SERVICE COST-SHARING
In order to determine the recommended cost-sharing amount, please place a check mark in the space provided next to the income range that most nearly indicates the client’s monthly income. Income includes earnings from wages, pensions, and Social Security benefits as determined by the statement of the client/family member or authorized representative. For additional information on whose income is to be included and the sources of income to be included, please see the Division of Aging’s Service Cost-Sharing Policies and Procedures contained in the Division of Aging Home and Community Care Block Procedures Manual for Community Service Providers.
| Monthly Income | Percentage | |
|---|---|---|
| Individual | Couple | |
| $1,196 - 1,358 | $1,604 - 1,821 | 30% |
| $1,359 - 1,521 | $1,822 - 2,040 | 40% |
| $1,522 - 1,684 | $2,041 - 2,258 | 50% |
| $1,685 - 1,847 | $2,259 - 2,477 | 60% |
| $1,848 - 2,010 | $2,478 - 2,695 | 75% |
| $2,011 - above | $2,696 - above | 100% |
| Service | Total Cost* |
| Congregate Meal | $5.01 per meal |
| Health Screening | $30.00 per screening |
| Home Delivered Meals | $5.15 per meal |
| In-Home Aide | $13.68 per hour |
| Respite | $13.59 per hour |
| Transportation | $4.58 per trip |
*Costs are subject to change.
Service(s) will not be terminated if you fail to submit the agreed upon cost-sharing amount.
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