Free 42822.pdf - Indiana

PLAN OF CARE / COST COMPARISON BUDGET FOR THE AGED AND DISABLED WAIVER
State Form 42822 (R3 / 3-96) HCBS 1D / 2D Approved by State Board of Accounts, 1994

CENTRAL OFFICE USE ONLY OMPP MWU Retuned Date Date Date Initials Initials Initials

This state agency is requesting disclousure of your Social Security number in order to expedite processing of your Plan of Care. Disclosure is voluntary and you will not be penalized for failure to disclose SSN per IC -4-1-8.

Initial Plan of Care Last name Address (Number, street) City, State, Zip code Medicaid number Social Security number

Re-Entry - Previous Termination Date First name

Update Plan of Care

Annual Plan of Care Middle initial

Date of birth Medicaid eligibility date

Level of care (please check one) A B C D E F G H

-

Date:

Area agency on aging number Level of care - current approval date Date: Diagnosis 2 MEDICAID FACILITY DISCHARGE DATE: From 450B Level of care - previous approval date

Diagnosis 1 START DATE WAIVER EFFECTIVE DATE: Recommendation

From 450B

Plan of care - effective from A. 1. Plan of care information:

to

HOME AND COMMUNITY - BASED CARE COSTS
( 1/4 hr.) Units auth. / mo. ________ x Unit cost $

a. Case management b. Homemaker c. Attendant Care / HHA / HSA - Other / IDDARS - ILS d. Respite Care / Attendant / Home Health Aide / LPN / RN / IDDARS - ILS / Other e. Adult Day Care f. Meals - one (1) per day g. Home Mod. (describe) h. Adaptive Aides and Devices 1 (describe) Adaptive Aides and Devices 2 (describe) Case Management Agency Case Manager I.D. Number (4 digits) Case Manager Authorization Number (9 digits)

= Mo. cost $ = Mo. cost $ = Mo. cost $ = Mo. cost $ = Mo. cost $ = Mo. cost $ = Mo. cost $ = Mo. cost $ = Mo. cost $ = Mo. cost $ = Mo. cost $ = Mo. cost $ = Mo. cost $ = Mo. cost $ = Mo. cost $

( 1 hr.) Units auth. / mo. ________ ( 1 hr.) Units auth. / mo. ________

x Unit cost $ x Unit cost $

( 1/2 hr.) Units auth. / mo. ________ x Unit cost $ ( 1 hr.) Units auth. / mo. ________ ( 1 hr.) Units auth. / mo. ________ ( 1 hr.) Units auth. / mo. ________ ( 1 hr.) Units auth. / mo. ________ x Unit cost $ x Unit cost $ x Unit cost $ x Unit cost $

( 1/2 hr.) Units auth. / mo. ________ x Unit cost $ ( 1 hr.) Units auth. / mo. ________ ( 1 hr.) Units auth. / mo. ________ (meal) Units auth. / mo. ________ x Unit cost $ x Unit cost $ x Unit cost $ Unit cost $ Unit cost $ Unit cost $ Total A.1 - Waiver Service Costs Total A.2 - Other Medicaid Cost Total A.5 - Total HCBS Cost Total B.7 - Facility Cost Factor

$ $ $ $
Page 1 of 4

Page 2 of 4 HCBS 1D / 2D State Form 42822 (R3 / 3-96)

Date budget was completed

2. a. Physician b. Pharmacy c. Therapy d. Lab / X - ray e. Supplies f. Durable medical equipment g. Transportation h. Other: i. Other: j. Other:

OTHER MEDICAID SERVICES 3 mo. payment history $ _____________ . 3 $ mo. payment history $ _____________ . . $ 3 mo. payment history $ _____________ . . 3 $ mo. payment history $ _____________ . . 3 $ mo. payment history $ _____________ . . 3 $ mo. payment history $ _____________ . . 3 $ mo. payment history $ _____________ . . 3 $ mo. payment history $ _____________ . . 3 $ mo. payment history $ _____________ . . 3 $ mo. payment history $ _____________ . . $
.

