Budget Workbook

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					Texas Department of                                                                        CMPAS CDS Budget
Aging and Disability Services                                                                    August 2008




                 Consumer Managed Personal Attendant Services
                                   Consumer Directed Services Budget
                       General Information and Instructions for Use of Workbook

                        THIS PAGE IS NOT CONSIDERED PART OF THE BUDGET

         Enter the appropriate information in the "Blue" cells (the cells with "dashed" lines around
       * them). Be sure the information you enter is accurate, as the budget calculations are based
         on the entries made in these cells.

       * Use the "TAB" key to move between the "Blue" cells. Entries may only be made in the
         "Blue" cells; all other cells are locked.

         You can use the keyboard to move between the pages in the workbook. Press "CTRL" and
       * "Page Down" at the same time to move to the next worksheet; Press "CTRL" and "Page Up"
         at the same time to move to the previous worksheet.


       * Watch for "Pop-Up" information windows for many of the cells. If the "Pop-Up" windows
         are covering the body of the budget, you may "drag and drop" them to a different area.

       * Be sure to read any error messages carefully. They give you instructions on how to correct
         data entry errors.

       * Complete the entire Workbook for each Consumer at the following times (and when
         required by program policy):
             Initially and at Annual Reassessment
             Termination of Services
             Change in Employee
             Change in Number of Hours Employee Works, Rate of Pay, Bonus, or Benefits
             Change in Employee Pay Rate or Benefits
             Change in Reimbursement Rate
             Change in Administrative Costs
             Change in Payment Option back to Agency Option
             Change in Number of Authorized Units for Hourly Services
             Use of Respite Services
             Anytime Other Time Required by Program Policy
         Complete the Quarterly Report at least Quarterly (more frequently if required by Program
         Policy)


       * Be sure both the Employer (Consumer or Legal Guardian), Designated Representative (if
         applicable), and the CDS Agency Representative sign Consumer Information & Budget
         Approval Page of the workbook, and that the budget Calculations are listed as "VALID".

       * Submit a copy of the current Budget Workbook to the appropriate Case Manager/Service
         Coordinator initially, annually, and as required by program policy.




                                                                                     Date and Time Created
                                                                                         1/10/2011 3:30 PM
Texas Department of                                                                                                                              CMPAS CDS Budget
Aging and Disability Services                                                                                                                          August 2008




                     Consumer Managed Personal Attendant Services
                                           Consumer Directed Services Budget
                                        Consumer Information & Budget Approval

                                                    Consumer Name:

                                 Consumer Medicaid Number:

                                             Consumer's Address:

                          Consumer's City, State, Zip Code:

                            Consumer's Telephone Number:

                                                                   Region:

         Does the Consumer Have a Designated Representative (DR) or
                            Legally Authorized Representative (LAR)?

                                                           LAR's Name:
                                                            DR's Name:

        Effective / Coverage Period (This does not guarantee
                                eligibility for the entire period):


                                                                          Budget Calculations are:                         VALID
       CERTIFICATION: By signature below I acknowledge that all calculations must fall within the allowable budget, and that all budget
       calculations are VALID, as indicated above. I acknowledge these budget calculations are not exact, and may need adjustment
       throughout the budget period. I also acknowledge receipt of a copy of the CDS Budget. I agree to remain within the boundaries of the
       budget set forth. I understand that failure to follow this budget may result in removal from the CDS Option and I accept personal
       liability for expenses that may be incurred due to my failure to follow the budget or program requirements. The budget does not imply
       eligibility for the entire budget period.




       Employer (Consumer or Legally Authorized Representative)                                                 Date




       Designated Representative (If Applicable)                                                                Date




       CDS Agency Representative                                                                                Date




                                                                                                                                               Date and Time Created:
                                                                                                                                                    1/10/2011 3:30 PM
Texas Department of                                                                  CMPAS CDS Budget
Aging and Disability Services                                                              August 2008




                  Consumer Managed Personal Attendant Services
                                     Consumer Directed Services Budget
                                                  Notes

                                      0                                               0
                                Consumer Name                                 Medicaid Number

                                          Coverage Period From:   1/0/1900   To:    1/0/1900




                                                                                   Date and Time Created
                                                                                       1/10/2011 3:30 PM
Texas Department of                                                                        CMPAS CDS Budget
Aging and Disability Services                                                                    August 2008




