{"text_format":"1","workbook":"xlsx","n_sheets":4,"sheets":["Resource Assessment","Shortfall","Instructions","Standards"],"not_rendered":{"charts":0,"images":1,"macros":1,"external_links":0,"defined_names":1,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Resource Assessment","index":0,"n_rows":118,"n_cols":3,"rows_kept":118,"cut":false,"hidden":false,"merged":[[107,0,107,2],[112,0,112,1],[113,0,113,1],[1,0,4,0],[57,3,57,4],[46,4,46,6],[12,0,12,2],[13,4,13,6],[36,4,36,6],[104,0,104,1],[98,0,98,2],[99,0,99,1],[101,0,101,1],[103,0,103,1]]}
[null,"Branch"]
["2024 OPI-M \nResource Assessment"]
[null,"Case name","ONE case number"]
[]
[null,"Date assessment requested:","Worker Name"]
[]
[null,"Date assessment completed:","Continuous Period of Care start date:"]
[]
["Applicant's name:","DOB:","SSN:"]
[]
["Community spouse's name:","DOB:","SSN:"]
[]
["Step 1: Enter the countable value of the below items owned by the applicant and/or spouse."]
["1. Liquid Resources ","On the date care started","Now"]
["Bonds:"]
["Cash:"]
["Certificate of Deposit:"]
["Check:"]
["Direct Express Card:"]
["Nursing Facility Resident Account:"]
["Reloadable Money Card:"]
["Checking Account:"]
["Escrow Account Sponsored by HUD:"]
["Foreign Cash:"]
["Individual Development Account:"]
["Individual Education Account (IEA):"]
["Mutual Fund:"]
["Pension/Retirement Plan:"]
["Savings Account:"]
["Securities:"]
["Stocks:"]
["Trust Fund:"]
["Sales Contract:"]
["Other"]
["Total Countable Value:",{"$f":"SUM(B15:B34)","v":0},{"$f":"SUM(C15:C34)","v":0}]
[]
["2. Vehicles","On the date care started","Now"]
["Car:"]
["Truck:"]
["Boat:"]
["Camper:"]
["Motor Home:"]
["Motorcycle:"]
["Trailer:"]
["Aircraft:"]
["Snow Mobile:"]
["Other:"]
["Total Countable Value:",{"$f":"SUM(B38:B47)","v":0},{"$f":"SUM(C38:C47)","v":0}]
[]
["3. Life Insurance and Burial ","On the date care started","Now"]
["Life Insurance"]
["Prepaid Burial Agreement"]
["Burial Space/Merchandise"]
["Whole Life Insurance"]
["Burial Insurance"]
["Total Countable Value:",{"$f":"SUM(B51:B55)","v":0},{"$f":"SUM(C51:C55)","v":0}]
[]
["4. Real Property and Life Estate","On the date care started","Now"]
["Residential Property"]
["Business Property (Non Rental)"]
["Rental Property"]
["Life Estate"]
["Other"]
[" Total Countable Value:",{"$f":"SUM(B59:B63)","v":0},{"$f":"SUM(C59:C63)","v":0}]
[]
["5. Annuities, Trusts, Loan/Property Agreements","On the date care started","Now"]
["Annuities:"]
["Trusts:"]
["Property Agreement:"]
["Promissory Note:"]
["Loan/Property Agreement:"]
["Mortgage:"]
[" Total Countable Value:",{"$f":"SUM(B67:B72)","v":0},{"$f":"SUM(C67:C72)","v":0}]
[]
["6. Other Resources","On the date care started","Now"]
["Deferred Payment Loan:"]
["Home Equity Line of Credit:"]
["Other Investments:"]
["Reverse Mortgage:"]
["Sale Lease Back:"]
["Time Share:"]
["Mineral/OiI Rights:"]
["Oil Rights:"]
["Inventory Not Related to Self-Employment:"]
["Animals (not income-producing)"]
["Personal Belongings:"]
["Other:"]
["Total Countable Value ",{"$f":"SUM(B76:B87)","v":0},{"$f":"SUM(C76:C87)","v":0}]
[]
["Calculation of all Countable Resources","On the date care started","Now"]
["Section #1",{"$f":"B35","v":0},{"$f":"C35","v":0}]
["Section #2",{"$f":"B48","v":0},{"$f":"C48","v":0}]
["Section #3",{"$f":"B56","v":0},{"$f":"C56","v":0}]
["Section #4",{"$f":"B64","v":0},{"$f":"C64","v":0}]
["Section #5",{"$f":"B73","v":0},{"$f":"C73","v":0}]
["Section #6",{"$f":"B88","v":0},{"$f":"C88","v":0}]
[" Total Countable Resources:",{"$f":"SUM(B91:B96)","v":0},{"$f":"SUM(C91:C96)","v":0}]
[]
["Step 2: Determine the Community Spouse's Share of Resources"]
["Half of total countable resources at the start of care:",null,{"$f":"B97/2","v":0}]
["Maximum Community Spouse Resource Standard:",null,{"$f":"Standards!F3","v":154140}]
["Smaller of the two lines above:",null,{"$f":"MIN(C100,C101)","v":0}]
["Minimum Community Spouse Resource Standard:",null,{"$f":"Standards!F2","v":30828}]
