Form 032 02 0147 01 Eng – Fill Out and Use This PDF

ALF ELIGIBILITY COMMUNICATION DOCUMENT INSTRUCTIONS

WHEN TO USE THIS FORM

This form is a communication tool between the local department of social services (LDSS) eligibility worker, the assessor/case manager responsible for the 12-month reassessment of the assisted living facility (ALF) resident, and DMAS. This form is completed by:

1.The assessor to the eligibility worker and to DMAS at the time of a 12-month reassessment (a finding that the resident continues to meet either residential or assisted living is required in order for the eligibility worker to redetermine eligibility for an Auxiliary Grant (AG) payment);

2.Either the assessor or eligibility worker to the other and to DMAS whenever either becomes aware of a change in address; and

3.The eligibility worker to the ALF assessor and to DMAS whenever the AG is terminated.

TO/FROM SECTION

Both TO/FROM sections must be completed. Completely fill in the locality of the DSS eligibility worker with address and indicate whether document is to be sent to or from the eligibility worker by circling “TO” or “FROM.” In the second TO/FROM section, completely fill in the assessor’s name, address and provider number and indicate whether the document is to be sent to or from the assessor or case manager by circling “TO” or “FROM.”

RESIDENT IDENTIFICATION SECTION

1.RESIDENT: Legibly print name of ALF resident who is being assessed, who has moved, or whose AG has been terminated.

2.SSN: Write in the resident’s social security number.

3.ALF: Legibly print the name of the ALF in which the resident resides.

4.ALF location: List the city/town in which the ALF is located.

5.Medicaid Number: Write in the resident’s Medicaid number.

PURPOSE OF COMMUNICATION SECTION: Check either 1, 2, or 3.

IF 1 IS CHECKED: (Annual Reassessment Completed), fill in the date of the reassessment. Check either a. (Resident continues to meet criteria for ALF placement at the following level of care) or b. (Resident does not meet criteria for residential or assisted living. If a. is checked, indicate which level of care the individual meets. If intensive assisted living is checked, respond to the two questions “continues to need intensive assisted living services” and “based on the UAI, continues to meet criteria for intensive assisted living.” Usually, both will be checked “yes.” When 1. is checked, the assessor sends a copy of the Uniform Assessment Instrument (UAI), the ALF Eligibility Communication Document (ECD), and the HCFA-1500 to DMAS. In addition, the assessor sends a copy of the ECD to the LDSS eligibility worker; copies of the UAI and ECD to the ALF; and a decision letter to the individual being assessed. The assessor should keep a copy of each of these documents.

NOTE: If a reassessment indicates a change in level of care, treat the assessment as a change in level of care. That is, send a copy of the UAI and the DMAS-96 to DMAS. In addition, send the eligibility worker a copy of the DMAS-96; send to the ALF copies of the UAI, DMAS-96, and decision letter; and send a decision letter to the individual being assessed. The assessor should keep a copy of each.

IF 2 IS CHECKED: (Resident no longer resides in ALF on record), indicate to where the resident moved (i.e., another ACR, home, or other). For each, indicate the last date of service in the ALF on record. Complete other information such as new address, etc., if known. When 2 is checked, the assessor/case manager or eligibility worker completing the ECD should send a copy to the other and a copy to DMAS and keep a copy for him- or herself.

IF 3 IS CHECKED: (Auxiliary Grant Eligibility Terminated), the eligibility worker indicates the effective date of termination and the reason. Then the eligibility worker sends a copy of the ECD to the assessor/case manager and to DMAS.

SIGNATURES SECTION

For each form completed, only one signature section will be completed. For example, if an assessor is completing the form for a reassessment, the left-hand side with assessor information will be completed. If the eligibility worker is completing the form for notification of AG eligibility termination, then the right-hand side is completed. Please completely fill in the applicable section with printed name of individual completing the form, signature, complete date with month/day/year, and telephone number with area code.

Please photocopy this form as needed; plain paper copies are acceptable.