Bulletin. Title IV-E Foster Care Per Diem Rates for Children s Residential Facilities and Child Placing Agencies TOPIC PURPOSE CONTACT SIGNED

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1 Bulletin NUMBER # DATE June 5, 2014 OF INTEREST TO County Directors Social Services Supervisors and Staff Fiscal Supervisors Financial Assistance Supervisors and Staff ACTION/DUE DATE Please read information and prepare for implementation Claims for April June 2014 are due July 20, 2014 EXPIRATION DATE June 5, 2016 Title IV-E Foster Care Per Diem Rates for Children s Residential Facilities and Child Placing Agencies TOPIC Quarterly list of Title IV-E eligible children s group residential facilities and Rule 4 child placing agencies. PURPOSE Inform county and tribal agencies of per diem and percentage rates to use when claiming Title IV-E federal reimbursement. Provide forms for use in reporting rate changes, lead county contract renewals and facility closings. CONTACT Deb Jensen, Title IV-E Fiscal Management Analyst DHS Financial Operations Division (651) or deb.jensen@state.mn.us SIGNED ALEXANDRA KOTZE Chief Financial Officer TERMINOLOGY NOTICE The terminology used to describe people we serve has changed over time. The Minnesota Department of Human Services (DHS) supports the use of "People First" language. Minnesota Department of Human Services PO Box St. Paul, MN

2 Bulletin # June 5, 2014 Page 2 BACKGROUND This bulletin contains the information, per diem rates and percentages, needed to claim Title IV-E federal reimbursement for children s residential group facilities and Rule 4 child placing agencies, as well as information needed to claim Medical Assistance (MA) federal reimbursement for children s group residential facilities with mental health certification. The per diem rates are established when the lead county (host county) establishes or amends the contract and properly notifies DHS using form DHS The per diem rates in this bulletin are effective for the dates of service beginning April 1, DHS calculates percentages using time studies and cost reports from the participating facilities. These percentages represent the portions of the per diem which are federally reimbursable under Title IV-E. Percentages in this bulletin are effective for dates of service April 1, 2014 through June 30, These percentages are calculated annually and will change on April 1, OVERVIEW OF ATTACHMENT A Per Diem Rates and Percentages Attachment A contains the per diem rates and percentages for the various types of facilities. Each type of facility is a separate group in the attachment. The page format for all groups is the same. However, not all columns are applicable to every group so some are left blank. Please refer to the Title IV-E Abstract Bulletin # (March 1, 2012) for information on the required claim elements, types of eligible claims and how the Title IV-E information in this bulletin is used to claim reimbursement through the IV-E Abstract. Column Headings Facility & Program Name Name of the IV-E approved facility and program. County/City Name of the county that holds the lead contract. Except on page Group 2 Out-of-State Facilities, this column lists the name of the city and state where the IV-E approved program is located. Rule The code that identifies the type of claim. DHS Lic# / Automation number The provider code that identifies the eligibility of the provider s licensure. Minnesota Department of Human Services PO Box St. Paul, MN

3 Bulletin # June 5, 2014 Page 3 IV-E Sub An additional code added to the provider code when facilities operate multiple programs under the same license. Approved Per Diem The per diem rate recognized in the lead county contract. Maintenance% The percentage of the approved per diem that is eligible for Title IV-E maintenance reimbursement. Title IV-E maintenance reimbursement is currently 50 percent of the eligible maintenance cost. [The per diem rate times the Maintenance% times 50% equals the IV-E reimbursement for one day.] Intake/Planning% The percentage of the approved per diem that is eligible for Title IV-E administration reimbursement. Title IV-E administration reimbursement is 50 percent of the eligible administration cost. [The per diem rate times the Intake/Planning% times 50% equals the IV-E reimbursement for one day.] Training% The percentage of the approved per diem that is eligible for Title IV-E training reimbursement. Title IV-E training reimbursement is 75 percent of the eligible training cost. [The per diem rate times the Training% times 75% equals the IV-E reimbursement for one day.] Approved MA% The percentage of the approved per diem that is eligible for Medical Assistance service reimbursement. Medical Assistance reimbursement is currently 50 percent of the eligible MA cost. [The per diem rate times the Approved MA% times 50% equals the MA reimbursement for one day.] Current Contract or Current License The effective dates for the current Lead County contract. Except on page Group 2 Outof-State Facilities, this column lists the effective dates for the program s current license. NOTE: The total of the approved percentages do not equal 100%. The difference between 100% and the total of the approved percentages is the portion of the per diem that is not eligible for any federal reimbursement. Page Titles Children s residential facilities and child placing agencies which have been reviewed and approved as Title IV-E eligible programs appear in Attachment A on one of these pages: Minnesota Department of Human Services PO Box St. Paul, MN

4 Bulletin # June 5, 2014 Page 4 Group 1 Children s Group Residential Facilities with Mental Health Certification These are the programs that are licensed by DHS as Children s Group Residential Facilities with Mental Health Treatment. This also includes specific out-of-state mental health treatment programs that are located in a state that borders Minnesota and that have met all of the requirements for Minnesota Statutes, section 256B Group 1 Group Residential These are the programs that are licensed by DHS as Children s Group Residential Facilities. Group 1 Other Facilities These are the programs that are licensed by either the Minnesota Department of Corrections or by a tribal government as Children s Group Residential Facilities. Group 2 New Facilities These are all of the new programs that have been approved for Title IV-E reimbursement but have not yet participated in a DHS time study which determines the facility-specific percentages. This group uses median percentages. Group 2 Other Facilities These are the programs that are licensed by DHS as independent living programs. Group 2 Out-of-State Facilities These are the programs that are licensed by other states as children s group residential facilities. Group 4 Rule 4 Child Placing Agencies Group 4 is used to recognize the administrative per diems of eligible Rule 4 (Minnesota Rules, Parts ) child placing agencies. These child placing agencies appearing in Group 4 have chosen to participate in the Placing Agency Time Study (PATS), and therefore a portion of the administrative fee charged to counties for children placed in family foster homes through these child placing agencies is eligible for Title IV-E reimbursement. NOTE: Some programs will move from the Group 2 New Facilities page to an appropriate Group 1 page when the new program has completed one year of participation in a DHS time study and has had its own facility-specific percentages calculated. The Group 1 -Children s Group Residential Facilities with Mental Health Certification programs are eligible for MA reimbursement as well as Title IV-E. The Approved MA% is the percentage of the per diem eligible for MA reimbursement. This data is not included on the Title IV-E Abstract. MA claims must be submitted to MMIS separately. The MA information is published to assist counties in claiming federal MA reimbursement. Minnesota Department of Human Services PO Box St. Paul, MN

