Free 49413.pdf - Indiana

PLAN OF CARE / COST COMPARISON BUDGET FOR THE TBI WAIVER
State Form 49413 (7-99) / HCBS 1E/2E Approved by State Board of Accounts, 1999

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 4 pages

Initial Plan of Care Update Plan of Care Re-Entry - Previous T ermination 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) S.B. provision (please check)

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

K
Diagnosis 1 (from 450B)

L
Diagnosis 2 (from 450B)

Yes Start Date Waiver Effective Date
Recommendation Plan of Care

No

Medical Facility Discharge Date

Effective From A. HOME AND COMMUNITY-BASED CARE COSTS

T o

1. Plan of Care Information a. Case Management . . . . . . . . . . . . . . . . . . . . . . . . . (1/4 hr.) Units auth. / mo. _____ x Unit cost $ ____________ b. Homemaker/HHA/HSA .. . . . . . . . . . . . . . . . . . . . . . ( 1 hr.) Units auth. / mo. _____ x Unit cost $ ____________ /Non Agency. . . . . . . . . . . . . . . . . . . . . ( 1 hr.) Units auth. / mo. _____ x Unit cost $ ____________ c. Adult Companion/HHA-HSA . . . . . . . . . . . . . . . . . . ( 1 hr.) Units auth. / mo. _____ x Unit cost $ ____________ / IDDARS-ILS . . . . . . . . . . . . . . . . . . . . ( 1 hr.) Units auth. / mo. _____ x Unit cost $ ____________ /Non Agency . . . . . . . . . . . . . . . . . . . . ( 1 hr.) Units auth. / mo. _____ x Unit cost $ ____________ d. Respite Care/Personal Care . . . . .. . . . . . . . . . . . . ( 1 hr.) Units auth. / mo. _____ x Unit cost $ ____________ /Companion . . . . . . . . . . . . . . . . . . . . . ( 1 hr.) Units auth. / mo. _____ x Unit cost $ ____________ /Homemaker. . . . . . . . . . . . . . . . . . . . . ( 1 hr.) Units auth. / mo. _____ x Unit cost $ ____________ /Home Health Aide. . . . . . . . . . . . . . . . ( 1 hr.) Units auth. / mo. _____ x Unit cost $ ____________ /LPN . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 1 hr.) Units auth. / mo. _____ x Unit cost $ ____________ /RN . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 1 hr.) Units auth. / mo. _____ x Unit cost $ ____________ /IDDARS-ILS . . . . . . . . . . . . . . . . . . . . ( 1/2 hr.) Units auth. / mo. _____ x Unit cost $ ____________ /Other . . . . . . . . . . . . . . . . . . . . . . . . . . ( e. Personal Care/HHA. . . . . . . . . . . . . . . . . . . . . . . . (

= = = = = = = = = = = = =

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. _____ x Unit cost $ ____________ = Mo. cost $ ____________ 1 hr.) Units auth. / mo. _____ x Unit cost $ ____________ = Mo. cost $ ____________ Units auth. / mo. _____ x Unit cost $ ____________ = Mo. cost $ ____________ Units auth. / mo. _____ x Unit cost $ ____________ = Mo. cost $ ____________ Units auth. / mo. _____ x Unit cost $ ____________ = Mo. cost $ ____________ Units auth. / mo. _____ x Unit cost $ ____________ = Mo. cost $ ____________ Unit cost $ ____________ = Mo. cost $ ____________ Unit cost $ ____________ = Mo. cost $ ____________ Unit cost $ ____________ = Mo. cost $ ____________ Unit cost $ ____________ = Mo. cost $ ____________ Unit cost $ ____________ = Mo. cost $ ____________ Unit cost $ ____________ = Mo. cost $ ____________ Unit cost $ ____________ = Mo. cost $ ____________ Unit cost $ ____________ = Mo. cost $ ____________ = Mo. cost $ ____________ = Mo. cost $ ____________ = Mo. cost $ ____________ = Mo. cost $ ____________

f. Residential Care/Community Residential /HHA/HSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( 1 hr.) /IDDARS-ILS . . . . . . . .. . . . . . . . . . . . . . . . . . . (1/2 hr.) /Non-Agency . . . . . . . .. . . . . . . . . . . . . . . . . . . ( 1 hr.) g. Rehabilitation Independent Living Skills . . . . . . . . . . . . . . . . . (1/4 hr.)

