.

If the minor lives with his/her parents, find the parents' cost of care contribution according to the Family Support Program.  For information about the Family Support Program, please visit the following website address:  http://www.dhs.wisconsin.gov/bdds/fsp or contact your local county Family Support Coordinator.  If the name and telephone number of the local county Family Support Coordinator is unknown, please call Wisconsin First Step at 1-800-642-7837; TTY 1-800-282-1663.

RESOURCE DOCUMENTS
Hardship Policy/Hidden Assets F-29323 (PDF, 14 KB)
Uniform Cost-Sharing Plan F-29324 (PDF, 10 KB)

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Last Revised: April 24, 2013