                     Consumer Managed Personal Attendant Services
                                          Consumer Directed Services Budget
                                  Authorized Units and Budget Calculations

                                      0                                                      0
                                Consumer Name                                      Medicaid Number

                                           Coverage Period From:   1/0/1900       To:       1/0/1900



                                    Total Annual CDS Budget              $0.00




                                                       Service                Priority
                                   Weekly Authorized PAS Hours
                                                          Rate
                                              Total PAS Dollars                  $0.00




                                                                                         Date and Time Created
                                                                                             1/10/2011 3:30 PM
Texas Department of                                                                                  CMPAS CDS Budget
Aging and Disability Services                                                                              August 2008




                  Consumer Managed Personal Attendant Services
                                      Consumer Directed Services Budget
                                Employer Support Services & Non-Taxable Costs

                                    0                                                                0
                                Consumer Name                                                 Medicaid Number

                                         Coverage Period From:          1/0/1900        To:         1/0/1900

                                                              Total Annual CDS Budget:                          $0.00

                            Estimated Employer Support Services Costs
                                 Maximum Amount Available for Employer Support Services Costs:                  $0.00
                                                                           Amount:                          Comments:
Advertising
Equipment & Supplies
Copies & Mailing
Criminal History Check
Other - Specify
Other - Specify
                                  Total Estimated Employer Support Services Costs:                              $0.00

                            Non-Taxable Employee Compensation Costs
                                                 Amount Available for Employee Compensation Costs: $0.00
                                                                              Amount:                       Comments:
Health Insurance Premium(s)
Worker's comp or liability insurance
Other - Specify
Other - Specify
                                  Total Estimated Non-Taxable Compensation Costs:                               $0.00

           Funds Available for Taxable Compensation Costs                                                  $0.00




                                                                                                   Date and Time Created
                                                                                                       1/10/2011 3:30 PM
     Texas Department of                                                                                                   CMPAS CDS Budget
     Aging and Disability Services                                                                                               August 2008




                                      Consumer Managed Personal Attendant Services
                                                        Consumer Directed Services Budget

                                                     Taxable Wage and Compensation Costs
                                  0                                                                                     0
                            Consumer Name                                                                        Medicaid Number
                                        Coverage Period From:           1/0/1900            To:               1/0/1900

                                                                  Available Amounts
                       Total Available for Taxable Compensation:     $0.00          Dollars Needed to Meet Minimum Compensation:                  $0.00
                                     Total Taxable Compensation:     $0.00                            Dollars Left in Budget:                     $0.00

                                              Taxable Wage and Compensation Validation
                                                                                             Minimum Amount for Employee
                                                                                                                                            Yes
Do the Total Employee Compensation Costs Fall Within the Required Parameters                   Compensation Costs met?
                                                for Employee Compensation?
                                                                                            Within Total Budget for Consumer?               Yes



                                       Employee Hours, Pay Rates and Other Compensation
 1                                                                          Weeks        S.U.T.A.    Total Annual
      Employee Name                                  Begin Date    End Date Employed       Rate         Wages      Annual Taxes        Annual Total
                                                                                  1.00                       $0.00         $0.00                $0.00


                                                                   Hours per
     Hourly Pay                                                      Week    Pay Rate     Weeks      OT Pay Rate       Wages
                                                       Priority                              1.00                        $0.00
                                                     Overtime                                1.00         $0.00          $0.00
                                NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                          more than the weekly authorized units.

                                                                             Number of
     Other Compensation                                             Amount   Payments     Wages
                                                       Bonuses                               $0.00
                                                  Paid Holidays                              $0.00
                                                   Vacation Pay                              $0.00
                                                     Sick Leave                              $0.00
                                                  Other -Specify                             $0.00

 2                                                                          Weeks        S.U.T.A.    Total Annual
      Employee Name                                  Begin Date    End Date Employed       Rate         Wages      Annual Taxes        Annual Total
                                                                                  1.00                       $0.00         $0.00                $0.00


                                                                   Hours per
     Hourly Pay                                                      Week    Pay Rate     Weeks      OT Pay Rate       Wages
                                                       Priority                              1.00                        $0.00
                                                     Overtime                                1.00         $0.00          $0.00
                                NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                          more than the weekly authorized units.

