HCBS Case Management 525-05-30-05

(Revised 4/1/22 ML #3665)

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Case Management is a service that assists individuals in learning about, applying for, accessing and maintaining home and community-based services in the most integrated setting appropriate to their needs.


The purpose of HCBS Case Management is to assist an individual to achieve and maintain independent living, in the living arrangement of their choice, until it is no longer appropriate or reasonably possible to maintain or meet the individual's needs in that setting. In order to facilitate independent living, the HCBS Case Manager leads the person-centered planning process that enables individuals and their natural and formal supports to explore and understand long-term service and support (LTSS) options, identify barriers, set goals, and collaborate with stakeholders to assist the individual in accessing needed community-based services. The HCBS Case Manager also advocates for and promotes individual-focused systems of service delivery, exercises an awareness of the larger target population in need, and exercises prudence in each individual's person-centered plan of care to link individuals with resources and services, utilizing those services and resources effectively.


Standards for HCBS Case Managers

The service shall be performed by a social worker or agency that employs individuals licensed to practice social work in North Dakota and who has met all the requirements to be enrolled as either an Individual or Agency Qualified Service Provider in NDAC 75-03-23 and agreed to comply with policy.


  1. Case Managers employed by Aging Services are eligible to receive payment for the service of Case Management and authorize services under the SPED and EXSPED Programs upon receiving a written notice from the HCBS Program Administration that an individual in the SPED or Expanded SPED Program Pool is authorized for services under the SPED or Expanded SPED Program.

  2. Case Managers employed by Aging Services are eligible to receive payment for the service of Case Management under the HCBS or TD Waiver and authorize services if the individual is eligible for services under either Waiver.

  3. Individual Case Managers or an Agency who is enrolled as a QSP for the Service of Case Management are eligible to receive payment for the service of Case Management under the HCBS or TD Waiver and are eligible to authorize services for an individual if the individual is eligible for services under either Wavier.

Case file documentation must be maintained:

  1. In a secure setting

  2. On each individual, in separate case files


Quarterly Visit Requirements for Medicaid Waiver

Case Managers are required to monitor during their quarterly face-to-face contacts to ensure an individual’s is being afforded the rights of privacy, dignity and respect, and freedom from coercion and restraint (including the limited use of restraints that are allowable under Adult Residential Services in accordance with NDCC 50-10.2-02 (1)).

Standards for Targeted Case Management (TCM) for persons in need of Long-Term Care


The following enrolled provider types are eligible to receive payment for TCM:


The following enrolled provider types are eligible to receive payment for TCM and Authorize Service(s):


The following enrolled provider types are eligible to receive payment for single event TCM:


Targeted Case Management (TCM)

The individual receiving TCM will meet the following criteria:

  1. Medicaid recipient.

  2. Not a recipient of HCBS (1915c Waiver) services.

  3. Not currently being covered under another case management/targeted case management system or payment does not duplicate payments made under other program's authorities for the same purpose.

  4. Lives in the community and desires to remain there; or be ready for discharge from a hospital within 7 days; or resides in a basic care facility; or resides in a nursing facility if it is anticipated that a discharge to alternative care is within six months.

  5. Case management services provided to individuals in Medical institutions transitioning to a community setting. Services will be made available for up to 180 consecutive days of the covered stay in the medical institution. The target group does not include individuals between the age of 22-64 who are served in Institutions for Mental Disease or inmates of public institutions.

  6. Has long-term care need (need anticipated to exceed 30 days). Document the required long-term care need on the Application for Services, SFN 1047. The applicant or legal representative must provide a describable need that would delay or prevent institutionalization.

The applicant or referred individual must agree to a home visit and participate in the assessment and person-centered planning.


Activities of Targeted Case Management


2-Person Centered Plan Development

3-Referral and Related Activities,

4-Monitoring and Follow-up Activities

(Details outlined in section- HCBS Case Management - Service Activities, Standards of Performance, and Documentation of HCBS Case Management Activities)


Case management does not include direct delivery of services such as counseling, companionships, provision of medical care or service, transportation, personal care, homemaker services, meal preparation, shopping (this is not an all-inclusive list).


