Appendix XXVI ICF-MR Vendor Payment Budget Worksheets by yda82100

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									                                                                                             Appendix XXVI
                                                                   ICF-MR Vendor Payment Budget Worksheets


 Client Name                           Client Number                                Date


                                 ICF-MR Vendor Payment Budget Worksheet #1
                                                    NET EARNINGS ≤ $30

 Unearned Income:            $                         $
                             $                         $
 Net Earned Income:          $                         $

                                                                          CALCULATIONS                          DEDUCTIONS
 STEP 1

   Unearned Income                                                       $              (Unearned)
 − 60 Personal Needs Allowance*                 (becomes a         −           60.00 * (PNA)                $60.00* (Total PNA)
                                                PNA deduction)

 = Difference (+ or −)                                             =     $              (+ or −)

 STEP 2
                                                                                       (Net
                                                                                       Earned)
   Net Earned Income                                                     $
 − Difference from Step 1            (Only if zero or a negative   −
                                     number)

 = Remaining Net Earned Income                                     =     $             (+ or −)
                                                                       (Remaining Net Earned)
 STEP 3

  Remaining Net Earned Income (from Step 2)                        =     $             (+ or −)         $            *   (Total PEI)
 [Becomes a PEI deduction]                                             (Remaining Net Earned)
 STEP 4

  Add deductions from Steps 1 and 3                                                                         $        *   (Step 1 PNA)
                                                                                                        + $          *   (Step 3 PEI)
  Result is Total PNA/PEI Deduction                                                                     = $              Total
                                                                                                                         PNA/PEI

 * can be $90 VA
                                    VENDOR PAYMENT BUDGET CALCULATIONS
 A. Client's Total Countable Income (Unearned & Net Earned)                                         $
 B. Total PNA/PEI (From Step 4 above)                                                              −$
 C. Remainder (A − B = C)                                                                          =$
 D. SMIB Deduction (if not MQMB)                                                                   −$
 E. Health Insurance Premium Deduction                                                             −$
 F. Other Incurred Medical Expense                                                                 −$
 G. Vendor Payment Budget Results(C − D − E − F = G)                                               =$



Completed by:                                           Date
 Appendix XXVI
 Page 2


 Client Name                       Client Number                                  Date


                            ICF-MR Vendor Payment Budget Worksheet #2
                                          NET EARNINGS > $30 ≤ $120

 Unearned Income:     $                            $
                      $                            $
 Net Earned Income:   $                            $

                                                                      CALCULATIONS                                  DEDUCTIONS
 STEP 1

   Unearned Income                                                    $               (Unearned)
 − 60 Personal Needs Allowance*            (becomes a         −              60.00 * (PNA)                  $60.00* (Total PNA)
                                           PNA deduction)

 = Difference (+ or −)                                        =       $               (+ or −)
 STEP 2
                                                                                      (Net
   Net Earned Income                                                  $               Earned)

 − Difference from Step 1       (Only if zero or a negative   −
                                number)

 = Remaining Net Earned Income                                =       $
                                                                  (Remaining Net Earned)
 STEP 3

    Remaining Net Earned Income (from Step 2)                     $                                             $        30.00
  −     $30                                                   −           30.00 (Partial PEI) =
  = Difference                                                    $             ( ÷ 2)                  +       $
    Remaining difference divided by 2 =                           $               (Partial PEI) =       =       $                *
 STEP 4

  Add deductions from Steps 1 and 3                                                                         $              *   (Step 1)
                                                                                                        + $                *   (Step 3)
  Result is Total PNA/PEI Deduction                                                                     = $                    Total
                                                                                                                               PNA/PEI


 * can be $90 VA
                               VENDOR PAYMENT BUDGET CALCULATIONS
 A. Client's Total Countable Income (Unearned & Net Earned)                                         $
 B. Total PNA/PEI (From Step 4 above)                                                            −$
 C. Remainder (A − B = C)                                                                        =$
 D. SMIB Deduction (if not MQMB)                                                                 −$
 E. Health Insurance Premium Deduction                                                           −$
 F. Other Incurred Medical Expense                                                               −$
 G. Vendor Payment Budget Results (C − D − E − F = G)                                            =$



Completed by:                                      Date
                                                                                                                 Appendix XXVI
                                                                                                                       Page 3


 Client Name                      Client Number                              Date

                          ICF-MR Vendor Payment Budget Worksheet #3
                                             NET EARNINGS > $120
 Unearned Income:     $                           $
 Net Earned Income:   $                           $
                                                                 CALCULATIONS                                DEDUCTIONS
 STEP 1
   Unearned Income                                               $               (Unearned)
 − 60 Personal Needs Allowance*           (becomes a       −            60.00 * (PNA)                $60.00* (Total PNA)
                                          PNA deduction)
 = Difference (+ or −)                                     =     $               (+ or −)
 STEP 2
                                                                                 (Net
   $120 of Net Earned Income                                     $     120.00 Earned)
 − Difference from Step 1 (Only if zero or a negative      −
                                number)
 = Remaining Net Earned Income                             =     $
                                                               (Remaining Net Earned)
 STEP 3
    Remaining Net Earned Income (from Step 2)   $                                                        $        30.00
  − 1st $30 of PEI                            −                      30.00 (Partial PEI) =
  = Difference ÷ 2                              $                          ( ÷ 2)                +       $
    Remaining Partial PEI                       $                            (Partial PEI) =     =       $                *
 STEP 4
    Total Net Earnings                              $
  − 1st $120                                      −   120.00 (Partial PEI) =
  = Difference × .3                                 $        × .3
    Remaining = 30% of Earnings in excess of $120   $        (Partial PEI) =                             $                *
 STEP 5
  Add deductions from Steps 1 and 4                                                                  $              *   (Step 1)
                                                                                                 + $                *   (Step 3)
                                                                                                 + $                *   (Step 4)
  Result is Total PNA/PEI Deduction                                                              = $                    Total
                                                                                                                        PNA/PEI

 * can be $90 VA
                               VENDOR PAYMENT BUDGET CALCULATIONS
 A. Client's Total Countable Income (Unearned & Net Earned)                                  $
 B. Total PNA/PEI (From Step 5 above)                                                       −$
 C. Remainder (A − B = C)                                                                   =$
 D. SMIB Deduction (if not MQMB)                                                            −$
 E. Health Insurance Premium Deduction                                                      −$
 F. Other Incurred Medical Expense                                                          −$
 G. Vendor Payment Budget Results(C − D − E − F = G)                                        =$



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