                                                                             Number of
     Other Compensation                                             Amount   Payments     Wages
                                                       Bonuses                               $0.00
                                                  Paid Holidays                              $0.00
                                                   Vacation Pay                              $0.00
                                                     Sick Leave                              $0.00
                                                  Other -Specify                             $0.00



                                                                                                                         Date and Time Created
                                                                                                                             1/10/2011 3:30 PM
    Texas Department of                                                                                                   CMPAS CDS Budget
    Aging and Disability Services                                                                                               August 2008




                                     Consumer Managed Personal Attendant Services
                                                       Consumer Directed Services Budget

                                                   Taxable Wage and Compensation Costs
                                 0                                                                                    0
                           Consumer Name                                                                       Medicaid Number
                                       Coverage Period From:           1/0/1900           To:                1/0/1900

3                                                                        Amounts S.U.T.A.
                                                                AvailableWeeks                      Total Annual
     Employee Name                                 Begin Date     End Date Employed       Rate         Wages      Annual Taxes        Annual Total
                                                                                 1.00                       $0.00         $0.00                $0.00


                                                                  Hours per
    Hourly Pay                                                      Week    Pay Rate     Weeks      OT Pay Rate      Wages
                                                      Priority                              1.00                        $0.00
                                                    Overtime                                1.00         $0.00          $0.00
                               NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                         more than the weekly authorized units.

                                                                            Number of
    Other Compensation                                             Amount   Payments     Wages
                                                      Bonuses                               $0.00
                                                 Paid Holidays                              $0.00
                                                  Vacation Pay                              $0.00
                                                    Sick Leave                              $0.00
                                                 Other -Specify                             $0.00

4                                                                          Weeks        S.U.T.A.    Total Annual
     Employee Name                                 Begin Date     End Date Employed       Rate         Wages      Annual Taxes        Annual Total
                                                                                 1.00                       $0.00         $0.00                $0.00


                                                                  Hours per
    Hourly Pay                                                      Week    Pay Rate     Weeks      OT Pay Rate      Wages
                                                      Priority                              1.00                        $0.00
                                                    Overtime                                1.00         $0.00          $0.00
                               NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                         more than the weekly authorized units.

                                                                            Number of
    Other Compensation                                             Amount   Payments     Wages
                                                      Bonuses                               $0.00
                                                 Paid Holidays                              $0.00
                                                  Vacation Pay                              $0.00
                                                    Sick Leave                              $0.00
                                                 Other -Specify                             $0.00

5                                                                          Weeks        S.U.T.A.    Total Annual
     Employee Name                                 Begin Date     End Date Employed       Rate         Wages      Annual Taxes        Annual Total
                                                                                 1.00                       $0.00         $0.00                $0.00


                                                                  Hours per
    Hourly Pay                                                      Week    Pay Rate     Weeks      OT Pay Rate      Wages
                                                      Priority                              1.00                        $0.00
                                                    Overtime                                1.00         $0.00          $0.00
                               NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                         more than the weekly authorized units.

                                                                            Number of
    Other Compensation                                             Amount   Payments     Wages
                                                                                                                        Date and Time Created
                                                                                                                            1/10/2011 3:30 PM
5
    Texas Department of                                                                                                       CMPAS CDS Budget
    Aging and Disability Services                                                                                                   August 2008




                                     Consumer Managed Personal Attendant Services
                                                       Consumer Directed Services Budget

                                                   Taxable Wage and Compensation Costs
                                 0                                                                                        0
                           Consumer Name                                                                           Medicaid Number
                                       Coverage Period From:            1/0/1900           To:                   1/0/1900

                                                      BonusesAvailable       Amounts          $0.00
                                                 Paid Holidays                                $0.00
                                                  Vacation Pay                                $0.00
                                                    Sick Leave                                $0.00
                                                 Other -Specify                               $0.00

6                                                                           Weeks        S.U.T.A.       Total Annual
     Employee Name                                 Begin Date      End Date Employed       Rate            Wages      Annual Taxes        Annual Total
                                                                                  1.00                          $0.00         $0.00                $0.00


                                                                   Hours per
    Hourly Pay                                                       Week    Pay Rate     Weeks         OT Pay Rate      Wages
                                                      Priority                              1.00                        $0.00
                                                    Overtime                                1.00         $0.00          $0.00
                               NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                         more than the weekly authorized units.

