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{"sheet":"INPUT","index":0,"n_rows":25,"n_cols":5,"rows_kept":25,"cut":false,"hidden":false,"merged":[[6,1,6,2],[2,1,2,2],[21,1,21,2],[13,1,13,2],[14,1,14,2],[15,1,15,2],[26,1,26,2],[0,1,0,2],[23,1,23,2],[24,1,24,2],[5,1,5,2],[8,1,8,2],[19,1,19,2],[20,1,20,2],[22,1,22,2],[10,1,10,2],[11,1,11,2],[17,1,17,2],[18,1,18,2]]}
[null,"Department of Developmental Services                                                                                             Rate Worksheet for Individuals Living in Their Own Home"]
[]
[null,"Data Input Table"]
[]
["Field",null,null,null,"Directions"]
["Person",null,null,null,"Enter person's name"]
["Provider",null,null,null,"Enter name of Qualified Provider with IHS service"]
[]
["Service Type",{"$f":"validations!A17","v":"Individualized Home Supports"},null,null,"Formula - DO NOT TYPE OVER FORMULA"]
[]
["LON Based on PRAT Determination",null,null,null,"Enter LON"]
["LON Assessment Date",null,null,null,"Eneter LON Assessment Date"]
[]
["Residential Health Domain Score",null,null,null,"Enter Residential Health Domain Score"]
["Residential Behavioral Domain Score",null,null,null,"Enter Residential Behavioral Domain Score"]
["Psychiatric Home Score",null,null,null,"Enter Psychiatric Home Score"]
[]
["Actual IHS hours",null,null,null,"Enter Actual IHS hours (if any)"]
["Actual Personal Support Hours",null,null,null,"Enter Actual Personal Support Hours (if any)"]
["Cluster 3rd Shift support required",null,null,null,"Select Yes or No from drop-down list"]
["Number of Participants in the Cluster",null,null,null,"Enter Number of Participants in the Cluster"]
["Calcualted Number of Participants in the Cluster",{"$f":"IF(B20=\"No\",0,B21)","v":0},null,null,"Calculated field if Cluster required"]
["Safety Net Category for people living independently",1,null,null,"Enter 1"]
["Additional Health Care Coordination Hours Authorized by PRAT",null,null,null,"Enter Additional Health Care Coordination Hours over the LON guidelines Authorized by PRAT (if any)"]
["Additional Clinical Behavioral Support Hours Authorized by PRAT",null,null,null,"Enter Additional Clinical Behavioral Support Hours over LON guidelinesAuthorized by PRAT (if any)"]

{"sheet":"Rate Form","index":1,"n_rows":42,"n_cols":15,"rows_kept":42,"cut":false,"hidden":false,"merged":[[35,2,35,3],[31,2,31,5],[10,5,10,6],[11,5,11,6],[43,2,43,4],[39,2,39,3],[40,2,40,3],[41,2,41,3],[36,2,36,3],[37,2,37,3],[21,3,21,4],[30,3,30,4],[0,2,0,6],[32,3,32,6],[1,2,1,6],[15,2,15,3],[2,2,2,6],[3,2,3,7]]}
[]
[]
[null,null,"IHS Rate Worksheet for Individuals Living in Their Own Home",null,null,null,null,null,null,"\"Over Allowed Amount\""]
[null,null,"***NOT AN OFFICIAL AUTHORIZATION***"]
[]
[null,null,null,"Individual:",{"$f":"INPUT!B6","v":0}]
[null,null,null,"Provider:",{"$f":"INPUT!B7","v":0}]
[null,null,null,"LON Assessment Date:",{"$f":"INPUT!B12","v":"00:00:00"}]
[]
[]
[null,null,"Level of Support Needs Based on PRAT Determination",{"$f":"INPUT!B11","v":0}]
