TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER d: MEDICAL PROGRAMS
PART 148 HOSPITAL SERVICES
SECTION 148.TABLE A RENAL PARTICIPATION FEE WORKSHEET



Section 148.TABLE A ††Renal Participation Fee Worksheet

 

Date

 

 

 

Initialed

 

 

 

Patient Identification Number

 

 

 

PATIENTíS NAME

 

 

 

Last

First

Middle Initial

 

In questions 1 through 4 below, please circle one number or group of numbers:

 

1.

NUMBER OF PERSONS IN FAMILY

1

2

3

4

5

6 or more

 

2.

NUMBER OF CHILDREN

 

1

2

3

4

5 or more

 

3.

AGE OF OLDEST CHILD IN YEARS

 

 

0-5

6-15

16-17

18 and over

 

4.

AGE OF HEAD OF HOUSEHOLD

 

 

Under 35

35-54

55-64

65 and over

 

 

BUREAU OF LABOR STATISTICS (BLS) EQUIVALENCE FACTOR=

 

 

 

 

 

(see Table B)

 

A.

LOCATION

 

 

 

(See Table C, List of Metropolitan Counties by SMSA Definition)

 

 

 

BLS METRO

=

$12,815

 

 

 

BLS NON-METRO

=

$11,604

 

B.

STANDARD BUDGET

 

 

 

BLS EQUIVALENCE

BLS STANDARD

FAMILY STANDARD

 

 

FACTOR

BUDGET

BUDGET

 

 

$

X

$

=

$

 

 

 

 

(metro or non-metro)

 

C.

PARTICIPATION DETERMINATION

 

 

ADJUSTED GROSS

FAMILY STANDARD

 

 

INCOME

BUDGET

 

 

$

†-

$

=

$

X

.333

=

$

 

 

 

 

 

D.

ADJUSTED GROSS INCOME

 

 

 

$

X

.125

=

$

 

 

 

 

LESSER OF C or D

=

$

 

E.

ADJUSTED GROSS INCOME

=

$

 

 

 

FAMILY STANDARD BUDGET

=

$

 

 

 

(B. above)

 

 

 

 

 

 

F.

FEDERAL INCOME TAX

STATE INCOME TAX

TOTAL TAX

 

 

$

+

$

=

$

 

 

 

TOTAL TAX

 

BLS STANDARD TAX

 

 

 

 

$

-

$

=

$

 

 

 

 

(metro $1,435)

 

 

 

 

 

(non-metro $1,260)

 

 

 

 

 

 

 

G.

SPECIAL CARE FOR CHILDREN

$

 

 

 

 

 

 

H.

SCHOOL TUITION

$

 

 

 

 

 

 

I.

FAMILY SUPPORT PAID

$

 

 

 

 

 

 

J.

OTHER PAYMENTS

 

 

 

1.

Transportation to and from dialysis

$

 

2.

Employment Expense (dues, uniforms, small tools)

$

 

SOCIAL SECURITY

BSL STANDARDS

 

$

-

$

=

$

 

 

 

(metro $702)

 

 

(non-metro $676)

 

 

 

K.

MEDICAL EXPENSES

BLS STANDARD

MEDICAL EXPENSES

 

 

 

ALLOWED

 

$

-

$

=

$

 

 

(includes medical

(metro $876)

 

insurance premiums)

(non-metro $671)

 

 

 

 

MEDICAL EXPENSES

TOTAL EXPENSES

INCOME IN EXCESS

 

ALLOWED

 

 

$

-

$

=

$

 

 

 

(E through K totaled, less

 

 

 

adjusted gross income)

 

 

 

L.

INCOME IN EXCESS

 

 

$

X†††† .333

=

$

 

 

 

M.

ENTER SMALLEST AMOUNT OF C or D or L

$

 

(Source:† Added at 26 Ill. Reg. 4825, effective March 15, 2002)