Case file documentation must be maintained:

  1. In a secure setting

  2. On each individual, in separate case files


HCBS Case Management - Service Activities, Standards of Performance, and Documentation of HCBS Case Management Activities


HCBS Case Management Service consists of the service activities or components listed below.

  1. Assessment of Needs - This component is completed initially and at least every six months thereafter. At least one home visit is required during the initial assessment of needs process.


Exception: In cases where the HCBS referral is initiated through ADRL Transition or MFP Transition Services by Money Follows the Person (MFP) and HCBS Case Management, the HCBS Case Manager may follow the established timeline of MFP Transition Coordination.

Individuals must sign and be given a “Your Rights and Responsibilities” brochure DN 46 annually and a signed copy of this must be kept in the individual's file.

During the assessment process, when applicable, the information needed for submission to Maximus is obtained. The case management entity must use the existing and established procedures for requesting a level-of-care determination from Maximus.  


For an adult (at least 18 years of age): Complete the HCBS comprehensive assessment and gather input from other knowledgeable persons as authorized by the applicant/individual.


For a child (under 18 years of age): Complete the HCBS Comprehensive assessment AND submit the necessary documents to Maximus for a level-of-care determination.


The following service combinations require approval by the HCBS Program Administrator as indicated in the chart below;


Approval Description Frequency
Hospice Pre-approval is not needed. However, the combination of HCBS services and hospice service requires documentation in the case note that the individual continues to meet eligibility for the service and there is no duplication of services. The hospice service must also be noted on the "other community-based services" section of the person-centered plan. For MSP-PC cases only: The following information must also be sent to provider enrollment: · name of the individual, · ND number, · date hospice started, · provider name, · provider number, · document in the email assurance that the hospice plan is on file (the hospice plan must be kept in the individuals HCBS file.) One-time
FPC Approval is needed when the Family Personal Care provider is a legal spouse or legal guardian. Include name, county, name of proposed provider, and why the person acting as the FPC provider is in the best interest of the individual. One-time
Out-of-state care If you are seeking to continue to authorize services for an individual while they are out of state: Include name, county of residence, funding source, description of situation for consideration, including whether medical treatment is being sought out of state. Each instance
FHC/FPC combined w/ any other service other than Respite Include name, county of residence, funding source, why the additional service is needed and/or cannot be provided by FHC or FPC provider. One-time
Chore When the cost of chore labor is over $500/month, or to approve specific tasks such as professional sanitation, floor care of unusual nature, etc. per policy. Include name, county of residence, funding source, description of need, task, provider, frequency, cost estimate. Each instance
Residential Habilitation or Community Support Include name, county of residence, ND number, medical diagnoses, a description and breakdown of all tasks needed, and the number of units needed on average each day or in one month. One-time, changes
Nurse Education/EPCS Include name, county of residence, funding source, medical diagnoses, list of medications, list of medical tasks needed. Each instance
Environmental Modification Must have prior approval for all. Include name, county of residence, funding source, and description of request. Once approved to proceed, include copy of written recommendation by professional to ensure modification will meet the needs (if cost over $500), name of who owns/rents home, current value of home if owned, bids, and proposed dates of services. Each instance
2-person assist If more than one provider is needed to complete a service or task, include the name, county of residence, funding source, and description of need – why one provider is unable to safety complete the service or task. Initial, every 6 months
MSP Level C Include name, county of residence, description of need/functional status, number of personal care units/and assurance that no units are authorized for l/s/h Initial, every 6 months
Respite when primary caregiver does not reside w/ recipient Include name, county of residence, funding source, and explain why respite care is appropriate (example: the primary caregiver provides frequent on-site visits throughout the day which is essential to allow the individual to live independently). Annual
Respite Care provider who resides w/ recipient Include name, county of residence, funding source, and explain why it is appropriate for the live-in caregiver to be authorized to provide respite care. Annual
Case remaining open when recipient in NH for over 3 months Include name, county of residence, funding source, date of nursing home admission, and information related to pending discharge plans back into the community/receipt of HCBS. Annual
Exceptions to services/ combinations/ situations not otherwise listed Include name, county of residence, funding source, services, and detailed description of the request for approval. If a reasonable modification request, include the age of the individual, whether they would reasonably meet LOC, if they are on Medicaid or at risk of being on Medicaid, and why the approval would assist in preventing institutionalization/possible detrimental outcomes of not approving the request. As needed depending on request


