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(Revised 4/1/12 ML #3325)
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In order to be determined eligible for the SPED program, the HCBS Case Manager must submit documentation for applicant to be entered into the SPED Pool maintained by the HCBS Program Administration.
The county social service board where the person physically resides must submit a completed SFN 1820, SPED Program Pool Data, and an SFN 676, Add New Record to MMIS Eligibility File. The information contained in the forms must be based on the completion of the comprehensive assessment.
In addition, the Case Managers must transfer the information from the form SFN 820 into the Income and Asset assessment in SAMS on each person for whom funding is being sought under the SPED Program. Only those persons who meet ALL of the following criteria are eligible for entry into the SPED Program Pool. Only those persons who are found eligible and have the SFN 1820 and SFN 676 forwarded to HCBS Program Administration will be pulled from the SPED Pool. Any documentation received incomplete or incorrect will not be entered into the weekly SPED Pool.
The HCBS Income and Asset assessment must be completed in SAMS within 10 working days of the individual’s SPED eligibility date.
- The individual is either functionally impaired in at least four (4) ADLs, OR in at least five (5) IADLs totaling eight (8) or more points (if living alone - totaling six (6) points).
- The impairments must have lasted or can be expected to last three (3) months or more (must be noted in the comprehensive assessment narrative of the source of the evidence).
- The applicant/client must have functional impairments due to a disability which are not the result of a diagnosis of intellectual disability or a related condition or mental illness.
- The individual is living in North Dakota in what is commonly considered a private family dwelling (house or apartment). In the latter, the renter’s living area consists of a bedroom with or without bath and possibly a sitting area. Congregate/group meals may be available or meals may be eaten off site.
- Capable of directing their own care or have a legal representative to act in their behalf.
- The individual would receive one or more covered services, in addition to Case Management, in accordance with Department policies and procedures for the specific service.
The applicant has a functional impairment to indicate eligibility.
The applicant’s functional impairment has lasted, or can be expected to last, three months or longer.
The applicant’s functional impairment is not the result of a mental illness, intellectual disability, or a closely related condition.
The applicant is living in North Dakota is a housing arrangement commonly considered a private family dwelling and not in an institution.
The applicant is not eligible for services under the Medicaid waiver program or the Medicaid state plan of personal care services.
The applicant would receive one or more of the covered services under department policies and procedures for the specific service.
The applicant’s parent or legal guardian agrees to the plan of care developed for the provision of home and community based services.
The applicant’s parent(s) is not responsible for one hundred percent of the cost of the covered service provided, under the SPED sliding fee scales.
The applicant’s parent(s) have not made a disqualifying transfer of assets.
The applicant is unable to regularly attend school or is severely limited in the amount of time the applicant is able to attend school.
- The individual must be screened in need of nursing facility level of care. When completing the LOC screening tool, the “HCBS/Other” check box must be completed.
- For an infant under 3 months of age and requiring apnea monitoring, see the Respite Care section.
- If applying for Family Home Care or Respite Care, see the sections for additional requirements that must be met.
- SPED Personal Care Service is not available for those under age 18.
- Parents are not eligible to be the paid service provider unless prior approval is granted by the HCBS Program Administrator.
Real property (e.g. land or farm) is NOT included in the asset resource determination. However, the income produced by the real property is considered when establishing the applicant’s/client’s share of the cost of services. If the client has real property from which income is NOT being received AT THEIR DISCRETION and the applicant/client continues that arrangement, the income that should have been received must be included in determining the client’s fee-for-service participation level.
State law requires that the client pay for services in accordance with a fee scale based on family size and income. The county social service board must use SFN 820, SPED Income and Asset form, to obtain the information needed to establish the client’s share of the costs.
SPED and Medicaid Eligible
It is not necessary that every SPED Program applicant/client make application for Medical Assistance. During completion of the comprehensive assessment; sufficient information may be obtained to determine whether their assets exceed Medicaid limits. Nor is screening for level-of-care mandatory for all Medicaid recipients. The HCBS Case Manager must note in the case file why the applicant or recipient is not considered eligible for medical assistance or would not meet nursing facility level-of-care or be eligible for Medicaid State Plan (Personal Care). If the service that is being requested is a non-Medicaid Waiver or State Plan service, the applicant/client is not required to apply for Medicaid.
