Service Payments for the Elderly and Disabled (SPED) 525-05-25-20

(Revised 07/01/22 ML #3687)

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In order to be determined eligible for the SPED program, the HCBS Case Manager must submit documentation for the applicant to be entered into the SPED Pool maintained by the HCBS Program Administration.

The HCBS case manager must submit a completed SFN 1820, SPED Program Pool Data, and an SFN 676, Add New Record to MMIS Eligibility File.  The information contained in the forms must be based on the completion of the comprehensive assessment.

In addition, the Case Managers must complete an SFN 820, which must be signed by the individual. Only those persons who meet ALL of the following criteria are eligible for entry into the SPED Program Pool. Only those persons who are found eligible and have the SFN 1820 and SFN 676 forwarded to HCBS Program Administration will be pulled from the SPED Pool. Any documentation received incomplete or incorrect will not be entered into the SPED Pool.  

1. Functional Eligibility for the SPED Program

1. If 18 years of age or older, must be the following:

• The individual is either functionally impaired in at least two (2) Activities of Daily Living (ADLs), OR at least four (4) Instrumental Activities of Daily Living (IADLs), totaling at least four (4) points if living alone, or six (6) points if living with an able-bodied adult.
• The impairments must have lasted or can be expected to last three (3) months or more (must be noted in the comprehensive assessment narrative of the source of the evidence).
• The applicant/recipient's functional impairments, for which SPED services are being authorized, must be due to a disability which are not the result of a diagnosis of intellectual disability or a related condition or mental illness.
• The individual is living in North Dakota 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.
• The individual must be capable of directing their own care or have a legal representative to act in their behalf.
• The individual would receive one or more covered services, in addition to Case Management, in accordance with Department policies and procedures for the specific service.

2. If under age 18, must meet the following:

• The applicant has a functional impairment to indicate eligibility.

• The applicant’s functional impairment has lasted, or can be expected to last, three months or longer.

• The applicant’s functional impairments for which SPED services are being authorized, are not the result of a mental illness, intellectual disability, or a closely related condition.

• The applicant is living in North Dakota in a housing arrangement commonly considered a private family dwelling and not in an institution. For unique circumstances, contact the HCBS Program Administrator for consideration.

• The applicant is not eligible for services under the Medicaid waiver program or the Medicaid state plan of personal care services.

• The applicant would receive one or more of the covered services under department policies and procedures for the specific service.

• The applicant’s parent or legal guardian agrees to the plan of care developed for the provision of home and community -based services.

• The applicant’s parent(s) is not responsible for one hundred percent of the cost of the covered service provided, under the SPED sliding fee scales.

• The applicant’s parent(s) have not made a disqualifying transfer of assets.

• The applicant is unable to regularly attend school or is severely limited in the amount of time the applicant is able to attend school.

• The individual must be screened in need of nursing facility level of care.  When completing the LOC screening tool, the “HCBS/Other” check box must be completed.  
• For an infant under 3 months of age and requiring apnea monitoring, see the Respite Care section.  
• If applying for Family Home Care or Respite Care, see the sections for additional requirements that must be met.
• SPED Personal Care Service is not available for those under age 18.
• Parents are not eligible to be the paid service provider unless prior approval is granted by the HCBS Program Administrator.

2. Financial Eligibility for the SPED Program

• The applicant’s resources cannot exceed a total of $50,000 in liquid assets and the value of residence(s) other than the primary residence. See instructions on completion of SFN 820, SPED Income and Asset form.  

Real property (e.g. land or farm) is NOT included in the asset resource determination. However, the income produced by the real property is considered when establishing the applicant’s/client’s share of the cost of services. If the client has real property from which income is NOT being received AT THEIR DISCRETION and the applicant/recipient continues that arrangement, the income that should have been received must be included in determining the client’s fee-for-service participation level.

Money and assets in a North Dakota Achieving a Better Life Experience (ABLE) Plan are not considered for the purpose of determining financial eligibility to receive SPED services. See SPED Income and Assets, SFN 820 (525-05-60-20) for specific eligibility guidelines.

• There is an unmet cost for the service(s); that is, the individual is not responsible for 100% of the costs of services delivered.