                                                                             Number of
    Other Compensation                                              Amount   Payments     Wages
                                                      Bonuses                                $0.00
                                                 Paid Holidays                               $0.00
                                                  Vacation Pay                               $0.00
                                                    Sick Leave                               $0.00
                                                 Other -Specify                              $0.00

7                                                                           Weeks        S.U.T.A.       Total Annual
     Employee Name                                 Begin Date      End Date Employed       Rate            Wages      Annual Taxes        Annual Total
                                                                                  1.00                          $0.00         $0.00                $0.00


                                                                   Hours per
    Hourly Pay                                                       Week    Pay Rate     Weeks         OT Pay Rate      Wages
                                                      Priority                              1.00                        $0.00
                                                    Overtime                                1.00         $0.00          $0.00
                               NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                         more than the weekly authorized units.

                                                                             Number of
    Other Compensation                                              Amount   Payments     Wages
                                                      Bonuses                                $0.00
                                                 Paid Holidays                               $0.00
                                                  Vacation Pay                               $0.00
                                                    Sick Leave                               $0.00
                                                 Other -Specify                              $0.00

8                                                                           Weeks        S.U.T.A.       Total Annual
     Employee Name                                 Begin Date      End Date Employed       Rate            Wages      Annual Taxes        Annual Total
                                                                                  1.00                          $0.00         $0.00                $0.00


                                                                   Hours per
    Hourly Pay                                                       Week    Pay Rate     Weeks         OT Pay Rate      Wages
                                                        Priority                                 1.00                          $0.00

                                                                                                                            Date and Time Created
                                                                                                                                1/10/2011 3:30 PM
     Texas Department of                                                                                                   CMPAS CDS Budget
     Aging and Disability Services                                                                                               August 2008




                                      Consumer Managed Personal Attendant Services
 8                                                      Consumer Directed Services Budget

                                                    Taxable Wage and Compensation Costs
                                  0                                                                                    0
                            Consumer Name                                                                       Medicaid Number
                                        Coverage Period From:           1/0/1900           To:                1/0/1900

                                                     OvertimeAvailable Amounts               1.00         $0.00          $0.00
                                NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                          more than the weekly authorized units.

                                                                             Number of
     Other Compensation                                             Amount   Payments     Wages
                                                       Bonuses                               $0.00
                                                  Paid Holidays                              $0.00
                                                   Vacation Pay                              $0.00
                                                     Sick Leave                              $0.00
                                                  Other -Specify                             $0.00

 9                                                                          Weeks        S.U.T.A.    Total Annual
      Employee Name                                 Begin Date     End Date Employed       Rate         Wages      Annual Taxes        Annual Total
                                                                                  1.00                       $0.00         $0.00                $0.00


                                                                   Hours per
     Hourly Pay                                                      Week    Pay Rate     Weeks      OT Pay Rate      Wages
                                                       Priority                              1.00                        $0.00
                                                     Overtime                                1.00         $0.00          $0.00
                                NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                          more than the weekly authorized units.

                                                                             Number of
     Other Compensation                                             Amount   Payments     Wages
                                                       Bonuses                               $0.00
                                                  Paid Holidays                              $0.00
                                                   Vacation Pay                              $0.00
                                                     Sick Leave                              $0.00
                                                  Other -Specify                             $0.00

10                                                                          Weeks        S.U.T.A.    Total Annual
      Employee Name                                 Begin Date     End Date Employed       Rate         Wages      Annual Taxes        Annual Total
                                                                                  1.00                       $0.00         $0.00                $0.00


                                                                   Hours per
     Hourly Pay                                                      Week    Pay Rate     Weeks      OT Pay Rate      Wages
                                                       Priority                              1.00                        $0.00
                                                     Overtime                                1.00         $0.00          $0.00
                                NOTE - The consumer must not develop a regular employee schedule that contains fewer than or
                                                          more than the weekly authorized units.

