MEMORANDUM

DISCUSSION:

The purpose of this memo is to introduce the changes of the Home and Community Based Referral form (IM-54A) that provides communication between the Department of Social Services, Family Support Division (FSD) and the Department of Health and Senior Services, Division of Senior and Disability Services (DSDS) and their Designee regarding the Home and Community Based Medicaid program.  The updates clarify what is requested from DSDS or FSD staff and removes unnecessary information in collaboration with both agencies.

The purpose of the Home and Community Based (HCB) program is to:

• Give equitable treatment of resources for married couples, by allowing an assessment and division of assets to persons choosing to remain in their own homes rather than entering a nursing facility, and
• Encourage people to remain in their own homes by establishing a higher MHABD income limit for individuals receiving HCB waiver services.

Completing and sending the Home and Community Based Referral Form (IM-54A) is required during the application process.  This form has been updated and is available in the Forms Manual.  Additional supplies may be ordered through the warehouse.  Replace all previous versions.  The following changes have been made:

• The applicant's social security number has been removed in the Participant Information.
• The DSDS Casemanager has been replaced by Designee.
• The load number of the DSDS/Designee has been removed.
• The address of the FSD Eligibility Specialist has been added.
• "Authorization for Aged and Disabled Waiver Services" has been added to the PARTICIPANT REFERRED TO DSDS/DESIGNEE FOR box, to clarify the referral approval.

INSTRUCTIONS:

• Participant Information
  • Enter the participant's name, Departmental Client Number (DCN), address and telephone number.  Enter the name of the county where the form is initially completed/or participant resides.

  NOTE:  The next section is for the Division of Senior and Disability Services (DSDS) Designee

• For Family Support Division (FSD) only
  • The FSD Eligibility Specialist will enter his/her name and load number.
  • The FSD Eligibility Specialist will enter the date of referral.
  • The FSD Eligibility Specialist will provide the office address.
  • The FSD Eligibility Specialist will check the "Level of Care Determination" box when referring a participant to DSDS/Designee for a level of care assessment of level of care and Aged and Disabled Waiver Services eligibility.
  • The FSD Eligibility Specialist will notify DSDS/Designee when the application for HCB Medicaid has been approved or denied, and the date of that determination.

The original IM-54A is kept in the file of the originating agency and a copy goes to the receiving agency.  The form is returned to the originating agency after a decision has been made, and the receiving agency will keep a copy.

NECESSARY ACTION:

• Review this memorandum with all staff.
• Begin using the Revised IM-54A upon receipt of this memo.

AC/dh

Attachment

Home and Community Services Regional Evaluation Teams