Application for a §1915 (c) hcbs waiver Submitted by



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Waiver Year: Year 4 (renewal only) SNF

Waiver Service

Col. 1

Col. 2

Col. 3

Col. 4

Col. 5

Unit

# Users

Avg. Units

Per User

Avg. Cost/

Unit

Total Cost

Adult Day Care



















Extended Day

8

27 days

50.81/day

10,975




Full Day

660

69 days

43.86/day

1,997,384




Half Day

191

37 half-days

23.21/day

164,025

Assistive Devices




2153

3 units

52.84/unit

341,294

CDAC



















Agency, non-assisted living – Daily

45


112 days

37.08/day

186,221




Agency, non-assisted living – Hourly

405

168 hrs

17.63/hr

1,199,868




Individual – Daily

334

206 days

34.17/day

2,351,033




Individual – Hourly

1637

563 hrs

10.09/hr

9,299,257


Assisted Living


256

6 months

1,042.47/mo

1,601,234

Chore Service




1186

61 half-hr

7.62/half-hr

551,277

Homemaker




5979

87 hrs

19.68/hr

10,237,005

Home Health Aide




111

36 hrs

38.47/hr

153,726

Nursing Care





197

10 visits

77.19/visit

152,064

Respite: Home Health Aide



















Specialized

19

57 hrs

41.61/hr

45,064




Basic

437

96 hrs

21.09/hr

884,768




Group

0

0 hrs


13.37/hr

0

Respite: Home Care Agency



















Specialized

0

0 hrs

34.42/hr

0




Basic

139

170 hrs

15.62/hr

369,101




Group

2

155 hrs

7.42/hr

2,300

Respite: Facility




















Hospital

14

232 hrs

7.43/hr

24,133




Nursing Facility

29

461 hrs

5.52/hr

73,797




Camps

0

0 hrs

13.37/hr

0




Adult Day Care

0

0 hrs


13.37/hr

0

Mental Health Outreach




242

40 hrs

22.31/hr

215,961

Home & Vehicle Mod.




367

1 unit

540.04/unit

198,195

Home Delivered Meals




7362

175 meals

5.22/meal

6,725,187

PERS




7824

8 mo


29.47/mo

1,844,586

PERS Install




1654

1 install

34.95/install

57,807

Senior Companion




238

290 hrs

4.39/hr

302,998

Transportation



















RTA

33

259 miles

0.32/mile


2,735




AAA

1351

61 trips

6.73/trip

554,626

Nutritional Counseling




269

9 qtr hrs

8.30/qtr hr

20,094

Case Management




11379

8 units

114.00/mo

10,377,648

















Financial Management Service




568

8 mo

65/mo

295,360

Independent Support Broker




568

12 mo

25/mo

170,400

Self directed personal care




190

8 mo

265

402,800

Individual directed goods and services




189

8 mo

264

399,168

Self directed community supports and employment





189

8 mo

264

399,168

GRAND TOTAL:

51,611,259

TOTAL ESTIMATED UNDUPLICATED PARTICIPANTS (from Table J-2-a)

11379

FACTOR D (Divide total by number of participants)

4,536

AVERAGE LENGTH OF STAY ON THE WAIVER

264 days




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