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Office of Mental Health

Home and Community Based Services Waiver
Guidance Document
Division of Children and Families

Individualized Care Buddget

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Date This Budget Plan was Prepared Program Name: Child’s Name: ID No:
Type of Service Provider Effective Date Number of Weeks/Months Frequency & Duration Rate Total Cost Annual
Waiver Services:            
ICC            
Respite Care Hourly            
Respite Care Overnight             
Family Support            
Skill Building            
Intensive In-Home            
Crisis Response            
Non–Waiver Mental Health  Services:            
Outpatient Psych: (clinic)             
Day Treatment (DT)            
Inpatient Psych:            
Psychiatrist             
CPEP            
Medical Services:            
Inpatient            
Physician          average waiver child $62.13
Specialist (specify)            
Dental         average waiver child $54.44
SSHP         average waiver child $1,114.67
Pharmacy         average waiver child $1,711.23
Managed Care Premium         average waiver child $167.72
Other: (Specify) (hearing test ect.)            
Projected Total Cost of Services:            

Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.