[null,null,"Residential Health Domain Score",{"$f":"INPUT!B14","v":0}]
[null,null,"Residential Behavioral Domain Score",{"$f":"INPUT!B15","v":0}]
[null,null,"Psychiatric Home Score",{"$f":"INPUT!B16","v":0}]
[]
[null,null," ",null,"Weekly Direct Hours","Estimated Monthly Amount","Estimated Annualized Amount"]
[null,null,"Maximum Weekly IHS Hours based on LON",null,{"$f":"IF(D26=\"No\",VLOOKUP(D11,tables!B3:D10,3,FALSE),VLOOKUP(D11,tables!A85:B90,2,FALSE))","v":{"$error":"#N/A"}}," ",null,null,null,null,{"$f":"+E21/1.1","v":0}]
[null,null,"Maximum Weekly Personal Support Hours based on LON",null,{"$f":"ROUND(+E17*1.1,0)","v":{"$error":"#N/A"}}," "]
[null,null,null,null,null,null,null,null,null,null," "]
[null,null,"Actual IHS hours"," ",{"$f":"INPUT!B18","v":0},{"$f":"E20*tables!B14*4","v":0},{"$f":"E20*tables!B14*52","v":0},null,null,null," "]
[null,null,"Actual personal Support Hours"," ",{"$f":"INPUT!B19","v":0},{"$f":"E21*tables!C14*4","v":0},{"$f":"E21*tables!C14*52","v":0},null,null,null,null," "]
[null,null,"Total Weekly Hours",{"$f":"IF((E20+K17)>E17,J3,(E21+E20))","v":{"$error":"#N/A"}},null,{"$f":"IF(D22=J3,0,+F20+F21)","v":{"$error":"#N/A"}},{"$f":"IF(D22=J3,0,+G20+G21)","v":{"$error":"#N/A"}},null,null,null,null," "]
[null,null,null,null,null,null,null,null," "," "," "," "]
[null,null,null,null,null,"Estimated Monthly Amount","Estimated Annualized Amount"]
[null,null,"Available Reserve Hours",0.3,{"$f":"IF(ROUND((IF(E21=0,(+E17-E20)*52*0.3,(E17-(E20+(E21*0.9)))*52*0.3)),0)<1,0,ROUND((IF(E21=0,(+E17-E20)*52*0.3,(E17-(E20+(E21*0.9)))*52*0.3)),0))","v":{"$error":"#N/A"}}]
[null,null,"Cluster 3rd Shift support required",{"$f":"INPUT!B20","v":0},null,{"$f":"+G26/12","v":{"$error":"#N/A"}},{"$f":"IF(D22=J3,0,IF(D26=\"no\",\"$0.00\",IF(D27=0,0,VLOOKUP(D27,tables!A20:B28,2,FALSE)))*12)","v":{"$error":"#N/A"}}]
[null,null,"Number of Participants in the Cluster",{"$f":"INPUT!B22","v":0}]
[null,null,"Eligible Health Care Coordination ",{"$f":"IF(D11>4,\"Yes\",IF(O32>6,\"Yes\",\"No\"))","v":"No"},null,null,{"$f":"IF(D22=J3,0,E36*tables!B57)","v":{"$error":"#N/A"}}]
[null,null,"Eligible Clinical Behavioral Support ",{"$f":"IF(D13>2,\"Yes\",\"No\")","v":"No"},null,null,{"$f":"IF(D22=J3,0,E40*tables!B57)","v":{"$error":"#N/A"}}]
[null,null,"Safety Net Category for people living independently",1,null,{"$f":"ROUND(+G30/12,0)","v":365},{"$f":"IF(D26=\"Yes\",0,VLOOKUP(D30,tables!A41:J42,10,FALSE))","v":4384}]
[null,null,"Total Annualized IHS Supports",{"$f":"+D22","v":{"$error":"#N/A"}},null,{"$f":"IF(D31=J3,0,SUM(F22:F30))","v":{"$error":"#N/A"}},{"$f":"IF(D31=J3,0,SUM(G22:G30))","v":{"$error":"#N/A"}}]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"+D11","v":0},{"$f":"IF(D13>D14,D13,IF(D14>D13,D14,+D13))","v":0},{"$f":"+M32+N32","v":0}]
[null,null,null,"Estimated Clinical Support Hours"]
[]
[null,null,null,null,"Estimated Hours","Estimated Annualized Amount"]
[null,null,"Maximimum Annualized Health Care Coordination Hours",null,{"$f":"IF(D31=J3,0,IF( D28=\"no\",0,IF(GESTEP(D12,D14)=1,VLOOKUP(D11+D12,tables!A61:B81,2,FALSE),D11+D14)))","v":{"$error":"#N/A"}},{"$f":"IF(D31=J3,0,G28)","v":{"$error":"#N/A"}}]
