Missouri Department of Health and Senior Services

Chapter

Policy

Policy Number

1. Introduction

Index

Introduction and Legal Authority

Final Rule Medicaid HCBS

2. Medicaid Funding

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 – State Plan (Agency Model)

3.05

Advanced Personal Care - State Plan (Agency Model)

3.10

Authorized Nurse Visits – State Plan (Agency Model)

3.15

Residential Care/ Assisted Living Facility Personal Care – State Plan (Agency Model)

3.20

Personal Care – State Plan (Consumer Directed Model)

3.25

Adult Day Care Waiver

3.31

Chore (Aged and Disabled Waiver (ADW)

3.35

Home Delivered Meals (ADW)

Adult Day Care - (ADW)

3.51

Independent Living Waiver

3.55

Non-Medicaid Eligibility (NME)

3.65

Social Services Grant General Revenue Protective Services Participants

3.70

Home and Community Based Service Units and Rates

3.00 Appendix 1

Home and Community Based Cost Maximums

3.00 Appendix 2

Customer Information, Management, Outcomes and Reporting (CIMOR)

3.00 Appendix 4

NME HCBS Referral Assessment Form

3.00 Appendix 5

NME Paper Authorization Request Form

3.00 Appendix 6

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

Case Notes Documentation

4.30

Service Coordination

4.35

DMH Service Coordination

Participant Choice Statement Form and Instructions (Agency, CDS, and ADC)
Form / Instructions

4.00 Appendix 2a

Participant Choice Statement Form and Instructions (RCF/ALF)
Form / Instructions

4.00 Appendix 2b

Adult Day Care Participant Rights and Responsibilities

4.00 Appendix 2c

Agency Model Participant Rights and Responsibilities

4.00 Appendix 2d

CDS Participant Rights and Responsibilities

4.00 Appendix 2e

RCF/ALF Personal Care Participant Rights and Responsibilities

4.00 Appendix 2f

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

CIMOR

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
Form / Instructions

4.00 Appendix 10

Participant Contact Letter
Form / Instructions

4.00 Appendix 11

Participant Communication - Reason for Contact

4.00 Appendix 12

Healthcare Professional Inquiry
Form / Instructions

4.00 Appendix 13

HCBS Assessment Attestation
Form / Instructions

4.00 Appendix 14

Healthcare Information Request
Form / Instructions

4.00 Appendix 15

5. Adverse Action

Adverse Action

5.00

Legal References for Adverse Action

5.00 Appendix 1

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

Notice of Closure
Form / Instructions

5.00 Appendix 6

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

Cover Letter

6.00 Appendix 7

7. Money Follow the Person Program

Money Follows the Person (MFP)

7.00

Money Follows the Person Regional Staff Contacts

7.00 Appendix 1

Money Follows the Person Option Counseling Transition Coordination Contractors Map

7.00 Appendix 2

MFP HCBS Referral Assessment Form

7.00 Appendix 3

MFP Participation Agreement

7.00 Appendix 4

MFP Transition Plan

7.00 Appendix 5

MFP Approval Notice Plan
Form / Instructions

7.00 Appendix 6

MFP Ombudsman Referral
Form / Instructions

7.00 Appendix 7

Health, Safety and Welfare Assessment For MFP

7.00 Appendix 8

MFP Referral Notification

7.00 Appendix 9

Request for MFP Funds

7.00 Appendix 10
7.00 Appendix 10

MFP Funds Notification

7.00 Appendix 11

8. Miscellaneous and Forms

Abuse, Neglect and Exploitation

8.00

Participant Case Records

8.05

Provider Complaint Process

8.15

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
Form

8.00 Appendix 4

Physician Prescription for Personal Care Services

8.00 Appendix 5

FSD HCB Medicaid Referral

8.00 Appendix 6

Provider Complaint Report

8.00 Appendix 7

Eligibility Letter

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 22

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

Home and Community Based Services Manual

Chapter

Policy

Policy Number