West Virginia Personal Options Intellectual/Developmental Disabilities Waiver Program Goods and Services Packet

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1 Goods and Services Packet This packet will assist you in requesting approval and payment for Participant Directed Goods and Services (PDGS). Your Resource Consultant may assist you with the necessary steps listed below. Participant Directed Goods and Services Please follow these steps to request approval: 1. Identify an item or service that will support the funds you have allocated to Participant Directed Goods and Services. 2. Complete the enclosed Application for Approval of PDGS and submit to your Resource Consultant. a. The submitted Application for Approval of PDGS will be reviewed and a decision will be made within 10 business days from the date the application is received. 3. Receive approval or denial notification on your Application for Approval of PDGS. 4. Update your Spending Plan with the approved item or service and purchase amount. Please follow these steps to request payment for the item or service: 1. Complete the enclosed forms for payment and submit to your Resource Consultant. 2. PPL will cut a check made out to the agency / vendor and send it to you. 3. Pay the agency / vendor. Some on-going payments for services may be sent directly to the agency / vendor upon request. 4. Save the receipt from your purchase and provide to your Resource Consultant. Forms to Complete for Payment: W-9: This form provides PPL with the agency / vendor s correct Tax Identification Number in order to complete yearend tax reporting. This only needs to be done once per vendor. Goods and Services Payment Request Form: This form must be completed to issue payments for goods and services. An invoice or quote must be submitted with the Payment Request Form in order for the request to be processed. All Payment Request Forms and supporting documentation must be submitted to your PPL Resource Consultant. (Note: The payment request form will be paid using the same pay schedule as timesheets. If the payment request form is not submitted by the timesheet deadline the payment will be issued on the next check date.) October 1, 2011

2 Useful Information: Participant Directed Goods and Services Disallow List: Defines what cannot be purchased with Participant-Directed Goods and Services. Instructions for Paying with a PPL Check: Will assist when you go to complete the purchase of your approved item or service. For more information: Visit the PPL website at to get more information and paperwork. Select Program Login and West Virginia from the drop down menu and enter the following username and password: Username: WVIDD Password: PPLWV20 Questions? Please contact your Resource Consultant or PPL Customer Service at or by pplwvidd@pcgus.com if you have any questions. Sincerely, Public Partnerships, LLC Fiscal/Employer Agent and Resource Consultant October 1, 2011

3 Participant Direct Goods and Services Disallow List Participant-Directed Goods and Services (PDGS) are services, equipment or supplies not otherwise provided through Medicaid that address an identified need in the Participant Directed Service Plan. PDGS must decrease your need for other Medicaid services or increase your independence and safety in the home and/or community. PDGS is included in your annual budget and cannot be carried over from one budget year to the next. PDGS combined with EAA is limited to $1,000 per budget period. You may not use Medicaid funds to purchase the following: Goods, services or supports covered by the State Plan, Medicare, other third-parties, including education, home-based schooling, and vocational services Goods, services, and supports available through another source Goods, services or supports provided to or benefiting persons other than the participant Room and board Personal items and services not related to the qualifying disability Gifts for staff/family/friends Payments to someone to serve as a representative Clothing Food and Beverages Electronic Entertainment Equipment Printers Utility Payments Swimming Pools and Spas Costs Associated with Travel Household furnishings such as Furniture, Comforters, Linens, and Drapes Vehicle Expenses including Routine Maintenance and Repairs, Insurance and Gas Money Medications, Vitamins, Herbal Supplements, Experimental or Investigational Treatments Monthly Internet Service Yard Work Illegal Drugs or Alcohol Household Cleaning Supplies Home Maintenance Pet Care Respite Services and Day Care Spa Services Personal Hygiene Discretionary cash October 1, 2011

4 Application for Approval of Participant Directed Goods and Services (PDGS) Review and answer only the questions in this application as they apply to your request for approval for goods and services. Participant Information Name: Representative: Resource Consultant: Participant ID: Date Completed: I am completing this application to request approval for goods and services to support my needs or goals. 1. My needs or goals that could be supported by the purchase of a PDGS item or service are (check all that apply): Adaptive Equipment Community Living Skills Dental Dietary Environmental Accessibility: Home Hygiene Motor Skills Environmental Accessibility: Vehicle Physical Health & Fitness Social Skills Learning (Functional Academics) Positive Behavior Support Safety Non-covered Durable Medical Equipment Vision Receptive or Expressive Language (Communication) Other Needs or Goals (Please explain): 2. What is the item or service that will support my needs or goals? (Example: A ramp, which will allow me to enter and exit my home safely.) 3. How does this item or service support my health and safety needs? (Example: The ramp will allow me to safely enter and exit my home in the event of an emergency.) August 1, 2012

