WI DHS Interim Medicaid HCB Waiver Manual: Appendix J

Bureau of Long-Term Support
Medicaid Home & Community-Based
Waivers Manual

APPENDIX J: Substitute Care

J-1	Guide to Determining Room and Board Costs in Substitute Care (Revised Appendix O) (PDF, 36 KB)
J-2	Formula to Determine Amount of Income Available to Pay for Room and Board (Former "page 39" instructions) F20920 (pdf) (PDF, 25 KB) F20920 (Excel)
J-3	DDE Memo Series 2002-25 and Attachments: Use of COP/COP-W/CIP II in CBRFs
~~J-4~~	COP Information Bulletin 151 - Use of COP and Waiver Funds in CBRFs and Attachments. 1) DSL Memo Series 2002-02, 2) Five Conditions on Use of Funds in CBRFs: Model Forms (PDF, 239 KB)
J-5	COP Information Bulletin 156 - Use of COP & COP-W/CIP II Funding in CBRFs: Model Criteria for the Determination of Quality Services & Environment
J-6	CBRF Model Contract page: Attachment 4 102504
J-7	Calculating Expenses for a Substitute Care Facility (Model)

Selected References

Several Medicaid Waivers Program allowable living arrangements are governed by rules located in Wisconsin State Statute. These rules are in addition to the Definitions, Standards and Documentation requirements associated with the specific service as defined in Chapter IV, Section 4.09 of the Medicaid Waivers Manual. The following resources provide useful information concerning the regulation of the services of:

Adult Family Home (3-4 bed) Licensing Standards (DQA)

Community Based Residential Facilities (CBRF's)

Children's Foster Homes

County Review of Nursing Home, IMD or ICF-MR Referrals
F20822 (pdf) (PDF, 46 KB)
F20822 (MS Word)

Adult Family Home Fire Safety Guide F-60953 (PDF, 109 KB)

Preadmission Screen and Resident Review (PASAAR) Level 1 Screen
F22191 (pdf) (PDF, 97 KB)
F22191 (MS Word)

Residential Care Apartment Complex Certification or Registration Application F62380 (PDF, 35 KB)

PDF: The free Acrobat Reader^® software is needed to view and print portable document format (PDF) files. Learn more.

Last Revised: April 17, 2013