the daily average. Home and Community **This is required Support Assessment. regardless of what is **This is required being requested. regardless of what is being requested. 11 Justification of hours on current plan above what Provide an explanation if the hours on the current plan are above what is is recommended by the Home and Community recommended by the Home and Community Support Assessment. Support Assessment. Situations that may be considered justified include extenuating circumstances such as seizure activity or behavioral needs that are not accounted for in the application of the Home and Community Support Assessment. 12 Describe the involvement in the Explain what involvement the participant has in the community church, participant’s – community. Special Olympics, clubs, activities with friends/family, etc. 13 Describe the natural supports available to the Explain all supports the participant receives from unpaid supports that assist participant. the participant in receiving needed care or being involved in the community. Include the relationship of the individuals providing (specific family, friend from church/work etc.), the type of support they provide, and the frequency of the support. 14 Describe how it was determined that the budget Provide a comparative analysis of all options available to meet the same end amendment request was the most cost-effective result and describe how the service/support/good presented in the budget strategy. amendment requested was determined to be the most cost-effective. This section should also detail any reason why the cheapest provider was not chosen. 15 If the participant is currently overspending their Review the value entered in the in Actual Spend column entitled “Variance existing budget, explain why. Plan Year to in Section 2. If the value indicates underspending, enter Date” applicable participant is spending within their If the value “Not – budget.” indicates overspending, provide an explanation as to why the overspending is occurring. Person Completing This Form The ICA staff that completes this form must also provide DHS with all relevant forms. When submitting this form, you are assuring that the information you provided has been verified and is accurate to the best of your knowledge. How to Submit This Form This form and any relevant accompanying forms should be attached electronically to the DHS Budget Amendment SharePoint site, in the appropriate file. participant’s
the daily average. **This is required regardless of what is being requested. Home and Community Support Assessment. **This is required regardless of what is being requested. 11 Justification of hours on current plan above what is recommended by the Home and Community Support Assessment. Provide an explanation if the hours on the current plan are above what is recommended by the Home and Community Support Assessment. Situations that may be considered justified include extenuating circumstances such as seizure activity or behavioral needs that are not accounted for in the application of the Home and Community Support Assessment. 12 Describe the participant’s involvement in the community. Explain what involvement the participant has in the community – church, Special Olympics, clubs, activities with friends/family, etc. 13 Describe the natural supports available to the participant. Explain all supports the participant receives from unpaid supports that assist the participant in receiving needed care or being involved in the community. Include the relationship of the individuals providing (specific family, friend from church/work etc.), the type of support they provide, and the frequency of the support. 14 Describe how it was determined that the budget amendment request was the most cost-effective strategy. Provide a comparative analysis of all options available to meet the same end result and describe how the service/support/good presented in the budget amendment requested was determined to be the most cost-effective. This section should also detail any reason why the cheapest provider was not chosen. 15 If the participant is currently overspending their existing budget, explain why. Review the value entered in the column entitled “Variance in Actual Spend Plan Year to Date” in Section 2. If the value indicates underspending, enter “Not applicable – participant is spending within their budget.” If the value indicates overspending, provide an explanation as to why the overspending is occurring. Person Completing This Form The ICA staff that completes this form must also provide DHS with all relevant forms. When submitting this form, you are assuring that the information you provided has been verified and is accurate to the best of your knowledge. How to Submit This Form This form and any relevant accompanying forms should be attached electronically to the DHS Budget Amendment SharePoint site, in the appropriate participant’s file.
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