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(Revised 1/1/10 ML #3214)
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Purpose: The Monthly Rate Worksheet, SFN 1012, is used by the Case Manager to determine the daily rate of payment for live in, 24 hour care. This is to be completed and forwarded to Medical Services/HCBS on an annual basis regardless of a change.
SECTION I: IDENTIFYING INFORMATION
Complete the individual’s name, the Case Manager’s name, date the assessment is completed, individual’s county of residence, the individual’s Medicaid number, the effective date of the rate as determined on the rate worksheet, and the SPED/ExSPED identification number.
Note: Any change in the rate becomes effective the first day of the following month. For example, if the Monthly Rate Worksheet is completed based on an assessment dated April 12, 2006, the rate change becomes effective with services delivered beginning May 1, 2006.
SECTION II: ASSIGNMENT OF POINT VALUE(S)
For each task that needs to be performed for the individual (as identified in the functional assessment) assign the associated point value in the appropriate service column.
Note: The point values of the tasks cannot be less or more than the pre-recorded point value. For example, in Bathing, individuals will receive 20 points if they need this assistance. No one would receive a point value greater than 20 if they need greater help or less than 20 if they need less help.
Exception (only applies to SPED personal care): If a provider is caring for more than one client in the home, some of the point tasks could be shared by the clients. For example, if there are two SPED personal care clients in the provider’s home, the housekeeping point value of 10 would be shared by the two clients (or each client would receive only 5 points each).
Effective January 1, 2010 full point values for laundry, shopping and housekeeping can be used to calculate AFFC rates for each AFFC private pay residents. The points for these tasks no longer need to be split between residents.
When point values have been assigned, the form will automatically sum up the points in the column and record the sum in Total Points row (applicable to the authorized service).
Note: The description for the task of supervision on the MRW.
SECTION III: RATE CALCULATION
When using the electronic MRW, a portion of the first area of Section III will automatically fill in the figures through the Unit Rate.
If the calculated rate exceeds the funding source maximum record the maximum rate in the column marked unit rate.
SECTION IV: PROVIDER INFORMATION
Enter the provider’s name, number, and mailing address in the space provided. In most instances, the provider will already have been assigned a Qualified Service Provider Number. Enter the provider’s number in the space provided.
DISTRIBUTION
File the original copy in the applicant’s/individual’s case record. Mail a copy to the Medical Services/HCBS within 3 days of completion.
This form is not available from the state office. It is available electronically through the state e-forms. This form should be completed online to assure the rate is calculated accurately.