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

(Revised 7/1/11 ML #3273)

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Eligibility for the Expanded SPED Program has two components: financial/Medicaid eligibility and functional eligibility. The applicant/client 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. 50-24.5-01(9)(a);  
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 or apartment). If in an apartment, the renter’s living area consists 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.  
6. The applicant/client(s) 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;
8. When the person’s needs can be met in either a basic care facility OR in their home, the least costly to the Department of meeting the applicant’s/client’s needs must be used. This is determined and documented by comparing the monthly cost of the basic care facility he/she would enter (or the local or closest basic care facility), minus the applicant’s/client’s recipient liability determined by the Eligibility Specialist, compared to the estimated monthly costs for the Expanded SPED Program plus the Medicaid State Plan Personal Care Service. If the costs of services to the Department under the Expanded SPED Program would be greater than those of the basic care facility, the person is not eligible for the Expanded SPED Program.  

2. Financial Eligibility for ExSPED

1. The first step is have a determination of Medicaid eligibility by the Economic Assistance Unit of the county by using Service Chapter 400-29 (Basic Care Assistance Program). Provided on the State’s e-forms is the form, SFN 21, to be used in transmitting information between the Economic Assistance Unit and Services Unit AND serves as the means of documenting eligibility for the Home and Community-Based Services (HCBS) Case Manager, Transmittal Between Units form (SFN 21). The individual must be approved through the Economic Assistance Unit for Medical Assistance prior to the individual’s submission to the Expanded SPED Pool.

In addition to being eligible for Medical Assistance, the applicants/clients 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)].

  b.  Estate Recovery

Legislation passed during the 1995 session gives the Department the authority to file a claim against a client’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. Annual Redetermination

At the time  of  the  annual  Medicaid  redetermination,  functional  eligibility  must  be  re-established  as  well. N.D.A.C. 75-02-10-06(2)

In addition, the case file must contain the annual verification of continued Medicaid eligibility with the completion of the Transmittal Between Units.

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 677

The documents above must be received no later than 5:00 on Tuesdays to be considered for entrance into the Wednesday ExSPED Pool.  Services must not be authorized until the County Social Service Board is notified the applicant was successfully removed from the ExSPED Pool. HCBS Program Administration will notify the County of the decision by forwarding a copy of the SFN 677 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 County Social Service Board or will be reviewed with the County Social Service Board.

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

The Department’s notification by the HCBS Program Administration is valid for 30 calendar days.  If services have not started within that time, the approval is voided.  The process for approval must start over.