Addendum No. 3 - HFW Budget Schedule FY 28-29.xlsx
XLSX spreadsheet 153 KB Posted
- Attached to
- RFP 25-187 High Fidelity Wraparound Services
- Solicitation number
- DBHE26-ADMN-6310
- Issued by
- California
About this file
This is a budget schedule addendum for the High Fidelity Wraparound (HFW) Program for San Bernardino County Department of Behavioral Health for fiscal year 2028-2029 (July 1, 2028 to June 30, 2029). The document provides detailed instructions and templates for completing budget schedules including staffing allocations, operating expenses, service projections, and dosage estimates. The HFW program is a comprehensive mental health service designed to serve children and youth with complex behavioral health needs and their families. The addendum specifies staffing roles and ratios including HFW Facilitators, Family Specialists, Caregiver/Parent Partners, HFW Supervisors/Managers, Clinical Supervisors, Fidelity Coaches, and Community Developers. Service delivery encompasses case management and intensive care coordination (SFC 01-09), mental health services (SFC 10-50), intensive home-based services (SFC 57), therapeutic behavioral services (SFC 58), medication support services (SFC 60-69), and crisis intervention (SFC 70). The budget template allocates 1.00% to case management and intensive care coordination, 72.00% to mental health services, 4.00% to intensive home-based services, 3.75% to therapeutic behavioral services, 9.00% to medication support services, 0.25% to crisis intervention, and 10.00% to Mode 60 services (client housing and flexible support).
Funding for the program is structured with 95.00% Medi-Cal (FFP) at a 50.00% share and 100.00% MHSA/BHSA funding sources, with net county funds required to equal zero. The monthly HFW bundled rate is established at $4,290 per client, with the contract amount and total funding amounts to be calculated based on the number of clients served and additional Mode 60 and Mode 15 services. Service delivery staff include positions such as Certified AOD Counselors, Mental Health Rehabilitation Specialists, Licensed Clinical Social Workers, Licensed Psychiatric Technicians, and Peer Support Specialists, with hourly rates ranging from $193.51 (Medical Assistant, Category 2) to $1,319.26 (Licensed Physician, Category 2). The program includes a targeted length of episode of eight months and employs a per-minute billing system for clinical services, with rates varying by staff classification and service function. Operating costs include an external database fee calculated at 0.26% of the contract amount, client housing support, client flexible support, and other non-Medi-Cal support services as applicable.
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Instructions
| Instructions for completing the budget schedules. | ||
| The yellow highlighted cells are the areas to be completed by the Provider. | ||
| Schedule A: | ||
| 1 | Complete the portions requiring Provider Information. | |
| Name, Address, etc. | ||
| 2 | Enter the distribution percentages for each service function. | |
| These percentages must equal 100%. | ||
| The percentage provided represent estimated service distributions, but may be modified by the Provider | ||
| DBH reserves the right to modify these percentages, as appropriate. | ||
| 3 | Enter the amount being requested in the Total DBH Allocation (Funding) Amount cell highlighted in yellow. | |
| This amount should equal the estimated amount for Monthly HFW Bundled Rate (Cell F16) PLUS amount required for Mode 60 and Mode 15 services. | ||
| 4 | Signature cells are to remain blank. | |
| HFW Bundled Rate Staff: | ||
| 1 | Input the Name of the Employee or Contractor. If position is vacant, input Vacant or TBD. | |
| If multiple employees in one position, input on multiple lines OR code column E (i.e., % of Time) to equal number of FTEs in that classification (e.g., 350% = 3.50 FTE). | ||
| NOTE: Monthly HFW Bundled rate requirements require all roles to be fullfilled. If you believe one staff may fulfill multiple roles, please list on more than one line and indicate the percentage of time they will be in each role. | ||
| While there are no fixed ratios of staff to clients, there are suggested ratios. Cells C39 through D45 will indicate if the staffing pattern proided for each role is within 25% of the suggested ratio, or higher (i.e., serving more clients than expected), or lower (i.e., serving few clients than expected). | ||
| 2 | Input the Degree/License of the Employee or Contractor. If position is vacant, leave blank. |
3 Select Position/Title. All positions contractually required to meet Monthly HFW Bugeted rate requirements.
4 In cell C35, input the targeted number of clients served per month
| Service Delivery Staff: | ||
| 1 | Input the Name of the Employee or Contractor. If position is vacant, input Vacant or TBH. | |
| If multiple employees in one position, input on multiple lines OR code column E (i.e., % of Time) to equal number of FTEs in that classification (e.g., 350% = 3.50 FTE). | ||
| 2 | Input the Degree/License of the Employee or Contractor. If position is vacant, leave blank. |
| 3 | Select Position/Title. If there are positions contractually required, those should be listed first. | |
| Please be careful to distinguish between "Mental Health Rehabilitation Specialist" and "Other Qualified Practitioner." | ||
| 4 | The column labeled D/C is to indicate Direct or Contractor. | |
| Service Delivery Staff Worksheet should ONLY include staff who will be providing direct services, so all should be listed with a "D" or "C" | ||
| If position is split between Direct and Indirect, please list on Service Delivery Staff and indicate the percentage of time expected as a direct staff. |
For Contracted staff that are direct service providers, please indicate the type of staff and FTE.
