Commissioner Michael F. Hogan, PhD
Governor Andrew M. Cuomo
Home and Community Based Services Waiver
Guidance Document
Division of Children and Families
Individualized Care Buddget
View Adobe Acrobat Version | Download Adobe Acrobat Reader
| Date This Budget Plan was Prepared | Program Name: | Child’s Name: | ID No: | |||
|---|---|---|---|---|---|---|
| Type of Service | Provider | Effective Date | Number of Weeks/Months | Frequency & Duration | Rate | Total Cost Annual |
| Waiver Services: | ||||||
| ICC | ||||||
| Respite Care Hourly | ||||||
| Respite Care Overnight | ||||||
| Family Support | ||||||
| Skill Building | ||||||
| Intensive In-Home | ||||||
| Crisis Response | ||||||
| Non–Waiver Mental Health Services: | ||||||
| Outpatient Psych: (clinic) | ||||||
| Day Treatment (DT) | ||||||
| Inpatient Psych: | ||||||
| Psychiatrist | ||||||
| CPEP | ||||||
| Medical Services: | ||||||
| Inpatient | ||||||
| Physician | average waiver child | $62.13 | ||||
| Specialist (specify) | ||||||
| Dental | average waiver child | $54.44 | ||||
| SSHP | average waiver child | $1,114.67 | ||||
| Pharmacy | average waiver child | $1,711.23 | ||||
| Managed Care Premium | average waiver child | $167.72 | ||||
| Other: (Specify) (hearing test ect.) | ||||||
| Projected Total Cost of Services: | ||||||
Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.