Behavior Programming/Counseling and Training (1/4 hr.) Units auth. / mo. _____ x Structured Day Program/Group . . . . . . . . . . . . (1/4 hr.) Units auth. / mo. _____ x Structured Day Program - Individual . . . . . . . . . (1/4 hr.) Units auth. / mo. _____ x Pre Vocational . . . . . . . . . . . . . . . . . . . . . . . . . . (1/4 hr.) Units auth. / mo. _____ x Supported Employment . . . . . . . . . . . . . . . . . . . (1/4 hr.) Units auth. / mo. _____ x h. Therapies Speech/Language/Hearing. . . . . . . . . . . . . . . . (1/4 hr.) Units auth. / mo. _____ x Occupational . . . . . . . . . . . . . . . . . . . . . . . . . . . (1/4 hr.) Units auth. / mo. _____ x Physical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (1/4 hr.) Units auth. / mo. _____ x i. Environmental Mod. (describe) ____________________________________________ j. Personal Emergency Response System / Installation . . . . . . . . . . . . . . . . . . . . . . . . . . .

Unit cost $ ____________ Unit cost $ ____________ / Monthly Charge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . k. Specialized Medical Equip/Supplies (describe) ________________________________ Unit cost $ ____________

TOTAL A.1 - Waiver Service Cost $ ____________ TOTAL A.2 - Other Medicaid Cost $ ____________
Case management agency

TOTAL A.5 - T otal HCBS Cost $ ____________
Case manager I.D. number (4 digits) Case manager authorization. number (9 digits)

TOTAL B.7 - Facility Cost Factor $ ____________

Page 2 of 4 pages Date budget completed (mo., day, yr.)

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. j. Other ____________________. . . . . . . . . . . . . . . 3 mo. payment history $ ________________ 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 $ ________________ .

TOTAL A.2 - Other Medicaid Cost $ ________________ 3. Total of Lines A.1 $ _____________ + A.2 $ ______________ = $ _______________ A.3

4. Minus Recipient Spend-down Amount 5. Total Home and Community Care Costs B. NURSING FACILITY INSTITUTIONAL COSTS 1. NF per diem $ __________ x 30 days

- $ _______________ A.4 = $ _______________ A.5

= $ _______________ B.1 2. Other Medicaid Services a. Physician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 mo. payment history $ ________________ b. Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 mo. payment history $ ________________ c. Lab / X-ray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 mo. payment history $ ________________ d. Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 mo. payment history $ ________________ e. Other ____________________. . . . . . . . . . . . . . . 3 mo. payment history $ ________________ f. Other ____________________. . . . . . . . . . . . . . . 3 mo. payment history $ ________________ g. 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 $ ________________

TOTAL B.2 - Other Medicaid Cost $ ________________ 3. Total of Lines B.1 $ _____________ + B.2 $ ______________ = $ _______________ B.3

4. Minus Recipient Liability Reduction 5. Total Nursing Facility Costs

- $ _______________ B.4 = $ _______________ B.5

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

Page 3 of 4 pages

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

Telephone Number

Frequency

PRIMARY CAREGIVER

Address

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

F 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 CommunityBased Waiver Services and must be offered the choice of Nursing Facility 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.7 $ _______________, then the recipient is MAY NOT BE ELIGIBLE for Home and Community-Based 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
Authorized signature of waiver unit

Denied
Date signed (month, day, year)

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 institutional setting. 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 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)

Page 4 of 4 pages

H. CHOICE OF PROVIDERS If the recipient chooses to receive waiver services, 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)

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

J. NOTES (including documentation of unmet needs)

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

L. STATE AGENCY PLAN OF CARE DETERMINATION
"INITIAL" and "RE-ENTRY" ONLY

Approved
Signature of Authorized Waiver Representative

Disapproved
Date signed (month, day, year)