Out-of-Home Care Program Report
Michigan Department of Health and Human Services
For fiscal year October 1, 20 through September 30, 20
Program Manager Name	Telephone Number	Date
This form must be completed for ALL Out-of-Home Care (OHC) programs included in the county’s Child Care Fund Annual Plan and Budget (AP&B). For delinquent youth under the jurisdiction of the court only. Do not complete this form for abuse/neglect youth. Provide the estimated projections for each unique rate being paid for the OHC program(s) identified in the county’s AP&B. Attach additional sheets if necessary. FOSTER CARE: Rates include minimally all of the following services: youth room & board, and defined supervision/supports/services by foster care provider. Any rate that exceeds $40 per day must be explained on the worksheet on page 2 of this form. PURCHASED FOSTER CARE: Rates include all of the following services: youth room & board; defined supervision/supports/services by foster care provider; case management by private child placing agency. Any rate that exceeds $85 per day must be explained on the worksheet on page 2 of this form. INDEPENDENT LIVING: Rates include all of the following services: youth room & board; defined supervision/supports/services by foster care provider; case management by private child placing agency. Any rate that exceeds $85 per day must be explained on the worksheet on page 2 of this form. INSTITUTIONAL CARE: Rates include all of the following services: youth room & board; defined supervision/supports/services by provider; case management by private child placing agency. Any rate that exceeds $315 per day must be explained on the worksheet on page 2 of this form.
Enter the following abbreviations in the corresponding columns in the table on page 2:
Placement Type Foster Care – Court supervised (FC-Court) Foster Care – PAFC In-State (FC-InSt) Foster Care – PAFC Out-of-State (FC-OutSt) Independent Living (IL) Institutional Care – County/Court Operated (IC-Cty/Ct) Institutional Care – Another County (IC-Other Cty) Institutional Care – Private In-State (IC-Prv InSt) Institutional Care – Private Out-of-State (IC-Prv OutSt) Other – attach documentation (Other)	Rate Type Daily Rate (Daily) Administrative Rate (Admin) Daily + Administrative Rate (Daily+Admin) IL Stipend (Stipend) IL Stipend + Administrative Rate (IL+Admin) Other – attach documentation (Other)
Placement Type	Rate Type	Rate Paid per Day	# Youth Served by Program	# Total Days in Care	Annual Estimated Cost (rate x youth x days)	Exceeds State-Established Maximum
(ex: FC-Court)	(ex: Daily)	(ex: $27.24)	(ex: 4)	(ex: 100)	(ex: $10,896.00)
$	$
$	$
$	$
$	$
$	$
$	$
$	$
$	$
$	$
$	$
$	$
$	$
$	$
$	$
$	$
INSTRUCTIONS: Approval of the AP&B, including this MDHHS-5731, constitutes approval of rates as required by Administrative Rule 400.2023. County established rates must be detailed in the categories provided on the form. The rates indicated by the county shall include services that meet appropriate needs in the respective out-of-home care placement types. Once the AP&B is approved with the completed MDHHS-5731, a county may determine a need to modify established rates for out-of-home care programs. In that circumstance, the county must submit a revised MDHHS-5731 for approval. If the modified rates cause the need for a budget amendment, the county is responsible to submit the revised MDHHS-5731 with the appropriate AP&B amendment in MiSACWIS for approval. EXCEPTION TO MAXIMUM RATE: Youth supervised by the department must conform to the State of Michigan’s contract and placement rate setting (see FOM 903-04, Purchased Care Payment Procedures, and FOM 905-3, Foster Care Rates). Any rate that exceeds the maximum indicated must be marked as such in the appropriate column and an explanation provided on the next page. Attach additional sheets if necessary.
EXAMPLE
Placement Type	Rate Type	Rate Paid per Day	# Youth Served by Program	# Total Days in Care	Annual Estimated Cost (rate x youth x days)	Exceeds State-Established Maximum
FC – InSt	Daily+Admin	$63.44	10	50	$31,720.00
IL	IL+Admin	$73.44	7	250	$128,520.00
FC – Court	Daily	$100.00	5	100	$50,000.00
OHC Program Type: FC – Court Type of Rate: Daily Rate Rate: $100 Explanation: The county has developed a specialized foster home to meet special medical needs of youth in care. The foster parent is a registered nurse and will provide unique care including but not limited to: tube feeding, blood pressure monitoring, dispensing IV and injection medications, etc.
OHC Program Type	Type of Rate	Rate
$
Explanation
OHC Program Type	Type of Rate	Rate
$
Explanation
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
AUTHORITY: P.A. 87 of 1978	COMPLETION: Is required.	CONSEQUENCE FOR NONCOMPLETION: Child Care Funds will not be reimbursed.