ChRIS CalAim Budget Schedule FY 26-27~1.xlsx
XLSX spreadsheet 146 KB Posted
- Solicitation number
- DBHE26-ADMN-6420
- Issued by
- California
About this file
This document is a budget schedule template for the San Bernardino County Department of Behavioral Health's Children's Residential Intensive Services (ChRIS) program under the CalAim initiative for fiscal year 2026-2027, covering the contract period from January 1, 2027 to June 30, 2027. The budget template is designed for provider submission and includes multiple worksheets for comprehensive financial planning: Schedule A addresses planning estimates and service distribution percentages across six service functions (Case Management & ICC, Mental Health Services, Intensive Home Based Services, TBS, Medication Support, and Crisis Intervention); Schedule B contains detailed staffing information for direct service delivery staff and other personnel, along with operating and administrative costs; and supporting worksheets provide service projections, dosage estimates, and rate tables. Providers are required to complete yellow-highlighted cells indicating their allocation amounts, service distribution percentages totaling 100%, staffing details with position titles and FTE allocations, and operating expense justifications. The instructions emphasize that signature cells remain blank during provider submission and that all personnel entries must be completed with either actual names or "Vacant"—placeholders such as "TBH" or "TBD" are not acceptable.
Funding for the ChRIS program is structured through Medi-Cal (FFP) at 50 percent and 2011 Realignment at 50 percent, with the contract amount derived by subtracting agency revenues from total DBH allocation. The budget template includes detailed rate schedules for various clinical positions, with hourly and per-minute rates established by DHCS; Mode 15 (Outpatient) services utilize weighted average rates calculated based on the staff composition defined in the Staffing Planning Worksheet. Operating costs are itemized separately and may include External Database Fees, Client Housing Support, Client Flexible Support, and other non-Medi-Cal support expenses, each with justification narratives required. The Service Planning Worksheet demonstrates sample program design with an expected 10 unduplicated clients and an annual contract budget of $567,329, with service distribution across Case Management (6.17%), Mental Health Services (68.64%), Intensive Home Based Services (24.69%), and Crisis Intervention (0.50%). All formulas, cell protections, and hidden rows are subject to verification by DBH's Behavioral Health Provider Support and Accounting Services (PSAS) staff prior to final provider distribution.
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Other files
| File | Type | Posted |
|---|---|---|
| RFQ 25-99 ChRIS.pdf | ||
| ChRIS CalAim Budget Schedule FY 28-29.xlsx | XLSX spreadsheet | |
| DBH RFQ 25-99 Proposer Conference for ChRIS.9.17.26.pdf | ||
| Addendum No. 2 - Fillable Forms~1.docx | DOCX document | |
| Addendum No. 1 - Questions and Answers.docx | DOCX document | |
| ChRIS CalAim Budget Schedule FY 29-30.xlsx | XLSX spreadsheet | |
| ChRIS CalAim Budget Schedule FY 27-28.xlsx | XLSX spreadsheet | |
| ChRIS CalAim Budget Schedule FY 30-31.xlsx | XLSX spreadsheet |
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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 DHB Allocation (Funding) Amount cell highlighted in yellow. | ||
| 4 | If applicable, complete the Agency Revenues section. | ||
| This is not typical for most Providers. | |||
| If unsure if this applies, leave blank and request further information. | |||
| 5 | Signature cells are to remain blank. | ||
| 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 Multiple and # of employees. | |||
| 2 | Input the Degree/License of the Employee or Contractor. If position is vacant, leave blank. | ||
