Free 46019.pdf - Indiana

PLAN OF CARE / COST COMPARISON BUDGET FOR THE MEDICALLY FRAGILE CHILDREN WAIVER
State Form 46019 (R4 / 11-98) HCBS 1C / 2C Approved by State Board of Accounts, 1998

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

PLEASE FILL FORM OUT COMPLETELY .
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 T ermination 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) J X Y Z

-

Date:

Area agency on aging number Level of care - current approval date Date: S.B. 30 Provision (please check) Yes No NURSING / HOS. FACILITY DISCHARGE DATE: Level of care - previous approval date

Diagnosis 1 START DATE WAIVER EFFECTIVE DATE: Recommendation

Diagnosis 2

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. Attendant Care c. Respite Care / Attendant / Home Health Aide / LPN / RN / IDDARS - ILS / Other d. Environmental Mod. 1 (describe) Environmental Mod. 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 $

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

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

Total A.1 - Waiver Service Costs Total A.2 - Other Medicaid Cost Total A.5 - HCBS Cost Total B.3 - Facility Cost

$ $ $ $

Page 1 of 4

Page 2 of 4 HCBS 1C / 2C State Form 46019 (R4 / 11-98)

Date budget was completed

2. a. Physician b. Pharmacy c. Therapy d. Lab / X - ray e. Supplies f. Durable medical equipment g. Transportation h. Private duty nursing i. Home health aide j. Other: k. Other: l. 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 mo. payment history $ _____________ . $ . $ mo. payment history $ _____________ . 3 . $

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 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.

= $
INSTITUTIONAL COSTS

1. Nursing facility institutional costs $ ________________________ x 30 days or Hospital institutional costs $ ________________________ x 30 days 2. Minus recipient liability reduction 3. Total institutional cost C.

= $ $

B.1 B.2 B.3

= $

DOCUMENTATION OF PAYMENT HISTORY - Indicate source(s) and dates of information used to determine cost reported in section A.2.

Page 3 of 4 HCBS 1C / 2C State Form 46019 (R4 / 11-98)

D. Type
Name

NON-REIMBURSED CAREGIVER Provider - specify name and address

T elephone number

Frequency NA

PRIMARY CAREGIVER E.

Address

DESCRIPTION

Please describe how the Plan of Care provides adequate coverage to ensure the health and welfare of the waiver recipient. For Update Plan of Care, explain reasons(s) for the change(s).

F . 1. Cost Comparison Data indicates:

COST COMPARISON DETERMINATION

a. If line A.5 $ ___________ is LESS THAN line B.3 $ _____________ , then the recipient is ELIGIBLE for Home and Community-Based Waiver Services and must be offered the choice of Nursing Facility / Hospital Institutional 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.3 $ _____________ , then the recipient MAY NOT BE ELIGIBLE for Home and CommunityBased Waiver Services. Recipient MAY NOT BE ELIGIBLE for Home and Community-Based Waiver Services. 2. Request for Approval to Exceed Calculations a. Monthly amount which exceeds institutional cost factor: $ ____________________ b. Duration of excess costs: ______________________________________________________________________________________________ 3. State Agency Determination to Exceed Cost Approved Denied
Date signed (month, day, year) Authorized signature of waiver unit

G.

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 / Hospital 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 H. 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 Date Date

Page 4 of 4 HCBS 1C / 2C State Form 46019 (R4 / 11-98)

I.

EMERGENCY BACKUP PLANS

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

J. Include documentation of any unmet needs.

NOTES

K. Signature of Case Manager L. Approved Disapproved

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

Date

Date