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



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Waiver Year: Year 5 (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


9

27 days

52.34/day

12,719




Full Day

772

69 days

45.18/day

2,406,648




Half Day

223

37 half-days

23.91/day

197,281

Assistive Devices




2,520

3 units

54.43/unit

411,491

CDAC


















Agency, non-assisted living - Daily

52

112 days

38.19/day

224,419




Agency, non-assisted living - Hourly

474

168 hrs

18.15/hr

1,445,321




Individual – Daily

390

206 days

35.19/day

2,827,165




Individual – Hourly

1915

563 hrs

10.39/hr

11,201,927




Assisted Living

300

6 mo

1,073.75/mo

1,932,750

Chore Service




1387

61 half-hr

7.84/half-hr

663,319

Homemaker




6995

87 hrs

20.27/hr

12,335,613


Home Health Aide




129

36 hrs

39.63/hr

184,042

Nursing Care




230

10 visits

79.51/visit

182,873

Respite: Home Health Aide



















Specialized

22

57 hrs

42.86/hr

53,747


Basic

511

96 hrs

21.72/hr

1,065,496




Group

0

0 hrs

13.78/hr

0

Respite: Home Care Agency



















Specialized

0

0 hrs

35.45/hr

0




Basic

162

170 hrs


16.08/hr

442,843




Group

2

155 hrs

7.64/hr

2,368

Respite: Facility



















Hospital

17

232 hrs

7.65/hr

30,172




Nursing Facility

34

461 hrs

5.68/hr


89,028




Camps

0

0 hrs

13.78/hr

0




Adult Day Care

0

0 hrs

13.78/hr

0

Mental Health Outreach




283

40 hrs

22.98/hr

260,134

Home & Vehicle Mod.




429

1 unit

556.24/unit

238,627


Home Delivered Meals




8,613

175 meals

5.38/meal

8,109,140

PERS




9154

8 mo

30.35/mo

2,222,581

PERS Install




1936

1 install

35.99/install

69,677

Senior Companion




292

290 hrs


4.52/hr

363,092

Transportation



















RTA

39

259

0.33/mile

3,162




AAA

1,581

61 trips

6.93/trip

668,336

Nutritional Counseling




315

9 qtr hrs


8.55/qtr hr

24,239

Case Management




13,314

8 mot

114.00/mo

12,142,368



















Financial Management




665

8 mo

67/mo

356,440

Independent Support Brokers




665

12 mo

27/mo


215,460

Self directed personal care




222

8 mo

271.11/mo

481,491

Individual directed goods and services




222

8 mo

271.11/mo

481,491

Self directed community support and employment




221

8 mo

271.11/mo

479,322



































GRAND TOTAL:

61,824,782

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

13,314

FACTOR D (Divide total by number of participants)

4,644

AVERAGE LENGTH OF STAY ON THE WAIVER

264ys




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