5 Bulletin # June 5, 2014 Page 5 OVERVIEW OF ATTACHMENT B Notice of Contracted Per Diem Rates Attachment B, form DHS-2825, is required when submitting information about facilities and/or programs regarding contracts and per diem rates. It is also required for all changes and renewals for existing programs and all new programs, or new facilities. This form is available in an electronic format on CountyLink under edocs. OVERVIEW OF ATTACHMENT C Title IV-E Checklist Attachment C, form DHS-6634, is required and must be submitted when requesting Title IV-E eligibility approval for new facilities and/or programs. This form is available in an electronic format on CountyLink under edocs. OVERVIEW OF ATTACHMENT D Facilities Licensed by Corrections Attachment D was added to this bulletin in response to county requests for more information about facilities licensed by the Minnesota Department of Corrections. This attachment lists all juvenile correctional facilities licensed by the Minnesota Department of Corrections. The facilities are listed alphabetically and include location and security status of the beds. Remember that not all of these facilities are Title IV-E eligible. If a program from a licensed correctional facility is Title IV-E eligible, it will be listed in Attachment A. LEGAL REFERENCES Social Services Act, Title IV, Part E Title 45, CFR Part to Minnesota Statutes, section Minnesota Statutes, section Minnesota Statutes, section Minnesota Statutes, section Minnesota Statutes, section 256B.0945 ACTION REQUIRED o Use Current Per Diem Rates Title IV-E claims must reflect the per diem rates shown in Attachment A for service dates of April 1, 2014 through June 30, This replaces Attachment A from DHS Bulletin # (March 6, 2014) which included the rates effective for service dates of January 1, 2014 through March 31, Minnesota Department of Human Services PO Box St. Paul, MN

6 Bulletin # June 5, 2014 Page 6 o Follow Procedures for Submitting Documentation for All Facilities and All Programs New Title IV-E Facility/Program When counties apply for a new Title IV-E facility and/or new Title IV-E program, they must submit the following information to DHS: Form DHS-2825 (Attachment B) Form DHS-6634 (Attachment C) License Description of program services Renewal for Title IV-E Facility/Program Documentation we need for the renewal of an existing Title IV-E facility and/or Title IV-E program: Form DHS-2825 (Attachment B) License New MA Facility/program When counties apply for a new MA facility and/or new MA program, they must submit the following information to DHS: Form DHS-2825 (Attachment B) Form DHS-6634 (Attachment C) License Description of program services MA Unique Minnesota Provider Identifier (UMPI) number or MA National Provider Identifier (NPI) number Renewal for MA Facility/program Documentation we need for the renewal of existing MA facility and/or MA program: Form DHS-2825 (Attachment B) License New Out-of-State Title IV-E facility /program When counties apply for a new Out-of-State Title IV-E facility and/or Out-of-State Title IV-E program they must submit the following information to DHS: Form DHS-2825 (Attachment B) Form DHS-6634 (Attachment C) License Description of program services Letter of IV-E eligibility from state of location Renewal for Out-of-State Title IV-E facility /program Documentation we need for the renewal of an existing Out-of-State Title IV-E facility and/or Title IV-E program: Form DHS-2825 (Attachment B) License Minnesota Department of Human Services PO Box St. Paul, MN

7 Bulletin # June 5, 2014 Page 7 New Out-of-State Children s Mental Health Treatment facility /program When counties apply for a new Out-of-State Children s Mental Health Treatment facility and/or new Out-of-State Children s Mental Health Treatment program bordering Minnesota they must submit the following information to DHS: Form DHS-2825 (Attachment B) Form DHS-6634 (Attachment C) License Description of program services Letter of IV-E eligibility from state of location MA provider UMPI or NPI number Documentation demonstrating satisfactory completion of inspection by the Licensing Division of the Department of Human Services and current certification by the Minnesota Department of Corrections as substantially meeting Minnesota s standards applicable to children s residential mental health treatment programs (under Minnesota Rules, chapter 2960). Renewal for Out-of-State Children s Mental Health Treatment facility /program Documentation we need for the renewal of an existing Out-of-State Children s Mental Health Treatment facility and/or Out-of-State Children s Mental Health Treatment program: Form DHS-2825 (Attachment B) License Description of program services Documentation demonstrating satisfactory completion of inspection by the Licensing Division of the Department of Human Services and current certification by the Minnesota Department of Corrections as substantially meeting Minnesota s standards applicable to children s residential mental health treatment programs (under Minnesota Rules, chapter 2960). New Rule 4 Placing Agency/Program When counties apply for a new Rule 4 Placing Agency and/or new Rule 4 program, they must submit the following information to DHS: Form DHS-2825 (Attachment B) License Description of program services Renewal for Rule 4 Placing Agency/Program Documentation we need for the renewal of an existing Title IV-E Rule 4 Placing Agency and/or Rule 4 program: Form DHS-2825 (Attachment B) License NOTE: The eligibility determination process can take time; therefore, DHS recommends that lead counties submit the required materials within the first 30 days of the calendar quarter. Minnesota Department of Human Services PO Box St. Paul, MN

8 Bulletin # June 5, 2014 Page 8 If all requested documentation has been received within the first 30 days of the quarter, determination can generally be made in that same quarter. Approval or denial notifications, with an explanation for denials, will be sent to the lead county. In some instances, further research or follow up may be required to determine eligibility. If this is the case, it may delay the determination process and result in a later effective date. o Notify DHS of Per Diem Rate Changes County agencies must notify DHS of per diem rate changes involving approved children s group residential facilities and Rule 4 child placing agencies. For Title IV-E claiming purposes, DHS will implement changes in per diem rates after the notice of the rate change has been received. Although the county may renew a contract and backdate the effective dates on the contract, those dates might not be the effective dates that DHS uses when publishing the quarterly per diem bulletin. All changes need to be received within the first 30 days of the calendar quarter. Lead county human service agencies must notify DHS of per diem rate changes for all facilities and programs appearing in Attachment A of this bulletin. Form DHS-2825 (Attachment B) is to be used for this purpose. It is recommended that lead counties negotiate per diem rate changes to be effective on the first day of a quarter and that these changes cover the entire quarter. Counties should then notify DHS using form DHS-2825 within the first 30 days of that quarter. This will maximize federal Title IV-E revenue to all counties. From DHS-2825 must be signed by the director of the lead county or an official authorized to sign for the director. EXAMPLE 1: The lead county contract specifies a new rate effective July 1, 2014 and DHS receives the notice of the rate change (DHS-2825) on or before July 30, The new per diem becomes effective for Title IV-E claims for service dates beginning July 1, EXAMPLE 2: The lead county contract specifies a new rate effective July 1, 2014 and DHS receives the notice of the rate change (DHS-2825) on August 1, The new per diem does not become effective for Title IV-E claims until September 1, EXAMPLE 3: The lead county contract specifies a new rate effective July 2, 2014 and DHS receives the notice of the rate change (DHS-2825) on or before July 30, The new per diem does not become effective for Title IV-E claims until August 1, o Notify DHS of Lead County Contract Renewal Lead county human service agencies must notify DHS if a new lead county contract has been negotiated, even when the per diem rate has not increased, or if an existing contract is extended. The Notice of Contracted Per Diem Rates, form DHS-2825, is to be used for this purpose. Minnesota Department of Human Services PO Box St. Paul, MN