If the individual referred to HCBS appears to potentially meet the criteria for ID/DD waiver, the case manager may contact an HCBS Program Administrator to request an interdisciplinary team staffing to determine the options available to meet the individuals request for services.


  1. Person-Centered Planning

Person-Centered Planning (PCP) is a way of thinking about a person as a whole. PCP is a way to develop a plan using both formal and natural supports to address all areas that are important to the individual. PCP is a process, not a procedure or document. HCBS case management has been utilizing PCP with the current assessment and care planning process. Utilizing the Charting the LifeCourse (CtLC) framework allows HCBS to enhance our PCP practices by really focusing on what matters to the individuals, what the individuals need to live the life they want and how they can be supported to meet their needs. PCP encourages community integration and recognizes the individual’s preferred role in the community. The case manager assists the individual to overcome barriers that prevent them from living their best lives in the most integrated setting appropriate.


The purpose of person-centered planning is to identify, arrange, and maintain the supports and services necessary to meet the individual's needs in the most integrated setting, consistent with the member's informed choice as appropriate to the individual’s needs.


Person centered plans will be developed with input at a minimum from:

  1. The individual to the fullest extent possible, including when the member has a legal guardian, consistent with state law N.D.C.C. 30-1-28-12. The individual will have the primary role in developing the person-centered plan when possible.

  2. The individual's family and/or friends with permissions and desire of the individual; and

  3. The individual's legal guardian, where applicable, to the extent the guardianship order confers residential and/or medical decision-making upon the guardian per N.D.C.C 30.1-28-04(5).

Any decision(s) made by the guardian about where the member will receive services should reflect the member’s preferences, as documented in the person-centered plan, to the fullest extent possible. See N.D.C.C. 30.1-26-01(3).


Case managers should facilitate a process to resolve conflicts that arise during the person-centered planning process if the individual and their family/natural supports or guardians do not agree on where the individual should live and receive services.


Role of Case Manager in Person-Centered Planning

The role of the case manager in the PCP process is to lead and facilitate conversations with the individual requesting or receiving home and community-based services. Person-centered planning is a way of developing a care plan that takes all aspects of what is important to an individual into consideration. The role of the case manager has four components.


  1. Request for an assessment/reaching out for services.

The role of the case manager during this phase is to gather information. Identify who is most important to the person and who they would like to be on their team. Discuss with the individual what your role is as a case manager and what you will be discussing at the home visit. Invite them to ask friends, family or other supports to be present at the assessment if they would like. An individual may wish to invite their QSP to the assessment planning process to ensure an understanding of what services are needed and the preferences of the individual. Remind the individual of the sensitive information that you will be discussing at the visit.

  1. Assessment

The case manager will engage in facilitated discussion with the individual requesting services. The case manager utilizes the HCBS Comprehensive Assessment, the Vision Tool and the Risk Assessment and Health and Safety Plan with every individual initially, annually, at six-months and when there are significant changes. When a case manager is completing the assessments and vision tool the individual may be asked to provide information about themselves, such as what is important to the individual, are there community supports or other formal supports that they are involved in? What roles does the individual have in life, such as do they identify as a friend, mother, grandmother, employee, friend, church member, quilter, wood carver, card player, veteran? How can the case manager support the individual to continue in their role? Through these conversations you will be discussing the life domains that are identified in the Charting the LifeCourse Vision tool. Additionally, the financial assessment and caregiver assessment may need to be completed.