State law requires that the individual pay for services in accordance with a fee scale based on family size and income. The HCBS Case Manager must use SFN 820, SPED Income and Asset form, to obtain the information needed to establish the individual’s share of the costs.  

• The individual has not made a disqualifying transfer of assets.

SPED and Medicaid Eligible

It is not necessary that every SPED Program applicant/recipient make an application for Medical Assistance (Medicaid). During completion of the comprehensive assessment, sufficient information may be obtained to determine whether their assets exceed Medicaid limits. Nor is screening for level-of-care mandatory for all Medicaid recipients.

 

The Department may not require an individual to apply for services under the state’s medical assistance program as a condition of being eligible to apply for services under SPED if the individual’s estimated monthly HCBS services benefits which could be covered by MSP-PC or Medicaid waiver (excluding the cost of case management) are between the most current medically needy income level for a household of one plus the $20 disregard established in NDCC 50-24.1-02.6, and the lowest level of the fee schedule for service under this chapter (currently $1,233), or if the individual is receiving a service that is not available under Medicaid or the Medicaid waiver.

 

The SPED sliding fee schedule will be adjusted each year on July 1, based on the current Social Security cost of living adjustment. Note that this may cause the lowest level of the fee schedule to either increase or decrease.

 

SPED Fee Schedule	Less the Medically Needy Amt	Less $20 Disregard	Max Service Amt
$1,223.00	($940.00)	($20.00)	$273.00

 

The HCBS Case Manager must request this exception from an HCBS Program Administrator when they submit the SPED pool application and note in the case file why the applicant or recipient is not considered eligible for medical assistance or would not meet nursing facility level-of-care or be eligible for Medicaid State Plan (Personal Care). If the service that is being requested is a non-Medicaid Waiver or State Funded service, the applicant/client is not required to apply for Medicaid.

 

If an individual's services are being paid for at the rural differential rate, determine the cost of the services using the regular rate. If that amount is $273 or less, they are not required to apply for Medicaid. If at any time an individual's service needs increase and the cost exceeds $273 per month, they will be required to apply for MA.

 

The HCBS Case Manger’s first action is to find out if the applicant/recipient is eligible for Medical Assistance; and, if there is a community spouse, if spousal impoverishment applies. This requires the involvement of an eligibility worker. At the same time the eligibility worker is determining Medicaid eligibility, the HCBS Case Manager should determine service need and provider availability.

 

If an immediate need for service(s) exists, SPED service(s) can be authorized for eligible clients pending determination of Medical Assistance. If it is found that the person does NOT meet eligibility under the Medicaid State Plan services, but does meet SPED Program eligibility, the effective date of the SPED Program will be established to cover those service costs (within the limits of the SPED Program).  

 

When it appears the applicant/recipient may be eligible for Medical Assistance, choosing not to apply for Medical Assistance is the applicant’s decision. However, the applicant/recipient is NOT eligible for the SPED Program as a result of refusal to apply for Medicaid or other federal funded programs. If the applicant/recipient's financial resources are determined by the Case Manager to exceed eligibility requirements for Medicaid, the applicant/recipient is not required to complete the Medicaid application. If the Case Manager is unsure if the individual will meet Medicaid eligibility, the applicant/recipient must request a financial review by the Economic Assistance financial eligibility worker prior to application.

 

If the applicant/recipient's Medicaid was closed due to not meeting recipient liability, or it is clear that they would not meet recipient liability (after summing the medical expenses, plus the case management, plus Medicaid State Plan Personal Care Services), then the individual may receive SPED Personal Care Services if found eligible through the SPED program.

 

Institutional Spouse and Community Spouse (Spousal Impoverishment)

Income and Medical Deductions:

If the institutional spouse resides in a nursing home and the community spouse is in need of SPED services:

• All income is counted for the community spouse which would include the deemed income;
• Medical deductions/prescription drugs are counted of community spouse only;
• Household number of one (if no other dependents reside in the home);
• All liquid assets cannot exceed $50,000 for the applicants/client's SPED services, which includes the deemed assets.

If the institutional spouse resides in the personal home or community based setting and the applicant/client needs SPED services:

• All household income is counted, which would include the deemed income;
• Medical deductions (up to the $850 maximum)/prescription drugs are counted for all persons in the household;
• Household number of two (if there are no other dependents residing in the home);
• All liquid assets cannot exceed $50,000, which includes the deemed assets.