9 Bulletin # June 5, 2014 Page 9 o Notify DHS of Closed Facilities County agencies are asked to submit written notification to DHS when a group facility or placing agency has closed or is in the process of closing including the date of closure. o Procedures for Out-of-State Facilities To keep accurate records of out-of-state facilities, DHS requests that the lead county submit the DHS-2825 (Attachment B) along with documentation identifying the facility as Title IV-E approved by its home state, and include a copy of the facility s current license(s) and program description. To keep the list of out-of-state facilities current, submit copies of all license renewals. If the license expires, the facility will be removed from the list. o Procedures for Out-of-State Facilities that Border Minnesota Counties that hold the lead county contract with a facility that is located in a state that borders Minnesota, and this facility has already been certified by the Minnesota Department of Corrections (MnDOC) as operating a program consistent with Minnesota children s residential mental health treatment standards, in compliance with Minnesota Statutes, section 256B.0945, should submit the DHS-2825 (Attachment B) along with a copy of the facility s current license(s), a copy of the MA certification document that includes the date of certification, and information on the facility and its programs. If this is a new program that has not previously been approved for Title IV-E reimbursement, the lead county must also submit documentation identifying the facility as Title IV-E approved by its home state. An updated form DHS-2825 and a current facility license will be required every year. The DHS Licensing Division maintains a list of DHS licensed children s residential facilities located in states that border Minnesota that have been inspected by DHS and certified by MnDOC. Facilities and programs that do not appear on this list are not eligible for MA reimbursement for Minnesota counties. o MA Reimbursement for Out-of-State Children s Mental Health Treatment Facilities Bordering Minnesota The criteria for Out-of-State Children s Mental Health Treatment Facilities that wish to participate in Minnesota s Mental Health Certified Facility quarterly time study and be included in Attachment A of the quarterly Per Diem Bulletin are as follows: 1) The out-of-state facility bordering Minnesota must become certified by the Minnesota Department of Corrections and licensed the Department of Human Services as an outof-state children s mental health treatment facility (Rule 5) and pay the $5, inspection fee. 2) The out-of-state facility bordering Minnesota must enroll as an MA provider for Minnesota clients and receive a UMPI number from the Department of Human Services Minnesota Department of Human Services PO Box St. Paul, MN

10 Bulletin # June 5, 2014 Page 10 or have an already established NPI number. (Each program per diem must have a separate UMPI number.) 3) The out-of-state facility bordering Minnesota must sign a lead county contract with a Minnesota county. 4) The out-of-state facility bordering Minnesota must agree to participate in Minnesota's Mental Health Certified group facility quarterly time study. 5) The lead county holding the contract with the out-of-state facility bordering Minnesota must submit paperwork to the Financial Operations Division at the Department of Human Services to have this facility added to the Mental Health Certified quarterly time study and the quarterly Per Diem Bulletin, per instructions in this bulletin. NOTE: Facilities will not be listed in the quarterly Per Diem Bulletin until all documentation is received by DHS and the program is approved for federal reimbursement. QUESTIONS Questions about submitting per diem rate changes or lead county contract renewals, adding a new facility, facility closing notifications, rule codes, sub codes, or other questions about Title IV-E claims should be directed to: Deb Jensen (651) ; or at deb.jensen@state.mn.us Questions about calculation of the approved percentages, or participation in a time study for child caring facilities should be directed to: Heide Moris (651) ; or at heide.moris@state.mn.us Questions about the process for inspection and certification of out-of-state facilities bordering Minnesota should be directed to: Tom Ruter (651) ; or at thomas.ruter@state.mn.us Send the required documentation to DHS using any of these methods: By U.S. mail: Deb Jensen Minnesota Dept. of Human Services Financial Operations Division PO Box St. Paul, MN Minnesota Department of Human Services PO Box St. Paul, MN

11 Bulletin # June 5, 2014 Page 11 Or By FAX: (651) Attn. Deb Jensen Or By ing PDF documents: Americans with Disabilities Act (ADA) Advisory This information is available in accessible formats for people with disabilities by calling (651) (voice), or toll free at (800) or by using your preferred relay service. For other information on disability rights and protections, contact the agency s ADA coordinator. Minnesota Department of Human Services PO Box St. Paul, MN

