CMS-10249 Budget Form

DRAFT - Money Follows the Person Demonstration
Budget Proposal
Instructions: Please fill in only the cells higlighted in yellow. All other cells will autopopulate. Please DO NOT alter any formulas.
State Name			State FMAP*			Enhanced	0.5
* FFY 2007 FMAP should be expressed as a decimal. (If the FMAP is 68.32%, it should be .6832.)
Populations to be Transitioned (unduplicated count**)
	Elderly	MR/DD	Physically Disabled	Mental Illness	Dual Diagnosis
FFY*** 2007
FFY 2008
FFY 2009
FFY 2010
FFY 2011
Total	0	0	0	0	0
	0
Populations for Dual Diagnosis:
** Unduplicated Count - Each individual is only counted once in the year that they physically transition.
*** All population counts and budget estimates should be based on the Federal Fiscal Years indicated.
Demonstration Budget
Total	Rate	Total Costs	Federal	State
Qualified HCBS****		0	0	0
Demonstration HCBS****		0	0	0
Supplemental****		0	0	0
Administrative - Normal*****		0	0	0
Administrative - 75%*****		0	0	0
Administrative - 90%*****		0	0	0
State Evaluation		0	0	0
Total		0	0	0
Per Capita Service Costs	#DIV/0!
Per Capita Admin Costs	#DIV/0!
Rebalancing Fund******	0
**** Qualified HCBS Services, Demonstration HCBS Services and Supplemental Services were defined in the RFP.
***** Administration - Normal should include all costs that adhere to CFR Title 42, Section 433(b)(7) Administrative - 75% should include all costs that adhere to CFR Title 42, Sections 433(b)(4) and 433(b)(10) Administrative - 90% should include all costs that adhere to CFR Title 42 Section 433(b)(3)
****** The Rebalancing Fund is a calculation devised by CMS to estimate the amount of State savings realized because of the enhanced FMAP rate that could be reinvested into rebalancing benchmarks.
FFY 2007	Rate	Total Costs	Federal	State
Qualified HCBS	0.5		0	0
Demonstration HCBS	0.5		0	0
Supplemental	0		0	0
Administrative - Normal	0.5		0	0
Administrative - 75%	0.75		0	0
Administrative - 90%	0.9		0	0
State Evaluation	0.5		0	0
Total		0	0	0
FFY 2008	Rate	Total Costs	Federal	State
Qualified HCBS	0.5		0	0
Demonstration HCBS	0.5		0	0
Supplemental	0		0	0
Administrative - Normal	0.5		0	0
Administrative - 75%	0.75		0	0
Administrative - 90%	0.9		0	0
State Evaluation	0.5		0	0
Total		0	0	0
FFY 2009	Rate	Total Costs	Federal	State
Qualified HCBS	0.5		0	0
Demonstration HCBS	0.5		0	0
Supplemental	0		0	0
Administrative - Normal	0.5		0	0
Administrative - 75%	0.75		0	0
Administrative - 90%	0.9		0	0
State Evaluation	0.5		0	0
Total		0	0	0
FFY 2010	Rate	Total Costs	Federal	State
Qualified HCBS	0.5		0	0
Demonstration HCBS	0.5		0	0
Supplemental	0		0	0
Administrative - Normal	0.5		0	0
Administrative - 75%	0.75		0	0
Administrative - 90%	0.9		0	0
State Evaluation	0.5		0	0
Total		0	0	0
FFY 2011	Rate	Total Costs	Federal	State
Qualified HCBS	0.5		0	0
Demonstration HCBS	0.5		0	0
Supplemental	0		0	0
Administrative - Normal	0.5		0	0
Administrative - 75%	0.75		0	0
Administrative - 90%	0.9		0	0
State Evaluation	0.5		0	0
Total		0	0	0