Page 51

Chapter: 1400 Technical Requirements Program: MSSI, SFP 47

For DDD applications, the new packet must include the following:

1. Original DDD packet; 2. New CF-ES-2909; 3. New CF-ES 2911 (Include information on physicians and treatments received since the last 2911 was completed. Enter information to indicate if the individual continues to suffer from the same condition and limitations as when last 2911 was completed. If no change in condition, the eligibility specialist may state no change or refer to previous 2911); 4. New CF-ES 2912, if mental disability is a factor; 5. New CF-ES 2514s for each medical provider who has treated the applicant; 6. Copy of hearing decision if the applicant was granted disability by the hearing officer through the appeal process. 1440.1300 APPROPRIATE PLACEMENT (MSSI) To qualify for the Institutional Care Program (ICP) or Home and Community Based Services (HCBS), or the Program for All-Inclusive Care for the Elderly (PACE), the individual must meet special institutional eligibility criteria, including “appropriate placement.”

Appropriate placement means that an individual must be placed in a facility or coverage certified to provide the type and level of care the Department has determined the individual requires.

Two basic requirements must be met for placement to be considered appropriate. These are:

1. Determined by the Department to be medically in need of the type of care provided by the specific coverage group, and 2. Actually receiving the services (or for HCBS, must be enrolled in the waiver) which the Department has determined that the individual needs.

To be appropriately placed for ICP, a person must have been determined in need of an ICP level of care (by CARES) and actually be placed in a Medicaid facility which provides the specified level of care. No level of care is required for a QMB eligible individual (Medicaid eligible individual with income less than the federal poverty level) in a nursing home during the Medicare coverage period.

For Home and Community Based Services (HCBS), to be appropriately placed, a person must be in need of waiver services and be enrolled in the waiver as documented by form CF-ES 2515 with the appropriate Aging and Disability Resource Center (ADRC).

Note: The need for a level of care is verified in the case record by the, DOEA CARES Form 603, the Notification of Level of Care. The need for a level of care and waiver services is verified in the case record by the CF-ES 2515, Certification of Enrollment for Home and Community Based Services. 1440.1301 When to Determine Need for Appropriate Placement (MSSI) A special determination to evaluate the individual's need for ICP or HCBS must be requested by the eligibility specialist at the following times:

1. application, 2. reapplication, 3. an ex parte from Community Medicaid to Long-Term Care Medicaid (ICP or HCBS), or