(Revised 07/01/2024 ML #3847)
Purpose: The Monthly Rate Worksheet, SFN 1012, is used by the Case Manager to determine the daily rate of payment for SPED Personal Care Assistive Living. This is to be completed and forwarded to Aging Services/HCBS initially when the case is opened, on an annual basis, as well as any time there is a change to the tasks and/or rate.
SECTION I: IDENTIFYING INFORMATION
Complete the client's name, client's identification number (ND number), date the assessment is completed, county of residence, HCBS Case Manager's name, the effective date of the rate as determined on the rate worksheet, and the client's date of birth.
Note: Any change in the rate becomes effective the first day of the following month. For example, if the Monthly Rate Worksheet (MRW) is completed based on an assessment dated April 12, 2006, the rate change becomes effective with services delivered beginning May 1, 2006.
SECTION II: ASSIGNMENT OF POINT VALUE(S)
For each task that needs to be performed for the individual (as identified in the functional assessment) assign the associated point value in the appropriate service column.
Note: The point values of the tasks cannot be less or more than the pre-recorded point value. For example, in Bathing, individuals will receive 20 points if they need this assistance. No one would receive a point value greater than 20 if they need greater help or less than 20 if they need less help.
When point values have been assigned, the form will automatically sum up the points in the column and record the sum in Total Points row (applicable to the authorized service).
SECTION III: RATE CALCULATION
When using the electronic MRW, a portion of the first area of Section III will automatically fill in the figures through the SFY24 Rate. The rate that calculates in this column is the daily rate.
If the calculated rate exceeds the funding source maximum (see maximum amounts at the bottom of the MRW), record the maximum rate in the column marked SFY24 Rate.
SECTION IV: PROVIDER INFORMATION
Enter the provider’s name, number, and mailing address in the spaces provided.
DISTRIBUTION
File the original copy in the individual’s case file. Email or fax a copy to Aging Services/HCBS within 3 days of completion.
An electronic copy is available through the state e-forms (SFN 1012).