The HCBS Case Manger’s first action is to find out if the applicant/client is eligible for Medical Assistance; and, if there is a community spouse, if spousal impoverishment applies. This requires the involvement of an eligibility worker. At the same time the eligibility worker is determining Medicaid eligibility, the HCBS Case Manager should determine service need and provider availability.
If an immediate need for service(s) exists, SPED service(s) can be authorized for eligible clients pending determination of Medical Assistance. If it is found that the person does NOT meet eligibility under the Medicaid State Plan services, but does meet SPED Program eligibility, the effective date of the SPED Program will be established to cover those service costs (within the limits of the SPED Program).
When it appears the applicant/client may be eligible for Medical Assistance, choosing not to apply for Medical Assistance is the applicant’s decision. The applicant/client is NOT eligible for the SPED Program as a result of refusal to apply for Medicaid or other federal funded programs. If the applicant/client’s financial resources are determined by the Case Manager to exceed eligibility requirements for Medicaid, the applicant/client is not required to complete the Medicaid application. If the Case Manager is unsure if the individual will meet Medicaid eligibility, the applicant/client must request a financial review by the Economic Assistance financial eligibility worker prior to application.
If the applicant/client was closed due to not meeting recipient liability (after summing the medical expenses, plus the case management, plus Medicaid State Plan Personal Care Services) then the individual may receive SPED Personal Care Services if found eligible through the SPED program.
Service Fee, SPED Program
With the completion of the SPED Income and Asset form, SFN 820, and by using the sliding fee schedules, the HCBS Case Manager will determine if a client participation fee percentage will be assessed to the service costs. The participation fee is applied to not only the direct services, but can also apply to HCBS Case Management.
Financial eligibility is not complete until the applicant/client has signed the SFN 820 indicating the acceptance of the accuracy of the information and service fee. If the service fee is not recorded correctly, the applicant/client must be required to sign a corrected page prior to the individual entering the SPED Pool.
Income Verification Method
An income verification method will be used for the client to indicate family income in all cases. HCBS Case Management staff will review a copy of most recent pay check stubs, bank statements and/or income tax forms to verify the client's income. If a client does not supply the documentation, the individual is not eligible to receive or continue SPED services.
All income, assets, and deductions must be verified by the case manager's review of the documents. Case file documentation must contain confirmation they have verified the information for financial eligibility. If the applicant/client is receiving Medicaid services, the HCBS case file may cross reference in the file that the verification can be found in the Medicaid eligibility case file.
Financial Status And Family Size Review
The client's family adjusted gross income and family size shall be reviewed at least every twelve months. In addition, a redetermination shall be made any time a significant change occurs in a family's income or size.
If an applicant/ recipient has a spouse who is residing in the NH and is receiving MA assistance under spousal impoverishment rules, consider the spouse requesting SPED services as living in a household of one for both functional and financial eligibility because the institutionalized spouse’s income has already been deemed to the community spouse. If a spouse is receiving services under the Medicaid Waiver and lives in the home with the applicant/ recipient requesting SPED services consider it a one person household for functional eligibility and a two person household for financial eligibility because the spouse is still responsible to pay for room, board etc.
If the fee schedule changes, the rate charged will be determined at the next visit. The redetermination fee will not be applied to services delivered prior to the date of redetermination. When the service fee changes, the fee will become effective the first day of the following month when the change was identified.
Financial Disclosure
Each applicant/client must provide full financial information upon initial assessment or redetermination, every twelve months thereafter, and at such time that the client s family income or size changes significantly. Clients not providing full financial information will be billed the full service fee.
An applicant/client who refuses to complete SFN 820, SPED Income and Asset form, will not be eligible for the SPED Program.