Charging for Services

If an individual has a recipient liability or SPED service fee, it is the responsibility of the provider to collect the individual's share of the cost directly from the individual or their identified legal payee or financial decision-maker.

 

Confidentiality of Financial Records

Financial information regarding a client shall remain confidential except where otherwise provided by law or departmental policy. (See Accounts Receivable Manual, Service Chapter 115-40).

 

SPED Eligibility & Medicaid Expansion

If a SPED applicant or recipient is eligible for and/or receiving Medicaid Expansion and is requesting personal care services, the individual must be asked to complete an SFN 1598 Medically Frail Questionnaire to determine if they may be eligible to receive their personal care under traditional Medicaid, unless the cost of the personal care services to SPED is $273 or less per month. The applicant is NOT eligible for the SPED program as a result of refusal to complete this process. If it is determined that the individual is considered to be medically frail and they want to receive personal care services, they must choose traditional Medicaid so they can access Medicaid State Plan personal care.

If the applicant's Medicaid was closed or would be closed due to not meeting recipient liability, (after adding the medical expenses, plus the case management fee, plus the cost of their Medicaid State Plan Personal care) then the individual may receive SPED personal care services if they are otherwise eligible.

 

Service Fee, SPED Program

With the completion of the SPED Income and Asset form, SFN 820, and by using the sliding fee schedules, the HCBS Case Manager will determine if a participation fee percentage will be assessed to the service costs. The participation fee is applied to not only the direct services but can also apply to HCBS Case Management, unless the SPED client is also on Medicaid. In that case, HCBS Case Management services will be billed to Medicaid, and may be subject to recipient liability.

 

Refer to Policy 525-05-60-20 SPED Income and Assets regarding the completion of the SFN 820 SPED Financial form and specific Asset, Income, and Deduction information.

 

Financial eligibility is not complete until the applicant/recipient has signed the SFN 820 indicating the acceptance of the accuracy of the information and service fee. If the service fee is not recorded correctly, the applicant/recipient must be required to sign a corrected page prior to the individual entering the SPED Pool.

 

Income Verification Method

An income verification method will be used for the individual to indicate family income in all cases. HCBS Case Management staff will review a copy of most recent pay check stubs, bank statements and/or income tax forms to verify the individual's income. If an individual does not supply the documentation, the individual is not eligible to receive or continue SPED services.

 

All income, assets, and deductions must be verified by the case manager's review of the documents. Case file documentation must contain confirmation they have verified the information for financial eligibility. If the applicant/recipient is receiving Medicaid services, the HCBS case file may cross reference in the file that the verification can be found in the Medicaid eligibility case file.

 

Financial Status And Family Size Review

The individual's family adjusted gross income and family size shall be reviewed at least every twelve months. In addition, a redetermination shall be made any time a significant change occurs in a family's income or size.

 

If an applicant/recipient has a spouse who is residing in the nursing home and is receiving Medical assistance under spousal impoverishment rules, consider the spouse requesting SPED services as living in a household of one for both functional and financial eligibility because the institutionalized spouse’s income has already been deemed to the community spouse. If a spouse is receiving services under the Medicaid Waiver and lives in a community-based setting or the home with the applicant/ recipient requesting SPED services, consider it a one-person household for functional eligibility and a two person household for financial eligibility because the spouse is still responsible to pay for room, board etc. If an applicant/ recipient has a spouse who is residing in the nursing home and both the applicant and spouse are on Medical assistance, consider the individual requesting SPED services as living in a household of one for both functional and financial eligibility.

 

If the fee schedule changes, the rate charged will be determined at the next visit. The redetermination fee will not be applied to services delivered prior to the date of redetermination. When the service fee changes, the fee will become effective the first day of the following month when the change was identified.

Financial Disclosure

Each applicant/recipient must provide full financial information upon initial assessment or redetermination, every twelve months thereafter, and at such time that the individual/spouse's income or the family size changes significantly. Individuals not providing full financial information will be billed the full service fee and would, therefore, no longer be eligible for SPED.

