State of Wisconsin
Department of Health Services

HISTORY

The policy on this page is from a previous version of the handbook. 

20-03 Version of 40.1 Worksheets

The following is a list of Medicaid worksheets. Workers should come here each time a worksheet is needed to insure they are using the most up to date worksheets.

WORKSHEETS

NUMBER

NAME

Wkst 01

Medicaid Non-Financial

Wkst 02

Dependent Care

Wkst 03

Medicaid Deductible

Wkst 04

Medicaid Institution Determination

Wkst 05

Medicaid Extensions (obsolete)

Wkst 06

Supplemental Security Income-Related Determination Worksheet

Wkst 07

Spousal Impoverishment Income Allocation

Wkst 08

Medicaid Purchase Plan (MAPPMedicaid Purchase Plan) Eligibility as of 8/1/2020

Medicaid Purchase Plan (MAPP) Eligibility prior to 8/1/2020

Wkst 09

Medicaid Purchase Plan (MAPP) Premium Calculation as of 8/1/2020

Medicaid Purchase Plan (MAPP) Premium Calculation prior to 8/1/2020

Wkst 10

Medicaid Purchase Plan (MAPP) Work Expenses

Wkst 11

Medicaid Purchase Plan (MAPP) Medicaid/Remedial Expenses

Wkst 12

Family Care Eligibility – Non-MA Financial Determination (obsolete)

Wkst 13

FFU Income (obsolete)

Wkst 14

AFDC-Related Determination Worksheet

This page last updated in Release Number: 20-03
Release Date: 08/03/2020
Effective Date: 08/01/2020


The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.

Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.

Publication Number: P-10030