12 Page A1 ATTACHMENT A TITLE IV-E FACILITY REIMBURSEMENT LISTS Participating Facilities for Title IV-E Group Facilities Project Effective for Service Dates Beginning April 1, 2014 Group 1 - Children's Group Residential - Mental Health Certification Facility & Program Name County/City Rule DHS Lic # or IV-E Automation Number IV-E Sub Approved Per Diem Matenaince% Intake/Planning % Training% Approved MA% Current Contract or Current License Avanti Center for Girls-Evaluation (VOA) ANOKA B $ % 1.26% 0.00% 51.21% 01/01/ /31/2014 Avanti Center for Girls-Residential (VOA) ANOKA A $ % 1.23% 0.00% 50.64% 01/01/ /31/2014 Bar None - Stepping Stone SED & Evaluation (VOA) ANOKA A $ % 1.19% 0.00% 48.36% 01/01/ /31/2014 Bar None - Sunrise SED and Evaluation (VOA) ANOKA J $ % 1.12% 0.00% 45.56% 01/01/ /31/2014 Catholic Charities - Intensive OTTER TAIL $ % 1.46% 0.00% 56.64% 01/01/ /31/2014 Children's Home Society - Boys Unit (South Dakota) Southwest Healt A $ % 1.35% 0.00% 50.37% 07/01/ /30/2014 Children's Home Society - Madsen House (South Dakota) Southwest Healt B $ % 1.27% 0.00% 44.41% 07/01/ /30/2014 Children's Home Society - VanDemark House (South Dakota) Southwest Healt C $ % 1.46% 0.00% 40.25% 07/01/ /30/2014 Children's Residential Treatment Center (VOA) HENNEPIN $ % 1.28% 0.00% 49.69% 01/01/ /31/2015 Eau Claire Academy - Transitional Living Program (Wisconsin) RAMSEY C $ % 1.57% 0.00% 60.98% 07/01/ /30/2014 Eau Claire Academy - West Unit (STOP Program) (Wisconsin) RAMSEY B $ % 1.59% 0.00% 49.39% 07/01/ /30/2014 Eau Claire Academy Res. Treat./Assess (Wisconsin) RAMSEY A $ % 1.66% 0.00% 53.25% 07/01/ /30/2014 Elmore Academy - Horizons FARIBAULT B $ % 1.36% 0.00% 49.64% 01/01/ /31/2014 Gerard (Nexus) - Assessment MOWER B $ % 1.84% 0.00% 58.58% 01/01/ /31/2014 Gerard (Nexus) - Bridging Program MOWER D $ % 1.84% 0.00% 58.58% 01/01/ /31/2014 Gerard (Nexus) - Long Term Residential MOWER A $ % 1.85% 0.00% 58.15% 01/01/ /31/2014 Gerard (Nexus) - Short Term Residential MOWER E $ % 1.84% 0.00% 58.58% 01/01/ /31/2014 I.T.A.S.K.I.N. Center - Assessment/Evaluation (North Homes) ITASCA B $ % 1.43% 0.00% 54.66% 01/01/ /31/2014 I.T.A.S.K.I.N. Center - Treatment (North Homes) ITASCA C $ % 1.43% 0.00% 54.51% 01/01/ /31/2014 Leo A. Hoffmann Center - Evaluation NICOLLET C $ % 1.53% 0.00% 59.64% 01/01/ /31/2014 Leo A. Hoffmann Center - Main NICOLLET D $ % 1.53% 0.00% 59.53% 01/01/ /31/2014 Leo A. Hoffmann Center - North Cottage - Low Functioning NICOLLET B $ % 1.53% 0.00% 59.64% 01/01/ /31/2014 Mille Lacs Academy - Mental Health Treatment MILLE LACS A $ % 1.19% 0.00% 46.99% 01/01/ /31/2014 Mille Lacs Academy - The Cornerstone Safari MILLE LACS J $ % 1.43% 0.00% 56.97% 01/01/ /31/2014 Milwaukee Academy - Residential Treatment (Wisconsin) RAMSEY A $ % 1.52% 0.00% 44.90% 07/01/ /30/2014 North Homes, Inc. - Cottage Treatment ITASCA A $ % 1.27% 0.00% 48.42% 01/01/ /31/2014 Northwood Children's - Diagnostic & Assessment ST. LOUIS $ % 1.39% 0.00% 68.95% 01/01/ /31/2014 Northwood Children's Home - Main ST. LOUIS $ % 1.28% 0.00% 45.36% 01/01/ /31/2014 Northwood Children's Home - West ST. LOUIS $ % 1.28% 0.00% 45.36% 01/01/ /31/2014 Omegon, Inc. HENNEPIN A $ % 1.27% 0.00% 49.56% 01/01/ /31/2017 Pathfinders Children's Treat Ctr - Mental Health (Sanford) PENNINGTON B $ % 1.17% 0.00% 44.41% 01/01/ /31/2014 St. Cloud Children's Home (Catholic Charities) STEARNS A $ % 1.43% 0.00% 59.40% 01/01/ /30/2014 St. Cloud Children's Home - Evaluation (Cath. Char.) STEARNS B $ % 1.42% 0.00% 71.06% 01/01/ /30/2014 St. Cloud Children's Home - Secure Unit (Catholic Charities) STEARNS C $ % 1.59% 0.00% 63.67% 01/01/ /30/2014 St. Joseph's Home for Children-Residential Treatment Ctr. HENNEPIN B $ % 1.39% 0.00% 56.03% 01/01/ /31/2015 Summit Oaks I (South Dakota) Southwest Healt A $ % 1.43% 0.00% 34.06% 01/01/ /31/2016 Summit Oaks II (South Dakota) Southwest Healt B $ % 1.62% 0.00% 36.84% 01/01/ /31/2016 Woodland Hills - Residential Treatment Mental Health ST. LOUIS K $ % 1.19% 0.00% 49.44% 01/01/ /31/2014

