Effective Date: 
1/2018

Documents

Instructions

Updated: 12/2011

Purpose

The purpose of Form 1032 is to provide a tool for calculating the Residential Care individual's contribution to the cost of care. Residential Care individuals are required to pay room and board from their monthly income. Additionally, a copayment may be required. The form provides the format for the correct calculation of both the room and board and the copayment amounts.

Procedure

When to Prepare

Complete this form for all individuals applying for Residential Care to determine the initial and ongoing amounts of room and board and copayments. This form is also used when an individual receiving services has a change in income or when Residential Care rates change.

Complete this form by using the tab key to move to the next field as information is entered. Using the tab key triggers the calculation of each section.

Form Retention

The case manager prints the original form and files in the case record. The original is kept in the case record for three years after the case is closed.

Detailed Instructions

Individual Name — Enter the individual's name.

ID No. — Enter the individual's Medicaid number or identification number assigned.

Date — Enter the date the form is completed.

Step 1. Calculation of Net Income

Individuals may have both earned and unearned income. Certain allowances are deducted from the individual's gross income depending on the type of income the individual receives.

Earned Income

If the individual has earned income, complete this section.

Gross Monthly Earned Income — Enter the amount of the gross income for the month. See Section 3300, Income Eligibility, in the Case Manager Community Care for Aged and Disabled (CM-CCAD) Handbook, for instructions on determining, verifying and calculating monthly earned income.

Earned Income Deduction — Enter the standard deduction of $65.00.

Withholding Tax — Enter the amount of withholding tax.

Mandatory Deductions — Enter the amount of any other mandatory deductions. Document the reason why the deduction is mandatory.

Federal Insurance Contributions Act (FICA) Tax — Enter the amount of the FICA tax withheld.

Net Monthly Earned Income — Tab to the next field and the form will calculate the net earned income for the month.

Unearned Income

If the individual has unearned income only or in addition to earned income, complete this section.

Gross Monthly Unearned Income (RSDI, SSI, etc.) — Enter the amount of the gross income for the month for unearned income, Retirement, Survivors and Disability Insurance (RSDI) or Supplemental Security Income (SSI), etc. See Section 3300, Income Eligibility, and Section 3400, Verification Procedures, in the CM-CCAD Handbook for instructions on determining and verifying unearned income.

Appendix XXXI, Budget Reference Chart, in the Medicaid for the Elderly and People with Disabilities Handbook.

Net Monthly Unearned Income — Tab to the next field and the form will calculate the net unearned income for the month.

Total Countable Income

Net Monthly Earned Income + Net Monthly Unearned Income — Tab to the next field and the form will calculate the total countable income by adding the net monthly earned income and the net monthly unearned income.

Step 2. Calculation of Room and Board Payment

www.hhsc.state.tx.us/rad/Rc/RcAlRc.html.

Room and Board Daily Rate — Check the box for either Residential Care Apartment or Residential Care Non-Apartment. Enter the appropriate dollar amount in the data field to the right. Tab to the next field and the form will calculate the monthly amount of room and board by multiplying by 30.4, the average number of days in a month. Enter this amount on Form 2065-A, Notification of Community Care Services, as the ongoing amount of room and board.

Step 3. Calculation of Personal Needs Allowance

The personal needs allowance (PNA) for individuals in Residential Care is a set amount based on the type of income and assistance available to the individual. All individuals receive a personal expense allowance of $93.00. However, the medical expense allowance is adjusted based on the type of assistance the individual receives.

Enter Medical Expense Allowance: — Check the appropriate box to indicate the type of income and assistance available to the individual based on the following chart. Enter the appropriate dollar amount in the data field to the right. Tab to the next field and the form will calculate by adding the appropriate dollar amount and the Personal Expense Allowance, which is the total monthly amount of PNA.

If the individual is a full Medicaid recipient, use the allowances under Medicaid Individual.

If the individual is a Qualified Medical Beneficiary (QMB) or has Specified Low-Income Medicare Beneficiary (SLMB), use the allowances under the QMB Non-Medicaid Individual.

If the individual is non-Medicaid and does not have QMB or SLMB, use the allowances under Non-Medicaid Individual.

  Medicaid Individual QMB Non-Medicaid
Individual
Non-Medicaid
Individual
Personal Needs Allowance (PNA) $93.00 $93.00 $93.00
Medical Expense Allowance $30.00 $89.00 $118.00
Total Monthly PNA $123.00 $182.00 $211.00

Total Personal Needs Allowance — Tab to the next field and the form will calculate the medical expense plus the standard personal expense allowance for the total PNA.

Step 4. Calculation of Monthly Copayment

Total Countable Income – Room and Board – Total PNA = Monthly Copayment — Tab to the next field and the form will calculate the monthly copayment by deducting the room and board amount and the PNA amount from the individual's net income. This total is the individual's monthly copayment. Enter this amount on Form 2065-A, Notification of Community Care Services, as the ongoing amount of copayment and on Form 2101, Authorization for Community Care Services, Item 21. Ongoing Amt.

Step 5. Prorated Calculations

If the individual enters the facility on any day other than the first of the month, the room and board amount and copayment are prorated for the number of days the individual is in the facility.

Initial Month of: — Enter the initial month and year of entry into the Residential Care facility.

Days in Initial Month — Enter the number of days in the month of entry into the facility.

Day of Admission — Enter the date the individual enters the facility.

Days of Service – Initial Month — Enter the number of days the individual is in the facility during the initial month.

Available Funds — Enter the amount the individual has reported as available funds (individual's cash on hand, plus any liquid resources from checking accounts, savings accounts, etc.). Since the individual is moving into the facility on a date other than the first of the month, he may have already used his monthly income before moving into the facility. The available funds are considered in determining the prorated copayment amount.

Room and Board Prorated Calculation

Room and Board Daily Rate — Enter the room and board daily rate from Step 2.

Days of Service in Initial Month — Enter the number of days of service in the initial month.

Prorated Room and Board — Tab to the next field and the form calculates the room and board daily rate times the days of service in initial month, the prorated amount of room and board. Enter this amount on Form 2065-A, Notification of Community Care Services, as the initial amount of room and board.

Prorated Copayment

Two calculations are performed to determine the amount of the prorated copayment the individual will pay for the initial month. Copayment A is prorated from the monthly copayment. Copayment B is based on the personal needs allowance and funds the individual has available, rather than on income received during the month. The lower result of the two calculations will be the individual's copayment amount.

Prorated Copayment A

Monthly Copayment Amount — Enter the total from Step 4.

Days in the Initial Month — Enter the number of days in the initial month.

Daily Copayment Rate — Tab to the next field and the form will calculate the daily rate.

Days of Service in Initial Month — Enter the number of days of service in the initial month.

Prorated Copayment A — Tab to the next field and the form will calculate the prorated copayment amount.

Prorated Copayment B

Monthly PNA — Enter the amount of the personal needs allowance from Step 3.

Days in the Initial Month — Enter the number of days in the initial month.

Daily Copayment Rate — Tab to the next field and the form will calculate the daily rate.

Days of Service in the Initial Month — Enter the number of days of service in the initial month.

Prorated PNA

Enter Available Funds — Enter amount of available funds listed in Step 5.

Available Funds – Prorated PNA — Tab to the next field and the form will calculate available funds minus prorated PNA, for the Prorated Copayment B amount.

Compare the prorated Copayment A to the prorated Copayment B. The individual pays the lesser amount. Enter this amount on Form 2065-A, Notification of Community Care Services, as the initial amount of copayment and on Form 2101, Authorization for Community Care Services, Item 21, Initial Amount.

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