| Service Projections: Modes 05, 10, 15 | ||
| 1 | Input the Starting Census of the Program as of July 1st of each year. | |
| 2 | Input the number of Admissions and Discharges for each month of service. | |
| This should be completed with an awareness of targeted length of episode, which is 8 months for HFW. | ||
| The monthly census amount should be equal to, or very close to, the number of clients to be served in one month on the HFW Bundled Rate Staff tab. | ||
| 3 | Please note that the “Productivity Level” represents the percentage of time clinical staff will need to code as a direct service to maximize the contract. | |
| This calculation takes into account 80 hours of vacation, 80 hours of holiday time, 40 hours of staff out sick, and a 10% vacancy rate. | ||
| This calculation only applies to Service Delivery Staff and does not include the HFW Bundled Rate Staff. | ||
| Dosage Estimates | ||
| 1 | This worksheet is calculated based upon program specific information, and information from throughout the workbook. |
Behavioral Health Provider Support and Accounting Services
PSAS Staff Instructions
| Instructions for reviewing and revising the budget schedules. |
| All Tabs: |
| Review all tabs for accuracy of information, formulas, locked cells, protection, and all relevant information. |
| These instructions are for all budget schedules and may not apply to all Programs. |
| Schedule A: | ||
| Prior to distribution to Providers: | ||
| 1 | Complete required sections | |
| Program Name | ||
| Fiscal Year and timeframe for the budget schedules. | ||
| 2 | Modes and Service Functions | |
| Verify with Program which modes and services functions are required. | ||
| If notes are needed to identify certain service functions require a minimum percentage, verify the percentage with Program. | ||
| 3 | Expenses Section | |
| Verify formulas are correct for each mode and service function, including totals. | ||
| 4 | Funding Section | |
| Verify with Budgets the correct funding sources, mix and share percentages | ||
| Verify formulas are correct for each funding source and totals. | ||
| 5 | Signature cells are to remain blank - do not type in any names as the person responsible for signing may change. This will be completed during the signing process. | |
| 6 | Verify all cells are locked that should be and sheet is protected. |
| Upon Provider Submission | |||
| 1 | Verify the Distribution Percentages exactly equal 100%. Notify Provider of the error and request revisions before sending to Program. | ||
| 2 | Expenses Section | ||
| Verify totals are correct and match corresponding tabs. | |||
| The total should match the Gross Costs Total Staffing and Operating Expenses on Operating Costs tab. | |||
| 3 | Funding Section | ||
| Verify totals are correct and match the Contract Amount. Do not use the Total Expenses amount as this will depend if any Agency Revenues were captured. |
| Service Delivery Staff | ||
| Prior to distribution to Providers: | ||
| 1 | Verify all formulas are correct. | |
| If the timeframe is less than the full fiscal year, adjust formulas in Budgeted Hours of Contract Services and Total Charged to Contract Services columns. | ||
| The Position Title is a drop down list. Provider must choose from one of the positions on the list. | ||
| 2 | Verify all cells are locked that should be and sheet is protected. |
| Upon Provider Submission | ||
| 1 | Verify provider has completed all sections. | |
| Name should be completed or "Vacant" should be input. TBH, TBD, or leaving blank is not acceptable. | ||
| Degree/License should be input. Leaving blank is not acceptable. | ||
| Position Title is a drop down list. Leaving blank is not acceptable. | ||
| Staff Position Column should be Y or N. Leaving blank is not acceptable. | ||
| Direct or Contract is a drop down list. Leaving blank is not acceptable. | ||
| Salary and Benefits are dollar amounts. Anything other than a dollar amount will be rejected. | ||
| The % Cost Allocated Contract should adhere to the instructions on the Instructions tab. |
| Other Staff | ||
| Prior to distribution to Providers: | ||
| 1 | Verify all formulas are correct. | |
| If the timeframe is less than the full fiscal year, adjust formulas in Budgeted Hours of Contract Services and Total Charged to Contract Services columns. | ||
| The Position Title is a drop down list. Provider must choose from one of the positions on the list. | ||
| Verify all cells are locked that should be and sheet is protected. |
| Upon Provider Submission | ||
| 1 | Verify provider has completed all sections. | |
| Name should be completed or "Vacant" should be input. TBH, TBD, or leaving blank is not acceptable. | ||
| Degree/License should be input. This can be left blank on this tab as some positions do not require a degree. | ||
| Position Title is a drop down list. Leaving blank is not acceptable. | ||
| Indirect or Contract is a drop down list. Leaving blank is not acceptable. | ||
| Salary and Benefits are dollar amounts. Anything other than a dollar amount will be rejected. | ||
| The % Cost Allocated Contract should adhere to the instructions on the Instructions tab. |
| Operating/Administrative Costs: | |
| Prior to distribution to Providers: | |
| 1 | Verify all formulas are correct, including contractor section. |
| 2 | Hide rows not required to specific programs, External Database to Operating Income, and calculations at the bottom. |
| Verify all cells are locked that should be and sheet is protected. |
| Upon Provider Submission | |
| 1 | Verify Totals are correct. The Gross Costs Total should equal the Subtotal B and Staffing Totals. |
| 2 | Adjust any cells, rows,and columns for formatting issues. |
| Operating/Administrative Costs Narrative: | ||
| Prior to distribution to Providers: | ||
| 1 | Verify all formulas are correct, including contractor section. | |
| 2 | Hide rows not required to specific programs, External Database to Operating Income, and calculations at the bottom. | |
| Verify all cells are locked that should be and sheet is protected. | ||
| Upon Provider Submission | ||
| 1 | Adjust any cells, rows,and columns for formatting issues. | |
| Service Projections: Modes 05, 10, 15 | ||
| Prior to distribution to Providers: | ||
| 1 | Verify with Program if this tab is required and the weighted rates for Modes 05 and 10. The weighted rates for Mode 15 are formula driven. | |
| 2 | Verify the dates are correct in the "Month" section. Change the year for July, the other months will update automatically. | |
| 3 | Verify all formulas are correct to include: | |
| Contractor section | ||
| Estimated Units of Service section. | ||
| Planned Clinical FTE's section | ||
| Projected Revenue Generated by Service Type section | ||
| Census section | ||
| Provider Type section. | ||
| 4 | If the timeframe is less than the full fiscal year, adjust formulas in Estimated Units of Service and Planned Clinical FTE's columns. | |
| Verify all cells are locked that should be and sheet is protected. | ||
| 5 | Hide all rows and columns that are for internal use and information only. | |
| This will include all program specific provider type tables, and estimated vacancy rate cells. | ||
| 5 | Verify all cells are locked that should be and sheet is protected. |
| Upon Provider Submission | ||
| 1 | Verify all required cells have been completed and calculated properly. | |
| Starting census should be completed, even if zero (0) |
| Dosage Estimates | |
| Prior to distribution to Providers: | |
| 1 | Verify Expected Length of Program (months) with Program. If left blank, the worksheet will not calculate properly. |
| 2 | This worksheet is completely formula driven. Verify all formulas are correct. |
| 3 | Verify all cells are locked that should be and sheet is protected. |
| Upon Provider Submission | |
| 1 | Verify the formulas calculated properly. |
| Rates | |
| 1 | Verify Rates are up-to-date. Update if necessary |
| 2 | Verify rates match the rates on the Rates Utilized by DBH Per Min tab. |
| Special Items | |
| 1 | Look for formulas in the Provider sections that are linked to the Provider's internal files. |
| Copy and Paste as Value in the same cell to keep the information and break the link. |
| The remaining tabs are to be completed by Program. PSAS should verify with Program all updates have been completed. | |
| Hide all tabs not relevant to the Provider. | |
| 1 | PSAS Staff Instruction |
| 2 | Rates |
| 3 | Program Instructions |
| 4 | Rates Utilized by DBH Per Min |
| 5 | SMHS Rates for Program |
| 6 | Service Planning Worksheet |
| 7 | Staffing Planning Worksheet |
| 8 | List of Values |
| 9 | Any other tabs not relevant to a particular program. For example, Dosage Estimates. |
Behavioral Health Provider Support and Accounting Services Behavioral Health Provider Support and Accounting Services
Schedule A
| SCHEDULE A - Planning Estimates | SAN BERNARDINO COUNTY | |
| CalAim/Fee for Service | DEPARTMENT OF BEHAVIORAL HEALTH | |
| Contractor Name: | High Fidelity Wraparound (HFW) Program | |
| RU # | FY 2028 - 2029 | |
| Contract # / RFP # | July 1, 2028 to June 30, 2029 | |
| Address: | ||
| City, State, Zip Code: | ||
| Date Form Completed: | ||
| Prepared by: | ||
| Title: |
| LINE | MODE OF SERVICE | 15 (Outpatient) | Mode 60 | TOTAL | ||||||||
| # | SERVICE FUNCTION | HFW Monthly Bundled Rate | Case Management & ICC | |||||||||
| (01-09) | Mental Health Services | |||||||||||
| (10-50) | Intensive Home Based Services | |||||||||||
| (57) | TBS | |||||||||||
| (58) | Medication Support | |||||||||||
| (60-69) | Crisis Intervention | |||||||||||
| (70) | Mode 60 (SFC72 & 78) | |||||||||||
| 1 | 100% | Distribution % | 1.00% | 72.00% | 4.00% | 3.75% | 9.00% | 0.25% | 10.00% | 100.00% | ||
| Allocation Amount | ||||||||||||
| 2 | Total DBH Allocation (Funding) Amount | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
Hougen, Timothy DBH: Total Amount Entered Should be Amount calculated of HFW Monthly Bundled Rate (F2) + Estimated Amount needed for additional SMHS.
