Vocaional Rehabilitation Provider Claim - Claiming Reimbursement SSA-199

Vocational Rehabilitation Provider Claim

Cost Form Worksheet 2019-RSA

Vocaional Rehabilitation Provider Claim - Claiming Reimbursement SSA-199

OMB: 0960-0310

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Cost Formula Worksheets

2019

OMB: 0960-0310


OPTION A – AVERAGE MONTHLY ACP COSTS METHOD WORKSHEET

Administrative, Counseling and Placement (ACP) Worksheet


Step 1


Obtain the amounts for Sections 1A, 1B, 2A, 3A, 3C, 3E, 3F and 3G from the form RSA-2, Schedule I – Total Expenditures and enter them on the appropriate lines below.


1A. Direct Administration Costs $ _______________


1B. Indirect Administration Costs $ ­­­­­­_______________


2A. Services Provided by Agency $ _______________

(2.A.1.a & b + +2.A.2.a & b)

3A. Establishment, Development, or

Improvement of Community Rehabilitation

Program $ _______________


3C. Special Services to Provide

Nonvisual Access to Information $ _______________


3E. Business Enterprise Program $ _______________


3F. Transition Consultation and

Technical Assistance $ _______________


3G. Transition Services to Youth and Students $ _______________



ADD THE ABOVE LINES TO ARRIVE AT THE

TOTAL INDIRECT ACP COSTS $ _______________


Step 2



Determine the total number of clients served during Federal FY 2018. __________

(Take from lines A15, B3, C3, D1, D2, D3 D4 of the final RSA-113 submission for the Federal FY18, Oct. to Sept. period)



Step 3



$ __________________ ÷ ______________________ = $ ______________

INDIRECT ACP COSTS TOTAL NO. OF CLIENTS YEARLY COST

(Total from Step 1) SERVED IN FY18 PER CLIENT

(Take from Step 2)



Step 4



$ ______________________ ÷ ________12________ = $ _______________

YEARLY COST PER CLIENT MONTHS AVERAGE MONTHLY

(Take from Step 3) COST PER CLIENT






To use this formula when filing a claim, multiply the “AVERAGE MONTHLY COST PER CLIENT,” derived in Step 4, by the number of months from the date the client entered VR through the date of final VR closure. The result is the cost to be submitted as the total for administration, counseling and placement for that claim.

OMB: 0960-0310



OPTION A – AVERAGE MONTHLY TRACKING COST WORKSHEET



Step 1


Obtain the sum of the Administration costs from line 1A & 1B of the form RSA-2. (This is line lD on the RSA-2 spreadsheet.)


1. Administration Costs $ _______­­________




Step 2



$ ______________________ ÷ _______________________ = $ _______________

ADMINISTRATION COSTS TOTAL NO. OF CLIENTS YEARLY COST PER

(From Step 1) SERVED IN FEDERAL FY18 CLIENT

(Take from lines A15, B3,

C3, D1, D2, D3, D4 of final RSA-113

submission, Oct.-Sept. period)


Step 3



$ ______________________ ÷ _________12__________ = $ _______________

YEARLY COST PER MONTHS AVERAGE MONTHLY

CLIENT (From Step 2) TRACKING COST

PER CLIENT




To use this formula when filing a claim, multiply the average monthly cost for tracking by the number of months after VR closure that the case is tracked, up to a maximum of 9 months.

OMB: 0960-0310



OPTION B – ADJUSTED MONTHS OF SERVICE ACP WORKSHEET

Administrative, Counseling and Placement (ACP) Worksheet


Step 1


Obtain the amounts for section 1A, 1B, 2A, 3A, 3C, 3E, 3F and 3G from the form RSA-2, Schedule I – Total Expenditures and enter them on the appropriate lines below.


1A. Direct Administration Costs $ _______________


1B. Indirect Administration Costs $ ­­­­­­_______________


2A. Services Provided by Agency $ _______________

(2.A.1.a & b + +2.A.2.a & b)

3A. Establishment, Development, or

Improvement of Community Rehabilitation

Program $ _______________


3C. Special Services to Provide

Nonvisual Access to Information $ _______________


3E. Business Enterprise Program $ _______________


3F. Transition Consultation and

Technical Assistance $ _______________


3G. Transition Services to Youth and Students $ _______________


ADD THE ABOVE LINES TO ARRIVE AT THE

TOTAL INDIRECT ACP COSTS $ _______________


Step 2


a. Calculate the ”Total Service Months of Clients Open” for the prior Federal FY (2018) using 2a through 2c. Remember the numbers are taken from your prior year’s form RSA-113.

RSA-113

Quarterly

Cumulative Period

# of Clients Open at End of Quarterly Period

(Add lines A15, B3, C3 for each quarter to get the period total)

# of New Acceptances

(Add lines A12, A13 and A14 from final/Period 4 2018 from

RSA 113)

Oct.-Dec.

Line A15

Line B3

Line C3

Period 1 Total

Oct.-Mar.

Line A15

Line B3

Line C3

Period 2 Total

Oct.-Jun.

