(Revised 5/1/19 ML #3515)
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Purpose: To provide evidence an applicant is eligible for the Service Payments for the Elderly and Disabled (SPED) program. This form, SPED Program Pool Data, SFN 1820, is forwarded to the Aging Services Division, along with the Add New Record MMIS Eligibility File, SFN 676, in order to enter the applicant into the SPED pool and to assign a recipient identification number.
Steps of Completion:
Name: Complete the name of the applicant
Social Security Number: Enter applicant’s SSN
Does the Person Live Alone: If the person lives alone or has minor children or the other family member(s) in the house that are physically or mentally unable to assist the client, check "yes".
ADLs: Based on the functional assessment, transfer the scores from the assessment document to the applicable score box. ADLs scored in this section include bathing, eating, mobility inside, transfer bed/chair, dressing, toileting, and continence.
The scoring criteria for ADLs is as follows:
0 = completely able
1 = able with aids/difficulty
2 = able with help
3 = unable
IADLs: Based on the functional assessment, transfer the scores from the assessment document to the applicable score box. IADLs scored in this section include meal preparation, communication, laundry, taking medication, shopping, mobility outside, transportation, housework, and management of money.
The scoring criteria for IADLs is as follows:
0 = without help
1 = with help
2 = unable to do at all
If the applicant is eligible for the SPED program, the following criteria must be met:
Impaired (score is 2 or 3) in at least four ADLs
OR
Impaired (score is 1 or 2) in at least five IADLs totaling eight or more points or if living alone, totaling six points.
For SPED Personal Cares Only: Record the estimated amount of SPED Personal Care Service and provide an explanation why the applicant is not medical assistance eligible and seeking Medicaid State Plan Personal Care Services.
Case Manager: Record the HCBS Case Manager’s name.
County and County Number: Record the county in which the client resides and the county number.
Client Participation Fee: Record the applicant’s percentage portion of the cost of services as determined by the SPED financial eligibility criteria. This percentage will be found by completing the SPED Income and Asset Form (SFN 820). This percentage must match the percentage on the “Add New Record to MMIS Eligibility File” (SFN 676).
The original is to be filed in the applicant’s case file. A copy must be sent to Aging Services/HCBS.
An electronic copy is available through the state e-forms (SFN 1820).