Expanded Service Payments for the Elderly and Disabled Eligibility (ExSPED) 525-05-25-25

(Revised 2/1/22 ML #3663)

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Eligibility for the Expanded SPED Program has two components: financial/Medicaid eligibility and functional eligibility. The applicant/individual must meet BOTH eligibility components before payment can be made by the Department under this Chapter.

1. Functional Eligibility, ExSPED Program

1. Is at least 65 years of age, OR is at least 18 years of age and disabled or blind based on Social Security criteria. N.D.C.C. 50-24.7-01(5)(b);  
2. Is not severely impaired in ANY of the three activities of daily living (ADLs): Toileting, Transferring to or from a bed, chair or toilet, or Eating as determined by completion of an comprehensive assessment.
3. Is impaired in at least three (3) of the following four (4) instrumental activities of daily living (IADLs): Meal Preparation, Housework, Laundry, or Taking Medicine based on completion of a comprehensive assessment. The impairments must have lasted or are expected to last, more than three (3) months.  

(Note: Or has health, welfare, or safety needs, including a need for supervision or a structured environment, which otherwise require care in a licensed adult family foster home or a licensed basic care facility. (The services of the Expanded SPED Program are provided in the recipient’s home or community instead of care in a basic care facility.)  

4. Capable of directing own care or has a legal representative to act in their behalf.
5. Living in what is commonly considered a private family dwelling (house, apartment, or camper if the camper is located in a long term campground that rents by the month/year etc.). The renter’s living area should consist of a bedroom with or without bath and possibly a sitting area. Congregate/group meals may be available or meals may be eaten off site.  For unique circumstances, contact the HCBS Program Administrator for consideration.
6. The applicant impairment is not the result of a intellectual disability or a closely related condition.
7. Service/care need is within the scope of services available under this chapter;

2. Financial Eligibility for ExSPED

1. The first step is to have a determination of Medicaid eligibility by the Economic Assistance Unit, as an applicant must be receiving Medical Assistance in order to be eligible for ExSPED.

In addition to being eligible for Medical Assistance, the applicant must be receiving Supplemental Security Income (SSI) OR, if not, their income cannot exceed an amount equal to SSI. [N.D.A.C. 75-02-10-05(4)]. Please note that the following income is disregarded:

Recovery Rebates authorized by section 2201 of the Coronavirus Aid, Relief, and Economic Security Act of 2020 [Pub. L. 116-136].

2. Estate Recovery

Legislation passed during the 1995 session gives the Department the authority to file a claim against an individual's estate to recover payments made under the Expanded SPED Program. The Department can file a claim for all payments made since the inception of the Program in 1994.

3. Overpayment

If an individual or legal representative provides inaccurate or false information about finances, health status, and/or the ability to complete functional tasks, the Department has the authority to recoup funds. The recoupment may be for payments for services that were provided when the individual was not eligible. An overpayment may be collected from any person that benefitted from or was responsible for the overpayment. A statute of limitations or similar statute does not apply.

4. Ongoing Medicaid Eligibility

Because Medicaid eligibility is part of the financial eligibility for ExSPED, the individual’s Medicaid status will need to be verified periodically. The HCBS Case Manager should verify in MMIS that the individual continues to have an active Medicaid case as part of the regularly scheduled quarterly contacts and home assessments.

3. Expanded SPED Pool

Upon finding the applicant meets the criteria for the Expanded SPED Program through the completion of the comprehensive assessment and verification from the Eligibility worker, forward the following to the HCBS Program Administration:

• Expanded SPED Pool Program Data form SFN 56
• Add New Record to MMIS Eligibility File (Expanded SPED) SFN 676

Services must not be authorized until the HCBS Case Manager is notified the applicant was successfully removed from the ExSPED Pool. HCBS Program Administration will notify the HCBS Case Manager of the decision by forwarding a copy of the SFN 676 with the ExSPED identification number and start date recorded on the form.

Documents with discrepancies, incompleteness, or apparent ineligibility will not be entered into the ExSPED Pool and will be either returned to the HCBS Case Manager.

When HCBS Program Administration forwards the applicant’s identification number and start date to the HCBS Case Manager, the HCBS Case Manager can complete the process for implementing services.

If a new or current recipient of services has not utilized services within a 30-day period of time, a citation to terminate the case may be requested from the Program Administrator (if appropriate) and an SFN 474 sent to Aging Services if the case is to be closed.

If the individual has not received services because a provider has not been secured, and the individual is still eligible and wants to continue pursuing a provider, the case must remain open. The case manager must make a quarterly contact with the individual. If the individual will incur a case management fee, they must be informed of this. The case manager is required to continue attempts in securing a provider. In doing so, they may need to staff the situation with Aging Services administrators and/or discuss strategies with the individual such as publishing an advertisement for service providers, etc.

If the services are expected to start or resume within 3 months, it is allowable for the case to remain open. This does not require approval from a Program Administrator. The purpose of this exception is to allow eligible individuals to resume services without having to complete the application process again.

• The reason for delay or pause in services must be documented in the individual’s file.
• The case manager must document how the need is met while the identified service needs are pending.
• The case manager must follow up monthly with the individual to provide support and assistance mitigating the issue causing the delay in service implementation.
• If the services do not resume or start within 3 months, approval must be received from the Program Administrator to keep the case open OR the case manager must request a termination to close the case and submit an SFN 474 to Aging Services/HCBS.

If a current recipient enters a skilled nursing facility or swingbed, and it is anticipated that the length of stay will be 3 months or less, it is allowable for the case to remain open. This does not require approval from a Program Administrator.

• The case manager must document the admission to the facility.
• The case manager must follow up monthly with the individual and collaborate with the nursing facility/discharge planning team to ensure appropriate services are secured for their return to the community.
• If the services do not resume within 3 months and approval has not been received, the case manager must terminate the case due to institutionalization.

There may be times when an ExSPED case is closed due to an anticipated long-term admission to a skilled nursing facility, but the circumstances change and the individual is able to discharge back to the community. For those instances:

If an ExSPED recipient closes due to a skilled nursing facility or swing bed admission, and they re-open SPED within 3 months:

• A new Application for Services (SFN 1047) does not need to be completed.
• An SFN 56 does not need to be completed.
• An SFN 676 does need to be completed and submitted to HCBS/Aging Services. If all information is the same, it is allowable to use the previously approved SFN 676 and simply indicate the date the individual is to re-open in the field “Date of Application” and select “Re-Open” in the “Application Type” field.

For further instruction and examples, please reference HCBS Policy & Procedure Manual: Closures, Denials, Terminations, Reductions, and Transfer of Services 525-05-40.

Expanded SPED Pool Exceptions

As long as the individual still meets all eligibility criteria, the individual does not have to go through the Ex-SPED pool to receive Ex-SPED services if one of the following applies:

• Individual was discharged from an inpatient hospital stay, skilled nursing facility, swing bed facility, long term care facility, or basic care facility and has been off the Ex-SPED program for fewer than 3 months
• Individual has been off the Ex-SPED program for 60 days or less for any reason