3 = Estimated mo. cost 3 = Estimated mo. cost 3 = Estimated mo. cost 3 = Estimated mo. cost 3 = Estimated mo. cost 3 = Estimated mo. cost 3 = Estimated mo. cost 3 = Estimated mo. cost 3 = Estimated mo. cost 3 = Estimated mo. cost

Total A.2 - Other Medicaid Cost

$
3. Total of lines A.1

$

A.2

$

= $ $

A.3 A.4 A.5

4. Minus Recipient Spend-Down Amount 5. Total Home and Community Care Costs B. 1. NF / I per diem $ ________________ x 30 days or NF /S per diem $ ________________ x 30 days 2. Other Medicaid services: a. Physician b. Pharmacy c. Lab / X - ray d. Transportation e. Other: f. Other: g. Other:

= $
NURSING FACILITY INSTITUTIONAL COSTS

= $
.

B.1

3 mo. payment history $ _____________ .
. 3 $ mo. payment history $ _____________ .

3 = Estimated mo. cost 3 = Estimated mo. cost 3 = Estimated mo. cost 3 = Estimated mo. cost 3 = Estimated mo. cost 3 = Estimated mo. cost 3 = Estimated mo. cost

$ 3 mo. payment history $ _____________ .
. 3 $ mo. payment history $ _____________ .

.

3 $ mo. payment history $ _____________ .
. 3 $ mo. payment history $ _____________ .

.

3 $ mo. payment history $ _____________ . $

.

Total B.2 - Other Medicaid Cost

$
3. Total of lines B.1

$

B.2

$

= $ $

B.3 B.4 B.5

4. Minus Recipient Liability Reduction 5. Total Nursing Facility Costs 6. Waiver Program Factor 7. Nursing Facility Cost Factor

= $ X = $ .90

B.6 B.7

Page 3 of 4 HCBS 1D / 2D State Form 42822 (R3 / 3-96)

C.

DOCUMENTATION OF PAYMENT HISTORY

Please document the Monthly Payment History / method used to determine costs in A.1 and B.2, (month and year).

D.

COST COMPARISON DETERMINATION

1. Cost Comparison Data Indicates: a. If line A.5 $ ______________ is less than line B.7 $ ______________, then the recipient is eligible for Home and Community- Based Waiver Services and must be offered the choice of Nursing Facility Instutional Care or Home and Community Based Services. Recipient is eligible for Home and Community-Based Waiver Services. b. If line A.5 $ ______________ is greater than line B.7 $ ______________, then the recipient is not eligible for Home and Community- Based Waiver Services. Recipient is not eligible for Home and Community-Based Waiver Services. E. DESCRIPTION Please describe how the Plan of Care provides adequate coverage to ensure the health and welfare of the recipient. For Update Plan of Care, explain reasons(s) for the change(s).

F .

FREEDOM OF CHOICE A Medicaid Waiver Services case manager has explained the array of services available to meet my needs through the Medicaid Home and Community - Based Services Waiver. I have been fully informed of the services available to me in a Nursing Facility institutional settting. I understand the alternatives available and have been given the opportunity to choose between waiver services and institutional care. As long as I remain eligible for waiver services, I will continue to have the opportunity to choose between waiver services and institutional care.

1. Choice of Waiver Services: At this time, I have chosen to receive waiver services in a home and community-based setting, rather than in an institutional setting. Signature of Recipient / Guardian 2. Choice of Institutional Services: At this time, I have chosen to receive services in an institutional setting, rather than in a home and community-based setting. Signature of Recipient / Guardian G. Date Date

CHOICE OF PROVIDERS If the receipient chooses to receive waiver services, they have the right to select any approved waiver service provider(s).

I have been informed of my right ot choose any certified waiver service provider when selecting waiver service providers. Signature of Recipient / Guardian Date H. EMERGENCY BACKUP PLANS

Describe how medical needs, supervision, behavior issues, etc., will be covered during an emergency.

Page 4 of 4 HCBS 1D / 2D State Form 42822 (R3 / 3-96)

I.

NOTES

J. Signature of Case Manager K. Approved Disapproved

SIGNATURES Case Manager's I.D. number STATE AGENCY PLAN OF CARE DETERMINATION Signature of Authorized Waiver Unit Representative

Date

Date