Eligibility Criteria 525-05-25

HCBS Program Eligibility Determination 525-05-25-05

(Revised 1/1/15 ML #3428)

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1. Application for services in service chapter shall be made to the county social service board in the county in which the applicant resides utilizing "Application for Services," SFN 1047.

An individual wishing to apply for benefits under this chapter must have the opportunity to do so, without delay.

 

An application is a request made to the department or its designee by individual seeking services under this chapter, or by an individual properly seeking services on behalf of another individual. "An individual properly seeking services" means an individual of sufficient maturity and understanding to act responsibly on behalf of the individual for whom services are sought. The case management entity must accept a referral from an individual who is acting in the best interest of the client and cannot require that the client themselves to actually make the initial request for services. However, the actual applicant must agree to a home visit. The applicant or their legal representative must sign the application and participate in the eligibility process.

 

The department or its designee shall provide information concerning eligibility requirements, available services and the rights and responsibilities of applicants and recipients to all who require it. The date of application is the date the department's designee receives the properly signed application.

 

The applicant shall provide information sufficient to establish eligibility for benefits, including a social security number and proof of age, identity, residence, blindness, disability, functional limitation, financial eligibility, and other information required under this chapter.

2. An applicant is eligible for these programs if the Case Management process (assessment of needs and care plan development) determines that the applicant meets functional and financial eligibility criteria for HCBS programs and requires those tasks/activities allowable within the scope of the services.

An initial functional assessment, using the form required by the department, must be completed as a part of the application for benefits under this chapter. A functional assessment must be completed at least semiannually in conjunction with the eligibility redetermination. The functional assessment must include an interview with the individual in the home where the individual resides.

3. Authorization to Provide Service, SFN 1699 is required as a standard form for care plan implementation.  The SFN 1699 identifies the specific tasks/activities the provider is authorized to perform for the eligible client and sets forth the scope of the service the client has agreed and understands will be provided.
4. To be eligible for the Medicaid Waiver for Home and Community Based Services,or the Expanded SPED program, the client must be an approved recipient of Medical Assistance.  The Medicaid Waiver client must also receive a Waivered service on a monthly basis. HCBS Case Management is not sufficient.
5. The client is eligible for covered services under the Medicaid Waivers, the SPED program, and/or ExSPED program once all eligibility criteria have been met. Continued eligibility is monitored under HCBS Case Management. At any time there is a question as to whether the client continues to meet functional or financial eligibility criterion, the HCBS case manager is to substantiate eligibility.

The authorization of services cannot begin until a level of care screening date, SPED Pool effective date, or ExSPED Pool effective date is processed.