DHS-5504B-ENG 12-22 (1.1.2)

Exception Request for Environmental Accessibility Adaptations that Exceed $40,000 (CAC, CADI, BI and DD Waivers)

When a person on a BI, CAC, CADI or DD waiver meets eligibility requirements, lead agencies use this form to request an exception to the $40,000 yearly limit (as per the service agreement timeframe) for environmental accessibility adaptations (EAA).

Examples

Levi was assessed to need the following EAA modifications to meet disability-related, assessed needs:

Accessible bathroom modification
Wheelchair ramp on his home
Vehicle modification for an adaptive driving mechanism.

The accessible bathroom modification costs $45,000. The ramp costs $7,500.00. The vehicle adaptive driving mechanism costs $5,000. Levi will exceed the $40,000 cap on the EAA service by $17,500 for a total costs of $57,500. As a result, his case manager must complete this exception request form and submit it to DHS for approval. The authorization will use $17,500 from Levi's waiver budget from next year in order to meet his disability-related assessed needs.

For exception information, criteria and policy, see CBSM – Environmental accessibility adaptations.

Instructions

DHS will not review incomplete requests. Use the EAA exception request checklist, DHS-5504C (PDF) as a tool to help you submit complete requests.

When you submit this form, make sure to attach the following:

Person's support plan describing the need.
Invoices and two or more bids for the proposed work.
Please submit the home or vehicle assessment if there was one completed. Home or vehicle assessments are typically done by a home assessment provider, a physical therapist or similar professional.
The completed EAA checklist (DHS-5504C).

If you need room for longer answers, attach another document with additional details. If this is a change order, please provide a revised 5504B and the change order from contractor or the invoice.

Information

Person

LAST NAME

FIRST NAME

PMI

DATE OF BIRTH

What waiver does the person use?

Brain Injury (BI)

Community Alternative Care (CAC)

Community Access for Disability Inclusion (CADI)

Developmental Disabilities (DD)

Case manager

FIRST NAME

LAST NAME

CONTRACTED CASE MANAGEMENT COMPANY NAME (if applicable)

COUNTY/TRIBAL NATION

BUSINESS PHONE NUMBER

EMAIL ADDRESS

Would you like to receive a copy of your submitted form by email?

Yes

Background information

New or update to current request?

New

Update to current request

Does this person use consumer directed community supports (CDCS)?

Yes

Note: the first $5,000 of the home and/or vehicle modification must come from the person's CDCS budget. For more information, see CDCS – Environmental modifications and provisions policy.

What is the start date for the current service agreement?

What is the total amount for all approved EAA installation and assessment lines authorized on the current service agreement?

Briefly describe the EAA services that have already been authorized during the current service agreement period.

Was the person on a waiver during the year prior to current service agreement start date?

Yes

What is the start date for the last years' service agreement?

What is the total amount for all approved EAA installation and assessment lines on last years' service agreement?

Briefly describe the EAA services the person received during last years' service agreement period.

NOTE: Attach a copy of the previous EAA approval letter.

Request to exceed $40,000 information

NOTE: If an EAA home or vehicle assessment was comleted, you must include the assessment with this form and enter the costs below.

Item	Cost

Total current project cost of the items above

Total amount requested for approval that exceeds $40,000

Includes costs:

Already authorized this year
From the last service agreement period if those costs exceeded $40,000
Proposed costs for this year

TOTAL

Reason for request

Complete all questions and provide details.

Describe how the environmental accessibility adaptation requested is necessary and meets the person's assessed need? Describe the assessed need. Please include the diagnosis that results in the need for the home or van modification.

Describe how the environmental accessibility adaptation is cost effective?

List and describe all other options that were explored under the $40,000 cap. Specifically, describe how, without this exception, each of those options will not provide the person:

Reasonable access to community integration
Functional use of the house.

How will the additional funds meet the person's immediate need?

The file was not added as an attachment.

Case manager attestation

I attest that the person has been made aware that he/she is using additional funds from next year's budget, and once these funds have been used, no additional funds can be used. I also attest that there is no additional exception process once the $80,000 has been used.

SIGNATURE

TODAY'S DATE