| For the ChRIS program, please input "Head of Service" in this area, as well as degree/license. | |||
| 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 both the Service Delivery Staff and Other Staff tabs. | |||
| Direct Staff to be input on Service Delivery Staff tab and Indirect Staff to be input on Other Staff tab, with the appropriate portions on each worksheet. | |||
| For Contracted staff that are direct service providers, please indicate the type of staff and FTE. | |||
| If you have included the costs related to the contacted staff under Operating Costs, do not include costs on Service Delivery Staff worksheet. | |||
| However, the costs are better reported on the Service Deliver worksheet, please do so. | |||
| For any administrative or clerical staff that are identified as direct, please ensure the required documentation is maintained to fill CFR 200.413 (c)(1) – (3) | |||
| 5 | Enter % Cost Allocated to Contract Services. | ||
| Enter the percentage of time the employee will be working. If employed for a portion of time, this should be reflected in this column. | |||
| The “% Cost Allocated Contracted Services” column may be used to indicated more than 1.0 FTE (e.g., 4.5 FTE = 450%). | |||
| If contractor, please enter the percentage of time for the contractor. | |||
| Other Staff: | |||
| 1 | Input the Name of the Employee or Contractor. If position is vacant, input Vacant. | ||
| If multiple employees in one position, input Multiple and # of employees. | |||
| 2 | Input the Degree/License of the Employee or Contractor. If position is vacant, leave blank. | ||
| 3 | Input Position/Title. If there are positions contractually required, those should be listed first. | ||
| 4 | In the column labeled I/C, I for Indirect; C for SubContractor. NOTE: Worksheet "Other Staff" should not have any portion of a staff intended to provided Modes 05, 10, and/or 15 services. | ||
| Note, administrative and clerical staff are normally treated as indirect cost. | |||
| If portion of a position is intended to provide Modes 05,10, and/or 15 services, then split between "Service Delivery Staff" and "Other Staff" worksheets with appropriate portions on each worksheet. | |||
| For any administrative or clerical staff that are identified as direct, please ensure the required documentation is maintained to fill CFR 200.413 (c)(1) – (3) | |||
| 5 | Enter dollar amount in the Full Time Annual Salary column. | ||
| This amount is based on 2,080 working hours. | |||
| If position is Contractor, leave blank or enter $0.00. | |||
| If multiple employees in one position, input the % Cost Allocated as described in item 7. | |||
| 6 | Enter dollar amount in Full Time Fringe Benefits. | ||
| Examples of Fringe Benefits: Employer FICA/Medicare, Workers Compensation, | |||
| Unemployment, Vacation/Sick/PTO Pay, Retirement Contributions, and Health Benefits | |||
| 7 | Enter % Cost Allocated to Contract Services. | ||
| Enter the percentage of time the employee will be working. If employed for a portion of time, this should be reflected in this column. | |||
| The “% Cost Allocated Contracted Services” column may be used to indicated more than 1.0 FTE (e.g., 4.5 FTE = 450%). | |||
| If contractor, please enter the percentage of time for the contractor. |
| Operating/Administrative Costs: | |
| 1 | Identify each cost item with commonly utilized terms in the Item column. |
| 2 | Input the annual expense of each item in the Total Cost to Organization column. |
| 3 | Input the percentage charged to DBH program in the % Charged to Program column. |
| 4 | The total Amount in the Gross Costs row should equal the annual allocation contract amount. |
| Operating/Administrative Costs Narrative: | ||
| 1 | Input the justification for each Operating Administrative Cost Item entered on the Operating/Admin Costs tab. | |