13 Page A2 Group 1 - Group Residential ATTACHMENT A TITLE IV-E FACILITY REIMBURSEMENT LISTS Participating Facilities for Title IV-E Group Facilities Project Effective for Service Dates Beginning April 1, 2014 Facility & Program Name County/City Rule DHS Lic # or IV-E Automation Number IV-E Sub Approved Per Diem Matenaince% Intake/Planning% Training% Approved MA% Current Contract or Current License Adolescent Treatment Center of Winnebago - Treatment FARIBAULT F $ % 6.06% 0.00% 0.00% 01/01/ /31/2014 Ain Dah Yung Center RAMSEY $ % 9.95% 0.00% 0.00% 01/01/ /31/2014 Arlington House Shelter Larpenter RAMSEY S $ % 7.91% 0.00% 0.00% 01/01/ /31/2014 Arlington House Shelter Larpenter RAMSEY S $ % 7.91% 0.00% 0.00% 01/01/ /31/2014 Avanti Center for Girls - Shelter (VOA) ANOKA S $ % 6.28% 0.00% 0.00% 01/01/ /31/2014 Bethany Crisis Shelter (LSS) ST. LOUIS A $ % 10.30% 0.00% 0.00% 01/01/ /31/2014 Bethany Crisis Shelter - 25 Day Evaluation (LSS) ST. LOUIS B $ % 10.30% 0.00% 0.00% 01/01/ /31/2014 Carlton Youth Shelter (LSS) CARLTON $ % 10.68% 0.00% 0.00% 01/01/ /31/2014 Crisis Stabilization - Youth Shelter (Woodland Center) KANDIYOHI S $ % 8.56% 0.00% 0.00% 01/01/ /31/2014 Evergreen Shelter - 35 Day Evaluation BELTRAMI C $ % 7.45% 0.00% 0.00% 01/01/ /31/2014 Evergreen Shelter - Crisis (14 Day) BELTRAMI A $ % 7.45% 0.00% 0.00% 01/01/ /31/2014 Evergreen Shelter - Short Term Crisis (Over 21 Days) BELTRAMI B $ % 7.55% 0.00% 0.00% 01/01/ /31/2014 Family Resource Ctr - (Bethany) Range Youth Shelter (LSS) ST. LOUIS A $ % 10.35% 0.00% 0.00% 01/01/ /31/2014 Franklin House - Regular (McLeod Treatment) MCLEOD B $ % 10.76% 0.00% 0.00% 01/01/ /31/2014 Harbor Shelter East-Hastings (Stivland,Inc) DAKOTA S $ % 8.96% 0.00% 0.00% 01/01/ /31/2015 Healing Spirit Girls Group Home HENNEPIN A $ % 9.82% 0.00% 0.00% 01/01/ /31/2015 Little Sand Group Home - Lakeside CASS $ % 3.08% 0.00% 0.00% 01/01/ /31/2014 Little Sand Group Home - West CASS $ % 3.08% 0.00% 0.00% 01/01/ /31/2014 Livingston House (Progressive Individual) RAMSEY $ % 5.78% 0.00% 0.00% 01/01/ /31/2014 Mapletree Group Home ANOKA $ % 8.51% 0.00% 0.00% 01/01/ /31/2014 Pathfinders Children's Treat Ctr - Residential (Sanford) PENNINGTON A $ % 7.98% 0.00% 0.00% 01/01/ /31/2014 Shelter Care (Greater Minnesota) KANDIYOHI $ % 3.53% 0.00% 0.00% 07/01/ /30/2014 Shelter Care for Kids HENNEPIN $ % 9.86% 0.00% 0.00% 07/01/ /30/2015 Sheppard House - Regular (McLeod Treatment) MCLEOD B $ % 10.76% 0.00% 0.00% 01/01/ /31/2014 St. Joseph's Home for Children-Main Shelter HENNEPIN S $ % 8.72% 0.00% 0.00% 01/01/ /31/2015 The Vintage Place - Cottage Ave RAMSEY $ % 2.40% 0.00% 0.00% 01/01/ /31/2014 The Vintage Place - Ivy Ave RAMSEY B $ % 2.40% 0.00% 0.00% 01/01/ /31/2014

14 Page A3 Group 1 - Other Facilities ATTACHMENT A TITLE IV-E FACILITY REIMBURSEMENT LISTS Participating Facilities for Title IV-E Group Facilities Project Effective for Service Dates Beginning April 1, 2014 Facility & Program Name County/City Rule DHS Lic # or IV-E Automation Number IV-E Sub Approved Per Diem Matenaince% Intake/Planning% Training% Approved MA% Current Contract or Current License Anoka County Juvenile Center ANOKA CP $ % 10.36% 0.00% 0.00% 01/01/ /31/2014 Bar None - Evaluation Shelter (VOA) ANOKA CP I $ % 8.73% 0.00% 0.00% 01/01/ /31/2014 Bar None - Evergreen (VOA) ANOKA CP F $ % 8.12% 0.00% 0.00% 01/01/ /31/2014 Bar None - Male Stabilization Unit (VOA) ANOKA CP S $ % 8.57% 0.00% 0.00% 01/01/ /31/2014 Elmore Academy FARIBAULT CP A $ % 9.82% 0.00% 0.00% 01/01/ /31/2014 Hayward Group Home (180 Degrees Inc) FREEBORN CP A $ % 10.31% 0.00% 0.00% 01/01/ /31/2014 Heartland Girls Ranch SWIFT CP A $ % 10.09% 0.00% 0.00% 01/01/ /31/2014 Heartland Girls Ranch - Strides SWIFT CP $ % 8.65% 0.00% 0.00% 01/01/ /31/2014 I.T.A.S.K.I.N - Shelter (North Homes) ITASCA CP E $ % 9.70% 0.00% 0.00% 01/01/ /31/2014 Mesabi Academy - Fire Setter Diagnostic & Residential ST. LOUIS CP A $ % 9.82% 0.00% 0.00% 01/01/ /31/2014 Mesabi Academy KidsPeace - Chemical Dependency ST. LOUIS CP D $ % 10.28% 0.00% 0.00% 01/01/ /31/2014 Mesabi Academy KidsPeace - Diagnostic Residential ST. LOUIS CP H $ % 9.82% 0.00% 0.00% 01/01/ /31/2014 Mesabi Academy KidsPeace - Open ST. LOUIS CP G $ % 9.95% 0.00% 0.00% 01/01/ /31/2014 Mesabi Academy KidsPeace - Sexual Issues (Non-Secure) ST. LOUIS CP I $ % 9.75% 0.00% 0.00% 01/01/ /31/2014 Mesabi Academy KidsPeace - Specialized Residential ST. LOUIS CP K $ % 10.53% 0.00% 0.00% 01/01/ /31/2014 Mille Lacs Academy - New Trails Group Home MILLE LACS CP $ % 10.05% 0.00% 0.00% 01/01/ /31/2014 North Homes Inc. - Next Step (Boys) ITASCA CP $ % 11.32% 0.00% 0.00% 01/01/ /31/2014 North Homes, Inc. - Boys Program ITASCA CP A $ % 11.32% 0.00% 0.00% 01/01/ /31/2014 North Homes, Inc. - Girls Program (Bemidji) ITASCA CP $ % 11.32% 0.00% 0.00% 01/01/ /31/2014 North Homes, Inc. - Girls Teens In Transition (Bemidji) ITASCA CP $ % 11.32% 0.00% 0.00% 01/01/ /31/2014 North Homes, Inc. - Teens in Transition (Boys) ITASCA CP B $ % 11.32% 0.00% 0.00% 01/01/ /31/2014 Northwestern MN Juv Ctr - Primary Residential (Non-Secure) BELTRAMI CP G $ % 8.66% 0.00% 0.00% 01/01/ /31/2014 Northwestern MN Juvenile Center - Consequence BELTRAMI CP J $ % 6.51% 0.00% 0.00% 01/01/ /31/2014 Northwestern MN Juvenile Center - Evaluation BELTRAMI CP H $ % 6.51% 0.00% 0.00% 01/01/ /31/2014 Port Boy's Group Homes (Port of Crow Wing) CROW WING CP G $ % 4.68% 0.00% 0.00% 01/01/ /31/2014 Port Girl's Group Home (Port of Crow Wing) CROW WING CP A $ % 4.68% 0.00% 0.00% 01/01/ /31/2014 Prairie Lakes Youth Programs - Alternative KANDIYOHI CP $ % 10.47% 0.00% 0.00% 01/01/ /31/2014 Prairie Lakes Youth Programs - Boys Home KANDIYOHI CP $ % 11.58% 0.00% 0.00% 01/01/ /31/2014 Prairie Lakes Youth Programs - Girls Home KANDIYOHI CP $ % 11.58% 0.00% 0.00% 01/01/ /31/2014 Red River Valley Juvenile Center - 90 Day (Non-Secure) POLK CP I $ % 9.82% 0.00% 0.00% 01/01/ /31/2014 Red River Valley Juvenile Center - Shelter POLK CP G $ % 9.82% 0.00% 0.00% 01/01/ /31/2014 Red River Valley Juvenile Center - Short Term (Non-Secure) POLK CP H $ % 9.82% 0.00% 0.00% 01/01/ /31/2014 Scott County Juvenile Alternative Facility-30 Day Evaluation SCOTT CP B $ % 11.69% 0.00% 0.00% 07/01/ /30/2014 Scott County Juvenile Alternative Facility-Non Secure SCOTT CP A $ % 11.69% 0.00% 0.00% 07/01/ /30/2014 Southwestern Youth Services Southwest Healt CP $ % 14.28% 0.00% 0.00% 01/01/ /31/2014 St Cloud Group Home (180 Degrees Inc) STEARNS CP $ % 10.31% 0.00% 0.00% 01/01/ /31/2014 Steps of Success - Andover ANOKA CP $ % 4.49% 0.00% 0.00% 01/01/ /31/2014 Valley Lake Boys Home WILKIN CP A $ % 8.32% 0.00% 0.00% 01/01/ /31/2014 Village Ranch - Tier I WRIGHT CP J $ % 9.26% 0.00% 0.00% 01/01/ /31/2014 Village Ranch - Tier II WRIGHT CP K $ % 8.63% 0.00% 0.00% 01/01/ /31/2014 Village Ranch - Tier III WRIGHT CP A $ % 9.65% 0.00% 0.00% 01/01/ /31/2014 Von Wald Group Home (180 Degrees Inc) OLMSTED CP $ % 10.31% 0.00% 0.00% 01/01/ /31/2014 West Central Regional Juvenile Center - Consequence CLAY CP G $ % 10.94% 0.00% 0.00% 01/01/ /31/2014 West Central Regional Juvenile Center - Evaluation CLAY CP H $ % 10.76% 0.00% 0.00% 01/01/ /31/2014 West Central Regional Juvenile Center - Pathways CLAY CP D $ % 10.76% 0.00% 0.00% 01/01/ /31/2014 West Central Regional Juvenile Center - Shelter CLAY CP I $ % 10.94% 0.00% 0.00% 01/01/ /31/2014 Woodland Hills - Chisolm House - Short Term ST. LOUIS CP I $ % 10.11% 0.00% 0.00% 01/01/ /31/2014 Woodland Hills - Residential Treatment ST. LOUIS CP G $ % 10.47% 0.00% 0.00% 01/01/ /31/2014 Woodland Hills - Transition ST. LOUIS CP J $ % 10.13% 0.00% 0.00% 01/01/ /31/2014