The case manager must document in the assessments and vision tool the exchange of information between the individual and the case manager. Additionally, collateral information from the individuals care team may be included. If an individual does not wish to discuss information or questions in the assessment or vision tool, the case manager must document in that area the individuals wish to not answer the questions or discuss the topic.


For each functional impairment identified the functional assessment note must include:

If the need is met through HCBS, the functional assessment must also include the following information:

  1. Developing the plan

Case managers will use the information gathered through the assessment process to coordinate with the individual and team members on an action plan that meets the needs of the individual and reflects their preferences. The plan will be reviewed and updated at least every 6 months, upon individual request, or as situations arise. The PCP of care is based off of the facilitated discussion. Components of the person-centered plan of care includes the Charting the LifeCourse, (CtLC) Vision tool, formal and natural supports, strengths, barriers, unmet needs, services offered and declined, timelines and strategies to meet the individual’s goals. Additionally, the Risk Assessment and Health and Safety Plan must be completed.


For Medicaid Waiver, Service Payments for the Elderly and Disabled, Expanded Services Payments for the Elderly and Disabled and Medicaid State Plan – Personal Care Services the following procedures for the person-centered plan of care applies:


The person-centered plan of care (PCP) includes the Vision Tool, Person-Centered Plan of Care (SFN 1265), the preauth in Therap and the Risk Assessment and Health and Safety Plan (SFN 1267). Additionally, the plan may include the caregiver assessment, transition plan (SFN 1266), and/or the Individual Program Plan.

When completing the person-centered plan of care the case manager will refer to the functional assessment section of the HCBS Comprehensive Assessment to review and discuss with the individual the services and scope of the tasks (limits to the tasks) that can be provided through HCBS. The discussions on services may require gathering additional information as follows:

The HCBS Case Manager must review with the individual or the individual's representative the following information about qualified service providers (QSP) available to provide the service and endorsements required by the individual:

  1. Name, address and telephone number of QSP.

  2. Whether QSP is an agency or individual.

  3. The unit rate per QSP.

  4. If applicable, limitations of the QSP available.

  5. If applicable, endorsements for specialized cares:

  6. Global Endorsements (Only a QSP who carries a global endorsement may provide these activities and tasks. Refer to the QSP list to determine which global endorsements the provider is approved to provide.) Global Endorsements include: Cognitive/Supervision, Exercises, Hoyer Lift/Mechanized Bath Chair, Indwelling Bladder Catheter, Medical Gases, Prosthesis/Orthotics/Adaptive Devices, Suppository, TED Socks, and Temperature/Blood Pressure/Pulse/Respiration Rate.

Qualified Service Providers who can provide the required care and whom the individual has selected will be listed on the ICP, SFN 1467 or the SFN 404.

The service, amount of each service to be provided, the costs of providing the selected services, the specific time-period, and the source(s) of payment are recorded on the SFN 1265 or web-based version of the SFN 1265 and PreAuth.

Contingency plans

  1. Contingency planning must occur in all person-centered plans of care. The backup provider or plan must be listed on the SFN 1265 or web-based version of the SFN 1265.

The case manager must review with all individuals and/or the individual's representative the individual stated goal. The goal must be recorded as part of the Person-Centered Plan of Care, SFN 1265. The individual goals must be reviewed and updated annually, every 6 months and as significant changes in the individual's needs occur or if the individual requests an update.

The final step in Care Planning is to review the completed SFN 1265 or web-based version of the SFN 1265, with the individual/legally responsible party and obtain required agreements/acknowledgments and signatures.

When services are reduced, you must provide the individual or their legal representative.


In situations where the individual has requested the reduction in services, they may sign a statement requesting the services be reduced. This request must be kept the individual’s record, and the reduction in service citation is not required.


