372 - Annual Report on Home and Community-Based Services Waivers

UT
0247
SUBMITTED
Waiver Year:
Report Type:
$11,067 <= $58,624
Level/s of Care:
Note: Average Per Capita (APC)
Annual Number of Section 1915c Waiver Recipients and Expenditures:
(Specify each service as in the approved waiver)
Service
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Adult Day Health Services
NF $111,707 27
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Homemaker Services
NF $1,521,908 489
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Respite Care Services
NF $143,823 50
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Respite Care Services LTC Facility
NF $11,484 5
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Waiver Case Management Services
NF $768,621 616
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Enhanced State Plan Supportive Maintenance Home Health Aide
NF $55,563 27
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Adult Companion Services
NF $405,193 263
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Chore Services
NF $11,240 22
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Environmental Accessibility Adaptations
NF $9,112 71
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Supplemental Meals - Home
NF $242,914 266
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Medication Reminder Services
NF $27,085 57
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Personal Attendant Services Participant employed
NF $547,580 66
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Personal Attendant Services Agency employed
NF $28,968 8
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Personal Attendant Training Services
NF $0 0
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Personal Emergency Response Systems Response Center Service
NF $89,081 358
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Personal Emergency Response Systems Purchase, Rental & Repair
NF $495 37
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Personal Emergency Response Installation, Testing & Removal
NF $1,835 51
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Specialized Medical Equipment Supplies, Assistive Technology
NF $32,466 195
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Transportation Services - nonmedical
NF $146,112 110
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Financial Management Services
NF $26,553 68
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Personal Budget Assistance
NF $4,097 6
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Community Transition Services
NF $64 1
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Service Name (no longer a required field): Level of Care Expenses in $ Participants Service Category Name
-- Other
If Other, specify:
Supplemental Meals - Community
NF $0 0
HCBS Taxonomy:
Category 1: Subcategory 1:
Category 2: Subcategory 2:
Category 3: Subcategory 3:
Category 4: Subcategory 4:
Assurances:
Documentation:
Findings of Monitoring:
Certification:
I, do certify that the information shown on the Form CMS-372(S) is correct to the best of my knowledge and belief:
Contact Information (optional):