Line A15

Line B3

Line C3

Period 3 Total

Oct.-Sept.

Line A15

Line B3

Line C3

Period 4 Total


___________________

___________________

___________________

___________________


___________________

___________________

___________________

___________________


___________________

___________________

___________________

___________________


___________________

___________________

___________________

___________________

















Oct.-Sept.

Line A12___________________

Line A13___________________

Line A14___________________

Period 4 Total: ______________

Enter 1/2 period 4 total on line (2) below.

Add period totals to get Fed. FY18 total

_________________ (1)

__________________ (2)



b. Divide Federal FY18 Total, Step 2a.(1), by 4 to determine “Average Clients Open per Month”.



____________ ÷ 4 = ________________

FEDERAL FY18 AVERAGE CLIENTS

TOTAL OPEN PER MONTH




c. Multiply “Average Clients Open per Month” from Step 2b. times 12 to determine “Total Service Months of Clients Open” in Federal FY18.



____________________ x 12 = _____________________

AVERAGE CLIENTS OPEN TOTAL SERVICE MONTHS

PER MONTH OF CLIENTS OPEN IN

FEDERAL FY18


Step 3



_______________________ - ____________________ = _____________________

TOTAL SERVICE MONTHS ONE-HALF OF THE NEW TOTAL ADJUSTED MONTHS

OF CLIENTS OPEN IN FY18 CLIENTS ACCEPTED FOR OF SERVICE

(Take from 2c.) SERVICE DURING FY18

Take from chart -

Step 2a.(2)




Step 4



$___________________ ÷ ______________________ = $ ___________________

INDIRECT ACP COSTS TOTAL ADJUSTED MONTHS TOTAL COST PER

(From Step 1) OF SERVICE (Total from MONTH OF SERVICE

Step 3 above)






To use this formula when filing a claim, multiply the “TOTAL COST PER MONTH OF SERVICE” (derived in Step 4) by the number of months from the date the client entered VR through the date of final VR closure. The

OMB: 0960-0310


result is the cost to be submitted as the total for administration, counseling and placement for that claim.

OMB: 0960-0310


OPTION B – ADJUSTED MONTHS OF SERVICE TRACKING COST WORKSHEET



Step 1


Obtain the sum of the Administration costs from line 1A & 1B of the form RSA-2. (This is line lD on the RSA-2 spreadsheet.)


1. Administration Costs $ _______________



Step 2


a. Calculate the ”Total Service Months of Clients Open” for the prior Federal FY16 using 2a through 2c Remember the numbers are taken from your prior year’s form RSA-113 (FY18).

RSA-113

Quarterly Periods (2018)

# of Clients Open at End of Quarterly Period

(Add lines A15, B3, C3 for each quarter to get the period total)

# of New Acceptances

(Add lines A12, A13 and A14 from final/Period 4 2018 form

RSA 113)

Oct.-Dec.

Line A15

Line B3

Line C3

Period 1 Total

Oct.-Mar.

Line A15

Line B3

Line C3

Period 2 Total

Oct.-Jun.

Line A15

Line B3

Line C3

Period 3 Total

Oct.-Sept.

Line A15

Line B3

Line C3

Period 4 Total


___________________

___________________

___________________

___________________


___________________

___________________

___________________

___________________


___________________

___________________

___________________

___________________


___________________

___________________

___________________

___________________

















Oct.-Sept.

Line A12___________________

Line A13___________________

Line A14___________________

Period 4 Total: ______________

Enter 1/2 period 4 total on line (2) below.

Add period totals to get Fed. FY18 total

_________________ (1)

__________________ (2)



b. Divide Federal FY18 Total, Step 2a(1), by 4 to determine “Average Clients Open per Month”.



____________ ÷ 4 = ________________

FEDERAL FY18 AVERAGE CLIENTS

TOTAL OPEN PER MONTH



OMB: 0960-0310



c. Multiply “Average Clients Open per Month” from Step 2b times 12 to determine “Total Service Months of Clients Open” in Federal FY18.



____________________ x 12 = _____________________

AVERAGE CLIENTS OPEN TOTAL SERVICE MONTHS

PER MONTH OF CLIENTS OPEN IN

FEDERAL FY18


Step 3



_______________________ - ____________________ = _____________________

TOTAL SERVICE MONTHS ONE-HALF OF THE NEW TOTAL ADJUSTED MONTHS

OF CLIENTS OPEN IN FY18 CLIENTS ACCEPTED FOR OF SERVICE

(Take from 2c) SERVICE DURING FY18

Take from chart -

Step 2a (2)




Step 4



$ ________________________ ÷ ______________________ = $__________________

ADMINISTRATION COSTS TOTAL ADJUSTED MONTHS MONTHLY TRACKING

(From Step 1 above) OF SERVICE (From COST PER CLIENT

Step 3 above) MONTH OF SERVICE






To use this formula when filing a claim, multiply the monthly cost for tracking by the number of months after VR closure that the case is tracked, up to a maximum of 9 months.

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File TitleOPTION II – AVERAGE MONTHLY COSTS METHOD WORKSHEET
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File Modified2019-12-23
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