Interim Care Plans

Interim care plans are limited to individuals who receive services though the HCBS Medicaid Waiver and require services immediately, or who are affected by a natural disaster or other emergency.  An interim care plan may be developed for an individual who is on Medicaid, has an approved Level of Care (LOC) Determination that was completed within the previous 90 days, and the case manager is unable to complete an immediate visit. When services are needed immediately the case manager will need to complete a face-to-face visit and complete an assessment within 10 working days of the request. During natural disasters or other emergencies, a face- to- face visit must be made within 60 days of the request. Prior approval from the Department is required.

Medicaid eligibility redetermination is completed by Economic Assistance. An individual who is receiving service through the HCBS Waiver is required to be receiving Medicaid. If, in the redetermination process, it is determined the individual is not eligible for Medicaid, payment for services stops the day Medicaid terminates. If the individual has an established ICP and Authorization and the termination is overturned, waiver services could be paid during that period of time.

  1. Implementation/Review

The case manager's role during implementation is to educate others in the team about the possibilities of long-term services and supports, facilitating planning now and into the future, problem solving, coordinating integrated services and supports, conflict resolution and advocacy (CtLC, 2020). The case manager is responsible for assessing and authorizing services offered under Aging Services in addition to working collaboratively other formal and natural supports. It is important to understand the role of the case manager in relation to the other team members involved in the individual’s care. Open discussion surrounding the roles of the team members should be included in the care planning meeting and implementation planning process. It is helpful to clearly define the roles of each member and write a list of tasks that team members are responsible for in the implementation of the plan. The case manager is responsible for monitoring the plan for progress and any changes in the individual's care needs.

Continuum of Care

In order to coordinate services for an individual, case managers may need to make referrals and gather other collateral information. Not all communication requires a release of information. For example, Case Managers can share individual information with health care professionals working in these following settings: Home Health Care, Hospitals, Clinics, PACE, and LTC facilities as this communication is part of the continuum of care guidelines under HIPAA. Case Managers can also share information with other case management entities (i.e. DD, VR, Behavioral Health) within the Department of Human Services, as well as Eligibility Workers under the Medical Services Division. Information shared without a release of information must be on a need-to-know basis to coordinate care for the individual, disclosing only the minimum necessary amount of information pursuant to 45 CFR 164.502(b). Disclosure of information related to Psychological or Substance Abuse Treatment requires that the individual sign a Release of Information.

  1. Implementing the Person-Centered Plan of Care - The Case Manager assures that services are implemented, and existing services continued as identified in the person-centered plan of care. This activity includes contacting the QSP and issuance of a Preauth.

  2. Monitoring - Service monitoring is an important aspect of case management and involves the case manager's periodic review of the quality and the quantity of services provided to service recipients. The Case Manager monitors the individual's progress/condition and the services provided to the individual. As monitoring reveals new information to the Case Manager regarding formal and informal supports, the care plan may need to be reassessed and appropriate changes implemented. The case management entity is responsible to monitor the service plan and individual's health and welfare. If the individual’s care needs cannot be met by the care plan and health, welfare, and safety requirements cannot be assured, case management must initiate applicable changes or request a team staff meeting through the HCBS Program Administrator to discuss possible terminate termination of services. If the case is closed, the individual is made aware of their appeal rights (see Closures, Denials, Terminations, and Reductions in Services 525-05). The case manager shall document all service monitoring activities and findings in the individual's case file.


  1. The HCBS Case Manager must contact the individual after the first 30 days from the initial care plan implementation. This may be via phone or face-to-face. (If the individual is unable to communicate via telephone, a face-to-face visit is required.) The purpose of this contact is to follow up on the implementation of the person-centered plan of care (PCP), ensure the individual’s needs are met and ensure the scope and amount of services authorized are provided.

  2. The HCBS case manager shall monitor the services provided under the PCP on an as needed basis but not less than direct individual contact at least once every three months for Medicaid Waiver, MSP level B and MSP level C.
  1. Residents of basic care facilities under Basic Care Assistance Program must have an initial and annual HCBS Comprehensive Assessment and completion of the SFN 662.

