Par.1.   Material Transmitted and Purpose -- Transmitted with this Manual Letter are revisions to Service Chapter 535-05, Medicaid State Plan Personal Care Service Policies and Procedures.  IMs 5051 has been superseded and now incorporated into this Manual Letter and manual sections.

Par. 2.   Effective Date – January 1, 2009

1.	Definitions 535-05-10

“Long term care need” means the need for the services available under the SPED Program, ExSPED Program, Medicaid Waiver Program, or the Medicaid State Plan Personal Care Option that is anticipated to exceed 30 days. 

2.	Case Management 535-05-35
Case management for an individual applying for or receiving personal care services shall be the responsibility of a county social service board HCBS case manager except when the individual is also receiving a service(s) through the developmental disabilities division. Case management for personal care services for an individual receiving a service(s) through the DD division shall be the responsibility of a DD case manager. If the individual is not receiving service(s) through the DD Waiver they have the right to choose the provider of case management services.

Targeted Case Management Eligibility Requirements:
The individual receiving TCM will meet the following criteria:
1.	Medicaid recipient.
2.	Be over 65 years of age, or be under 65 years of age and meet Social Security disability criteria.
3.	Not currently be covered under any other case management/targeted case management system.
4.	Not a recipient of HCBS (1915C Waiver) Service.
5.	Lives in the community and desires to remain there; or be ready for discharge from a hospital within 7 days; or resides in a basic care facility; or reside in a nursing facility if it is anticipated that a discharge to alternative care is within six months.
6.	Has “long-term care need.” Document the required “long-term care need” on the Application for Services, SFN 1047. The applicant or legal representative must provide a describable need that would delay or prevent institutionalization.
7.	The focus or purpose of TCM is to identify what the person needs to remain in their home or community and be linked to those services and programs. The applicant or referred individual must agree to a home visit and provide information in order for the process to be completed.
8.	An assessment be completed and a care plan be developed. The TCM client’s case file must contain documentation of eligibility for TCM. This should be accomplished by the Application for Service and completion of a comprehensive assessment.
9.	Targeted case management is considered a “medical need” and thus included as a health care cost.  Use of Medicaid funding for targeted case management may result in the recipient paying for/toward the cost of their case management.  The client must be informed of that fact by noting Case Management Service and cost on the Personal Care Service Plan.  Clients must also check and sign acknowledgment that if they are on Medicaid they may have a recipient liability. Payments from the Medicaid Program made in behalf of recipients 55 years or older are subject to estate recovery including for Targeted Case Management.

If case management is not provided under any waivered service, Targeted Case Management must be identified on the Personal Care Services Plan SFN 662. Targeted case management is considered as a medical need and is recognized as a health care cost by the Medicaid program. The individual must be informed that TCM may result in an individual with recipient liability being responsible for payment of case management and that payments made for TCM by the Medicaid program are subject to Medicaid estate recovery.
3.	Appeals 535-05-50 (IM 5051)
An individual dissatisfied with a decision made regarding personal care services may appeal that decision to the Department of Human Services under the fair hearing rules set forth in N.D.A.C. 75-01-03-03. An individual must be informed of the right to appeal any actions by the case manager or the department that result in denial, suspension, reduction, discontinuance, or termination of personal care services. Refer to Service Chapter 449-08 for more information with regard to Hearings and Appeals.

Denial/Termination/Reduction 
The applicant/client must be informed in writing of the reason(s) for the denial/termination/reduction.  The Case Manager is responsible to send a completed SFN 1647 with all applicable information to the client or applicant.

The Notice of Denial/Termination/Reduction form is dated the date of the mailing. Contact the HCBS Program Administrator to obtain the legal reference required at “as set forth . . ." The legal reference must be based on federal law, state law and/or administrative code; reliance on a policy and procedures manual reference is not sufficient.

The client must be notified in writing at least 10 days (it may be more) prior to the date of terminating services UNLESS it is for one of the reasons stated in this section. The date entered on the line, the effective date field, is 10 calendar days from the date of mailing the Notice (SFN 1647) or the next working day if it is a Saturday, Sunday, or legal holiday.

