Form Soc 449 - In-Home Supportive Services Program - Public Authority/non-Profit Consortium Rate
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
COUNTY:
PUBLIC AUTHORITY/NON-PROFIT
CONTACT NAME:
CONSORTIUM RATE
PA NAME:
TELEPHONE:
FAX NUMBER:
(
)
(
)
ADDRESS:
To: California Department of Social Services
Adult Programs Division
Public Authority Unit
744 P Street, MS 9-9-04
EMAIL ADDRESS:
Sacramento, CA 95814
Please address questions regarding this form to the Public Authority Unit, at (916) 651-3488.
Please complete the budget narrative below and attach supporting documentation explaining how each component of the rate
was determined. The total Public Authority (PA) and Non-profit Consortium (NPC) rate should include a rate for services (wage
and benefits) and a rate for administrative costs. The total rate for wages and benefits should be broken down to include an
hourly wage, payroll taxes, health and non-health benefits. The State is legally authorized to share only in the costs of individual
health benefits for IHSS providers, however, these costs may be eligible for Title XIX reimbursement.
•
The state will only participate in hourly wage and benefits up to $12.10 per hour unless otherwise provided for in the Annual
Budget Act or appropriated by statute.
•
The state will not participate in increases to wages or employment taxes, or increases or expansions of benefits negotiated
or agreed to by a PA or NPC unless provided for in the Annual Budget Act or appropriated by statute.
•
No increase in wages or benefits negotiated or agreed to by a PA or NPC shall take effect until it has been approved by the
State (CDSS/DHCS) or unless provided for in the Annual Budget Act or appropriated by statute.
I hereby certify that the proposed IHSS MOE adjustment includes no locally negotiated health benefit rate changes and
no changes that modify who is eligible for health benefits (only applies to non-locally negotiated health benefit rates).
Approved by: ______________________________________________________ Date:______________________
BUDGET NARRATIVE
Current Rate
Requested Rate
Difference
PA/NPC Hourly Rate:
1
PA/NPC Hourly Administrative Cost:
2
Hourly Services Cost:
Total
3
Hourly Wage (locally negotiated)
4
Hourly Wage (non-locally negotiated)
5
Payroll Taxes (FUTA, SUI, FICA)
6a
Health Benefits (locally negotiated)
6b
7
Health Benefits (non-locally negotiated)
8
Non-Health Benefits (if any)
Comments: Please include the Line-by-Line Budget Narrative with PA Rate Change Package
SOC 449 (2/15)
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