Free 51549ig.FH11 - Indiana

PLAN OF CARE/COST COMPARISON BUDGET CHILDREN WITH SERIOUS EMOTIONAL DISTURBANCE (SED) WAIVER
State Form 51549 (R / 8-05) / TS 0003 Approved by State Board of Accounts, 2005

* This agency is requesting the disclosure of your Social number in accordance with IC 4-1-8-1. Disclosure is voluntary and you will not be penalized for refusal. The information in this document is confidential according to IC 16-39-2.

Name of recipient (last, first, and middle) Address (number and street, city, state, ZIP code) Date of birth (month, day, year) LOC decision date (month, day, year) Social Security number * LOC previous approval date (month, day, year) Medicaid number LOC pending?

Yes Initial POC/CCB Quarterly POC/CCB
From

No

Update POC/CCB
To

Re-entry -- Previous termination date _____________________________
Parental income excluded?

Medicaid eligibility date (month, day, year)

POC effective dates (month, day, year)

Yes

No

LIFE DOMAINS: STRENGTHS & NEEDS (Describe the childs and/or familys/caretakers problems, issues, and needs. Include strengths/assets which are relevant to meeting the needs.) LIFE DOMAINS Home/Housing STRENGTHS NEEDS

Family

Financial/Economic

Medical

Legal

Leisure/Recreation

Safety

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LIFE DOMAINS School/Job

STRENGTHS

NEEDS

Socialization

Emotional/Behavioral

Other

PRESENTING PROBLEM: (Describe childs problem/needs prior to the plan of care)

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STATEMENT OF GOALS/OUTCOMES: (Describe how the child will function when all objectives are met. Examples: Child (name) will have no evidence of suicidal thoughts or gestures. Child will attend full day of school without running away.) OUTCOME OBJECTIVES (Based on Needs and Strengths) 1. SERVICE AND SUPPORT NEEDED (Interventions) RESPONSIBLE PERSON DURATION AND FREQUENCY BILLABLE SERVICES/UNITS

2.

3.

4.

5.

6.

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CRISIS PLAN
Name of child Name of parent

PLAN DATE (month, day, year):

BACKGROUND INFORMATION: (Include best approaches to support parents/family during crisis, using the prompts below.) Parents/Caregivers

Child

ANTICIPATED PROBLEMS (HOME, SCHOOL, AND COMMUNITY): (Suicidal intentions, self-harm/mutilation, aggression, assault, property destruction, theft, substance/medication abuse, sexual activity/acting out, animal cruelty, isolation, fire setting, runaway, medical problems, use of weapons, etc.)

WHAT APPROACHES ARE MOST USEFUL? (Nurturing, confrontive, directive, supportive, matter-of-fact, interactive, active, solitary, quiet, stimulating, etc.) Parents/Caregivers

Child

RECOMMENDED INTERVENTIONS (HOME, SCHOOL, AND COMMUNITY): (Quiet time alone, journaling, relaxation/breathing exercises, going for a walk, putting hands under cold water, listening to music, calling a friend/therapist/pastor, exercising, cold ice pack, art work, talking with an adult, shower or bath, etc.) Parents/Caregivers

Child

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CRISIS PLAN: (continued)
I have reviewed the services contained in this plan and I choose to accept this plan and the services explained to me.
Signature of applicant/parent/guardian Signature of representative Signature of wraparound facilitator Signature of DMHA waiver manager Relation Date (month, day, year) Date (month, day, year) Date (month, day, year) Date (month, day, year)

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A. HOME AND COMMUNITY-BASED CARE COST 1. Plan of Care Information a. Wraparound Facilitation b. Family Support and Training c. Independent Living Skills d. Respite Care Scheduled Hourly e. Respite Foster Care Hourly f. Respite Care Crisis Hourly g. Respite Care Scheduled Day h. Respite Foster Care Day i. Respite Care Crisis Day (15 min) Units auth/mo (15 min) Units auth/mo (hour) Units auth/mo (15 min) Units auth/mo (15 min) Units auth/mo (15 min) Units auth/mo (per diem) Units auth/mo (per diem) Units auth/mo (per diem) Units auth/mo X Unit Cost X Unit Cost X Unit Cost X Unit Cost X Unit Cost X Unit Cost X Unit Cost X Unit Cost X Unit Cost $ $ $ $ $ $ $ $ $ = Mo. Cost = Mo. Cost = Mo. Cost = Mo. Cost = Mo. Cost = Mo. Cost = Mo. Cost = Mo. Cost = Mo. Cost