 

An applicant/recipient who refuses to complete SFN 820, SPED Income and Asset form, will not be eligible for the SPED Program.  

 

Individual Fees Charged For Services

Each family member who receives a service for which a fee is assessed shall be charged the fee for that service, in accordance with the billing schedule.

 

Service Fee Changes

Once services have been established and there is a change to the service fee, the HCBS Case Manager must notify the HCBS Program Administration by submitting an SFN 676 to the Aging Services Division within three working days. The change in fee is effective the first of the month following the month in which the change occurred. The coinciding care plan must be signed on/prior to the first of the following month of the effective date in order for the rate change to go into effect. Fee change requests cannot be retroactive. If extenuating circumstances exist, contact the SPED Program Administrator for consideration.

 

3. Ineligibility for the SPED Program

1. Other Funding Sources

The individual is NOT eligible for SPED services if their service needs can be met by:

• Medicaid Waiver for Home and Community Based Services;
• Medicaid Waiver for Developmental Disabilities (MR);
• Medicaid State Plan Services;
• Mental Health Services;

An individual is NOT eligible for SPED if they are eligible for the HCBS Waiver or Medicaid State Plan Personal Care and the cost of their HCBS services to SPED (excluding the cost of case management) will exceed $273.

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.

2. Disqualifying Transfer

Per NDCC 50-06.2-07, a disqualifying transfer has occurred if at any time before or after making application, the individual or the individual's spouse has made any assignment or transfer of any asset for the purpose of making that individual eligible for benefits. A disqualifying transfer is also transferring of any asset which results in making the individual eligible for benefits or decreasing their SPED cost share. If a disqualifying transfer has occurred per N.D.A.C. 75-03-23-14, the individual is not eligible for the SPED program. However, if all of the transferred assets are returned to the applicant, then the situation could be treated as if no transfer ever occurred.

If a disqualifying transfer occurred five years prior to the date that an individual initially applies for SPED services, the Department will presume that the transfer was not for the purpose of obtaining SPED benefits.

If assets are transferred to a child, grandchild, brother, sister, niece, nephew, parent, grandparent, stepparent, stepchild, son-in-law, daughter-in-law, or grandchild-in-law of the individual or the individuals’ spouse as payment made for goods and/or services the amount transferred must be supported by a contractual agreement signed and dated by the SPED applicant/recipient before the goods and/or services were received or provided. Payment for such goods and/or services must be reasonable.

If the applicant/recipient is denied Medicaid based on a disqualifying transfer of assets, the SPED Program applicant/recipient is also ineligible for SPED Program funded services.

An individual is not considered to have made a disqualifying transfer and is not ineligible for SPED if:

• The value of the transferred asset when added to the value of the individual’s other assets would not otherwise make them ineligible for SPED or does not decrease the individual’s service fee.
• The asset transferred was the title to a home and the home was transferred to the individual’s spouse, or to a son or daughter who is under age 21, or who is blind or disabled.
• Assets were transferred to or from the individual’s spouse or to another person for the sole benefit of the individual’s spouse.
• The individual can show that they intended to dispose of the assets at fair market value as defined in N.D.A.C. 75-03-23-14 and the individual had an objectively reasonable belief that fair market value was received.
• The individual can show that they transferred the assets for a purpose other than to qualify for SPED benefits.
• Where any income or asset is transferred to a relative for services or assistance furnished by the relative, the services or assistance furnished may not be treated as consideration for the transferred income or asset unless:

1. The transfer is made pursuant to a valid written contract entered into prior to rendering the services, or in the absence of a valid written contract, evidence is provided the services were required and provided.
2. The contract was executed by the individual or the individual’s fiduciary who is not a provider of services or assistance under the contract.

• There is a presumption that a transfer was made for the purpose of making an individual eligible for SPED if:
• An inquiry about SPED benefits or benefits under this chapter was made by or on behalf of the individual to any other individual before the date of transfer;
• The individual or the individual’s spouse was an applicant for or recipient of SPED benefits before the date of transfer;
• A transfer is made by or on behalf of the individual’s spouse, if the value of the transferred asset, when added to the value of the individual’s other assets would exceed SPED limits; or
• The transfer was made, on behalf of the individual or the individual’s spouse, by a guardian, conservator, or attorney-in-fact, to the guardian, conservator, or attorney-in-fact or to any spouse, child, grandchild, brother, sister, niece, nephew, parent, or grandparent, by birth, adoption, or marriage, of the guardian, conservator, or attorney-in-fact.