Individual Fees Charged For Services
Each family member who receives a service for which a fee is assessed shall be charged the fee for that service, in accordance with the billing schedule.
Service Fee Changes
Once services have been established and there is a change to the service fee, the HCBS Case Manager, must notify the HCBS Program Administration by submitting an SFN 676 when a change in the client’s income results in changes in the client’s service fee. The change in fee is effective the first of the month following the month in which the change occurred.
The individual is NOT eligible for SPED services if their service needs can be met by:
Per NDCC 50-06.2-07, a disqualifying transfer has occurred if at any time before or after making application, the individual or the individual's spouse has made any assignment or transfer of any asset for the purpose of making that individual eligible for benefits. If a disqualifying transfer has occurred per N.D.A.C. 75-03-23-14, the individual is not eligible for the SPED program. However, if all of the transferred assets are returned to the applicant, then the situation could be treated as if no transfer ever occurred.
If a disqualifying transfer occurred five years prior to the date that an individual initially applies for SPED services, the Department will presume that the transfer was not for the purpose of obtaining SPED benefits.
If assets are transferred to a child, grandchild, brother, sister, niece, nephew, parent, grandparent, stepparent, stepchild, son-in-law, daughter –in-law, or grandchild-in-law of the individual or the individuals’ spouse as payment made for goods and/or services the amount transferred must be supported by a contractual agreement signed and dated by the client before the goods and/or services were received or provided. Payment for such goods and/or services must be reasonable.
If the applicant/client is denied Medicaid based on a disqualifying transfer of assets, the SPED Program applicant/client is also ineligible for SPED Program funded services.
An individual is not considered to have made a disqualifying transfer and is not ineligible for SPED if:
A transfer is complete when the individual, or the individual’s spouse, making the transfer has no lawful means of undoing the transfer or requiring a restoration of ownership.
Contact a HCBS Program Administrator to determine if a disqualifying transfer has occurred.
Upon completion of the comprehensive assessment and the SPED Income and Asset form, AND if it is determined the applicant meets the functional and financial eligibility criteria for the SPED Program, the Case Manager will forward to the HCBS Program Administration:
In addition, the Case Managers must transfer the information from the form SFN 820 into the Income and Asset assessment in SAMS on each person for whom funding is being sought under the SPED Program.
The documents above must be received no later than 5:00 on Tuesdays to be considered for entrance into the Wednesday SPED Pool. Services must not be authorized until the County Social Service Board is notified the applicant was successfully removed from the SPED Pool. HCBS Program Administration will notify the County of the decision by forwarding a copy of the SFN 676 with the SPED identification number and start date recorded on the form.
Documents with discrepancies, incompleteness, or apparent ineligibility will not be entered into the SPED Pool and will be either returned to the County Social Service Board or will be reviewed with the County Social Service Board.
When HCBS Program Administration forwards the applicant’s identification number and start date to the County, the HCBS Case Manager can complete the process for implementing services.
At the time the person is approved for services funded by the SPED Program, the HCBS Case Manager must re-verify that the person continues to meet the eligibility criteria, develop a care plan and authorize services in accordance with HCBS Case Management.
The Department’s notification of the SPED applicant by the HCBS Program Administration is valid for 30 calendar days. If services have not started within that time, the approval is voided and an SFN 474 is completed and forwarded to Medical Services/HCBS. The process for approval must start over.
SPED Pool Exceptions
A recipient of Medicaid State Plan Personal Care, HCBS Medicaid Waiver, Technology Dependent Waiver, or Expanded SPED who becomes ineligible for services under these programs does not have to go through the SPED program pool to receive SPED services provided the recipient meets all other SPED eligibility criteria.
An individual who is discharged from an inpatient hospital stay, skilled nursing facility, swing bed facility, long term care facility, or basic care facility or who has been off the SPED program for fewer than 60 days, does not have to go through the SPED pool to receive SPED services provided the recipient meets all other eligibility criteria.
The HCBS Case Manager must include the reason for the exception and the date that SPED services should start on the SFN 676, Add New Record to MMIS Eligibility File.