In the landscape of healthcare and family services within the Commonwealth of Kentucky, the Map 109 form plays a pivotal role, bridging the gap between Medicaid beneficiaries and necessary waiver services. Revamped in July 2008 by the Cabinet for Health and Family Services, this comprehensive document serves multi-fold purposes, from initiating care plans to securing prior authorization for a suite of waiver services crucial for individuals with varied needs. Structured to streamline the planning and approval process, the form meticulously captures critical details spanning the recipient's identification, residential status, waiver program type including SCL, HCB, MP ABI, Traditional, and blended models. With a focus on person-centered care, it further delves into case management, outlining a structured plan encompassing identified needs, proposed outcomes, interventions, and meticulously chosen service providers. Beyond enumerating the services and financial aspects, the form underscores a commitment to informed decision-making, as evidenced by required signatures from members or guardians, case managers, and representatives, encapsulating a holistic approach towards tailoring healthcare services to individual needs within Kentucky's Medicaid framework.
| Question | Answer |
|---|---|
| Form Name | Form Map 109 Kentucky |
| Form Length | 5 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 15 sec |
| Other names | ky medicaid formmap 350, map 350 form, map 350 kentucky, map 350 form kentucky |
Map 109
Commonwealth of Kentucky
Cabinet for Health and Family Services
(Rev 07/08)
Department for Medicaid Services
PLAN OF CARE/PRIOR AUTHORIZATION FOR WAIVER SERVICES
Initial
30Day Annual Modification
Residential Status
In Home
Family Home Provider
Adult Foster Care Provider
Staffed Residence
Group Home
Type of Waiver Program
SCL
HCB
MP
ABI Traditional
CDO
Blended (CDO/Traditional)
1. MEMBER NAME: __________________________ |
_______________ |
___ |
Sex: |
Last |
First |
MI |
|
MALE
FEMALE
2. MEDICAID MEMBER ID #: ________________________________ 3. DOB: ______________________
4.ADDRESS: ______________________________________________________________________________
Street
_________________________ |
_____ |
_________ |
_______________ |
5. HOME PHONE:________________ |
City |
State |
Zip |
County |
|
6.CASE MANAGEMENT/SUPPORT BROKER AGENCY (CDO):____________________ ______________
Phone
7.GUARDIAN NAME: _______________________________________ ________________ _____________
Relationship: Phone
8.POWER OF ATTORNEY: _________________________________ ________________ _______________
Relationship: Phone
9.REPRESENTATIVE NAME (CDO ONLY): ___________________________________: ________________
Relationship
10.ADDRESS: _____________________________________________________________________________
Street
_________________________ |
_____ |
_________ |
_______________ |
11. PHONE:______________________ |
City |
State |
Zip |
County |
|
12.LEVEL OF CARE (LOC) CERTIFICATION NUMBER: _________________
13.LOC CERTIFICATION DATES: FROM: _______________ TO: ____________________
14.PRIMARY CAREGIVER: _____________________________________________ ___________________
Relationship
15.ADDRESS: _____________________________________________________________________________
Street
_________________________ |
_____ |
_________ |
_______________ |
16. PHONE:______________________ |
City |
State |
Zip |
County |
|
Page 1 of 5
Map 109
Commonwealth of Kentucky
Cabinet for Health and Family Services
(Rev 07/08)
Department for Medicaid Services
PLAN OF CARE/PRIOR AUTHORIZATION FOR WAIVER SERVICES
Member Name: _____________________________ Medicaid Member ID#:__________________________
Identification of Needs/Outcomes/Services/Providers
NEED(S) |
OUTCOMES/GOAL(S) |
OBJECTIVES/INTERVENTION(S) |
SERVICE |
PROVIDER NAME/# |
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Page 2 of 5
Map 109
Commonwealth of Kentucky
Cabinet for Health and Family Services
(Rev 07/08)
Department for Medicaid Services
PLAN OF CARE/PRIOR AUTHORIZATION FOR WAIVER SERVICES
Member Name: ____________________________________ Medicaid Member ID#: ____________________ Date Services Start: ___________
Support Spending Plan
Traditional Waiver Services
Service Code
A
Provider Name and Number
B
Units per
Week
C
Units per
Month
D
Cost per
Unit
E
Cost per Week (Column CxE)
F
Total Cost Monthly
(4.6xColumn F)
G
Total Cost per Month
$
Consumer Directed Services
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Service |
Description of Service |
Employee |
Units |
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Units per |
Hourly |
Number of |
Sum of |
Administrative |
Total |
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Code |
B |
Providing the |
per |
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Month (Column |
Wage |
Hours per |
Wages Times |
Costs |
Monthly |
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A |
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Service |
week |
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D x 4.6) |
F |
Month |
Hours |
I |
Amount |
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C |
D |
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G |
H |
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Total Cost |
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Per Month |
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Page 3 of 5
Map 109
Commonwealth of Kentucky
Cabinet for Health and Family Services
(Rev 07/08)
Department for Medicaid Services
PLAN OF CARE/PRIOR AUTHORIZATION FOR WAIVER SERVICES
Member Name: ______________________________________ Medicaid Member ID #: ______________________
List each provider/employee name, address and telephone number:
Provider/Employee Name
Provider Number Address
Phone Number
Clinical Summary:
_______________________________________________________________________________________________
________________________________________________________________________________________________
_______________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
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________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________________________________________
Page 4 of 5
Map 109
Commonwealth of Kentucky
Cabinet for Health and Family Services
(Rev 07/08)
Department for Medicaid Services
PLAN OF CARE/PRIOR AUTHORIZATION FOR WAIVER SERVICES
Member Name: _______________________________________________ Medicaid Member ID #: ________________________
Emergency
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
I certify the information contained above is accurate and that I have made an informed choice when selecting the providers/employees to provide each service.
_______________________________________________________________ |
________________________ |
Member/Guardian Signature |
Date |
_______________________________________________________________ |
________________________ |
Case Manager/Support Broker Signature |
Date |
_______________________________________________________________ |
__________________ |
Representative Signature (CDO) |
Date |
Plan of Care/Support Spending Plan
Approved
Denied
_______________________________________________________________ |
__________________ |
QIO Signature/Title |
Date |
Page 5 of 5