(Revised 9/1/18 ML #3543)
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Purpose: In order for an individual to be enrolled in the benefit plans of SPED or Ex-SPED and to receive a client identification number, to change the service fee, to update client statistical information, or to begin applicant client eligibility for payment purposes.
This form is used to identify active SPED & Ex-SPED program recipients in the payment system. When billings are received from providers, the claim is checked against the SPED or Ex-SPED eligibility Medicaid Management Information System (MMIS) file.
This form is also used if there is a change in the statistical information such as address or corrections to the Social Security Number or birthdate. In addition if there is a change to the SPED service fee (percentage), this form must be completed and forwarded to the Aging Services Division (HCBS) along with the date of the change.
If this form is not submitted when a SPED service fee changes and it results in an over payment or underpayment to the provider the case manager must file an adjustment to correct the payment error.
Steps of Completion:
Client Information: Complete the client’s name, identification number, physical address, mailing address (if different from physical address), gender, date of birth and social security number. Record the HCBS case manager’s name, the county in which the client resides and county number.
Application Information: Select one of the following boxes: initial, rate change, address change, or re-open.
Funding Type: Select SPED or Ex-SPED.
Date of Application and Approval: The HCBS case manager will complete the date of application, which is the date of the most recent assessment (or level of care screening, if a child) was completed. The approval date will be completed by Aging Services when approved by an HCBS Program Administrator and MMIS has been updated. This field would be completed by the HCBS Case Manager only when there is an exception requested to the SPED or Ex-SPED Pool approval date.
Liability Information: This section is to be completed for SPED clients only. Record the percentage of SPED costs that is the client’s responsibility (also referred to as recipient liability, client participation fee, or client share) and the effective date. This percentage will be found by completing the SPED Income and Asset Form (SFN 820). This percentage must match the percentage on the “SPED Program Pool Data” (SFN 1820). If the client does not have a fee, enter zero. After the opening of a new case, a change in liability is effective the first of the month following the month of action.
Note: for changes to the SPED service fee, changes occur the first of the following month of the change. Dates should not include partial months.
New SPED or Ex-SPED Clients Only: This demographic section is to be completed for new SPED clients only.
For new clients, this completed form is to be emailed or faxed to Aging Services/HCBS at the same time as the SPED or Ex-SPED Program Pool Data form is submitted (SFN 1820 or SFN 56).
For rate change, address change, or to re-open within two calendar months, this completed form is to be emailed or faxed to Aging Services/HCBS.
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 676).