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Template for Transition - Initial Plan

County Name: Consortia Name:
Estimated Transition Start Date (County fills in Start Date) Start Date: Oct-08 Current Waiver and Wait List Individuals (County fills in actual current waiver and wait list enrollment) Current Waiver COR CIP 1B CIP 1A BIW CIP II COP W CLTS People Wait List FE PD DD People Data Run-date:

Enrollment Plan (Consortium/County/ADRC consult with MCO to establish enrollment targets) Waivers DHFS expects rollovers to be completed in first six months Month Month 1 2 COR CIP 1B CIP 1A BIW CIP 11 COP W CLTS Subtotal Rollovers -

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Waitlist DHS allows 1/36 of wait list number to be enrolled in each of the first 36 months Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Month 13 Month 14 Month 15 Month 16 Month 17 Month 18 Month 19 Month 20 Month 21 Month 22 Month 23 Month 24 Month 25 Month 26 Month 27 Month 28 Month 29 Month 30 Month 31 Month 32 Month 33 Month 34 Month 35 Month 36 -

FE PD DD Subtotal Wait List

Institutional Relocations Individuals relocating from nursing homes and ICFs-MR may enroll immediately in managed long-term care. These individuals may skip the wait list. Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Month 13 Month 14 Month 15 Month 16 Month 17 Month 18 Month 19 Month 20 Month 21 Month 22 Month 23 Month 24 Month 25 Month 26 Month 27 Month 28 Month 29 Month 30 Month 31 Month 32 Month 33 Month 34 Month 35 Month 36 -

Nursing Home Relocations ICF-MR Relocations State Center Relocations Subtotal Relocations

Total Enrollment Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Month 13 Month 14 Month 15 Month 16 Month 17 Month 18 Month 19 Month 20 Month 21 Month 22 Month 23 Month 24 Month 25 Month 26 Month 27 Month 28 Month 29 Month 30 Month 31 Month 32 Month 33 Month 34 Month 35 Month 36 -

Revised: 4/21/09, R. Hotynski (revised to auto-populate waitlist from over 24 mos to over 36 mos)