Medicaid Services and Supports Form Requirements (10/2018)

Transcription

1 Goes to: Medicaid Services and Supports Requirements (10/2018) # Name / Notes State Plan Personal Care (SPPC BPA/BPO) X X X X SDS 002N Assessment Summary At intake when Title XIX is completed and at Redetermination when Title XIX is completed X X OHP 0097 DMAP Important Letter Language in Multiple Languages at intake or redetermination when the * X X X SDS 354 Workers Compensation Agreement and Consent - if using a CEP X X X X SDS 541 Notice of Eligibility and Responsibility At redetermination when a Title XIX has not been completed. X* X X X X X X SDS 546PC SPPC Service Plan and Task List * X X X X SDS 737 Representative Choice Not required with IHCA only X* X X X X SDS 2780N Service Plan and Notice (SPAN) At intake when Title XIX is completed and at Redetermination when Title XIX is completed. If XIX not completed, SPAN is not required. Page 1 of 10

2 Goes to: Medicaid Services and Supports Requirements (10/2018) # Name / Notes State Plan Personal Care (SPPC BPA/BPO) Cont.. X X X X X SDS 4105 Homecare Worker Notice of Authorized Hours and Services with new service plans and/or when a HCWs hours or services being provided have changed In-Home Services (APD In-Home) X X X X X Pay-inN Pay-In Calculation Worksheet only when consumer has a pay-in at intake/redet. or when their pay-in changes X X X X* X SDS 002N Assessment Summary *Included at redet. if the SPAN notice is required. X X X X SDS 003N Client Details X X OHP 0097 DMAP Important Letter Language in Multiple Languages at intake or redetermination when the * X X X SDS 354 Workers Compensation Agreement and Consent - if using a CEP X X X X X SDS 546N In-Home Service Plan Page 2 of 10

3 Goes to: Medicaid Services and Supports Requirements (10/2018) # Name / Notes In-Home Services (APD In-Home) Cont.. * X X X X SDS 737 Representative Choice Not required with IHCA only X X X X X X SDS 598N Task List * X X X X Service Plan Agreement Service Plan Agreement This replaces forms 001N and the 914. This is included now as part of the SPAN. This also needs to be updated if the consumer goes to/from a NF ICF level of stay to another living situation. X* X X X* X SDS 2780N Service Plan and Notice (SPAN) *Included at redet. if all of the following are true: The SPL has changed, hours have changed, if a service option (i.e. exception, shift services, spousal pay) has been requested, or if the consumer has not received at least one of the following - SPAN, 2780, 2781, 2782, or 2783 X X X X DHS 2794 Exception Process for Consumers X X X X X SDS 4105 Homecare Worker Notice of Authorized Hours and Services with new service plans and/or when a HCWs hours or services being provided have changed X X X X DHS 5139 What to Expect from Your Assessment for Long-term Services and Supports (Please note that brochure is not yet orderable through FBOS, it will not be required until transmittal is issued) X X X DHS 8958 Medicaid In-home Service Options brochure Page 3 of 10

4 Goes to: Medicaid Services and Supports Requirements (10/2018) # Name / Notes Independent Choices Program (ICP) X X X X* X SDS 002N Assessment Summary * Included at redet. if the SPAN notice is required. X X X X SDS 003N Client Details X X OHP 0097 DMAP Important Letter Language in Multiple Languages at intake or redetermination when the * X X X SDS 353 Workers Compensation Consent and Agreement Send copy to ICP Coordinator, originals must be kept in file X X X X X X X SDS 546IC Independent Choices Benefit Calculation Send copy to ICP Coordinator * X X X X X SDS 548 Independent Choices Program Employee Provider(s) Information Send copy to ICP Coordinator, originals should be retained in file * X X X X Service Plan Agreement Service Plan Agreement This replaces forms 001N and the 914. This is included now as part of the SPAN. This also needs to be updated if the consumer goes to/from a NF ICF level of stay to another living situation. Page 4 of 10

5 Goes to: Medicaid Services and Supports Requirements (10/2018) # Name / Notes Independent Choices Program (ICP) Cont.. X* X X X X SDS 2780N Service Plan and Notice (SPAN) Included at redet. if all of the following are true: The SPL has changed, hours have changed, if a service option (i.e. exception, shift services, spousal pay) has been requested, or if the consumer has not received at least one of the following - SPAN, 2780, 2781, 2782, or 2783 X X X X DHS 2794 Exception Process for Consumers X X X X DHS 5139 What to Expect from Your Assessment for Long-term Services and Supports * X X X X DHS 7262i Request for Direct Deposit Copy must be kept in file, send originals to ICP Coordinator X X X DHS 8958 Medicaid In-home Service Options brochure * X X X Click for link ICP Participation Agreement Originals must be kept in file * X X X Click for link ICP Representative Agreement Originals must be kept in file X* X X X X Click for link ICP Budget Worksheet Budget and Payroll forms and samples section X X Click for link ICP Six Month Budget Review Checklist Budget and Payroll forms and samples section Page 5 of 10