["Court-ordered Community Spouse Resource Allowance:"]
["Complete the \"Shortfall Tab\" to calculate spouse's amount necessary to generate Income:",null,{"$f":"Shortfall!C44","v":0}]
["Largest amount (actual CSRA):",null,{"$f":"LARGE((C102:C105),1)","v":30828}]
[]
["Step 3: Determine applicant's resource eligibility"]
["Countable resources now",null,{"$f":"C97","v":0}]
["Subtract spousal allowance",null,{"$f":"C106","v":30828}]
["Resources available to client",null,{"$f":"IF(C109-C110<0,0,C109-C110)","v":0}]
["OPI-M resource limit for one person",null,{"$f":"Standards!F8","v":94523}]
["Amount of excess resources as of the date this RA was completed",null,{"$f":"IF(C111-C112<0,0,C111-C112)","v":0}]
["To be eligible, the couple's total resources cannot exceed (CSRA + $87,214.56):",null,{"$f":"C110+C112","v":125351}]
["Resource eligibility decision:",null,{"$f":"IF(C109>C114,\"Ineligible\",\"Eligible\")","v":"Eligible"}]
[]
["Important! This calculation will change if your resources change. Please notify your worker if your resources change."]
["                   If you disagree with this action, you have a right to a hearing. Read your hearing rights below. "]

{"sheet":"Shortfall","index":1,"n_rows":45,"n_cols":3,"rows_kept":45,"cut":false,"hidden":false,"merged":[[0,0,1,2],[33,0,33,2]]}
["Community Spouse Income Shortfall Calculator"]
[]
[" Calculate Recipient's Income"]
["a. Earned income amount"]
["b. Unearned income amount","+"]
["c. Other income amount","+"]
["d. Standard earned income deduction of $65","-",{"$f":"IF(C4>65,65,C4)","v":0}]
["e. OSIPM maintenance for in-home services ","-",{"$f":"Standards!F9","v":1443}]
["Recipient adjusted income","=",{"$f":"IF((C4+C5+C6-C7-C8)<0,0,(C4+C5+C6-C7-C8))","v":0}]
[" Calculate Community-Spouse Income Allowance "]
["a. Community Spousal Allowance standard is $2,465.00",null,{"$f":"Standards!F4","v":2465}]
["b. Shelter Expenses:  Rent or mortgage"]
["                                     Taxes/insurance","+"]
["                                     Federal Utility Allowance (FUA)","+",{"$f":"Standards!F5","v":469}]
["                                     Total Shelter Expenses","=",{"$f":"(C12+C13+C14)","v":469}]
["     Shelter Allowance:","-",{"$f":"Standards!F6","v":739.5}]
["     Total Allowance:","=",{"$f":"IF(C15>C16,C15-C16,0)","v":0}]
["     Subtotal (CAP of $3,853.50)",null,{"$f":"IF(C15>C16,C15-C16,0)","v":0}]
["c. Spouse's gross countable income"]
["Total community spouse income allowance",null,{"$f":"IF((C18-C19)>0,C18-C19,0)","v":0}]
["Calculate Dependent Income Allowance (skip if no eligible dependents)"]
["     Dependent allowance standard",null,{"$f":"Standards!F7","v":2465}]
["     Number of eligible dependents","X"]
["     Subtotal","=",{"$f":"C22*C23","v":0}]
["     Eligible dependents' total gross monthly income","-"]
["     Subtotal","=",{"$f":"IF((C24-C25)>0,C24-C25,0)","v":0}]
["     Dependent allowance ","=",{"$f":"C26/3","v":0}]
["List deductions allowed from recipient income"]
["a. Community spouse income allowance",null,{"$f":"C20","v":0}]
["b. Dependent income allowance ","+",{"$f":"C27","v":0}]
["c. Possible Income Diversion to Spouse (LDS)","=",{"$f":"C29+C30","v":0}]
["d. Actual LDS amount.",null,{"$f":"IF(C9<C31,C9,C31)","v":0}]
["Spouse Income Shortfall",null,{"$f":"C20-C32","v":0}]
[{"$f":"IF(C33=0, \"No shortfall. Return to Resource Assessment Tab.\", \"There is a shortfall. Continue to next step.\")","v":"No shortfall. Return to Resource Assessment Tab."}]
["Determine the Single-point Annuity Amount "]
["1- Open the Fidelity Annuity Calculator"]
["2- Check \"Just Me\" and enter the spouses information"]
["3- Do not select \"I'd prefer income for a set number of years.\""]
["4- Enter the community spouse's date of birth, gender and state of residence. "]
["5- Check \"How much I want to get each month\""]
["6- In \"Amount\", enter the shortfall from the above calculation in whole dollars."]