| 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. | ||
| 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. | ||
| 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: | Children's Residential (ChRIS) | |||
| RU # | FY 2026-2027 | |||
| Contract # / RFP # | January 1, 2027 | to | June 30, 2027 | |
| Address: | ||||
| City, State, Zip Code: | ||||
| Date Form Completed: | ||||
| Prepared by: | ||||
| Title: |
| LINE | MODE OF SERVICE | 15 (Outpatient) | TOTAL | |
| # | SERVICE FUNCTION | Case Management & ICC | ||
| (01-09) | Mental Health Services | |||
| (10-50) | Intensive Home Based Services | |||
| (57) | TBS | |||
| (58) | Medication Support | |||
| (60-69) | Crisis Intervention |
(70)
| 1 | 100% | Distribution % | 16.00% | 75.00% | 7.50% | 1.00% | 0.50% | 100.00% | ||
| Allocation Amount | ||||||||||
| 2 | Total DBH Allocation (Funding) Amount | 0 | 0 | 0 | 0 | 0 | 0 | |||
| AGENCY REVENUES | ||||||||||
| 6 | PATIENT FEES | 0 | ||||||||
| 7 | PATIENT INSURANCE | 0 | ||||||||
| 8 | MEDI-CARE | 0 | ||||||||
| 9 | GRANTS/OTHER | 0 | ||||||||
| 10 | TOTAL AGENCY REVENUES (6+7+8+9) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| 11 | CONTRACT AMOUNT (5-10) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Mix % | FUNDING* | Share % | ||||||||
| 3 | 100.00% | MEDI-CAL (FFP) | 50.00% | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| 100.00% | MHSA/BHSA | 0.00% | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
| MHSA Match | 0.00% | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| 1991 Realignment | 0.00% | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| 4 | 2011 Realignment | 50.00% | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
| FUNDING TOTAL | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||
| 5 | NET COUNTY FUNDS (Local Cost) MUST = ZERO | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| 6 | STATE FUNDING (Including Realignment) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| 7 | FEDERAL FUNDING | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| TOTAL FUNDING | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||
| 8 | TARGET COST PER UNIT OF SERVICE | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| 9 | UNITS OF SERVICE | 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)
Service Delivery Staff
| SAN BERNARDINO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH | |
| Schedule B | STAFFING DETAIL |
| FY 2026-2027 | |
| 0 | |
| Staffing Detail - Personnel (Includes Personal Services Contracts for Professional Services) |
| CONTRACTOR NAME: | ||
| Name | 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 | |||||
| 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 | |||||||||
| 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 | |||||||||||||
| COST: |
Other Staff
| SAN BERNARDINO COUNTY DEPARTMENT OF BEHAVIORAL HEALTH | |
| Schedule B | STAFFING DETAIL |
| FY 2026-2027 | |
| 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 | |||
| Children's Residential (ChRIS) | Contractor Name: | ||
| FY 2026-2027 | 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]
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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 | |||
| FY 2026-2027 | 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 2026-2027 | ||||||
| 0 | Mode 15 | |||||
| DHCS | DHCS | 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 | $ 276.24 | $ 4.60 | $ 4.60 | 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.
| Community Health Worker | $ 256.82 | $ 4.28 | $ 4.28 | 0 | Don't Include | Include | Don't Include | Don't Include | Don't Include | Don't Include | |||||||||||||||||||
| 0.00% | Weighted Rate | Weighted Rate | Weighted Rate | Weighted Rate | Weighted Rate | Weighted Rate | Contract # / RFP # | LCSW (Licensed, Waivered or Registered) | $ 333.03 | $ 5.55 | $ 5.55 | 0 | Include | Include | Include | Don't Include | Don't Include | Include | |||||||||||