15 Page A4 Group 2 - New Facilities ATTACHMENT A TITLE IV-E FACILITY REIMBURSEMENT LISTS Participating Facilities for Title IV-E Group Facilities Project Effective for Service Dates Beginning April 1, 2014 Facility & Program Name County/City Rule DHS Lic # or IV-E Automation Number IV-E Sub Approved Per Diem Matenaince% Intake/Planning % Training% Approved MA% Current Contract or Current License Gerard (Nexus) - Shelter MOWER C $ % 9.82% 0.00% 0.00% 01/01/ /31/2014 Mesabi Academy KidsPeace - Fire Setter Evaluation ST. LOUIS CP B $ % 9.82% 0.00% 0.00% 01/01/ /31/2014

16 Group 2 - Out of State Facilities ATTACHMENT A TITLE IV-E FACILITY REIMBURSEMENT LISTS Participating Facilities for Title IV-E Group Facilities Project Effective for Service Dates Beginning April 1, 2014 Facility & Program Name County/City Rule DHS Lic # or IV-E Automation Number IV-E Sub Approved Per Diem Matenaince% Intake/Planning% Training% Approved MA% Current Contract or Current License Chileda Institute, Inc. (Hennepin) La Crosse, WI OSF OSF1002 $ % 9.82% 0.00% 0.00% 07/01/ /30/2016 Clarinda Academy Residential (Ramsey) Clarinda, IA OSF OSF1003 A $ % 9.82% 0.00% 0.00% 07/01/ /30/2018 Clarinda Academy Treatment (Ramsey) Clarinda, IA OSF OSF1003 B $ % 9.82% 0.00% 0.00% 07/01/ /30/2018 Forest Ridge Youth Services-Anita College Trans Liv (Ramsey) Estherville, IA OSF OSF1006 C $ % 9.82% 0.00% 0.00% 07/01/ /30/2014 Forest Ridge Youth Services-Residential Treatment (Ramsey) Estherville, IA OSF OSF1006 A $ % 9.82% 0.00% 0.00% 07/01/ /30/2014 Forest Ridge Youth Services-Shelter (Ramsey) Estherville, IA OSF OSF1006 B $ % 9.82% 0.00% 0.00% 07/01/ /30/2014 Glen Mills School-Residential (Ramsey) Concordville, PA OSF OSF1008 A $ % 9.82% 0.00% 0.00% 07/01/ /30/2014 Homme Programs-Journey/Alliance (Hennepin) Wittenberg, WI OSF OSF1010 C $ % 9.82% 0.00% 0.00% 07/01/ /30/2016 Homme Programs-Journey/Quest (Hennepin) Wittenberg, WI OSF OSF1010 D $ % 9.82% 0.00% 0.00% 07/01/ /30/2016 Homme Programs-Regular (Hennepin) Wittenberg, WI OSF OSF1010 A $ % 9.82% 0.00% 0.00% 07/01/ /30/2016 Indiana Developmental Training Ctr. - Intensive (Ramsey) Lafayette, IN OSF OSF1011 B $ % 9.82% 0.00% 0.00% 01/01/ /30/2014 Indiana Developmental Training Ctr. - Regular (Ramsey) Lafayette, IN OSF OSF1011 A $ % 9.82% 0.00% 0.00% 01/01/ /30/2014 McCrossan Boy's Ranch-Residential (Ramsey) Sioux Falls, SD OSF OSF1014 $ % 9.82% 0.00% 0.00% 07/01/ /30/2014 Mingus Mountain Academy-Level I Residential (Ramsey) Prescott Valley, AZ OSF OSF1015 A $ % 9.82% 0.00% 0.00% 07/01/ /30/2018 Mingus Mountain Academy-Level II Beh. Health Res. (Ramsey) Prescott Valley, AZ OSF OSF1015 B $ % 9.82% 0.00% 0.00% 07/01/ /30/2018 Northwest Passage - Behavior Stabilization (Ramsey) Frederic, WI OSF OSF1032 D $ % 9.82% 0.00% 0.00% 10/01/ /30/2015 Northwest Passage - CAC 30 Day Assessment (Ramsey) Frederic, WI OSF OSF1032 E $ % 9.82% 0.00% 0.00% 10/01/ /30/2015 Northwest Passage I - Boys (Ramsey) Webster, WI OSF OSF1032 A $ % 9.82% 0.00% 0.00% 10/01/ /30/2015 Northwest Passage II - Boys 90 Day (Ramsey) Spooner, WI OSF OSF1032 B $ % 9.82% 0.00% 0.00% 10/01/ /30/2015 Northwest Passage III - Girls (Ramsey) Frederic, WI OSF OSF1032 C $ % 9.82% 0.00% 0.00% 10/01/ /30/2015 Woodward Academy-Community Residential Program (Ramsey) Woodward, IA OSF OSF1021 B $ % 9.82% 0.00% 0.00% 07/01/ /30/2018 Woodward Academy-Highly Structured Program (Ramsey) Woodward, IA OSF OSF1021 A $ % 9.82% 0.00% 0.00% 07/01/ /30/2018 Woodward Academy-Sex Offender Treatment (Ramsey) Woodward, IA OSF OSF1021 C $ % 9.82% 0.00% 0.00% 07/01/ /30/2018 Page A5