5 4. Does the item or service support my independence in my home or my community? If so, how? 5. Does the item or service decrease my need of direct care services from my employee? If so, how? 6. What other funding sources can pay for or assist me with paying for the needed item or service? (Example: Friends and Family can help. Medicaid card may assist with Durable Medical Equipment purchases. Community organizations may assist with eye glasses or hearing aids.) 7. What is the estimated cost of the item or service and where do I intend to purchase it? (Example: A microwave oven could be purchased at Walmart and it will cost $75.00 to purchase.) Please submit this application and all other supporting documentation to your Resource Consultant. Supporting documentation may include a recommendation from a physician or other healthcare professional, newspaper ad, on-line service description or any other additional information about the item or service that could be used during the approval process. Your Resource Consultant will assist with your Spending Plan changes. TO BE COMPLETED BY PPL Reviewer: Approved: YES NO Date: Explanation: If the Application for Approval of Goods and Services is approved it becomes an addendum to the participant s Spending Plan. August 1, 2012

6 Form W-9 (Rev. January 2011) Department of the Treasury Internal Revenue Service Name (as shown on your income tax return) Request for Taxpayer Identification Number and Certification Give Form to the requester. Do not send to the IRS. Print or type See Specific Instructions on page 2. Business name/disregarded entity name, if different from above Check appropriate box for federal tax classification (required): Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate Exempt payee Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) Other (see instructions) Address (number, street, and apt. or suite no.) Requester s name and address (optional) City, state, and ZIP code List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the Name line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Social security number Employer identification number Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person (defined below). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 4. Sign Here Signature of U.S. person General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners share of effectively connected income. Date Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester s form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: An individual who is a U.S. citizen or U.S. resident alien, A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, An estate (other than a foreign estate), or A domestic trust (as defined in Regulations section ). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. Cat. No X Form W-9 (Rev )

7 Goods and Services Payment Request Form IMPORTANT INFORMATION 1. The submitted request form must identify a pre-approved item or service. 2. Ensure that all of the required forms for the agency or vendor to receive payment have been completed and submitted to PPL prior to submitting the request for payment information. 3. A quote or invoice must be attached in order for the payment request form to be processed. 4. Clearly fill in all of the fields below, either with Black or Blue ink. 5. Submit the Payment Request and other necessary information to your Resource Consultant. 6. PPL will make the payment payable to the vendor and mail the check directly to you, unless you otherwise confirm below that the payment is to be sent to the vendor directly. 7. Payment request that exceeds the allocated amount on your spending plan will be paid to the maximum. Any difference in the amount owed will be your responsibility. Participant Name: Participant ID: Item / Service Being Purchased: Waiver Service Code (PPL use only): T2028SC Requested Payment Amount: $ Request for Payment Date: For PDGS payment be sure the amount includes all taxes or fees. On-going Monthly Payment? YES NO Payment Sent to Vendor: Yes NO Vendor Name: PPL ID (if known): E Phone Number: Fax Number: Mailing Address: _ City: State: Zip: Vendor tax exempt or Non-profit: YES NO Signatures: Participant / Employer: Date: Resource Consultant: Date: IMPORTANT: Do not pre-purchase an item or service and then plan to request for reimbursement. You will not be reimbursed for the purchased items or services. August 1, 2012

8 Paying with a PPL Check Overview In the Personal Options program, participants may request payment to purchase approved item and services. While convenient, this process is often confusing to big box stores such as Walmart and Best Buy. Please keep these instructions with you and use them as a reference when you go to purchase your good or service. It is important that you follow these steps, because even if your purchase seems to go through all the time, the store could be doing something wrong that will cause problems for the next participant who tries to pay with a PPL check. Things to Remember: Never present a driver s license, give your social security number or share other forms of ID when paying with this check. Stores will attempt to match this information against PPL s bank account and it will inevitably fail since you are not associated with PPL s bank account. If a cashier insists upon ID, explain that it is a payroll check cut by a company. Stores should know that this kind of check does not require ID. If you have problems, call PPL Customer Service ASAP at (877) We can talk to the store for you and explain things. If your check is declined and you cannot call PPL, keep as much information as possible (Store name, Location, Date Check was Declined, etc ). PPL will need as much information as possible to assist in clearing the issue. If you encounter problems, give the following to the store: Information about this check The check being presented to you is a payroll check that is funded by state and federal funds. The issuing company, Public Partnerships, LLC, it a fiscal intermediary that processes these funds. Please note: Do not ask the person presenting the check for ID of any kind. Many stores have systems that automatically attempt to cross verify social security numbers, driver s licenses, or other IDs with the bank account. These will result in a declined check, since the person presenting the check has no affiliation with Public Partnerships, LLC. Do not adjust this check for any amount other than its face value. Doing so will result in a declined check. If you have questions about processing this check, please ask the person presenting it to call PPL immediately at (877)

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