Home and Community Based Services Manual

Chapter

Policy

Policy Number

 

1. Introduction

Index

 

Introduction

1.00

 

Abbreviations

1.05

 

2. Medicaid Funding

Medicaid Eligibility

2.00

 

 

General Requirements

2.00 Appendix 1

 

Medicaid Income Charts

2.00 Appendix 2

 

Medicaid Eligibility Codes

2.00 Appendix 3

 

3. Available Home and Community Based Services

Home and Community Based Service (HCBS)  Introduction

3.00

 

Basic Personal Care Agency Model (State Plan)

3.05

 

Advanced Personal Care - Agency Model (State Plan)

3.10

 

Authorized Nurse Visits

3.15

 

Residential Care Facility Personal Care (State Plan)

3.20

 

Personal Care Consumer Directed Model (State Plan)

3.25

 

Adult Day Care Waiver

3.31

 

Chore (Aged and Disabled Waiver (ADW)

3.35

 

Home Delivered Meals (ADW)

3.40

 

Homemaker (ADW)

3.45

 

Respite Care (ADW)

3.50

 

Adult Day Care - (ADW)

3.51

 

 

Independent Living Waiver

3.55

 

Program of All-Inclusive Care for the Elderly (PACE)

3.60

 

Non-Medicaid Eligibility (NME)

3.65

 

Home and Community Based Service Units
and Rates

3.00 Appendix 1

 

Home and Community Based Cost Maximums

3.00 Appendix 2

 

PACE HCBS Referral-Assessment Form
Form

3.00 Appendix 3

Customer Information, Management, Outcomes and Reporting (CIMOR)

3.00 Appendix 4

 

4. Home and Community Based Assessment, Care Planning and Authorization Process

HCBS Service Processes Introduction

4.00

 

Intake and Prescreen Process

4.05

 

Explanation of the Level of Care Determination

4.10

 

Initial Assessment Process

4.15

 

Person Centered Care Planning and Maintenance Process

4.20

 

Reassessment Process

4.25

 

Collateral Contacts

4.00 Appendix 1

 

HCBS Care Plan and Participant Choice Statement
Form / Instructions

4.00 Appendix 2

 

In-Home Services Worksheet
Form / Instructions

4.00 Appendix 3

 

Consumer-Directed Services Worksheet
Form / Instructions

4.00 Appendix 4

 

Physician Notification
Form / Instructions

4.00 Appendix 5

 

Physician Notification of Assessment
Form / Instructions

4.00 Appendix 6

 

Department of Mental Health, Developmental Disabilities Office List

4.00 Appendix 7

 

SLUMS
Form / Instructions

4.00 Appendix 8

 

 

HCBS Community Options Information

4.00 Appendix 9

 

Self Direction Assessment Questions

4.00 Appendix 10

 

Initial Contact Letter

4.00 Appendix 11

 

Reassessment Letter

4.00 Appendix 12

 

5. Adverse Action

Adverse Action

5.00

 

Legal References for Adverse Action

5.00 Appendix 1

 

Adverse Action Cover Letter
Form / Instructions

5.00 Appendix 2

 

Adverse Action
Form / Instructions

5.00 Appendix 3

 

Application for a State Hearing
Form / Instructions

5.00 Appendix 4

 

Reversal of Adverse Action
Form / Instructions

5.00 Appendix 5

 

6. Appeals and Hearing Process

Appeal and Hearing Process

6.00

 

Division of Legal Services Regional Offices

6.00 Appendix 1

 

Witness Information

6.00 Appendix 2

 

Qualifying Witness Statement

6.00 Appendix 3

 

Cover Letter to Participant
Form / Instructions

6.00 Appendix 4

 

Cover Letter to Authorized Representative
Form / Instructions

6.00 Appendix 5

 

CMS Letter

6.00 Appendix 6

 

7. Money Follow the Person Program

Money Follows the Person (MFP)

7.00

 

Money Follows the Person Regional Staff Contacts

7.00 Appendix 1

 

8. Miscellaneous and Forms

Abuse, Neglect and Exploitation

8.00

 

Provider Complaints

8.05

 

Abuse, Neglect and Exploitation Reported Adult Indicators

8.00 Appendix 1

 

Abuse, Neglect and Exploitation Alleged Perpetrators Indicators

8.00 Appendix 2

 

HCBS Referral Form

8.00 Appendix 3

 

HCBS General Health Evaluation and Level of Care Recommendation Form/Instructions

8.00 Appendix 4

 

Physician Prescription for Personal Care Services

8.00 Appendix 5

 

FSD HCB Medicaid Referral
Form / Instructions

8.00 Appendix 6

 

Provider Complaint Communication
Form / Instructions

8.00 Appendix 7

 

HCBS Referral Assessment form

8.00 Appendix 8

 

9. Confidentiality and HIPAA

Confidentiality Requirements

9.00

 

DHSS Notice of Privacy Policies

9.00 Appendix 1

 

Administrative Manual Chapter 11

9.00 Appendix 2

 

 

Administrative Manual Chapter 19

9.00 Appendix 3

 

Administrative Manual Chapter 24

9.00 Appendix 4

 

Acknowledgement
Form / Instructions

9.00 Appendix 5

 

Authorization
Form / Instructions

9.00 Appendix 6

 

10. HCBS Web Tool Guide

Web Tool - Introduction

10.00

 

 

WebTool - Icon Guide

10.01

 

 

Web Tool - Initial Assessment

10.05

 

 

Web Tool - Care Plan Change

10.10

 

 

Web Tool - Reassessment

10.15

 

 

Web Tool - Closing a Case

10.20

 

HCBS Memos