| AGENCY REVENUES | ||||||||||||
| 3 | PATIENT FEES | 0 | ||||||||||
| 4 | PATIENT INSURANCE | 0 | ||||||||||
| 5 | MEDI-CARE | 0 | ||||||||||
| 6 | GRANTS/OTHER | 0 | ||||||||||
| 7 | TOTAL AGENCY REVENUES (6+7+8+9) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||
| 8 | CONTRACT AMOUNT (5-10) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Mix % | FUNDING* | Share % | ||||||||||
| 9 | 95.00% | MEDI-CAL (FFP) | 50.00% | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
| 100.00% | MHSA/BHSA | 0.00% | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| MHSA Match | 0.00% | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||
| 1991 Realignment | 0.00% | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||
| 10 | BHSA Match & Non-M/C | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| FUNDING TOTAL | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||
| 11 | NET COUNTY FUNDS (Local Cost) MUST = ZERO | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| 12 | STATE FUNDING (Including Realignment) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| 13 | FEDERAL FUNDING | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| TOTAL FUNDING | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||
| 14 | TARGET COST PER UNIT OF SERVICE | See HFW Bundled Rate | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| 15 | UNITS OF SERVICE | See HFW Bundled Rate | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| * Subject to CFS Match funding per MOU. |
APPROVED:
PROVIDER AUTHORIZED SIGNATURE DATE DBH PSAS DATE DBH PROGRAM MANAGER DBH PROGRAM MANAGER DATE
PROVIDER AUTHORIZED SIGNER (PRINT NAME) DBH PSAS (PRINT NAME) DBH PROGRAM MANAGER (PRINT NAME) DBH PROGRAM MANAGER (PRINT NAME)
HFW Bundled Rate Staff
| SAN BERNARDINO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH | 25% | |||||||||
| Schedule B | STAFFING DETAIL | HFW Staffing Titles | Ratio to Clients | FTEs | Ratio Test | Ratio Concern | ||||
| 0 | HFW Facilitator | 10 | 0 | ERROR:#DIV/0! | ERROR:#DIV/0! | |||||
| 0 | Family Specialist | 10 | 0 | ERROR:#DIV/0! | ERROR:#DIV/0! | |||||
| Staffing Detail - Personnel (Includes Personal Services Contracts for Professional Services) | Caregiver/Parent Partner | 10 | 0 | ERROR:#DIV/0! | ERROR:#DIV/0! | |||||
| HFW Supervisor/Manager | 40 | 0 | ERROR:#DIV/0! | ERROR:#DIV/0! | ||||||
| CONTRACTOR NAME: | Clinical Supervisor (Licensed) | 80 | 0 | ERROR:#DIV/0! | ERROR:#DIV/0! | |||||
| Name | HFW Core Team | % Time | If Staff Position is not Clinical FTE Providing SMHS, change to "N" | Direct or Contract |
| D/C | Full | Full | Total | % Time | Total Salaries | Budgeted | Total Salaries Charged to Contract Services | Total Benefits Charged to Contract Services | Fidelity Coach | 40 | 0 | ERROR:#DIV/0! | ERROR:#DIV/0! | |||||||||
| Degree/ | Position | Allocated | Time | Time | Full Time | Allocated | and Benefits | Hours of | Clinical | Community Developer | 80 | 0 | ERROR:#DIV/0! | ERROR:#DIV/0! | ||||||||
| License | Title | to Program | Annual | Fringe | Salaries & | to Program | Charged to | Contract | FTE | |||||||||||||
| Salary | Benefits | Benefits | Contract Services | Services | ||||||||||||||||||
| Y | 0 | |||||||||||||||||||||
| Y | 0 | |||||||||||||||||||||
| Y | 0 | |||||||||||||||||||||
| Y | 0 | |||||||||||||||||||||
| Y | 0 | |||||||||||||||||||||
| Y | 0 | |||||||||||||||||||||
| Y | 0 | |||||||||||||||||||||
| Y | 0 | |||||||||||||||||||||
| Y | 0 | |||||||||||||||||||||
| Y | 0 | |||||||||||||||||||||
| Y | 0 | |||||||||||||||||||||
| Y | 0 | |||||||||||||||||||||
| Y | 0 | |||||||||||||||||||||
| Y | 0 | |||||||||||||||||||||
| Y | 0 | |||||||||||||||||||||
| Y | 0 | |||||||||||||||||||||
| Y | 0 | |||||||||||||||||||||
| Y | 0 | |||||||||||||||||||||
| Y | 0 | |||||||||||||||||||||
| - 0 | 0 | |||||||||||||||||||||
| TOTAL | TOTAL | |||||||||||||||||||||
| COST: | COST: | |||||||||||||||||||||
| Proposed HFW Monthly Bundled Rate | $4,290 | |||||||||||||||||||||
| Number of Clients to be Provided HFW Bundled Rate in One Month | ||||||||||||||||||||||
| Annual Estimate of HFW Monthly Bundled Rate | $0 | |||||||||||||||||||||
| Staffing Pattern Ratios | ||||||||||||||||||||||
| HFW Facilitator | ERROR:#DIV/0! | |||||||||||||||||||||
| Family Specialist | ERROR:#DIV/0! | |||||||||||||||||||||
| Caregiver/Parent Partner | ERROR:#DIV/0! | |||||||||||||||||||||
| HFW Supervisor/Manager | ERROR:#DIV/0! | |||||||||||||||||||||
| Clinical Supervisor (Licensed) | ERROR:#DIV/0! | |||||||||||||||||||||
| Fidelity Coach | ERROR:#DIV/0! | |||||||||||||||||||||
| Community Developer | ERROR:#DIV/0! |
Service Delivery Staff
| SAN BERNARDINO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH | |
| Schedule B | STAFFING DETAIL |
| 0 | |
| 0 | |
| Staffing Detail - Personnel (Includes Personal Services Contracts for Professional Services) |
