Revision 12-1; Effective March 1, 2012

Step 1

Determine the total actual and projected co-payment amounts for the reconciliation period.

Actual Co-payment — For each month in the reconciliation period, calculate the actual co-payment (co-payment based on actual variable income received and incurred medical expenses (IMEs) paid). Calculate the personal needs allowance (PNA)/protected earned income (PEI) allowance based on actual earnings received. Total the actual co-payment for the reconciliation period.

Note: For fixed income, do not include an increase that is subject to restitution policy rather than reconciliation policy.

Projected Co-payment — Total co-payment amounts for each month in the reconciliation period.

Example: A review is completed on an ICF-ID case in January, with the preceding six months being July through December.

Actual Co-payment (AI)

Month	Fixed	Earned	Other	IMEs	PNA/PEI	App. Inc.
July	$250	$60	$0	$0	$105.00	$205.00
August	$250	$75	$0	$0	$112.50	$212.50
September	$250	$85	$0	$0	$117.50	$217.50
October	$250	$78	$0	$0	$114.00	$214.00
November	$250	$65	$0	$0	$107.50	$207.50
December	$250	$80	$0	$0	$115.00	$215.00
Total						$1,271.50

Projected AI

Month	From Co-pay Screen
July	$275
August	$275
September	$275
October	$275
November	$275
December	$275
Total	$1,650

Step 2

Determine the co-payment adjustment by subtracting total projected co-payment for the reconciliation period from the total actual co-payment for the reconciliation period. The result is the co-payment adjustment.

A. Total Actual Co-payment (from Step 1)	$1,271.50
B. Total Projected Co-payment (from Step 1)	– $1,650.00
C. Total Co-payment Adjustment	– $378.50
D. Number of Months in Reconciliation Period	÷ 6
E. Average Monthly Adjustment	– $63.08

If the average monthly adjustment is +$4.99 or less, stop. Do not reconcile.

If the average monthly adjustment is +$5 or more, proceed to Step 3.

If the average monthly adjustment is a negative (–) figure in any amount, proceed to Step 3.

Step 3

Reconcile co-payment for the most recent month in the reconciliation period.

If the total co-payment adjustment (from Step 2C) is a positive (+) number, add it to the co-payment for the most recent month in the reconciliation period. The result is the co-payment adjustment.

If the total co-payment adjustment (from Step 2C) is a negative (–) number, subtract it from the co-payment for the most recent month in the reconciliation period. The result is reconciled co-payment.

A. Co-payment Month: December	$275.00
B. Total co-payment adjustment (from Step 2C)	– $378.50
C. Reconciled co-payment	$–103.50
D. If A.-B. is less than $0, enter the negative (–) amount here	( – $103.50) Excess Negative Adjustment

If there is an "excess negative adjustment" from Step 3D, proceed to Step 4.

Step 4

If there is an "excessive negative adjustment" (from Step 3D), subtract the excess amount from the co-payment for the next-to-most-recent month in the reconciliation period.