[null,null,"Additional Health Care Coordination  Hours by DDS",null,{"$f":"IF(D31=J3,0,INPUT!B24)","v":{"$error":"#N/A"}},{"$f":"IF(D31=J3,0,E37*tables!B57)","v":{"$error":"#N/A"}}]
[null,null,"Total Maximimum Annualized Healthcare Coordination Hours ",null,{"$f":"+E36+E37","v":{"$error":"#N/A"}},{"$f":"+F36+F37","v":{"$error":"#N/A"}}]
[]
[null,null,"Maximimum Clinical Behavioral Support Hours Available",null,{"$f":"IF(D31=J3,0,IF(D13=0,\"0.00\",VLOOKUP(D13,tables!A46:B53,2,FALSE)))","v":{"$error":"#N/A"}},{"$f":"IF(D31=J3,0,G29)","v":{"$error":"#N/A"}}]
[null,null,"Additional Clinical Behavioral Support  Hours by DDS",null,{"$f":"IF(D31=J3,0,INPUT!B25)","v":{"$error":"#N/A"}},{"$f":"IF(D31=J3,0,E41*tables!B57)","v":{"$error":"#N/A"}}]
[null,null,"Total Maximimum Annualized Clinical Behavioral Support  Hours ",null,{"$f":"+E40+E41","v":{"$error":"#N/A"}},{"$f":"+F40+F41","v":{"$error":"#N/A"}}]

{"sheet":"tables","index":2,"n_rows":90,"n_cols":10,"rows_kept":90,"cut":false,"hidden":true,"merged":[]}
["Table 1 - IHS"]
["Max Hours/wk","LON","Funding","Max Hours/wk"]
[14,1,21112,14]
[17,2,25636,17]
[20,3,30160,20]
[23,4,34684,23]
[28,5,42224,28]
[36,6,54288,36]
[42,7,63336,42]
[48,8,72384,48]
[]
["Table 2 - Rates"]
[null,"Table 2 - IHS","Personal Supports"]
[null,29,27.09]
[]
["Table 3 - Cluster Rate"]
["# of"]
["Participants in ","Monthly"]
["Cluster","Rate"]
[0,920]
[1,920]
[2,920]
[3,920]
[4,920]
[5,920]
[6,920]
[7,920]
[8,706]
[9,706]
[10,706]
[11,706]
[12,706]
[13,706]
[14,706]
[15,706]
[]
["Table 4 - Safety Net"]
[null,null," ","Annual"]
[null,"Annual","Hourly","Staff","Direct & Sup","Fringes","Indirect","Sal Fringe","A&G"]
[null,"HRS","Rate","Cost","Salaries",0.26350000000000001,2.5000000000000001E-2,"& Indirect",0.12,"Total"]
[1,108.5,28,3038,3038,800.51300000000003,75.95,3914.4629999999997,469.73555999999996,4384]
[2,108.5,46,4991,4991,1315.1285,124.77500000000001,6430.9034999999994,771.70841999999993,7203]
[]
["Table 5 - Residential Behavioral Domain Score (Annual Behavioral Support hours per year)"]
["Residential Behavioral Domain Score","Maximimum Clinical Behavioral Support Hours Available"]
[1,0]
[2,0]
[3,2]
[4,2]
[5,4]
[6,4]
[7,8]
[8,12]
[]
["Table 6 - Clinical Behavioral Supports (CBS) rate"]
["current rate",120]
["adjusted rate",{"$f":"B56*1.01","v":121.2}]
[]
["Table 7 - Maximum Annualized Authorized HCC Hours"]
["Score","Annual Hours"]
[4,24]
[5,24]
[6,24]
[7,36]
[8,36]
[9,36]
[10,48]
[11,48]
[12,48]
[13,48]
[14,48]
[15,48]
[16,48]
[17,48]
[18,48]
[19,48]
[20,48]
[21,48]
[22,48]
[23,48]
[24,48]
[]
["Table 8 - Cluster Supports"]
["LON ","hours/week"]
[3,17]
[4,20]
[5,25]
[6,33]
[7,39]
[8,45]

{"sheet":"validations","index":3,"n_rows":17,"n_cols":1,"rows_kept":17,"cut":false,"hidden":true,"merged":[]}
["Service Type"]
["Individual Home Supports"]
["Personal Supports"]
[]
["LON based on PRAT determination"]
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[]
[]
[]
["Individualized Home Supports"]