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(Revised 1/1/09 ML #3173)
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Purpose: To take action on a level of care screening for a Medicaid Wavier case that would temporarily or permanently end a screening or to reopen a current screen.
Client Name: Record the first and last name;
ID Number: Record the Medicaid recipient identification number;
Street Address, Date of Birth, City, State, Zip Code, County: Self Explanatory;
Waiver: Indicate the name of the waiver (i.e. Medicaid Waiver for Home and Community Based Services);
Reopen Current Screening effective date: Record the date the Waiver services are to begin. This line is used when a previous Waiver client was screened skilled nursing facility level of care, the individual was admitted to a facility or received services from a non-Waiver services, and now the individual will be transitioning back to the Waiver services. If the initial screening had expired during the individual's stay in the facility or while seeking other services, a new HCBS screening would be required and this form would not be completed/submitted;
Termination/Closure effective date: Use this line for closures/terminations that may occur due to ineligibility, death, or other that is not related to entering a nursing home or swingbed or Basic Care facility. This will designate when the waiver services are to end.
Case Manager Name/Date: Indicate the name of the Case Manager submitting the SFN 1288. Date the form.
**Send information to – Medical Services is to receive a copy of the SFN 1288 for the re-opening of a current LOC screening or when the waiver screening prematurely closes or terminates.
This form is not available from the state office. An electronic copy is available through the state e-forms.