| Rate Per Minute | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | Address: | Licensed Physician | $ 1,279.64 | $ 21.33 | $ 21.33 | 0 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||||||||||
| City, State, Zip Code: | Licensed Psychiatric Technician | $ 234.08 | $ 3.90 | $ 3.90 | 0 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | ||||||||||||||||||
| Date Form Completed: | Licensed Vocational Nurse | $ 273.05 | $ 4.55 | $ 4.55 | 0 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | ||||||||||||||||||
| Medical Assistant | $ 187.70 | $ 3.13 | $ 3.13 | 0 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||||||||||||||||||
| Mental Health Rehabilitation Specialist | $ 250.56 | $ 4.18 | $ 4.18 | 0 | Include | Include | Include | Don't Include | Don't Include | Include | |||||||||||||||||||
| MONTH | Estimated Units of Service (Minutes) | Planned Clinical FTE's | |||||||||||||||||||||||||||
| Mode 15 | Clients Served | MFT/LPCC (Licensed, Waivered or Registered) | $ 333.03 | $ 5.55 | $ 5.55 | 0 | Include | Include | 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 | Nurse Practitioner | $ 636.34 | $ 10.61 | $ 10.61 | 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 | Occupational Therapist | $ 443.32 | $ 7.39 | $ 7.39 | 0 | Don't Include | Include | Don't Include | Don't Include | Don't Include | Don't Include | |||||||||||||||||
| Other Qualified Practitioner | $ 250.56 | $ 4.18 | $ 4.18 | 0 | Include | Include | Include | Don't Include | Don't Include | Include | |||||||||||||||||||
| Jul-27 | 0 | Peer Support Specialists | $ 263.09 | $ 4.38 | $ 4.38 | 0 | Don't Include | Include | Don't Include | Don't Include | Don't Include | Don't Include | |||||||||||||||||
| Aug-27 | 0 | Physician Assistant | $ 573.92 | $ 9.57 | $ 9.57 | 0 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||||||||||||||||
| Sep-27 | 0 | Psychologist (Licensed or Waivered) | $ 514.63 | $ 8.58 | $ 8.58 | 0 | Don't Include | Include | Don't Include | Don't Include | Don't Include | Don't Include | |||||||||||||||||
| Oct-27 | 0 | Registered Nurse | $ 519.77 | $ 8.66 | $ 8.66 | 0 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||||||||||||||||
| Nov-27 | 0 | ||||||||||||||||||||||||||||
| Dec-27 | 0 | ||||||||||||||||||||||||||||
| Jan-28 | 0 | 0.00 | 0 | Weighted Averages | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||||||||||||||||||
| Feb-28 | 0 | 0.00 | 0 | ||||||||||||||||||||||||||
| Mar-28 | 0 | 0.00 | 0 | ||||||||||||||||||||||||||
| Apr-28 | 0 | 0.00 | 0 | ||||||||||||||||||||||||||
| May-28 | 0 | 0.00 | 0 | ||||||||||||||||||||||||||
| Jun-28 | 0 | 0.00 | 0 | ||||||||||||||||||||||||||
| TOTAL | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |||||||||||||||||||
| Total Revenue | 0.00 | 0.00 | Unduplicated Clients Served | ||||||||||||||||||||||||||
| Estimated Cost Per Client: | $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 | 12.00 | |
| 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 | 257.82 | 276.24 | 368.32 |
| Community Health Worker | 239.70 | 256.82 | 342.43 |
| LCSW (Licensed, Waivered or Registered) | 310.83 | 333.03 | 444.04 |
| Licensed Physician | 1,194.33 | 1,279.64 | 1,706.19 |
| Licensed Psychiatric Technician | 218.47 | 234.08 | 312.11 |
| Licensed Vocational Nurse | 254.85 | 273.05 | 364.07 |
| Medical Assistant | 175.19 | 187.70 | 250.27 |
| Mental Health Rehabilitation Specialist | 233.86 | 250.56 | 334.08 |
| MFT/LPCC (Licensed, Waivered or Registered) | 310.83 | 333.03 | 444.04 |
| Nurse Practitioner | 593.92 | 636.34 | 848.45 |
| Occupational Therapist | 413.77 | 443.32 | 591.09 |
| Other Qualified Practitioner | 233.86 | 250.56 | 334.08 |
| Peer Support Specialists | 245.55 | 263.09 | 350.79 |
| Physician Assistant | 535.66 | 573.92 | 765.23 |
| Psychologist (Licensed or Waivered) | 480.32 | 514.63 | 686.17 |
