SFN 21, Transmittal Between Units 400-29-85-05

(Revised 6/1/11 ML #3269)

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PURPOSE:  A communication tool between two separate units within the County Social Service Board.  This form is used by the HCBS Case Managers to inform eligibility workers that a individual meets functional eligibility criteria for Basic Care Assistance.  This form is also used by eligibility workers to inform HCBS Case Managers an individual meets financial eligibility criteria for BCAP.

 

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms. (111kb pdf)

 

1. County Eligibility Worker - The transmittal between units is used by the county eligibility staff to notify the Home and Community Based social worker of an action taken on a basic care applicant or recipient.

1. Notification of approval, denial, or closure of a Basic Care Assistance Program applicant or recipient.
2. Initial functional assessment needed or review of functional assessment due.
3. Review due for Medicaid and Basic Care Assistance Program.
4. A recipient moves from one basic care facility to another.

2. The Home and Community Based Social Worker - The transmittal between units is used by the Home and Community Based social worker to notify the county eligibility worker of actions taken or the status of a recipient.

1. Completion date of an initial or review of a functional assessment.
2. A recipient moves from one basic care facility to another.

 

INSTRUCTIONS FOR TRANSMITTAL BETWEEN UNITS FORM (SFN 21)

 

Name:  First and last name of individual to receive services.  Complete the name as enrolled through Medical Assistance.

 

Address/City/State/Zip: Address where the individual will be residing and receiving services in a basic care facility.  

 

Medicaid ID Number: This is the Medicaid ID number assigned by TECS.

 

Date of Birth: Enter mm/dd/yyyy for the individual’s birth date.

 

Case Number:  Enter the Medicaid case number assigned by TECS.  

 

Social Security Number: self explanatory

 

Facility/Facility Provider Number: Enter the name/provider number of the Basic Care Facility the individual will be entering or is currently residing.

 

Date of Admit: Enter the date (mm/dd/yyyy) the individual entered or will enter the Basic Care facility. It is not necessary to complete this section if this is being used for the annual review or to share information.  

 

Date/To/From –This section is completed by the Home and Community Based Services (HCBS) social worker.  It may be used for the initial review and for the annual review.  

 

The remaining boxes on this form are used to indicate why the form is being completed.  

• If a functional assessment is need, the eligibility worker completes the form and checks this box.  The form is sent to the HCBS social worker for completion.  
• If it is the annual review time, the MA Review and the Functional Assessment Review box is checked by the eligibility worker and sent to the HCBS social worker.  
• The eligibility worker or the HCBS social worker either completes the Functional/Medicaid Eligibility Criteria.  
• The eligibility worker or the HCBS social worker enter the effective date of either the functional assessment or the date of eligibility for Medicaid and Basic Care.  
• The eligibility worker or the HCBS social worker either completes the closing date. This date is the date the case closed or the date the individual left the basic care facility.  

 

The eligibility worker or the HCBS social worker to indicate that the place in a basic care facility is temporary either completes this. If a placement is temporary, the individual is allowed to retain specific assets such as a home during the temporary stay. (See 400-29-40-10 Temporary Basic Care Assistance)

 

Most often the eligibility worker collects the doctor’s statement from the individual in the basic care facility or from the individual’s representative.

 

Assessments and Effective Dates for Payment Eligibility.

 

A Functional Assessment and Personal Care Plan assessment should be completed by the social worker or DD program manager promptly when the individual applies for MA/Basic Care services. They have to be Medicaid eligible to receive Basic Care services. The county cannot be reimbursed for the assessment unless the individual is Medicaid eligible.

 

The social worker or DD program manager can only establish retroactive eligibility for 10 working days prior to the date they visited with the client for the assessment. This is the Effective Date of the plan. If the individual entered/needs Basic Care for any time prior to that assessment effective date, the social worker or DD program manager will need to inform Medical Services so the effective date can be established to coincide with the effective date of Medicaid eligibility. Any retroactive eligibility beyond the 10 days approved by the social worker or DD program manager must be approved by the state office – Medical Services, Home and Community Based Services (HCBS) Unit. The request for retroactive eligibility is requested by the eligibility worker based on the application submitted.