A transfer is complete when the individual, or the individual’s spouse, making the transfer has no lawful means of undoing the transfer or requiring a restoration of ownership.

Contact a HCBS Program Administrator to determine if a disqualifying transfer has occurred.

4. SPED Pool

Upon completion of the comprehensive assessment and the SPED Income and Asset form, AND if it is determined the applicant meets the functional and financial eligibility criteria for the SPED Program, the HCBS Case Manager will forward to the HCBS Program Administration:

• SPED Pool Program Pool Data form (SFN 1820)
• Add New Record to MMIS Eligibility File (SFN 676)

In addition, the Case Managers must transfer the information from the form SFN 820 into the Income and Asset assessment in the web-based data collection system on each person for whom funding is being sought under the SPED Program.  

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

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

At the time the individual is approved for services funded by the SPED Program, the HCBS Case Manager must re-verify that the person continues to meet the eligibility criteria, develop a care plan and authorize services in accordance with HCBS Case Management.

If a new or current recipient of services has not utilized services within a 30-day period of time, a citation to terminate the case may be requested (if appropriate) from the Program Administrator and an SFN 474 sent too Aging Services if the case is to be closed.

If the individual has not received services because a provider has not been secured, and the individual is still eligible and wants to continue pursuing a provider, the case must remain open. The case manager must make a quarterly contact with the individual. If the individual will incur a case management fee, they must be informed of this. The case manager is required to continue attempts in securing a provider. In doing so, they may need to staff the situation with Aging Services administrators and/or discuss strategies with the individual such as publishing an advertisement for service providers, etc.

If the services are expected to start or resume within 3 months, it is allowable for the case to remain open. This does not require approval from a Program Administrator. The purpose of this exception is to allow eligible individuals to resume services without having to complete the application process again.

• The reason for delay or pause in services must be documented in the individual’s file.
• The case manager must document how the need is met while the identified service needs are pending.
• The case manager must follow up monthly with the individual to provide support and assistance mitigating the issue causing the delay in service implementation.
• If the services do not resume or start within 3 months, approval must be received from the Program Administrator to keep the case open OR the case manager must request a termination to close the case and submit an SFN 474 to Aging Services/HCBS.

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.

• The case manager must document the admission to the facility.
• The case manager must follow up monthly with the individual and collaborate with the nursing facility/discharge planning team to ensure appropriate services are secured for their return to the community.
• If the services do not resume within 3 months and approval has not been received, the case manager must terminate the case due to institutionalization.

There may be times when a SPED 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 a SPED recipient closed due to a skilled nursing facility or swing bed admission, but they re-open SPED within 3 months:

• A new Application for Services (SFN 1047) does not need to be completed.

• A new SPED financial assessment (SFN 820) does not need to be completed unless there has been a substantial financial change, or the individual is due for a required annual assessment.

• An SFN 1820 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.

SPED Pool Exceptions

As long as the individual still meets all eligibility criteria, the individual does not have to go through the SPED pool to receive SPED services if one of the following applies:

• Individual was discharged from an inpatient hospital stay, skilled nursing facility, swing bed facility, long term care facility, or basic care facility and has been off the SPED program for fewer than 3 months
  
  
• Individual has been off the SPED program for 60 days or less for any reason

The HCBS Case Manager must document the date that SPED services re-should start on the SFN 676, Add New Record to MMIS Eligibility File, in the “Date of Application” field and select “Re-open” in the “Application Type” field. For further instruction, please reference HCBS Policy & Procedure Manual: Closures, Denials, Terminations, Reductions, and Transfer of Services 525-05-40.

The HCBS Case Manager should also include a request for an exception to apply for Medicaid on these forms if the applicant will be receiving personal care but the cost of their services (excluding case management) are less than $273. If SPED personal cares are to be authorized, the Case Manager must complete the bottom section of the SFN 1820, outlining the estimated amount of SPED Personal Cares, and an Explanation as to why they are to be funded by SPED and not Medicaid State Plan Personal Care Services.