6 Goes to: Medicaid Services and Supports Requirements (10/2018) # Name / Notes Oregon Project Independence (OPI) X* X X X X SDS 287L Oregon Project Independence (OPI) Service Agreement X* X X X X SDS 287K Oregon Project Independence (OPI) Income/Fee Determination Record X X X X SDS 287J Oregon Project Independence (OPI) Risk Assessment Tool Also required when closing an OPI case * X X X SDS 354 Workers Compensation Agreement and Consent - if using a CEP X X X X X SDS 546N In-Home Service Plan X X X X X X SDS 598N Task List * X X X X SDS 737 Representative Choice Not required with IHCA only X X X X X SDS 4105 Homecare Worker Notice of Authorized Hours and Services with new service plans and/or when a HCWs hours or services being provided have changed Community Based Care (ALF, AFH, RCF APD Residential) X X X X* X SDS 002N Assessment Summary *At redet. If the SPAN is required or if the SPL changes. X X X X 002N Cover Ltr. X X X X SDS 003N Client Details 002N Cover Letter At redet. if there is a change in SPL and the consumer is still eligible, but the SPAN is not sent. Page 6 of 10

7 Goes to: Medicaid Services and Supports Requirements (10/2018) # Name / Notes Community Based Care (ALF, AFH, RCF APD Residential) Cont.. X X* X* X OHP 0097 DMAP Important Letter Language in Multiple Languages * at intake or redetermination when the X X X X X SDS 450N Liability Worksheet for Long Term Care or CBC Used for Spousal Pay Allowance situations * X X X X Service Plan Agreement This replaces forms 001N and the 914. This is included now as part of the SPAN. This also needs to be updated if the consumer goes to/from a NF ICF level of stay to another living situation. X* X X X* X SDS 2780N Service Plan and Notice (SPAN) *At redet. when the consumer is no longer SPL eligible X X X X DHS 5139 What to Expect from Your Assessment for Long-term Services and Supports Nursing Facility (NFC) X X X X* X SDS 002N Assessment Summary *At redet. it is required only if there was a change in SPL Page 7 of 10

8 Goes to: Medicaid Services and Supports Requirements (10/2018) # Name / Notes Nursing Facility (NFC) Cont.. X X X X 002N Cover Ltr. Page 8 of N Cover Letter At redet. if there is a change in SPL and the consumer is still eligible, but the SPAN is not sent. X X X X SDS 003N Client Details X X OHP 0097 DMAP Important Letter Language in Multiple Languages at intake or redetermination when the X X X X X SDS 450N Liability Worksheet for Long Term Care or CBC Used for Spousal Pay Allowance situations X X X X SDS 460 Pre-Admission Screening/Resident Review (PASRR) Level 1 * X X X SDS 542 Designation of Management of Personal Funds X X X X SDS 458AN Financial Planning Title XIX at intake or if the consumer s income/liability changes. You must also include their Hearing Rights X X X X X SDS 458P Financial Planning Title XIX For NF providers * X X X X Service Plan Agreement This replaces forms 001N and the 914. This is included now as part of the SPAN. This also needs to be updated if the consumer goes to/from a NF ICF level of stay to another living situation.

9 Goes to: Medicaid Services and Supports Requirements (10/2018) # Name / Notes Nursing Facility (NFC) Cont.. X* X X X* X SDS 2780N Service Plan and Notice (SPAN) *At redet. when the consumer is no longer SPL eligible X X X X DHS 5139 What to Expect from Your Assessment for Long-term Services and Supports Program for All-Inclusive Care for the Elderly (PACE) X X X X* X SDS 002N Assessment Summary *At redet. it is required only if there was a change in SPL X X X X SDS 003N Client Details X X OHP 0097 DMAP Important Letter Language in Multiple Languages at intake or redetermination when the X X X X SDS 460 Pre-Admission Screening/Resident Review (PASRR) Level 1 X* X X X X SDS 2780N Service Plan and Notice (SPAN) *At redet. when the consumer is no longer SPL eligible X X X X DHS 5139 What to Expect from Your Assessment for Long-term Services and Supports Page 9 of 10

10 Goes to: Medicaid Services and Supports Requirements (10/2018) # Name / Notes Program for All-Inclusive Care for the Elderly (PACE) Cont. Additional s (Used When Needed) * X X X MSC 231 Designation of Authorized Representative or Alternate Payee Used to identify who the consumer X X X SDS 514 Request for Exception For in-home service requests X X X X SDS 514A Exception Request Worksheet CBC requests X X X SDS 539H Notification of Pending Status X X X SDS 540 Notification of Planned Action For SPPC and general Medicaid financial eligibility decisions X X X X MSC 647 Real and Personal Property Send to EAU. X X X X SDS 753 APD Long Term Care Community Nursing (LTCCN) Program Client Referral Note: Contact Christine Maciel at (541) or via at Christine.C.Maciel@dhsoha.state.or.us for comments or questions. Page 10 of 10