(Revised 7/1/15 ML #3460)
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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 Medical 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.
Social Security Number: Enter applicant’s SSN
Check Here if Person Lives 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 the box.
Last/First Name: Print the name of the applicant
Birth Year/Birth Month/Birth Day: self-explanatory
Sex: If the applicant is a male, record a 1 in the box; if female – record a 2.
ADLs: Based on the functional assessment, transfer the scores from the assessment document to the applicable score box. If the applicant is eligible for the SPED program based on ADLs, the applicants ADL score fields will reflect a minimum of 4 impairments (which means the applicant must have four activities with a score of 2 or 3 recorded in the boxes).
OR
IADLs: Based on the functional assessment, transfer the scores from the assessment document to the applicable score box. If the applicant is eligible for the SPED program based on IADLs, the applicants IADL score fields will reflect a minimum of 5 impairments (which means the applicant must have five activities with a score of 1 or 2 recorded in the boxes). In addition, the individual’s scores must have a minimum score of 6 if the Live Alone box is checked or a minimum score of 8 if the Live Alone box is not checked.
Cost of Service Estimated Monthly Dollars: Record the estimated dollar amount per service that will be anticipated as an authorized service.
Note: Personal Care Service – record the estimated amount of SPED Personal Care service and record the reason why SPED Personal Care service will be authorized as opposed to the Medicaid State Plan Personal Care service. This will be recorded in the section at the bottom of the form.
Case Manager, County Number: Record the Case Manager’s name and County.
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).
The form, SFN 820, is not available from the state office. It is available through the state electronic e-forms. Click here to view and/or print.