                                                                             Number of
     Other Compensation                                             Amount   Payments     Wages
                                                       Bonuses                               $0.00
                                                  Paid Holidays                              $0.00
                                                   Vacation Pay                              $0.00
                                                     Sick Leave                              $0.00
                                                  Other -Specify                             $0.00




                                                                                                                         Date and Time Created
                                                                                                                             1/10/2011 3:30 PM
Texas Department of                                                                                                                      CMPAS CDS Budget
Aging and Disability Services                                                                                                               Quarterly Report
                                                                                                                                               August 2008




                                         Consumer Managed Personal Attendant Services
                                                             Consumer Directed Services Budget
                                                                         Quarterly Report

                                                         0                                                                 0
                                                   Consumer Name                                                    Medicaid Number

                                           Quarterly Report Coverage Period From:                             To:
                                                                 Quarter Number:



                                       NOTE - All Budgeted Amounts on the Quarterly Report are Estimates

                                                                 Employer Support Services
                                                                                                       Budgeted                Actual
                                                             Quarter 1 Dollars                            $0.00
                                                             Quarter 2 Dollars                            $0.00
                                                             Quarter 3 Dollars                            $0.00
                                                             Quarter 4 Dollars                            $0.00
                                       Employee Compensation Totals (Dollars):                            $0.00                 $0.00



                                                                Employee Compensation
                                                Annual Dollars Budgeted for Employee Compensation:                  $0.00
                                               Minimum Dollars Required for Employee Compensation:                  $0.00

                                                                              Dollars
                                                                                                       Budgeted                Actual
                                                             Quarter 1 Dollars                            $0.00
                                                             Quarter 2 Dollars                            $0.00
                                                             Quarter 3 Dollars                            $0.00
                                                             Quarter 4 Dollars                            $0.00
                                       Employee Compensation Totals (Dollars):                            $0.00                 $0.00

                                                                              Priority
                                                                                                   Authorized                  Actual
                                                               Quarter 1 Units                           0.00
                                                               Quarter 2 Units                           0.00
                                                               Quarter 3 Units                           0.00
                                                               Quarter 4 Units                           0.00
                                         Employee Compensation Totals (Units):                           0.00                    0.00
                                                                                              Remaining Units                    0.00


                                   Dollars Remaining (negative indicates the consumer has
                                                                                overspent):                         $0.00
                                       Percent of Budgeted Dollars Spent (negative amount
                                                    indicates the consumer has overspent):                          #DIV/0!
                                NOTE - The consumer must not develop a regular employee schedule that contains fewer than
                                                       or more than the weekly authorized units.




                                CERTIFICATION: By signature below I certify that the numbers entered into this quarterly report are
                                accurate as reported to me.




                                                 CDS Agency Representative Printed Name                               Phone Number
                                                                                                                     (with Area Code)



                                                   CDS Agency Representative Signature                              Date

                                                                                                                                        Date and Time Created
                                                                                                                                            1/10/2011 3:30 PM
Texas Department of                                                                          CMPAS CDS Budget
Aging and Disability Services                                                                      August 2008




                  Consumer Managed Personal Attendant Services
                                       Consumer Directed Services Budget

                                Taxable and Non-Taxable Employee Compensation

                     THIS PAGE IS NOT CONSIDERED PART OF CLIENT BUDGET



                                    TAXABLE EMPLOYEE COMPENSATION
SALARIES/WAGES                                            MILEAGE (MAXIMUM IS 48.5¢ PER MILE)
(Includes Employee-Paid Payroll Taxes:)                   (Not Directly Related to Client Care)
     Regular Time                                            Communiting Costs & Assistance
     Overtime
     Bonus
     Paid Vacation Leave
     Paid Sick Leave
     Paid Other Leave (Jury Duty, Funeral, etc.)




                                  NON-TAXABLE EMPLOYEE COMPENSATION
EMPLOYEE BENEFITS/INSURANCE                               MILEAGE (MAXIMUM IS 48.5¢ PER MILE)
  Insurance Premiums and Paid Claims,                     (Use of Employee's Personal Car Directly Related
      Including Health/Medical/Dental/Disability          Related to Client Care)
  Life Insurance Premiums                                    Client Appointments
  Employer-Paid Contributions to:                            Shopping
      Deferred Compensation Plans                            Escort
      Retirement & Pension Plans
      Child Day Care                                      WORKERS' COMPENSATION COSTS
      Accrued Leave                                         Premium Costs
                                                            Paid Claims
PAYROLL TAXES (EMPLOYER-PAID)                               Other Premium/Claims for Employee
  FICA                                                      Work-Related Injury/Illness Coverage
  MEDICARE
  SUTA                                                    CONTRACTED SERVICE FEE
  FUTA                                                    (When Contracted With an Agency)
  Other as applicable                                        Back-Up PAS
                                                             In-Home Respite




                                                                                          Date and Time Created
                                                                                              1/10/2011 3:30 PM

				
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Description: Budget Workbook document sample