17 Page A6 Group 4 - Rule 4 - Child Placing Agencies ATTACHMENT A TITLE IV-E FACILITY REIMBURSEMENT LISTS Participating Facilities for Title IV-E Group Facilities Project Effective for Service Dates Beginning April 1, 2014 Facility & Program Name County/City Rule DHS Lic # or IV- E Automation Number IV-E Sub Approved Per Diem Matenaince% Intake/Planning % Training% Approved MA% Current Contract or Current License 180 Degrees - Professional Family Foster Home - Standard FREEBORN B $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 American Indian Fam. & Children's Svcs-Emergency Shelter RAMSEY D $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 American Indian Fam. & Children's Svcs-Standard RAMSEY A $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 Anu Family Services Inc. - Exceptional Treatment Foster Care OLMSTED A $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 Anu Family Services Inc. - Foster Care (Non-Treatment) OLMSTED B $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 Anu Family Services Inc. - Treatment Foster Care OLMSTED C $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 Family Alternatives - Intensive HENNEPIN C $ % 73.18% 2.20% 0.00% 07/01/ /30/2015 Family Alternatives - Treatment HENNEPIN B $ % 73.18% 2.20% 0.00% 07/01/ /30/2015 Family and Children's Center WINONA A $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 Family Focus - Alternative to Residential MOWER A $ % 73.18% 2.20% 0.00% 07/01/ /30/2014 Family Focus - Emergency Foster Care MOWER E $ % 73.18% 2.20% 0.00% 07/01/ /30/2014 Family Focus - Short Term Foster Care MOWER D $ % 73.18% 2.20% 0.00% 07/01/ /30/2014 Family Focus - Specialized Foster Care MOWER F $ % 73.18% 2.20% 0.00% 07/01/ /30/2014 Family Focus - Therapeutic Foster Care MOWER C $ % 73.18% 2.20% 0.00% 07/01/ /30/2014 Family Focus - Whole Family Placement - County MOWER G $ % 73.18% 2.20% 0.00% 07/01/ /30/2014 Family Focus - Whole Family Placement - Parent MOWER H $ % 73.18% 2.20% 0.00% 07/01/ /30/2014 Fond Du Lac - On Reservation - Emergency CARLTON 4 TR0006 A $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 Fond Du Lac - On Reservation - Standard CARLTON 4 TR0006 B $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 Fond Du Lac Licensing and Placement ST. LOUIS A $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 Kindred Family Services - Alternative to Residential MOWER C $ % 73.18% 2.20% 0.00% 07/01/ /30/2014 Kindred Family Services - Emergency Foster Care MOWER E $ % 73.18% 2.20% 0.00% 07/01/ /30/2014 Kindred Family Services - Short Term Foster Care MOWER D $ % 73.18% 2.20% 0.00% 07/01/ /30/2014 Kindred Family Services - Specialized Foster Care MOWER G $ % 73.18% 2.20% 0.00% 07/01/ /30/2014 Kindred Family Services - Therapeutic Foster Care MOWER F $ % 73.18% 2.20% 0.00% 07/01/ /30/2014 Kindred Family Services - Whole Family Placement - County MOWER H $ % 73.18% 2.20% 0.00% 07/01/ /30/2014 Kindred Family Services - Whole Family Placement - Parent MOWER J $ % 73.18% 2.20% 0.00% 07/01/ /30/2014 LSS Bethany Foster Care ST. LOUIS I $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 LSS Family & Behavioral Health Services (Moorhead) Standard CLAY A $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 LSS Therapeutic Foster Care (Mankato) - Intensive NICOLLET E $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 LSS Therapeutic Foster Care (Mankato) - Standard NICOLLET C $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 LSS Therapeutic Foster Care (Willmar) - Standard KANDIYOHI G $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 LSS Treatment Foster Care (Brainerd) - Standard BENTON K $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 LSS Treatment Foster Care (Metro) - Standard CLAY L $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 LSS Treatment Foster Care (St. Cloud) - Standard BENTON J $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 Mille Lacs Band-Foster Care Program PINE 4 TR0007 A $ % 73.18% 2.20% 0.00% 07/01/ /30/2015 Mille Lacs Band-Independent Living Program PINE 4 TR0007 B $ % 73.18% 2.20% 0.00% 07/01/ /30/2015 North Homes Inc. - Emergency Crisis Shelter Care ITASCA F $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 North Homes Inc. - Medical Fragile ITASCA G $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 North Homes Inc. - Special Foster Treatment ITASCA D $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 North Homes Inc. - Standard ITASCA A $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 North Homes Inc. - Treatment Foster Care ITASCA B $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 Northwood Children's Services -Therapeutic Foster Care ST. LOUIS A $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 PATH Inc. - Intensive Treatment Foster Care FARIBAULT-MARTI A $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 PATH Inc. - Short Term Foster Care FARIBAULT-MARTI B $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 PATH Inc. - Standard FARIBAULT-MARTI C $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 PATH Inc. - Whole Family Placement - County FARIBAULT-MARTI D $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 PATH Inc. - Whole Family Placement - Parent FARIBAULT-MARTI E $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 Pinehaven Youth & Family Services - Professional CROW WING A $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 Pinehaven Youth & Family Services - Specialized CROW WING B $ % 73.18% 2.20% 0.00% 01/01/ /31/2014