| CONTRACTOR NAME: | ||
| Name | If Staff Position is not Clinical FTE Providing SMHS, do not include | Direct or Contract |
| D/C | Full | Full | Total | % Time | Total Salaries | Budgeted | Total Salaries Charged to Contract Services | Total Benefits Charged to Contract Services | |||||
| Degree/ | Position | Time | Time | Full Time | Allocated | and Benefits | Hours of | Clinical | |||||
| License | Title | Annual | Fringe | Salaries & | to Program | Charged to | Contract | FTE | |||||
| Salary | Benefits | Benefits | Contract Services | Services | |||||||||
| 0 | |||||||||||||
| 0 | |||||||||||||
| 0 | |||||||||||||
| 0 | |||||||||||||
| 0 | |||||||||||||
| 0 | |||||||||||||
| 0 | |||||||||||||
| 0 | |||||||||||||
| 0 | |||||||||||||
| 0 | |||||||||||||
| 0 | |||||||||||||
| 0 | |||||||||||||
| 0 | |||||||||||||
| 0 | |||||||||||||
| 0 | |||||||||||||
| 0 | |||||||||||||
| 0 | |||||||||||||
| 0 | |||||||||||||
| 0 | |||||||||||||
| - 0 | 0 | ||||||||||||
| TOTAL | |||||||||||||
| COST: |
Other Staff
| SAN BERNARDINO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH | |
| Schedule B | STAFFING DETAIL |
| 0 | |
| 0 | |
| Staffing Detail - Personnel (Includes Personal Services Contracts for Professional Services) |
| CONTRACTOR NAME: | |||||||||||||
| Name | Indirect or Contract | ||||||||||||
| I/C | Full | Full | Total | % Cost | Total Salaries | Budgeted | Total Salaries Charged to Contract Services | Total Benefits Charged to Contract Services | |||||
| Degree/ | Position | Time | Time | Full Time | Allocated | and Benefits | Hours of | ||||||
| License | Title | Annual | Fringe | Salaries & | Contract | Charged to | Contract | ||||||
| Salary | Benefits | Benefits | Services | Contract Services | Services | ||||||||
| 0 | 0 | - 0 | 0 | 0 | |||||||||
| 0 | 0 | - 0 | 0 | 0 | |||||||||
| 0 | 0 | - 0 | 0 | 0 | |||||||||
| 0 | 0 | - 0 | 0 | 0 | |||||||||
| 0 | 0 | - 0 | 0 | 0 | |||||||||
| 0 | 0 | - 0 | 0 | 0 | |||||||||
| 0 | 0 | - 0 | 0 | 0 | |||||||||
| 0 | 0 | - 0 | 0 | 0 | |||||||||
| 0 | 0 | - 0 | 0 | 0 | |||||||||
| 0 | 0 | - 0 | 0 | 0 | |||||||||
| 0 | 0 | - 0 | 0 | 0 | |||||||||
| 0 | 0 | - 0 | 0 | 0 | |||||||||
| 0 | 0 | - 0 | 0 | 0 | |||||||||
| 0 | 0 | - 0 | 0 | 0 | |||||||||
| 0 | 0 | - 0 | 0 | 0 | |||||||||
| 0 | 0 | - 0 | 0 | 0 | |||||||||
| 0 | 0 | - 0 | 0 | 0 | |||||||||
| 0 | 0 | - 0 | 0 | 0 | |||||||||
| 0 | 0 | - 0 | 0 | 0 | |||||||||
| - 0 | - 0 | - 0 | |||||||||||
| TOTAL | |||||||||||||
| COST: | 0 |
Operating Costs
| SAN BERNARDINO COUNTY | |||
| DEPARTMENT OF BEHAVIORAL HEALTH | |||
| SCHEDULE B | |||
| High Fidelity Wraparound (HFW) Program | Contractor Name: | ||
| 0 | RU # | ||
| 0 | Contract # / RFP # | ||
| Prepared by: | Address: | ||
| Title: | City, State, Zip Code: | ||
| Date Form Completed: | |||
| Operating Expenses - Please list all operating costs charged to this program, including administrative support costs and management fees along with a detail explanation of the categories below. |
| Budget Revision | ||||||||||||
| ITEM | TOTAL COST TO | |||||||||||
| ORGANIZATION | % CHARGED TO OTHER FUNDING SOURCE | TOTAL COST TO OTHER FUNDING SOURCE | PERCENT CHARGED TO PROGRAM | TOTAL COST TO PROGRAM | Request Change | Revised Budget | ||||||
| 1 | External Database Fee (.26% of Contract) | 100% | $0 | $0 | 0 | 0 | ||||||
| 2 | Client Housing Support (70) | 100% | $0 | $0 | 0 | |||||||
| 3 | Client Flexible Support (72) | 100% | $0 | $0 | 0 | |||||||
| 4 | Other Non-MediCal Support (78) | 100% | $0 | $0 | 0 | |||||||
| 5 | Operating Income | 100% | $0 | $0 | 0 | |||||||
| 6 | 100% | $0 | $0 | 0 | ||||||||
| 7 | 100% | $0 | $0 | 0 | ||||||||
| 8 | 100% | $0 | $0 | 0 | ||||||||
| 9 | 100% | $0 | $0 | 0 | ||||||||
| 10 | 100% | $0 | $0 | 0 | ||||||||
| 11 | 100% | $0 | $0 | 0 | ||||||||
| 12 | 100% | $0 | $0 | 0 | ||||||||
| 13 | 100% | $0 | $0 | 0 | ||||||||
| 14 | 100% | $0 | $0 | 0 | ||||||||
| 15 | 100% | $0 | $0 | 0 | ||||||||
| 16 | 100% | $0 | $0 | 0 | ||||||||
| SUBTOTAL B: | $0 | $0 | $0 | 0 | 0 | 0% |
tc={4719DA4B-D36C-4D5E-BE86-72D06CA138ED}: [Threaded comment]
Your version of Excel allows you to read this threaded comment; however, any edits to it will get removed if the file is opened in a newer version of Excel. Learn more: https://go.microsoft.com/fwlink/?linkid=870924
Comment:
This calculation provides an easy visual for portion of overall contract going to staffing costs.
GROSS COSTS TOTAL STAFFING AND OPERATING EXPENSES: $0
| These rows are to be locked and hidden when sending to providers. | ||
| Total Administrative Costs | 0 | |
| Staffing | 0 | 0 |
| Client Housing Support | 0 | |
| Client Flexible Support | 0 | |
| Other Non-MediCal Support | 0 | |
| Operating Income | 0 | |
| Net Total | 0 | |
| Net Admin Costs | 0 |
This calculation provides an easy visual for portion of overall contract going to staffing costs.
