Expanded Service Payments for the Elderly and Disabled Eligibility (ExSPED) 525-05-25-25

(Revised 7/1/21 ML #3628)

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Eligibility for the Expanded SPED Program has two components: financial/Medicaid eligibility and functional eligibility. The applicant/individual must meet BOTH eligibility components before payment can be made by the Department under this Chapter.

1. Functional Eligibility, ExSPED Program

1. Is at least 65 years of age, OR is at least 18 years of age and disabled or blind based on Social Security criteria. N.D.C.C. 50-24.7-01(5)(b);  
2. Is not severely impaired in ANY of the three activities of daily living (ADLs): Toileting, Transferring to or from a bed, chair or toilet, or Eating as determined by completion of an comprehensive assessment.
3. Is impaired in at least three (3) of the following four (4) instrumental activities of daily living (IADLs): Meal Preparation, Housework, Laundry, or Taking Medicine based on completion of a comprehensive assessment. The impairments must have lasted or are expected to last, more than three (3) months.  

(Note: Or has health, welfare, or safety needs, including a need for supervision or a structured environment, which otherwise require care in a licensed adult family foster home or a licensed basic care facility. (The services of the Expanded SPED Program are provided in the recipient’s home or community instead of care in a basic care facility.)  

4. Capable of directing own care or has a legal representative to act in their behalf.
5. Living in what is commonly considered a private family dwelling (house, apartment, or camper if the camper is located in a long term campground that rents by the month/year etc.). The renter’s living area should consist 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.  For unique circumstances, contact the HCBS Program Administrator for consideration.
6. The applicant impairment is not the result of a intellectual disability or a closely related condition.
7. Service/care need is within the scope of services available under this chapter;

2. Financial Eligibility for ExSPED

1. The first step is to have a determination of Medicaid eligibility by the Economic Assistance Unit, as an applicant must be receiving Medical Assistance in order to be eligible for ExSPED.

In addition to being eligible for Medical Assistance, the applicant must be receiving Supplemental Security Income (SSI) OR, if not, their income cannot exceed an amount equal to SSI. [N.D.A.C. 75-02-10-05(4)]. Please note that the following income is disregarded:

Recovery Rebates authorized by section 2201 of the Coronavirus Aid, Relief, and Economic Security Act of 2020 [Pub. L. 116-136].

2. Estate Recovery

Legislation passed during the 1995 session gives the Department the authority to file a claim against an individual's estate to recover payments made under the Expanded SPED Program. The Department can file a claim for all payments made since the inception of the Program in 1994.

3. Overpayment

If an individual or legal representative provides inaccurate or false information about finances, health status, and/or the ability to complete functional tasks, the Department has the authority to recoup funds. The recoupment may be for payments for services that were provided when the individual was not eligible. An overpayment may be collected from any person that benefitted from or was responsible for the overpayment. A statute of limitations or similar statute does not apply.

4. Ongoing Medicaid Eligibility

Because Medicaid eligibility is part of the financial eligibility for ExSPED, the individual’s Medicaid status will need to be verified periodically. The HCBS Case Manager should verify in MMIS that the individual continues to have an active Medicaid case as part of the regularly scheduled quarterly contacts and home assessments.

3. Expanded SPED Pool

Upon finding the applicant meets the criteria for the Expanded SPED Program through the completion of the comprehensive assessment and verification from the Eligibility worker, forward the following to the HCBS Program Administration:

• Expanded SPED Pool Program Data form SFN 56
• Add New Record to MMIS Eligibility File (Expanded SPED) SFN 676

Services must not be authorized until the HCBS Case Manager is notified the applicant was successfully removed from the ExSPED Pool. HCBS Program Administration will notify the HCBS Case Manager of the decision by forwarding a copy of the SFN 676 with the ExSPED identification number and start date recorded on the form.

Documents with discrepancies, incompleteness, or apparent ineligibility will not be entered into the ExSPED Pool and will be either returned to the HCBS Case Manager.

When HCBS Program Administration forwards the applicant’s identification number and start date to the HCBS Case Manager, the HCBS Case Manager can complete the process for implementing services.

The Department’s notification by the HCBS Program Administration is valid for 30 calendar days.  If services have not started within that time, the approval is voided.  The process for approval must start over, unless prior approval is received from the ExSPED Program Administrator.

 

If a current recipient of services has not utilized services within a 30-day period of time, a citation may be requested to terminate the case. However, if the services are expected to resume within 3 months, it is allowable for the case to remain open. This does not require approval from a Program Administrator.

 

If a current recipient enters a skilled nursing facility or swingbed, and it is anticipated that the length of stay will be 3 months or less, it is allowable for the case to remain open. This does not require approval from a Program Administrator.

 

There may be times when an ExSPED case is closed due to an anticipated long-term admission to a skilled nursing facility, but the circumstances change and the individual is able to discharge back to the community. For those instances:

 

If an ExSPED recipient closes due to a skilled nursing facility or swing bed admission, and they re-open SPED within 3 months:

• A new Application for Services (SFN 1047) does not need to be completed.
• An SFN 56 does not need to be completed.
• An SFN 676 does need to be completed and submitted to HCBS/Aging Services. If all information is the same, it is allowable to use the previously approved SFN 676 and simply indicate the date the individual is to re-open in the field “Date of Application” and select “Re-Open” in the “Application Type” field.

For further instruction and examples, please reference HCBS Policy & Procedure Manual: Closures, Denials, Terminations, Reductions, and Transfer of Services 525-05-40.