Any of the reasons below do not require a 10-day notice:
1.	The client enters a nursing home.
2.	The county or human service center has received in writing the client’s decision to terminate services.
3.	The client agrees with the plan of care.
4.	Client’s whereabouts are unknown.
5.	State or federal government initiates a mass change which uniformly and similarly affects all similarly situated applicants, recipients, and households.
6.	Case Management has factual information confirming the death of the client.

4.	Instructions for Completing Personal Care Services Plan, SFN 662 535-05-70-01 (IM 5051)
The individual (or the individual’s legal representative) and the case manager both must sign to signify agreement with the PCSP. If the individual refuses to sign the PCSP, then the case manager should deny the personal care services and inform the individual of the right to appeal the decision(s) that precipitated the individual’s refusal to sign the PCSP. If the individual was determined not to qualify for personal care services in Section II, then the individual must be informed of the right to appeal per NDAC 75-01-03. Check the box indicating the individual’s agreement or disagreement with the plan and have the individual sign the form or note the individual’s refusal to sign. If the individual refuses to sign the plan, a copy of the plan must be forwarded to the respective state office.  

If the client is not in agreement with the PCSP, they should enter their initial indicating they are not in agreement with the plan of care. Then the Case Manager must provide the client with a completed SFN 1647, HCBS Notice of Reduction, Denial or Termination Form.

5.	Instructions for Completing HCBS Notice of Reduction, Denial or Termination, SFN 1647 535-05-70-10
Purpose: The applicant must be informed in writing of the reason(s) for a denial or termination of service. 

The case manager may send a cover letter with the Notice identifying other public and/or private service providers or agencies that may be able to meet the applicant's needs.

When the client is no longer eligible or ineligible for the Medicaid State Plan Personal Care Service Option, the case manager must terminate or deny services and inform in writing of the reason(s) for a reduction, denial, or termination of service. The case manager must also cancel any current “Authorization to Provide Personal Care Services,” SFN 663, issued to the client’s providers.  Even if services continue under another funding source, the client must be informed in writing of the reasons he/she is no longer eligible for the program.

If a client initials or checks the check box on the SFN 662 indicating that they are not in agreement with the plan and/or before providing a 10 day closure notice, you must send an email to the HCBS Program Administrator responsible to provide citations for MSP-PC.

The email must include the client’s name, funding source (i.e. MSP-PC) and the reason you are reducing, closing, or terminating services. You do not need to send a copy of the completed SFN 1647 to the State office. 

Date:  Record the date of completion;

Denial, Termination, or Reduction, Checkbox: Check the appropriate box whether it is a denial of a requested service or program; or termination of an existing service or program; or reduction of an existing service.

Client Name, Client ID: Record the individual’s first and last name and the identification number (if applicable);

Case Manager Name, County or Human Service Center Name, Title of Employee: Self Explanatory;

“It has been determined...program or service”: Indicate the service(s) or program(s) being denied, terminated, or reduced.

“Reason”:  Record the reason why the individual is being terminated for service or program or the reason for denial or the reason for a reduction in existing services.

“As Set Forth”: Record the state or federal legal reference supporting the reason for denial, termination, or reduction in service that you received from the Program Administrator. 

Date This Denial . . . is Effective: The client must be notified in writing at least 10 days prior to the date  of termination, denial, or reduction of a service or program. The date entered on the line is 10-calendar days from the date of mailing the Notice or the next working day if it is a Saturday, Sunday, or legal holiday. 

If you disagree with this decision, please contact the following: If Case Management other than County, enter your supervisor’s name.

And to request a conference with the County Director or designee, contact the following: If Case Management other than County, enter your supervisor’s name.

If a Medicaid appeal is received before the date of termination above is effective, services can continue until a hearing decision has been made. If the department's decision is upheld, the individual will be required to reimburse for services provided after the termination date.

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