Op. Cost Narrative
| SAN BERNARDINO COUNTY | |||
| DEPARTMENT OF BEHAVIORAL HEALTH | |||
| SCHEDULE B | |||
| BUDGET NARRATIVE | |||
| 0 | Contractor Name: | ||
| 0 | RU # | ||
| Contract # / RFP # | |||
| Prepared by: | Address: | ||
| Title: | City, State, Zip Code: | ||
| Date Form Completed: | |||
| Budget Narrative for Operating Expenses. Explain each expense by line item. Provide an explanation for determination of all figures ( rate, duration, quantity, Benefits, FTE's, etc.) for example explain how overhead or indirect cost were calculated. |
| ITEM | Justification of Cost | |
| 1 | External Database Fee (.26% of Contract) | Participation in external database is a required aspect of program to facilitate focus of treatment servicesand reporting of outcomes. |
| 2 | Client Housing Support (70) | |
| 3 | Client Flexible Support (72) | |
| 4 | Other Non-MediCal Support (78) | |
| 5 | Operating Income | |
| 6 | ||
| 7 | ||
| 8 | ||
| 9 | ||
| 10 | ||
| 11 | ||
| 12 | ||
| 13 | ||
| 14 | ||
| 15 | ||
| 16 |
Srv Proj Modes 05,10,15
| SAN BERNARDINO COUNTY | ||||||
| DEPARTMENT OF BEHAVIORAL HEALTH | ||||||
| SCHEDULE B | ||||||
| FY 2028 - 2029 | ||||||
| July 1, 2028 to June 30, 2029 | Mode 15 | |||||
| For this Program | For this Program | Per Minute Rates | CM&ICC | |||
| (01-09) | MHS | |||||
| (10-50) | IHBS | |||||
| (57) | TBS | |||||
| (58) | MSS | |||||
| (60-69) | CI |
(70)
| Est. Vacancy Rate | Provider Type | Hourly Rate | Min Rate | For This Program | Direct Staff Count | |||||||||||
| Mode 15 | Contractor Name: | of Clinical Staff | Certified AOD Counselor | $ 284.79 | $ 4.75 | $ 4.75 | 0 | Include | Include | Don't Include | Don't Include | Don't Include | Include | |||
| CM&ICC | ||||||||||||||||
| (01-09) | MHS | |||||||||||||||
| (10-50) | IHBS | |||||||||||||||
| (57) | TBS | |||||||||||||||
| (58) | MSS | |||||||||||||||
| (60-69) | CI | |||||||||||||||
| (70) | RU # | 10.00% |
Chestnut, Ann DBH: DBH: To be verified with Program.
| Mental Health Rehabilitation Specialist | $ 258.31 | $ 4.31 | $ 4.31 | 0 | Include | Include | Include | Include | Don't Include | Include | |||||||||||||||||||
| 0.00% | Weighted Rate | Weighted Rate | Weighted Rate | Weighted Rate | Weighted Rate | Weighted Rate | Contract # / RFP # | Other Qualified Provider | $ 258.31 | $ 4.31 | $ 4.31 | 0 | Include | Include | Include | Include | Don't Include | Include | |||||||||||
| Rate Per Minute | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | Address: | Peer Support Specialists | $ 271.23 | $ 4.52 | $ 4.52 | 0 | Include | Don't Include | Don't Include | Don't Include | Don't Include | Don't Include | |||||||||||
| City, State, Zip Code: | Community Health Worker | $ 264.77 | $ 4.41 | $ 4.41 | 0 | Include | Don't Include | Don't Include | Don't Include | Don't Include | Don't Include | ||||||||||||||||||
| Date Form Completed: | LCSW (Licensed, Waivered or Registered) | $ 343.34 | $ 5.72 | $ 5.72 | 0 | Include | Include | Don't Include | Don't Include | Don't Include | Include | ||||||||||||||||||
| MFT/LPCC (Licensed, Waivered or Registered) | $ 343.34 | $ 5.72 | $ 5.72 | 0 | Include | Include | Don't Include | Don't Include | Don't Include | Include | |||||||||||||||||||
| Licensed Psychiatric Technician | $ 241.33 | $ 4.02 | $ 4.02 | 0 | Include | Include | Don't Include | Don't Include | Don't Include | Include | |||||||||||||||||||
| MONTH | Estimated Units of Service (Minutes) | Planned Clinical FTE's | |||||||||||||||||||||||||||
| Mode 15 | Clients Served | Psychologist (Licensed or Waivered) | $ 530.56 | $ 8.84 | $ 8.84 | 0 | Include | Include | Don't Include | Don't Include | Don't Include | Include | |||||||||||||||||
| CM&ICC | |||||||||||||||||||||||||||||
| (01-09) | MHS | ||||||||||||||||||||||||||||
| (10-50) | IHBS | ||||||||||||||||||||||||||||
| (57) | TBS | ||||||||||||||||||||||||||||
| (58) | MSS | ||||||||||||||||||||||||||||
| (60-69) | CI | ||||||||||||||||||||||||||||
| (70) | Starting Census | 0 | Licensed Vocational Nurse | $ 281.50 | $ 4.69 | $ 4.69 | 0 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | ||||||||||||||||
| Admissions | |||||||||||||||||||||||||||||
| (Episodes Opened) | Discharges | ||||||||||||||||||||||||||||
| (Episodes Closed) | Monthly Census | Medical Assistant | $ 193.51 | $ 3.23 | $ 3.23 | 0 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||||||||||||||||
| Licensed Physician | $ 1,319.26 | $ 21.99 | $ 21.99 | 0 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||||||||||||||||||
| Jul-28 | 0 | 0.00 | 0 | Nurse Practitioner | $ 656.03 | $ 10.93 | $ 10.93 | 0 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||||||||||||||
| Aug-28 | 0 | 0.00 | 0 | Occupational Therapist | $ 457.04 | $ 7.62 | $ 7.62 | 0 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||||||||||||||
| Sep-28 | 0 | 0.00 | 0 | Physician Assistant | $ 591.68 | $ 9.86 | $ 9.86 | 0 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||||||||||||||
| Oct-28 | 0 | 0.00 | 0 | Registered Nurse | $ 535.86 | $ 8.93 | $ 8.93 | 0 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||||||||||||||
| Nov-28 | 0 | 0.00 | 0 | ||||||||||||||||||||||||||
| Dec-28 | 0 | 0.00 | 0 | ||||||||||||||||||||||||||
| Jan-29 | 0 | 0.00 | 0 | Weighted Averages | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||||||||||||||||||
| Feb-29 | 0 | 0.00 | 0 | ||||||||||||||||||||||||||
| Mar-29 | 0 | 0.00 | 0 | ||||||||||||||||||||||||||
| Apr-29 | 0 | 0.00 | 0 | ||||||||||||||||||||||||||
| May-29 | 0 | 0.00 | 0 | ||||||||||||||||||||||||||
| Jun-29 | 0 | 0.00 | 0 | ||||||||||||||||||||||||||
| TOTAL | 0 | $ - | $ - | $ - | $ - | $ - | $ - | 0 | 0 | 0 | |||||||||||||||||||
| Total Revenue | $ - | $ - | Unduplicated Clients Served | ||||||||||||||||||||||||||
| Total Estimated Monthly HFW Bundled Rate: | $0 | Estimated Mode 15 Cost Per Client: | $0 | ||||||||||||||||||||||||||
| Total Estimated Mode 60: | $0 | ||||||||||||||||||||||||||||
| Total Estimated Contract: | $0 | Estimated Monthly HFW Bundled Rate Per Client: | $34,320 | ||||||||||||||||||||||||||
| Estimated Mode 60 Cost Per Client: | ERROR:#DIV/0! | ||||||||||||||||||||||||||||
| Estimated Total Cost Per Client: | ERROR:#DIV/0! |
Dosage Estimates
| Mode 15 | ||||||||||
| CM&ICC | ||||||||||
| (01-09) | MHS | |||||||||
| (10-50) | IHBS | |||||||||
| (57) | TBS | |||||||||