  2. Monitoring contacts and reassessments may be required if there is a change in the individual’s condition or critical incident report (CIR) that requires a follow up to ensure health and safety of the individual.

  3. Monitoring for Abuse, Neglect, or Exploitation: When completing monitoring tasks, if the case manager suspects a Qualified Service Provider or other individual is abusing, neglecting, or exploiting a recipient of HCBS, the following protocol is to be followed by the HCBS Case Manager:

In all situations:

  1. Initiate a formal VAPS (Vulnerable Adult Protective Services) referral according to ND Century Code 50-25.2-03(4).

  1. Notify the HCBS Program Administrator responsible for complaint resolution in writing of all actions taken to follow up on a suspected case of abuse, neglect, or exploitation of an HCBS recipient.

  2. The Risk Assessment and Health and Safety Plan (SFN 1267 or online equivalent) may need to be updated and reviewed in the following circumstances.


Documentation for an event involving abuse, neglect, exploitation, CIR, QSP complaint or VAPS must be included in the case note and include the following:


Process specific to the individual's living arrangements, individuals implicated, or the Provider type (all incidents/actions must be reported to the Aging Services Program Administrator):

  1. Individual lives in his or her own home and the qualified service provider is an Individual or Agency enrolled QSP:

If you can document that no immediate risk exists, but a problem requires further action, work with the recipient and other interested parties to resolve the matter as soon as possible.

Notify the Ombudsman Program Administrator, Aging Services Division


The North Dakota Department of Health Facilities.

Notify the Ombudsman Program Administrator, Aging Services Division


The DHS Program Administrator responsible for Assisted Living Licensing.

File a report with law enforcement and/or Adult Protective Services as indicated by the seriousness of the allegation.

Contact the HCBS Case Manager responsible for AFC licensing,


Contact the Aging Services Division Program Administrator.  

The Department of Human Services may remove a Qualified Service Provider from the list of approved providers if the seriousness and nature of the complaint warrants such action. The Department will terminate the provider agreement with a Qualified Service Provider who performs substandard care, fraudulent billing practices, abuse, neglect, or exploitation of a recipient. North Dakota Administrative Code section 75-03-23-08 lists reasons why the Department may terminate a Qualified Service Provider.

  1. Reassessing - The case manager reassesses the individual, care plan, and services on an ongoing basis, but must do a reassessment at six-month intervals and the comprehensive assessment annually. At the six month and annual visit, the individual stated goal must be reviewed, and progress or continuation of the goal must be noted in the narrative of the vision tool.

  2. Termination of Service - When documenting that service(s) on the Individual Care Plan or the Person-Centered Plan of Care were terminated, and indicating the reason(s) for termination, refer to Closures, Denials, Terminations, and Reductions in Services (525-05-40) unless the individual is requesting services to be reduced. In situations where the individual has requested the reduction in services, they may sign a statement requesting the services be reduced.


Contacts with Individuals




All required contacts must include responses to the following questions:

Reimbursement/Payment for Service

The Case Management Entity may bill for case management if the individual meets the eligibility criteria of the programs as identified in HCBS Case Management - Service Activities, Standards of Performance, and Documentation of HCBS Case Management Activities.


Request for reimbursement must be supported by documentation in the individual’s case file and/or web-based case management system that case management service activities were completed.


When a change in funding source occurs, initial Case Management can be claimed under the new funding source the month of transfer (opening under new funding). The annual case management cycle starts with this action. No claim for case management can be made to the funding source being closed. Initial case management is allowed to establish the case under the new funding source.  


A higher rate is used for higher-level case management for individuals eligible for Medicaid Waiver for Home and Community Based Services.


Administrative Tasks (Non-billable)

Any task or activity that is not directly related to the following cannot be billed as case management; person-centered planning and coordination; assessment or reassessment of an individual; development, implementation, or monitoring of a care plan. Administrative tasks such as those listed below are examples of non-billable activities:

  1. Assisting a provider with billing issues or enrollment; participating in appeal hearings; attending training or staff meetings; supervising/scheduling of In-home Care Specialists, etc.  