["7- Under \"Funding Source\" select Nonqualified"]
["8- Select \"See my results\""]
["9- Enter the amount listed next to \"Cash Refund\" here  -------------->"]
["Return to the Resource Assessment Tab"]

{"sheet":"Instructions","index":2,"n_rows":27,"n_cols":1,"rows_kept":27,"cut":false,"hidden":false,"merged":[]}
["Instructions for Completing The OPI-M Resource Assessment Worksheet"]
["Before you begin: \n   • Calculations on this form are specific to OPI-M. Do not use this form for other programs.\n   • This form does not determine what resources are countable. For more information see \"Treatment\n      of Specific Assets\" section in OPEN  (Chapter 2 Eligibility, Section 5 Financial Eligibility). \n   • You will only complete the blue-shaded cells. \n   • Pre-filled cells are based on the current years standards. Make sure you are using the current year's\n      worksheet.\n\n"]
["1. Complete Applicant and Community Spouse Personal Information"]
["Branch - enter your branch"]
["Case name - name of individual requesting OPIM"]
["ONE case number - enter if applicable"]
["Date assessment requested - for courtesy RAs only"]
["Date assessment completed - enter date the RA is complete, not the date it was started"]
["Applicant's name, DOB, SSN - enter info of individual seeking OPI-M services"]
["Community spouse's name, DOB, SSN - enter info from spouse of applicant"]
["Case mailing address - enter the address where the RA should be mailed."]
["Continuous period of care start date - The date the person started getting care in their home or a \nfacility. The date resets if there is a break in care 30 days or longer. *Note: \"Care\" means they were getting help with mobility, elimination, eating, or cognition. *See OAR 411-015-0005 for definitions of these terms."]
["Name and address of place of care - Enter address of where applicant is currently or will be receiving care (paid or unpaid). "]
["2. Enter countable resources for sections 1 through 6. "]
["In each category, combine both the applicant's and community spouse's countable resources (per policy) at the start of care and resources available now."]
["3. Resource Assessment Calculations"]
["Determination of countable resources"]
["This section totals the value of the countable resources entered above."]
["Determine the community spouse's share of resources"]
["This figure represents half of the total of the couple's countable resources at the beginning of the \ncontinuous period of care."]
["Determine the CSRA"]
["This section calculates the potential community spouse resource allowance (CSRA) "]
["If applicable, enter the court-ordered community spouse resource allowance (not common)"]
["Complete the calculation on the shortfall tab. This will calculate and populate the amount of resources needed to generate income if there is an income shortfall for the community spouse."]
["4. Determine applicant's resource eligibility"]
["This section displays the applicant's resource eligibility based on the current value of the couple's\n resources versus what it was at the beginning of the continuous period of care."]
["The form displays the eligibility decision based on the calculations entered above."]

{"sheet":"Standards","index":3,"n_rows":9,"n_cols":6,"rows_kept":9,"cut":false,"hidden":false,"merged":[[0,0,0,5]]}
["2024 Standards used in determination"]
["Min. Community Spouse Resource Allowance",null,null,null,null,30828]
["Max. Community Spouse Resource Allowance",null,null,null,null,154140]
["Community Spousal Allowance Standard",null,null,null,null,2465]
["Federal Utility Allowance",null,null,null,null,469]
["Shelter Allowance",null,null,null,null,739.5]
["Dependents Allowance Standard",null,null,null,null,2465]
["OPI-M Resource Limit for one person",null,null,null,null,94523]
["OPI-M Maintenance for in-home services",null,null,null,null,1443]