| (58) | MSS | |||||||||
| (60-69) | CI | |||||||||
| (70) | TOTAL | Avg Monthly Census | Expected Length of Program (months) | |||||||
| Total Minutes of Services | 0 | 0 | 0 | 0 | 0 | 0.00 | 0 | 0 | 8.00 | |
| Total Monthly Minutes of Services (Average) | 0 | 0 | 0 | 0 | 0 | 0.00 | 0 | |||
| Dosage (minutes) per client per month | 0 | 0 | 0 | 0 | 0 | 0.00 | 0 | |||
| Dosage (hours) per client per month | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
Total Hours Per Unduplicated Client for Duration of the Program: 0.00
RATES
Hourly Payment Rate
| Position Type | Category 1 | Category 2 | DHCS Rates |
| Certified AOD Counselor | 265.81 | 284.79 | $379.72 |
| Mental Health Rehabilitation Specialist | 241.09 | 258.31 | $344.42 |
| Other Qualified Provider | 241.09 | 258.31 | $344.42 |
| Peer Support Specialists | 253.15 | 271.23 | $361.64 |
| Community Health Worker | 247.12 | 264.77 | $353.03 |
| LCSW (Licensed, Waivered or Registered) | 320.45 | 343.34 | $457.79 |
| MFT/LPCC (Licensed, Waivered or Registered) | 320.45 | 343.34 | $457.79 |
| Licensed Psychiatric Technician | 225.24 | 241.33 | $321.77 |
| Psychologist (Licensed or Waivered) | 495.19 | 530.56 | $707.41 |
| Licensed Vocational Nurse | 262.74 | 281.50 | $375.34 |
| Medical Assistant | 180.61 | 193.51 | $258.02 |
| Licensed Physician | 1,231.31 | 1,319.26 | $1,759.01 |
| Nurse Practitioner | 612.30 | 656.03 | $874.71 |
| Occupational Therapist | 426.57 | 457.04 | $609.39 |
| Physician Assistant | 552.23 | 591.68 | $788.91 |
| Registered Nurse | 500.14 | 535.86 | $714.49 |
| Interactive Complexity | 13.22 | 13.22 | 13.22 |
| Interpretive Services | 22.32 | 22.32 | 22.32 |
| Category 1 Rates are calculated at 70% of the DHCS Rate | |||
| Category 2 Rates are calculated at 75% of the DHCS Rate |
Program Instructions
| Instructions for Program staff to complete budget schedules. |
| Service Planning Worksheet: |
Staffing Planning Worksheet
Behavioral Health Provider Support and Accounting Services
Rates Utilized by DBH Per Min
| Rate Sheet | SMHS Rates | SMHS per Minute | ||||
| DBH DHCS Provider Type (DBH Practitioner Category) | DBH Discipline in myAvatar via DHCS Billing Manual | DHCS Equivalent | MH | DHCS Rate | Category 2 | SMHS |
| ALL | ALL | Certified AOD Counselor | X | $ 379.72 | 284.79 | $ 4.75 |
| ALL | ALL | Mental Health Rehabilitation Specialist | X | $ 344.42 | 258.31 | $ 4.31 |
| ALL | ALL | Other Qualified Provider | X | $ 344.42 | 258.31 | $ 4.31 |
| ALL | ALL | Peer Support Specialists | X | $ 361.64 | 271.23 | $ 4.52 |
| ALL | ALL | Community Health Worker | X | $ 353.03 | 264.77 | $ 4.41 |
| ALL | ALL | LCSW (Licensed, Waivered or Registered) | X | $ 457.79 | 343.34 | $ 5.72 |
| ALL | ALL | MFT/LPCC (Licensed, Waivered or Registered) | X | $ 457.79 | 343.34 | $ 5.72 |
| ALL | ALL | Licensed Psychiatric Technician | X | $ 321.77 | 241.33 | $ 4.02 |
| ALL | ALL | Psychologist (Licensed or Waivered) | X | $ 707.41 | 530.56 | $ 8.84 |
| ALL | ALL | Licensed Vocational Nurse | X | $ 375.34 | 281.50 | $ 4.69 |
| ALL | ALL | Medical Assistant | X | $ 258.02 | 193.51 | $ 3.23 |
| ALL | ALL | Licensed Physician | X | $ 1,759.01 | 1,319.26 | $ 21.99 |
| ALL | ALL | Nurse Practitioner | X | $ 874.71 | 656.03 | $ 10.93 |
| ALL | ALL | Occupational Therapist | X | $ 609.39 | 457.04 | $ 7.62 |
| ALL | ALL | Physician Assistant | X | $ 788.91 | 591.68 | $ 9.86 |
| ALL | ALL | Registered Nurse | X | $ 714.49 | 535.86 | $ 8.93 |
| Instructions if new fee schedules are made available | ||||||
| 1 | Paste new information into this table, but DO NOT paste over the "…Per Min" columns (i.e., N, P, R, T, & V) | |||||
| 2 | Sort "DHCS Dquivalent" alphabetically | |||||
| 3 | Rename "MFT/LPCC (Licensed, Waivered or Registered)" to "MA/MS Clinician" | |||||
| 4 | Delete Row for "LCSW (Licensed, Waivered or Registered)" to "MA/MS Clinician" |
San Bernardino DBH Draft and Confidential
&F | &A &G
SMHS Rates for Program
| Type of Program: | Category 2 | SMHS per Minute | ||
| Provider Type | Hourly Rate | Min Rate | Enter Rates for This Program | Category 2 |
| Certified AOD Counselor | 284.79 | $ 4.75 | $ 4.75 | $ 4.75 |
| Mental Health Rehabilitation Specialist | 258.31 | $ 4.31 | $ 4.31 | $ 4.31 |
| Other Qualified Provider | 258.31 | $ 4.31 | $ 4.31 | $ 4.31 |
| Peer Support Specialists | 271.23 | $ 4.52 | $ 4.52 | $ 4.52 |
| Community Health Worker | 264.77 | $ 4.41 | $ 4.41 | $ 4.41 |
| LCSW (Licensed, Waivered or Registered) | 343.34 | $ 5.72 | $ 5.72 | $ 5.72 |
| MFT/LPCC (Licensed, Waivered or Registered) | 343.34 | $ 5.72 | $ 5.72 | $ 5.72 |
| Licensed Psychiatric Technician | 241.33 | $ 4.02 | $ 4.02 | $ 4.02 |
| Psychologist (Licensed or Waivered) | 530.56 | $ 8.84 | $ 8.84 | $ 8.84 |
| Licensed Vocational Nurse | 281.50 | $ 4.69 | $ 4.69 | $ 4.69 |
| Medical Assistant | 193.51 | $ 3.23 | $ 3.23 | $ 3.23 |
| Licensed Physician | 1,319.26 | $ 21.99 | $ 21.99 | $ 21.99 |
| Nurse Practitioner | 656.03 | $ 10.93 | $ 10.93 | $ 10.93 |
| Occupational Therapist | 457.04 | $ 7.62 | $ 7.62 | $ 7.62 |
| Physician Assistant | 591.68 | $ 9.86 | $ 9.86 | $ 9.86 |
| Registered Nurse | 535.86 | $ 8.93 | $ 8.93 | $ 8.93 |
| Instructions for DBH Program Staff to Complete | ||||
| Set Column D cells to equal the cells under the type of progam (e.g., MH Outpatient = Column G). |
Service Planning Worksheet
| DESIGNING A PROGRAM BY INDICATING TYPICAL SERVICES FOR ONE CLIENT | |||
| Type of program per Fee Sched. Categories | Episode Length (Month) | 8.00 | |
| Category 2 | |||
| Unduplicated Client Count For Whole Contract: | 10 |
| NOTE: Unless the program is a Crisis Program, we don't include Crisis Intervention in the planning. | |||||||||
| Crisis Intervention will have a percentage of funding allocated on Schedule A. For planning, enter this percentage in cell T19. | |||||||||
| Average Type, Duration, and Frequency of SMHS for One (1) Client | Summary of Services for One (1) Client | Summary of Services for Expected | Summary of Expected Costs based on | ||||||
| Freq of Service | Total Min | Total Min. Per | Total Hr Per | Unduplicated Clients | "Staff Planning Worksheet" | ||||
| Avg Face to Face Minutes | Service Provided | Per Month |
Hougen, Timothy DBH: This should represent the number per month, as averaged over the duration of tx (e.g., 1 Assessment per episode is "=1/F4".
