9-Justification for Fee for Service Budget.pdf

Justification for Fee for Service Budget

Provide the following detailed budget information for each treatment service being proposed.

1. Service Category: Outpatient Telepsychiatry Clinical Services During Scheduled Clinic

Hours - Hourly

2. Fee charged per unit of service: $ ____________

3. Number of units of service to be provided: ____________

4. Total cost for these services (# 2 x # 3 = # 4) $ ____________

5. Definition of the unit of service.

Clearly define what specific services will constitute a single unit of service.

6. Detailed justification for the calculation of the fee per unit of service.

Category Cost per unit of service

Total fee charged

1. Service Category: On Demand Phone Calls 24 hours/day, 365 days/year - Per Call

(20 min. or less)

1. Service Category: On Demand Crisis Evaluation 24 hours/day, 365 days/year - Hourly

EXAMPLE OF

Detailed Justification for Fee for Service Budget

If the fee charged per unit of service (#2) was $35.25, then the justification could be:

1. Salary $22.50 per unit of service

2. Fringe $4.25 per unit of service

2. Equipment/supplies $3.50 per unit of service

3. Travel/parking $3.00 per unit of service

4. Other(s) (define each) $2.00 per unit of service

$35.25 per unit of service

Expenditure/Category – Potential Lines:

1) Personnel Salaries:

Please use the most logical and concise manner to convey the personnel cost of each program. Each person participating in the provision of services should be listed with the annual salary and the percent of time allocated to the program. Example:

Position Title Supervisor

Staff Name Jones, Bill

Annual Salary $30,000

% Time 80%

Total $24,000

2) Personnel Fringe Benefits:

FICA, SUTA, Medicare, medical, dental, retirement, workers compensation, and unemployment tax are considered fringe benefits. There may be others specific to your agency. Please list as appropriate. Some items may be carried as indirect costs under the Other expenditure line.

3) Personnel Training:

These costs are those associated with maintaining credentials and licenses, including registration fees and in-service training. In agencies that receive funding from multiple sources, please do not assign all training to this budget. Instead, use an assignment based on the percentage of time employees receiving training are dedicated to the HCCSCD’s residential facility.

4) Personnel Travel:

This expenditure line item should include only travel by personnel in the performance of HCCSCD residential program related business and include staff mileage reimbursement (at no more than the IRS rate per mile), per diem meals, lodging, and public transportation costs. Travel costs for residents or personal travel is not allowable in this category. Travel to training should also be included. (Expenses for agency vehicles used to transport staff and residents should be listed under the “Transportation” expenditure line.)

5) Equipment:

This expenditure line item may include leased equipment, insurance, and annual depreciation of equipment used in this program. For any vendor-owned equipment associated with the program, appropriate percentages may be depreciated and charged as an indirect cost in the “Other” expenditure line. Appropriate depreciation schedules must be attached with indication of total indirect costs and the percentage charged to the HCCSCD program.

6) Transportation:

Transportation costs, such as gasoline, parking, etc., of transporting residents to and from facilities or related program activities are to be placed in this line item. Mileage logs will be required for audit purposes. Transportation costs associated with HCCSCD-owned vehicles will be paid from the HCCSCD facility budget.

7) Consumable Supplies:

This expenditure line includes office supplies, tests, educational supplies, posters, food for residents, housekeeping costs, postage, linens, resident medical supplies, urinalysis testing supplies, etc.

8) Other:

Included in this expenditure line are profit, professional services (specify type of service), insurance, pest control service, janitorial, and miscellaneous indirect costs (please specify and attach an explanation of the allocation method and expenditure items included for indirect costs, along with the percentage applicable to the HCCSCD program).

9) Facility:

This line item includes items such as building rental, maintenance, insurance (content and liability), utilities, building depreciation or use allowance (attach schedule). Purchase or lease-purchase payments for facilities are not allowable expenditures from State funds.

Comments:

All expenditures must be reasonable and allowable and related to the program. Vendors should not include unallowable costs in their Justification for Fee for Service Budgets. A list of Unallowable Costs is available on the following page.

All records on vendor expenditures must be maintained for auditing purposes, and any expenditure not properly documented may be disallowed. Vendors must maintain an accounting system in accordance with the line-item categorization as outlined in the Vendor Program Budget (Request for Funding) for the HCCSCD-funded program.

Depreciation schedule for any equipment items or building that are budgeted in this program budget.

“Use allowance” documentation applicable for equipment or buildings if included in this budget.

Either: Indirect and/or overhead cost allocation plan, including explanation of allocation method, expenditure items included, total indirect and/or overhead amount to be allocated to all of vendor’s programs, number of vendor programs to which allocated, and percentage allocated to the HCCSCD’s program; Or: A certified statement (or copy of approval letter) that the vendor’s allocation plan has been approved by another state or federal agency.

NOTE: EXAMPLE AND INFORMATION ONLY. PAGES 4-6 DO NOT NEED TO BE RETURNED

WITH THE PROPOSAL.

Unallowable Costs

Any item unallowable by State or any authorized agency, statute, policy, or procedure including, but not limited to, federal guidelines for operation of for-profit and not-for-profit entities;

Alcoholic beverages;

Bad debts;

Building and Land purchase, rental purchase, lease purchase, renovation;

Cash payments to intended recipients of Services;

Equipment items exceeding $1,000 (CPU, Monitor and Keyboard are one unit) counted as a direct expense toward the program. Such items may be charged to the program only through an approved depreciation methodology.

Expenses or reimbursements to or on behalf of vendor-related entities for allowable indirect costs;

Expenses or costs reimbursed to vendor by other funds with respect to amounts paid by the CSCD for vendor services;

Fines and Penalties;

Firearm, Firearm Components, and Ammunition;

Fundraising; Marketing; and Advertising (advertising is allowable for personnel vacancies and procurement of goods and services only);

Legislative expenses for payment to any elected official from funds received from the CSCD;

Lobbying;

Payments to or on behalf of individuals related to principals of any vendor-affiliated organization(s) or to their employees, unless as allowable indirect costs or unless specific approval is received from the CSCD;

and

Tobacco Products.