ii. Estimate of Factor D Concurrent §1915(b)/§1915(c) Waivers, or other authorities utilizing – capitated arrangements (i.e., 1915(a), 1932(a), Section 1937). Complete the following table for each waiver year. Enter data into the Unit, # Users, Avg. Units Per User, and Avg. Cost/Unit fields for all the Waiver Service/Component items. If applicable, check the capitation box next to that service. Select Save and Calculate to automatically calculate and populate the Component Costs and Total Costs fields. All fields in this table must be completed in order to populate the Factor D fields in the J-1 Composite Overview table. Waiver Year: Year 1 Col. 1 Col. 2 Col. 3 Col. 4 Col. 5 Col. 6 Waiver Service / Check if Avg. Units Avg. Cost/ Component included in Unit # Users Total Cost Per User Unit capitation GRAND TOTAL: Total: Services included in capitation Total: Services not included in capitation TOTAL ESTIMATED UNDUPLICATED PARTICIPANTS (from Table J-2-a) FACTOR D (Divide grand total by number of participants) Services included in capitation Services not included in capitation AVERAGE LENGTH OF STAY ON THE WAIVER Waiver Year: Year 2
ii. Estimate of Factor D – Concurrent §1915(b)/§1915(c) Waivers, or other authorities utilizing capitated arrangements (i.e., 1915(a), 1932(a), Section 1937). Complete the following table for each waiver year. Enter data into the Unit, # Users, Avg. Units Per User, and Avg. Cost/Unit fields for all the Waiver Service/Component items. If applicable, check the capitation box next to that service. Select Save and Calculate to automatically calculate and populate the Component Costs and Total Costs fields. All fields in this table must be completed in order to populate the Factor D fields in the J-1 Composite Overview table. Waiver Year: Year 1 Waiver Service / Component Col. 1 Col. 2 Col. 3 Col. 4 Col. 5 Col. 6 Check if included in capitation Unit # Users Avg. Units Per User Avg. Cost/ Unit Total Cost GRAND TOTAL: Total: Services included in capitation Total: Services not included in capitation TOTAL ESTIMATED UNDUPLICATED PARTICIPANTS (from Table J-2-a) FACTOR D (Divide grand total by number of participants) Services included in capitation Services not included in capitation AVERAGE LENGTH OF STAY ON THE WAIVER Waiver Year: Year 2
ABI%20Waiver%20Amendment%20-%20Final%20Draft%20for%20Public%20Comment.docx