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
/ /
County/Tribe
This form must be completed for any Out-of-Home Care (OHC) program expenditures included in the county’s Child Care Fund Annual Plan and Budget (AP&B) that are not currently included in MDHHS contractual rates found in FOM 905-5, Rates for Child Care Institutions and PAFC Providers (A-Z). This form is to be completed for delinquent youth under the jurisdiction of the court only. Do not complete this form for abuse/neglect youth; do not include any in county or out-of-county detention charges. Provide the estimated projections for each unique rate being paid outside of current contracted rates 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 3 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 3 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 not currently included on the FOM 905-5 must be explained on the worksheet on page 3 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 not currently included on the FOM 905-5 must be explained on the worksheet on page 3 of this form.
Enter ONE of 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 – 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 in this Placement Type	Total Days in Care per Youth	Annual Estimated Cost (rate x youth x days)
(ex: FC-Court)	(ex: Daily + Admin)	(ex: $63.44)	(ex: 10)	(ex: 50)	(ex: $31,720.00)
(ex: IC-Prv OutSt)	(ex: Daily)	(ex: $675.00)	(ex: 2)	(ex: 30)	(ex: $40,500.00)
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INSTRUCTIONS: Approval of the AP&B, including this MDHHS-5731, constitutes approval of rates as required by Administrative Rule 400.2023. County established rates above contracted rates found in MDHHS policy FOM 905-5 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. 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, Rates for Child Care Institutions and PAFC Foster Care Providers).
EXCEPTION TO MAXIMUM RATE: 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 in this Placement Type	Total Days in Care per Youth	Annual Estimated Cost (rate x youth x days)
IC-Prv OutSt	Daily	$675.00	2	30	$40,500.00
OHC Program Type: IC-Prv OutSt Type of Rate: Daily Rate Rate: $675.00 Explanation: The placement is an out-of-state short-term intensive assessment program, prior to admission, that includes 24-hour one-on-one supervision and COVID safety protocols, requiring a higher initial rate.
OHC Placement Type	Type of Rate	Rate
$
Explanation
OHC Placement Type	Type of Rate	Rate
$
Explanation
The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, gender identification or expression, sexual orientation, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.
AUTHORITY: P.A. 87 of 1978 COMPLETION: Is required. CONSEQUENCE FOR NONCOMPLETION: Child Care Funds will not be reimbursed.