0.00 $ 0.00
$ $

0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00
Total A.1. Waiver Service Cost Total A.2. Other Medicaid Cost Total A.5. Total HCBS Cost (from page 7) Total B.5. Facility Cost Factor (from page 7) $

0.00

$0.00 $ $

2. Other Medicaid Services a. Physician b. Pharmacy c. Therapy d. Lab/X-Ray e. Supplies f. Durable Medical Equipment g. Transportation h. MRO Page 6 of 8 3 month payment history 3 month payment history 3 month payment history 3 month payment history 3 month payment history 3 month payment history 3 month payment history 3 month payment history $ $ $ $ $ $ $ $ 3= 3= 3= 3= 3= 3= 3= 3= Estimated monthly Cost Estimated monthly Cost Estimated monthly Cost Estimated monthly Cost Estimated monthly Cost Estimated monthly Cost Estimated monthly Cost Estimated monthly Cost $ $ $ $ $ $ $ $

2. Other Medicaid Services (continued) i. Other j. Other k. Other 3 month payment history 3 month payment history 3 month payment history $ $ $ 3= 3= 3= Estimated monthly Cost Estimated monthly Cost Estimated monthly Cost Total A.2. - Other Medicaid Cost 3. Total of Lines A.1. $ $ $ $ $

0.00

0.00

+ A.2.

$ 0.00

=$ -$ =$

0.00

A.3. A.4. A.5.

4. Minus Recipient Spend-Down Amount 5. Total Home and Community Care Costs B. PSYCHIATRIC HOSPITAL COSTS 1. Hospital per diem $ X 30 days =$

B.1.

2. Other Medicaid Services a. Physician b. Pharmacy c. Lab/X-Ray d. Transportation e. Other f. Other g. Other 3 month payment history 3 month payment history 3 month payment history 3 month payment history 3 month payment history 3 month payment history 3 month payment history $ $ $ $ $ $ $ 3= 3= 3= 3= 3= 3= 3= Estimated monthly Cost Estimated monthly Cost Estimated monthly Cost Estimated monthly Cost Estimated monthly Cost Estimated monthly Cost Estimated monthly Cost Total B.2. Other Medicaid Cost 3. Total of Lines B.1. $ + B.2. $ $ $ $ $ $ $ $ $

0.00

0.00

=$ -$ =$

0.00

B.3. B.4. B.5.

4. Minus Recipient Liability Reduction 5. Total Psychiatric Hospital Cost

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C. DOCUMENTATION OF PAYMENT HISTORY (Indicate sources and dates of information used to determine cost report in Section A.2.)

D. DESCRIPTION (Describe how the Plan of Care provides adequate coverage to ensure the health and welfare of the child. For updated Plan of Care , explain reason for change.) (Detail reasons for high cost)

E. COST COMPARISON DETERMINATION 1. Cost Comparison Data Indicates; a. If Line A.5. $__________ is equal to or less than B.5. $__________, the child is ELIGIBLE for Home and Community-Based Services the choice of hospital or community-based services must be offered. Recipient is ELIGIBLE for Home and Community Based Services. b. If Line A.5. $__________ is greater than B.5. $__________, the child MAY NOT BE ELIGIBLE for Home and Community-Based Services. Child may not be eligible for Home and Community-Based Services 2. Request for Approval to Exceed Calculations a. Monthly amount which exceeds hospital cost factor: $__________ b. Duration of excess costs: _________________________________
Signature of Wraparound Facilitator Date (month, day, year)

3. State Agency Determination to Exceed Cost
Authorized signature of Waiver Manager

Approved

Denied

NA
Date (month, day, year)

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