In another example, if a program plans for 10 therapy sessions, then ongoing case management, then enter "=10/F4" to calcluate the average number per month.
| Per Episode | Client Per | Client Per | Total Min Per | Total Hr Per | Expect Costs | Total Expect | ||||||||||||
| SMHS | Column of Services | for Service | 1x/Episode | Column of Services | Episode | Episode | Column of Services | Contract | Contract | Column of Services | Per Client | Costs | Target % for Sched. A | |||||
| CM - TCM/ICC | CM (SFC 1-09) | 30 | No | 0.05 | 12 | CM (SFC 1-09) | 12 | 0.20 | CM (SFC 1-09) | 120 | 2.00 | CM (SFC 1-09) | $ 51 | $ 514 | 0.25% | |||
| MHS - Assessment | MHS (SFC 10-50) | 90 | Yes | 0.13 | 90 | MHS (SFC 10-50) | 2,168 | 36.14 | MHS (SFC 10-50) | 21,684 | 361.40 | MHS (SFC 10-50) | $ 9,029 | $ 90,285 | 44.08% | |||
| MHS - Plan Development | MHS (SFC 10-50) | 60 | No | 0.33 | 158 | IHBS (SFC 57) | 960 | 16.00 | IHBS (SFC 57) | 9,600 | 160.00 | IHBS (SFC 57) | $ 4,133 | $ 41,330 | 20.18% | |||
| MHS - Therapy | MHS (SFC 10-50) | 60 | No | 4.00 | 1,920 | TBS (SFC 58) | 960 | 16.00 | TBS (SFC 58) | 9,600 | 160.00 | TBS (SFC 58) | $ 4,133 | $ 41,330 | 20.18% | |||
| MHS - Group | MHS (SFC 10-50) | 60 | No | 0.00 | 0 | |||||||||||||
| Hougen, Timothy DBH: Minutes are divided by 4.5 to equal the calculation done in payment from DHCS. | MSS (SFC 60) | 138 | 2.30 | MSS (SFC 60) | 1,380 | 23.00 | MSS (SFC 60) | $ 3,034 | $ 30,343 | 14.81% | ||||||||
| MHS - Rehab | MHS (SFC 10-50) | 60 | No | 0.00 | 0 | CI (SFC 70) | $ 102 | $ 1,019 | 0.50% | |||||||||
| MHS - Rehab Group | MHS (SFC 10-50) | 60 | No | 0.00 | 0 |
Hougen, Timothy DBH: Minutes are divided by 4.5 to equal the calculation done in payment from DHCS.
Hougen, Timothy DBH: This should represent the number per month, as averaged over the duration of tx (e.g., 1 Assessment per episode is "=1/F4".
In another example, if a program plans for 10 therapy sessions, then ongoing case management, then enter "=10/F4" to calcluate the average number per month.
| Total % | 100.00% | |||||||||
| MHS - IHBS | IHBS (SFC 57) | 60 | No | 2.00 | 960 | Cost Per Client | Total Contract | |||
| MHS - TBS | TBS (SFC 58) | 60 | No | 2.00 | 960 | $ 20,482 | $ 204,822 | |||
| MSS - Assessment/Evaluation | MSS (SFC 60) | 90 | Yes | 0.13 | 90 | |||||
| MSS - Ongoing Care | MSS (SFC 60) | 30 | No | 0.20 | 48 | |||||
| Hrs | ||||||||||
| Monthly Minutes | 529.80 | 4,238 | 70.64 | |||||||
| Monthly Hours | 8.83 | |||||||||
| REVERSE ENGINEERING THE SAME PROGRAM BY TOTAL BUDGET | ||||||||||
| Annual Contract Budget Amount | $ 567,329 | |||||||||
| Cost Per Client as indicated above | $ 20,482 | |||||||||
| Expected Unduplicated Client Count | 28 |
| Column of Services | ||
| CM (SFC 1-09) | $ 1,423.48 | 0.25% |
| MHS (SFC 10-50) | $ 250,078.21 | 44.08% |
| IHBS (SFC 57) | $ 114,479.51 | 20.18% |
| TBS (SFC 58) | $ 114,479.51 | 20.18% |
| MSS (SFC 60) | $ 84,045.75 | 14.81% |
| CI (SFC 70) | $ 2,836.65 | 0.50% |
| $ 567,343.11 | 100.00% |
Staffing Planning Worksheet
| Mode 15 | ||||||
| Hourly Rate | Min Rate | Rates Pulled from "SMHS Rates for Program" | Theoretical Direct Staff Count | CM&ICC | ||
| (01-09) | MHS | |||||
| (10-50) | IHBS | |||||
| (57) | TBS | |||||
| (58) | MSS | |||||
| (60-69) | CI |
(70)
| Certified AOD Counselor | $284.79 | $ 4.75 | $ 4.75 | 0.00 | Include | Include | Don't Include | Don't Include | Don't Include | Include | |||
| Mental Health Rehabilitation Specialist | $258.31 | $ 4.31 | $ 4.31 | 0.00 | Include | Include | Include | Include | Don't Include | Include | |||
| Other Qualified Provider | $258.31 | $ 4.31 | $ 4.31 | 1.00 | Include | Include | Include | Include | Don't Include | Include | |||
| Peer Support Specialists | |||||||||||||
| Hougen, Timothy DBH: The scope of this professional exceeds what is indicated; however, since almost 100% of the services provided are MSS, this is the only column with "Include." | $271.23 | $ 4.52 | $ 4.52 | 1.00 | Include | Don't Include | Don't Include | Don't Include | Don't Include | Don't Include | |||
| Community Health Worker | |||||||||||||
| Hougen, Timothy DBH: The scope of this professional exceeds what is indicated; however, since almost 100% of the services provided are MSS, this is the only column with "Include." | $264.77 | $ 4.41 | $ 4.41 | 0.00 | Include | Don't Include | Don't Include | Don't Include | Don't Include | Don't Include | |||
| LCSW (Licensed, Waivered or Registered) | |||||||||||||
| Hougen, Timothy DBH: The scope of this professional exceeds what is indicated; however, since almost 100% of the services provided are MSS, this is the only column with "Include." | $343.34 | $ 5.72 | $ 5.72 | 0.00 | Include | Include | Don't Include | Don't Include | Don't Include | Include | |||
| MFT/LPCC (Licensed, Waivered or Registered) | |||||||||||||
| Hougen, Timothy DBH: The scope of this professional exceeds what is indicated; however, since almost 100% of the services provided are MSS, this is the only column with "Include." | $343.34 | $ 5.72 | $ 5.72 | 0.00 | Include | Include | Don't Include | Don't Include | Don't Include | Include | |||
| Licensed Psychiatric Technician | |||||||||||||
| Hougen, Timothy DBH: A mental health rehabilitation specialist shall be an individual who has a baccalaureate degree and four years of experience in a mental health setting as a specialist in the fields of physical restoration, social adjustment, or vocational adjustment. Up to two years of graduate professional education may be substituted for the experience requirement on a year-for-year basis; up to two years of post associate arts clinical experience may be substituted for the required educational experience in addition to the requirement of four years' experience in a mental health setting. | $241.33 | $ 4.02 | $ 4.02 | 1.00 | Include | Include | Don't Include | Don't Include | Don't Include | Include | |||