Level of Care Determination (LOC)

It is the responsibility of the HCBS case manager to initiate the screening either by submitting information to Maximus.


A LOC determination/screening must be completed for an individual who is requesting services through a waiver program, or an individual who under the age of 18 and requesting SPED services, and MSP-PC Level B or C. LOC determinations must be updated as significant changes occur that would impact the LOC determination outcome and at minimum on an annual basis. Following are the screen types listed on the LOC Determination Form.

For the purposes of opening/re-opening or prematurely closing a HCBS screening, see the instruction for the SFN 474.


No screening will be needed if Waiver Services are re-implemented within 90 days of the individual's discharge from the nursing home or swing bed and prior to end date of the LOC of the current HCBS screening.


Upon completion of LOC determination, Maximus will submit to the Aging Services Division a list of the recipients, with the approval or effective date of eligibility, ID Number, and date of birth. This information will then be entered on the Nursing Home Eligibility file in the payment system. DDM will also send written confirmation of HCBS (NF) determination to the HCBS case manager for filing in the individual's record.


When an HCBS individual screened for Medicaid Waiver services appears to no longer meet nursing facility (NF) care (Screen Type: HCBS), a re-screening should occur. A significant improvement in the recipient's medical/physical status or a decrease or cessation of services provided are examples that could trigger a re-screening. Maximus needs to be informed of the reason for the screening and intended outcome to "othIFer." If Maximus concurs the recipient no longer needs NF care, an ending date of services needs to be given to Aging Services by using the SFN 474, to Aging Services/HCBS. The ending date is the responsibility of the case manager and needs to allow sufficient time in which to give the individual a ten-day (calendar days) notice of service termination under the Medicaid Waiver funding source. Maximus will report screening terminations with closing dates to Aging Services. Aging Services will input the ending date of services on the computerized screening.


Nursing Facility (HCBS) Level of Care Determination But The Individual Is Not Receiving Waiver Services

The stop date on the screening is important for Medicaid recipients having a spouse in the household who qulify for spousal impoverishment. The recipient is treated, for Medicaid budgeting purposes, as if living in the nursing facility only when RECEIVING services paid by the Waiver. If an individual is residing in their home, receiving spousal impoverishment under Medicaid, they must receive a Medicaid Waiver service each month to remain eligible under the spousal impoverishment guidelines. If Waiver funded services are NOT provided, the screening must be "closed" so that the correct budgeting method is reflected in the Medicaid data system. Submit SFN 474, HCBS Case Closure/Transfer Notice, so a closing date is entered in the Medicaid data system.


Case File Contents

  1. For all programs, all case files, or in the web-based case management system should have (at a minimum):
  1. Application for Service SFN 1047

  2. A signed copy of Your Rights and Responsibilities brochure (DN 46)

  3. Preauth for Medicaid Waiver, SPED/Ex-SPED, and MSP (updated every six months)

  4. Monthly Rate Worksheet (if applicable)(SFN 1012 updated annually)

  5. HCBS Notice of Denial or Termination SFN 1647 (if applicable)

  6. HCBS Case Closure/Transfer Notice SFN 474 (if applicable)

  7. A end dated or deleted Preauth (if applicable)

  1. The case file for each Medicaid Waiver individual must contain:
  1. Documentation of verification the person is a Medicaid recipient

  2. Medical information (if applicable)

  3. Record of current level-of-care determination(s) (updated annually)

  1. The case file for each Expanded SPED individual must contain:
  1. Expanded SPED Program Pool Data SFN 56

  2. Add New Record to MMIS Eligibility File, SPED and ExSPED, SFN 676

  1. The case file for each SPED individual must contain the:
  1. SPED Program Pool Data SFN 1820

  2. Add New Record to MMIS Eligibility, SPED and ExSPED, SFN 676

  3. SPED Income and Asset SFN 820, (updated annually)