Form F 01306 PDF Details

Understanding the nuances of the F-01306 form is fundamental for individuals navigating the complexities of healthcare and financial considerations within the state of Wisconsin, particularly with regard to spousal impoverishment. This form, officially titled the "Spousal Impoverishment Income Allocation Worksheet," serves as a critical tool in organizing and calculating the income allocations between a community spouse and an institutionalized spouse. The worksheet is designed to ensure that the financial needs of the non-institutionalized spouse are met while determining the financial contribution of the institutionalized spouse towards their own medical or remedial care. It encompasses sections meticulously structured to cover the allocation for the community spouse, any dependent family members, and the calculation of the cost of care and cost sharing. Moreover, it importantly considers variables such as personal allowances, court-ordered fees, and health insurance premiums in its comprehensive assessment. Ensuring the accurate completion of this form is vital for maintaining compliance with state regulations and safeguarding the financial security and well-being of families during challenging times. The form also instructs users to retain the completed document in case records, highlighting its importance in ongoing healthcare management and accountability.

QuestionAnswer
Form NameForm F 01306
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesSUBTRACT, Remedial, SPOUSAL, Premiums

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DEPARTMENT OF HEALTH SERVICES

 

 

 

State of Wisconsin

Division of Health Care Access and Accountability

 

 

 

Worksheet 07

F-01306 (07/14)

 

 

 

 

 

 

 

SPOUSAL IMPOVERISHMENT INCOME ALLOCATION WORKSHEET

 

 

 

 

 

 

 

Primary Person Name (Last, First, MI)

 

 

Social Security Number

 

 

 

 

 

 

 

Section A – Community Spouse Income Allocation

 

 

 

 

Spouse’s Name (Last, First, MI)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

ENTER Maximum Community Spouse Income Allocation

 

$

 

 

 

 

 

 

 

 

 

 

2.

SUBTRACT Gross Income of Community Spouse

 

-

 

 

 

 

 

 

 

 

 

 

3.

EQUALS Community Spouse Income Allocation

 

=

 

 

 

 

 

 

 

 

 

Section B – Dependent Family Member Income Allocation

 

 

 

 

 

 

Name

 

Name

 

 

Name

 

 

 

 

 

 

 

 

1.

ENTER – Maximum

$

 

$

 

 

$

 

Dependent Family

 

 

 

Member Income Allocation

 

 

 

 

 

 

2.

SUBTRACT – Dependent

-

 

-

 

 

-

 

Family Member’s Income

 

 

 

 

 

 

 

 

 

3.

EQUALS – Individual

=

 

=

 

 

=

 

Allowance

 

 

 

 

 

 

 

 

 

4.

ENTER – Total Dependent

Total $

 

 

 

 

 

Family Member Allocation

 

 

 

 

 

(Add Line 3 of all columns)

 

 

 

 

 

 

Section C – Cost of Care/Cost Sharing Calculation

 

 

 

 

1.

ENTER Institutionalized Spouse’s Gross Income

 

$

 

 

 

 

 

 

 

 

2.

SUBTRACT Personal Allowance

 

-

 

 

 

 

 

 

 

 

 

 

3.

EQUALS

 

 

 

=

 

 

 

 

 

 

 

 

4.

SUBTRACT Community Spouse Income Allocation

 

-

 

 

 

(from Section A, Item 3)

 

 

 

 

 

 

 

 

 

 

 

 

5.

EQUALS

 

 

 

=

 

 

 

 

 

 

 

 

6.

SUBTRACT Total Dependent Family Member Allocation

 

-

 

 

 

(From Section B, Item 4)

 

 

 

 

 

 

 

 

 

 

 

 

7.

EQUALS

 

 

 

=

 

 

 

 

 

 

 

8.

SUBTRACT Any Court-Ordered Guardian or Attorney Fees &

-

 

 

 

any other special exempt income

 

 

 

 

 

 

 

 

9.

EQUALS

 

 

 

=

 

 

 

 

 

 

 

 

10.

SUBTRACT Medical/Remedial Costs and Cost of Person’s

 

-

 

 

 

Health Insurance Premiums

 

 

 

 

 

 

 

 

 

 

 

 

11.

EQUALS Nursing Home Liability Amount / Community Waivers

=

 

 

 

Cost Sharing Amount

 

 

 

 

 

 

 

 

 

 

 

 

RETAIN COMPLETED FORM IN CASE RECORDS

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