| Psychologist (Licensed or Waivered) | $530.56 | $ 8.84 | $ 8.84 | 0.00 | Include | Include | Don't Include | Don't Include | Don't Include | Include | |||
| Licensed Vocational Nurse | $281.50 | $ 4.69 | $ 4.69 | 0.00 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||
| Medical Assistant | |||||||||||||
| Hougen, Timothy DBH: The scope of this professional covers SFC 10-58; however the table is currently set to "Include" only SFC 10-50. It would be very unusual for an OT to provide IHBS or TBS. | $193.51 | $ 3.23 | $ 3.23 | 0.00 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||
| Licensed Physician | |||||||||||||
| Hougen, Timothy DBH: Typically used for Case Manager who does not meet requirements for "Mental Health Rehabilitation Specialist". For DBH, this would be a Mental Health Specialist (MHS). | $1,319.26 | $ 21.99 | $ 21.99 | 0.05 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||
| Nurse Practitioner | $656.03 | $ 10.93 | $ 10.93 | 0.00 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||
| Occupational Therapist | |||||||||||||
| Hougen, Timothy DBH: The scope of this professional exceeds what is indicated; however, since almost 100% of the services provided are MSS, this is the only column with "Include." | $457.04 | $ 7.62 | $ 7.62 | 0.00 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||
| Physician Assistant | |||||||||||||
| Hougen, Timothy DBH: The scope of this professional exceeds what is indicated; however, since per min rate for Psychologist would increase the weighted rate per min and most services are SFC 10-50, "Include" is only on one column. If the program design requires psychologists to provide a wider array of services, please adjust the table as needed. | $591.68 | $ 9.86 | $ 9.86 | 0.00 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||
| Registered Nurse |
Hougen, Timothy DBH: The scope of this professional exceeds what is indicated; however, since almost 100% of the services provided are MSS, this is the only column with "Include."
Hougen, Timothy DBH: The scope of this professional exceeds what is indicated; however, since almost 100% of the services provided are MSS, this is the only column with "Include."
Hougen, Timothy DBH: The scope of this professional exceeds what is indicated; however, since almost 100% of the services provided are MSS, this is the only column with "Include."
Hougen, Timothy DBH: The scope of this professional exceeds what is indicated; however, since almost 100% of the services provided are MSS, this is the only column with "Include."
Hougen, Timothy DBH: The scope of this professional exceeds what is indicated; however, since almost 100% of the services provided are MSS, this is the only column with "Include."
Hougen, Timothy DBH: A mental health rehabilitation specialist shall be an individual who has a baccalaureate degree and four years of experience in a mental health setting as a specialist in the fields of physical restoration, social adjustment, or vocational adjustment. Up to two years of graduate professional education may be substituted for the experience requirement on a year-for-year basis; up to two years of post associate arts clinical experience may be substituted for the required educational experience in addition to the requirement of four years' experience in a mental health setting.
Hougen, Timothy DBH: The scope of this professional covers SFC 10-58; however the table is currently set to "Include" only SFC 10-50. It would be very unusual for an OT to provide IHBS or TBS. $535.86 $ 8.93 $ 8.93 0.00 Don't Include Don't Include Don't Include Don't Include Include Don't Include
| Weighted Averages | $ 4.28 | $ 4.16 | $ 4.31 | $ 4.31 | $ 21.99 | $ 4.16 | |
| Instructions complete this form | |||||||
| 1. Construct a hypothetical program with ratios of direct staff that will bill Medi-Cal for SMHS | |||||||
| 2. Enter the FTE for each classification included in the theoretical program in Column F. | |||||||
| 3. Columns H, I, J, & K are set for which classifications will likely provide the type of service. | |||||||
| Many classifications may provide services for which "Don't Include" is set. This is being done to create a more accurate estimate of costs (e.g., Registered Nurses are set to "Don't Include" for all services except MSS, as that is the primary service provided by this staff. | |||||||
| If you have 0.00 FTE for a classificationin Column F, then that classification's rate will not be included in the weighted average. | |||||||
| NOTE: What is critical to this worksheet is: | |||||||
| 1. Identification of which classifications are included in the program via FTE in Column F | |||||||
| 2. The ratio of staff in the program (e.g., 2 nurses for each psychiatrist; 4 AOD Counselors per Clinician; etc.). | |||||||
| 3. Identifying which staff type will provide which type of aggregated SMHS (e.g., SFC 10-50). NOTE - This only needs to be adjusted in unusual circumstances. | |||||||
| Do not include staff who will NOT provide Mode 15 services. |
List of Values
| Y/N | Column of Services | Included Staff | Staffing | Other Staff | Type of Program | HFW Staffing Titles | Ratio to Clients |
| Yes | CM (SFC 1-09) | Include | D | I | Category 1 | HFW Facilitator | 10 |
| No | MHS (SFC 10-50) | Don't Include | C | C | Category 2 | Family Specialist | 10 |
| IHBS (SFC 57) | Caregiver/Parent Partner | 10 | |||||
| TBS (SFC 58) | HFW Supervisor/Manager | 40 | |||||
| MSS (SFC 60) | Clinical Supervisor (Licensed) | 80 | |||||
| Crisis Intervention (SFC 70) | Fidelity Coach | 40 | |||||
| Community Developer | 80 |
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File details come from the government source that posted it. Updated .