Illinois Administrative Code (Last Updated: March 27, 2024) |
TITLE89. SOCIAL SERVICES |
PART148. HOSPITAL SERVICES |
SUBPARTF. EMERGENCY PSYCHIATRIC DEMONSTRATION PROGRAM |
§148.TABLE A. Renal Participation Fee Worksheet
-
Date
Initialed
Patient Identification Number
PATIENT’S 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)