18 Page A6 Group 4 - Rule 4 - Child Placing Agencies ATTACHMENT A TITLE IV-E FACILITY REIMBURSEMENT LISTS Participating Facilities for Title IV-E Group Facilities Project Effective for Service Dates Beginning April 1, 2014 Facility & Program Name County/City Rule DHS Lic # or IV- E Automation Number IV-E Sub Approved Per Diem Matenaince% Intake/Planning % Training% Approved MA% Current Contract or Current License Pinehaven Youth & Family Services - Treatment CROW WING C $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 Pinehaven Youth & Family Svcs - Corporate Foster Care CROW WING D $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 St David's - Multidimensional Treatment Foster Care HENNEPIN C $ % 73.18% 2.20% 0.00% 01/01/ /30/2016 St. David's Child Dev. & Fam. Svcs-Intensive Fost. Care HENNEPIN B $ % 73.18% 2.20% 0.00% 07/01/ /30/2015 St. David's Child Dev. & Fam. Svcs-Treat. Foster Care HENNEPIN A $ % 73.18% 2.20% 0.00% 07/01/ /30/2015 TSA Inc. - Adolescent Treatment PINE C $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 TSA Inc. - Child Treatment Program PINE H $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 TSA Inc. - Full Family Foster Care PINE J $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 TSA Inc. - Shelter PINE G $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 TSA Inc. - Standard Foster Care PINE I $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 TSA Inc. - Support Network PINE E $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 TSA Inc. - Teen Mom PINE D $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 Upper Midwest American Indian Center - Standard HENNEPIN $ % 73.18% 2.20% 0.00% 07/01/ /30/2015 Village Ranch Child & Family Svcs - Intensive Foster Care WRIGHT C $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 Village Ranch Child & Family Svcs - Moderate Foster Care WRIGHT B $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 Village Ranch Child & Family Svcs - Supportive Foster Care WRIGHT A $ % 73.18% 2.20% 0.00% 01/01/ /31/2014 VOA - Multidimensional Treatment Foster Care HENNEPIN G $ % 73.18% 2.20% 0.00% 01/01/ /30/2016 Volunteers of America - Intensive HENNEPIN C $ % 73.18% 2.20% 0.00% 07/01/ /30/2015 Volunteers of America - Treatment HENNEPIN B $ % 73.18% 2.20% 0.00% 07/01/ /30/2015

19 ATTACHMENT B FORM DHS NOTICE OF CONTRACTED PER DIEM RATES For Title IV-E and MA Approved Children's Group Residential Facilities (GRF) and Title IV-E Approved Rule 4 Child Foster Care Placing Agencies New Contract Renew Contract 1. Agency Name New Facility (as indicated on the Per Diem Bulletin) New Program Bordering State MA Yes No 2. Lead County Type of license (Rule) * A copy of the facility's license, Attachment C and program description of services must be attached to this document. Other * If applying for bordering state MA, a copy of the DOC certification document NPI or UMPI # must also be attached. GRF Per Diem: Program (as indicated on the Per Diem Bulletin) Other (specify) Other (specify) Other (specify) Rule 4 Standard Administrative Fee (as indicated on the Per Diem Bulletin) Other (specify) Other (specify) Other (specify) Please answer each of the following: 3. Old Per Diem Rates 4. New Per Diem Rates 5. Contract Dates : ( from ) (to) REQUIREMENTS: * Signature by Lead County Director or other authorized official. * Per diem must be effective on first of day of quarter. Effective dates other than the first day of the quarter will not be recognized for Title IV-E reimbursement purposes until the following quarter. * Received by DHS Financial Operations on timely basis for Title IV-E Purposes. All DHS-2825 forms must be received no later than 30 days into the quarter. PURPOSE: * Provide per diem information when new lead county contract is negotiated. * Provide per diem information when new contract is signed even if per diem has not changed. * Provide per diem information when contracting parties agree to extend existing contracts beyond the end of existing contract period. Please mail or fax this form to: Minnesota Department of Human Services Financial Operations Division P.O. Box St. Paul, MN FAX: (651) Attention: Deb Jensen DHS USE ONLY License Group Rule Director's Signature Prepared by Phone DHS FINANCIAL OPERATIONS DIVISION (9/2012)

20 ATTACHMENT C FORM DHS TITLE IV-E CHECKLIST (Not required for Rule 4 Child Placing Agencies) Facility Name: Address: City: State: Zip : Directors Name: Phone Number: County: County Submitting Request: Prepared By: Phone Number: IN-STATE facilities and/or programs Please complete this form and submit to DHS the form DHS-2825, this checklist, a copy of the current license, and promotional material, for consideration and approval. OUT-OF-STATE facilities and/or programs Please complete the top portion of this form. There is no need to complete the questions listed below. Please submit to DHS the documentation of Title IV-E eligibility from the host state, promotional material, a current license and form DHS-2825, for consideration and approval. I. If the facility and/or program provides 24 hour out-of-home care of children, Is the facility and/or program: YES NO 1. in a foster family home or family group home? 2. in a private, non-medical group home or residential care facility? 3. in a public, non-medical group home or residential care facility that has a licensed capacity of 25 or fewer children? 4. an independent living assistance for youth? If all answers for section I (1) through (4) are NO, the facility and/or program is not Title IV-E eligible. If YES is checked for any of (1) through (4) above, please continue to section II. II. Is the facility and/or program licensed: YES NO 1. by Department of Human Services? 2. by Department of Corrections? 3. or approved by Tribal government? If all answers for section II (1) through (3) are NO, the facility and/or program is not Title IV-E eligible. If YES is checked for any of (1) through (3) above, please continue to section III. III. Is the facility and/or program: YES NO 1. in a medical facility licensed by the Department of Health? 2. in a primarily secure, physically restricting detention facility licensed by the Department of Corrections? If the answer to section III (1) or (2) is YES, the facility and/or program is not Title IV-E eligible. If all of the answers are NO in section III, please submit this form and the required documentation to DHS for consideration and approval. DHS FINANCIAL OPERATIONS DIVISION (11/12)