40.1 Worksheets

The following is a list of Medicaid financial worksheets.

Worksheet	Form Number	Name
3	F-01298	Medicaid Deductible Worksheet
4	F-01297	Medicaid Institution Determination Worksheet
6	F-01305	Supplemental Security Income-Related Determination
7	F-01306	Spousal Impoverishment Income Allocation Worksheet
8	F-01307	Medicaid Purchase Plan (MAPP) Eligibility Worksheet (as of 8/1/2020) Click here for old version (prior to 8/1/2020)
9	F-01316	Medicaid Purchase Plan (MAPP) Premium Calculation Worksheet (as of 8/1/2020) Click here for old version (prior to 8/1/2020)
10	F-01317	Medicaid Purchase Plan (MAPP) Impairment Related Work Expenses (IRWE) Worksheet
11	F-01318	Medicaid Purchase Plan (MAPP) Medicaid and Remedial Expenses (MRE) Worksheet

This page last updated in Release Number: 22-02
Release Date: 08/01/2022
Effective Date: 08/01/2022

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