MEMORANDUM

DISCUSSION:

The purpose of this memo is to introduce revisions to the Home and Community Based Referral (IM-54A) form. The IM-54A is revised for improved interagency communication between the Family Support Division (FSD) eligibility specialist (ES) and the Department of Health and Senior Services, Division of Senior and Disability Services (DSDS)  or their Designee regarding the Home and Community Based Services program. Revisions include:

• Participant information is moved to the top of the form.
• The telephone number field is changed to participant telephone to clarify this is the participant's telephone, not the agency's telephone.
• An alternate telephone number field is added to list a cell phone or other telephone number for the participant.
• Spouse name, and Spouse DCN fields are added.
• FSD ES information, including a new email address field, is located immediately after the participant information.
• A comment section is added to allow the ES to communicate any special information or instructions to the DSDS representative.
• The DSDS section includes an email address field and is now located after the FSD section.
• Participant authorized for Aged and Disabled Waiver Services has been changed to Participant determined eligible for Aged and Disabled Waiver Services.

Prior to making a referral for Home and Community Based (HCB) assessment, the ES must:

• complete the participant information section of the IM-54A, confirming the correct mailing address and a current telephone number is entered for the participant (the DSDS cannot contact the participant without this information);
• complete the "For FSD Use Only" sections of the form; and
• make a preliminary review of basic HCB eligibility factors.

A referral for Home and Community Based (HCB) assessment is not appropriate if:

• the participant is not at least 65 years old, or
• the participant is not 63 years old AND disabled, or
• the participant  is not in need of HCB services, or
• the participant's income exceeds the HCB income limit or
• the participant's resources exceed the HCB resource limit.

Individuals who are applying for MO HealthNet for the Aged, Blind, and Disabled (MHABD) and who are considering placement in a long-term care facility, or who appear to be potentially eligible for HCB waiver services, must be referred to the DHSS/DSDS for a determination.

Refer individuals to the DHSS/DSDS using form IM-54A (Home and Community Based Referral). The DHSS/DSDS will use the form to notify FSD of its decision, including the date the individual was authorized for HCB waiver services.

The revised IM-54A form and instructions are available in the Forms Manual. ES should download the new version and overwrite the existing version.

NECESSARY ACTION:

• Review this memorandum with appropriate staff.
• Refer individuals to the DHSS/DSDS using the revised IM-54A immediately.
• Destroy versions of IM-54A with dates prior to 1/2013.

AC/vb