Free 50149.pdf - Indiana

PLAN OF CARE / COST COMPARISON BUDGET FOR THE AL AND AFC WAIVER
State Form 50149 (9-01) / HCBS 1F/2F Approved by State Board of Accounts, 2001

Information contained in this record is CONFIDENTIAL pursuant to 42 CFR 431(f).
* THIS STATE AGENCY IS REQUIRING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER PER IC 4-1-8-1. THE INFORMATION OBTAINED ON THIS FORM IS CONFIDENTIAL UNDER STATE AND FEDERAL REGULATIONS. THIS INFORMATION WILL NOT BE RELEASED EXCEPT AS PERMITTED OR REQUIRED BY LAW OR WITH THE CONSENT OF THE APPLICANT.

Page 1 of 3 pages

Initial Plan of Care Update Plan of Care Re-Entry - Previous Termination Date __________________________
Last name Address (number and street, rural route or box number) Medicaid number Level of Care (please check) Medicaid eligibility date First name City Date of birth

Annual Plan of Care
Middle initial

CENTRAL OFFICE USE ONLY Date Initials OMPP MWU Returned
Area agency number BDDS number State ZIP code

Social Security number Level of Care - previous approval date (month, day, year)

Level of Care - current approval date (month, day, year)

B00
Diagnosis 1 (from 450B)

B50
Diagnosis 2 (from 450B)

Start Date Waiver Effective Date
Recommendation Plan of Care

Medicaid Facility Discharge Date

Level of Service Point Total:

Beginning From To A. HOME AND COMMUNITY-BASED CARE COSTS (Calculations are based on 30 days) 1. Plan of Care Information: Monthly Authorizations: Case Management Assisted Living - Level 1 Assisted Living - Level 2 Assisted Living - Level 3 Assisted Living - Level 4 Assisted Living - Level 5 Adult Foster Care - Level 1 Adult Foster Care - Level 2 Adult Foster Care - Level 3 Adult Foster Care - Level 4 Adult Foster Care - Level 5 2. Other Medicaid Services a. Physician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 mo. payment history $ ________________ b. Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 mo. payment history $ ________________ c. Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 mo. payment history $ ________________ d. Lab / X-ray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 mo. payment history $ ________________ e. Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 mo. payment history $ ________________ f. Durable medical Equipment . . . . . . . . . . . . . . . . . . 3 mo. payment history $ ________________ g. Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 mo. payment history $ ________________ h. Other ____________________. . . . . . . . . . . . . . . . 3 mo. payment history $ ________________ i. Other ____________________. . . . . . . . . . . . . . . . 3 mo. payment history $ ________________ j. Other ____________________. . . . . . . . . . . . . . . . 3 mo. payment history $ ________________ . 3 = Estimate mo. cost $ ________________ . . 3 = Estimate mo. cost $ ________________ . . 3 = Estimate mo. cost $ ________________ . . 3 = Estimate mo. cost $ ________________ . . 3 = Estimate mo. cost $ ________________ . . 3 = Estimate mo. cost $ ________________ . . 3 = Estimate mo. cost $ ________________ . . 3 = Estimate mo. cost $ ________________ . . 3 = Estimate mo. cost $ ________________ . . 3 = Estimate mo. cost $ ________________ . CMGT AL1 AL2 AL3 AL4 AL5 AFC 1 AFC 2 AFC 3 AFC 4 AFC 5 (0.25 Hour) units auth. / mo. _________ X rate $ ____________ = M/Cst $ _______________ (1.00 Day) units auth. / mo. _________ X rate $ ____________ = M/Cst $ _______________ (1.00 Day) units auth. / mo. _________ X rate $ ____________ = M/Cst $ _______________ (1.00 Day) units auth. / mo. _________ X rate $ ____________ = M/Cst $ _______________ (1.00 Day) units auth. / mo. _________ X rate $ ____________ = M/Cst $ _______________ (1.00 Day) units auth. / mo. _________ X rate $ ____________ = M/Cst $ _______________ (1.00 Day) units auth. / mo. _________ X rate $ ____________ = M/Cst $ _______________ (1.00 Day) units auth. / mo. _________ X rate $ ____________ = M/Cst $ _______________ (1.00 Day) units auth. / mo. _________ X rate $ ____________ = M/Cst $ _______________ (1.00 Day) units auth. / mo. _________ X rate $ ____________ = M/Cst $ _______________ (1.00 Day) units auth. / mo. _________ X rate $ ____________ = M/Cst $ _______________

TOTAL A.2 - Other Medicaid Cost $ ________________ 3. Total of Lines
Case management agency

A.1 $ _____________ + A.2 $ ______________ = $ _______________ 4. Minus Recipient Spend-down Amount

A.3

- $ _______________ A.4

Case manager I.D. number (4 digits) Case manager authorization. number (9 digits)

5. Total Home and Community Care Costs = $ _______________ A.5

Page 2 of 3 pages Date budget completed (mo., day, yr.)

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

C. NON-REIMBURSED CAREGIVER(S) (i.e., family, friends) Type Provider (specify name and address)
Name

Telephone Number

Frequency

PRIMARY CAREGIVER

Address

D. DESCRIPTION (please describe how the Plan of Care provides adequate coverage to ensure the health and welfare of the waiver services recipient. For Update Plan of Care, explain reason for change.)

E. 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 setting. I understand the alternatives available and have been given the opportunity to choose between waiver services in a home and community-based setting and institutional care. As long as I remain eligible for waiver services, I will continue to have the opportunity to choose between waiver services in a home and community-based setting 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 services in an institutional setting.
Signature of recipient / guardian Date signed (month, day, year)

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 Date signed (month, day, year)

F. CHOICE OF PROVIDERS If the recipient chooses to receive waiver services in a home and community-based setting, they have the right to select any approved waiver service provider(s). I have been informed of my right to choose any certified waiver service provider when selecting waiver service providers.
Signature of recipient / guardian Date signed (month, day, year)

Page 3 of 3 pages

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

H. NOTES (including documentation of unmet needs)

I. SIGNATURES
Signature of Case Manager Case Manager I.D. number Date signed (month, day, year)

AAA signature

I.D. number

Date signed (month, day, year)

BDDS signature

Date signed (month, day, year)

J. STATE AGENCY PLAN OF CARE DETERMINATION Approved Disapproved
Date signed (month, day, year)

Signature of Authorized Waiver Program Representative