| Registered Nurse | 485.12 | 519.77 | 693.03 |
| Interactive Complexity | 13.22 | ||
| Interpretive Services | 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 | $ 368.32 | 276.24 | $ 4.60 |
| ALL | ALL | Community Health Worker | X | $ 342.43 | 256.82 | $ 4.28 |
| ALL | ALL | LCSW (Licensed, Waivered or Registered) | X | $ 444.04 | 333.03 | $ 5.55 |
| ALL | ALL | Licensed Physician | X | $ 1,706.19 | 1,279.64 | $ 21.33 |
| ALL | ALL | Licensed Psychiatric Technician | X | $ 312.11 | 234.08 | $ 3.90 |
| ALL | ALL | Licensed Vocational Nurse | X | $ 364.07 | 273.05 | $ 4.55 |
| ALL | ALL | Medical Assistant | X | $ 250.27 | 187.70 | $ 3.13 |
| ALL | ALL | Mental Health Rehabilitation Specialist | X | $ 334.08 | 250.56 | $ 4.18 |
| ALL | ALL | MFT/LPCC (Licensed, Waivered or Registered) | X | $ 444.04 | 333.03 | $ 5.55 |
| ALL | ALL | Nurse Practitioner | X | $ 848.45 | 636.34 | $ 10.61 |
| ALL | ALL | Occupational Therapist | X | $ 591.09 | 443.32 | $ 7.39 |
| ALL | ALL | Other Qualified Practitioner | X | $ 334.08 | 250.56 | $ 4.18 |
| ALL | ALL | Peer Support Specialists | X | $ 350.79 | 263.09 | $ 4.38 |
| ALL | ALL | Physician Assistant | X | $ 765.23 | 573.92 | $ 9.57 |
| ALL | ALL | Psychologist (Licensed or Waivered) | X | $ 686.17 | 514.63 | $ 8.58 |
| ALL | ALL | Registered Nurse | X | $ 693.03 | 519.77 | $ 8.66 |
| 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 | 276.24 | $ 4.60 | $ 4.60 | $ 4.60 |
| Community Health Worker | 256.82 | $ 4.28 | $ 4.28 | $ 4.28 |
| LCSW (Licensed, Waivered or Registered) | 333.03 | $ 5.55 | $ 5.55 | $ 5.55 |
| Licensed Physician | 1,279.64 | $ 21.33 | $ 21.33 | $ 21.33 |
| Licensed Psychiatric Technician | 234.08 | $ 3.90 | $ 3.90 | $ 3.90 |
| Licensed Vocational Nurse | 273.05 | $ 4.55 | $ 4.55 | $ 4.55 |
| Medical Assistant | 187.70 | $ 3.13 | $ 3.13 | $ 3.13 |
| Mental Health Rehabilitation Specialist | 250.56 | $ 4.18 | $ 4.18 | $ 4.18 |
| MFT/LPCC (Licensed, Waivered or Registered) | 333.03 | $ 5.55 | $ 5.55 | $ 5.55 |
| Nurse Practitioner | 636.34 | $ 10.61 | $ 10.61 | $ 10.61 |
| Occupational Therapist | 443.32 | $ 7.39 | $ 7.39 | $ 7.39 |
| Other Qualified Practitioner | 250.56 | $ 4.18 | $ 4.18 | $ 4.18 |
| Peer Support Specialists | 263.09 | $ 4.38 | $ 4.38 | $ 4.38 |
| Physician Assistant | 573.92 | $ 9.57 | $ 9.57 | $ 9.57 |
| Psychologist (Licensed or Waivered) | 514.63 | $ 8.58 | $ 8.58 | $ 8.58 |
| Registered Nurse | 519.77 | $ 8.66 | $ 8.66 | $ 8.66 |
| 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) | 12.00 | |
| 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 | 2.00 | 720 | CM (SFC 1-09) | 720 | 12.00 | CM (SFC 1-09) | 7,200 | 120.00 | CM (SFC 1-09) | $ 3,502 | $ 35,015 | 6.17% | |||
| MHS - Assessment | MHS (SFC 10-50) | 90 | Yes | 0.08 | 90 | MHS (SFC 10-50) | 8,008 | 133.46 | MHS (SFC 10-50) | 80,076 | 1,334.60 | MHS (SFC 10-50) | $ 38,943 | $ 389,430 | 68.64% | |||
| MHS - Plan Development | MHS (SFC 10-50) | 60 | No | 0.33 | 238 | IHBS (SFC 57) | 2,880 | 48.00 | IHBS (SFC 57) | 28,800 | 480.00 | IHBS (SFC 57) | $ 14,006 | $ 140,062 | 24.69% | |||
| MHS - Therapy | MHS (SFC 10-50) | 60 | No | 4.00 | 2,880 | TBS (SFC 58) | 0 | 0.00 | TBS (SFC 58) | 0 | 0.00 | TBS (SFC 58) | $ - | $ - | 0.00% | |||
| MHS - Group | MHS (SFC 10-50) | 60 | No | 8.00 | 1,280 | |||||||||||||
| Hougen, Timothy DBH: Minutes are divided by 4.5 to equal the calculation done in payment from DHCS. | MSS (SFC 60) | 0 | 0.00 | MSS (SFC 60) | 0 | 0.00 | MSS (SFC 60) | $ - | $ - | 0.00% | ||||||||
| MHS - Rehab | MHS (SFC 10-50) | 60 | No | 4.00 | 2,880 | CI (SFC 70) | $ 282 | $ 2,823 | 0.50% | |||||||||
| MHS - Rehab Group | MHS (SFC 10-50) | 60 | No | 4.00 | 640 |
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 | 4.00 | 2,880 | Cost Per Client | Total Contract | ||
| MHS - TBS | TBS (SFC 58) | 60 | No | 0.00 | 0 | $ 56,733 | $ 567,329 | ||
| MSS - Assessment/Evaluation | MSS (SFC 60) | 90 | Yes | 0.00 | 0 | ||||
| MSS - Ongoing Care | MSS (SFC 60) | 30 | No | 0.00 | 0 |
| REVERSE ENGINEERING THE SAME PROGRAM BY TOTAL BUDGET | ||
| Annual Contract Budget Amount | $ 567,329 | |
| Cost Per Client as indicated above | $ 56,733 | |
| Expected Unduplicated Client Count | 10 |
| Column of Services | ||
| CM (SFC 1-09) | $ 35,015.39 | 6.17% |
| MHS (SFC 10-50) | $ 389,429.51 | 68.64% |
| IHBS (SFC 57) | $ 140,061.57 | 24.69% |
| TBS (SFC 58) | $ - 0 | 0.00% |
| MSS (SFC 60) | $ - 0 | 0.00% |
| 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 | $276.24 | $ 4.60 | $ 4.60 | 0.00 | Include | Include | Don't Include | Don't Include | Don't Include | Include | |||
| Community Health Worker | $256.82 | $ 4.28 | $ 4.28 | 0.00 | Don't Include | Include | Don't Include | Don't Include | Don't Include | Don't Include | |||
| LCSW (Licensed, Waivered or Registered) | $333.03 | $ 5.55 | $ 5.55 | 1.00 | Include | Include | Include | Don't Include | Don't Include | Include | |||
| Licensed Physician | |||||||||||||
| 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." | $1,279.64 | $ 21.33 | $ 21.33 | 1.00 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||
| Licensed Psychiatric Technician | |||||||||||||
| 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." | $234.08 | $ 3.90 | $ 3.90 | 0.00 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||
| Licensed Vocational 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." | $273.05 | $ 4.55 | $ 4.55 | 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 exceeds what is indicated; however, since almost 100% of the services provided are MSS, this is the only column with "Include." | $187.70 | $ 3.13 | $ 3.13 | 0.00 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||
| Mental Health Rehabilitation Specialist | |||||||||||||
| 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. | $250.56 | $ 4.18 | $ 4.18 | 1.00 | Include | Include | Include | Don't Include | Don't Include | Include | |||
| MFT/LPCC (Licensed, Waivered or Registered) | $333.03 | $ 5.55 | $ 5.55 | 0.00 | Include | Include | Include | Don't Include | Don't Include | Include | |||
| Nurse Practitioner | $636.34 | $ 10.61 | $ 10.61 | 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 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. | $443.32 | $ 7.39 | $ 7.39 | 0.00 | Don't Include | Include | Don't Include | Don't Include | Don't Include | Don't Include | |||
| Other Qualified Practitioner | |||||||||||||
| 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). | $250.56 | $ 4.18 | $ 4.18 | 0.00 | Include | Include | Include | Don't Include | Don't Include | Include | |||
| Peer Support Specialists | $263.09 | $ 4.38 | $ 4.38 | 0.00 | Don't Include | Include | Don't Include | Don't Include | Don't Include | Don't Include | |||
| Physician Assistant | |||||||||||||
| 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." | $573.92 | $ 9.57 | $ 9.57 | 0.00 | Don't Include | Don't Include | Don't Include | Don't Include | Include | Don't Include | |||
| Psychologist (Licensed or Waivered) | |||||||||||||
| 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. | $514.63 | $ 8.58 | $ 8.58 | 0.00 | Don't Include | Include | Don't Include | Don't Include | Don't 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. $519.77 $ 8.66 $ 8.66 0.00 Don't Include Don't Include Don't Include Don't Include Include Don't Include
| Weighted Averages | $ 4.86 | $ 4.86 | $ 4.86 | $ 21.33 | $ 4.86 | |
| 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 |
| Yes | CM (SFC 1-09) | Include | D | I | Category 1 |
| No | MHS (SFC 10-50) | Don't Include | C | C | Category 2 |
| IHBS (SFC 57) | |||||
| TBS (SFC 58) | |||||
| MSS (SFC 60) | |||||
| Crisis Intervention (SFC 70) |
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File details come from the government source that posted it. Updated .