Overview

The Department of Healthcare and Family Services (HFS) uses income and asset standards to determine whether or not an individual may receive Medicaid. Individuals who earn or have too much money have a "monthly spenddown obligation." Before getting a MediPlan card, they must document to the Department of Human Services (DHS) Family Community Resource Center (FCRC) that they have met the spenddown obligation.

The costs of certain DHS-funded developmental disabilities services may be used to meet an individual's spenddown obligation. Allowable DDD-funded services currently include services that meet both of the following criteria:

  • Services are covered under one of the Medicaid DD waivers, whether or not the individual is enrolled in a DD waiver.
  • The services are predictable and steady over time, so that it is reasonable to anticipate that the individual will receive the same amount of services reliably for an indefinite period.

Providers may use the Notice of DHS Community-Based Services (HFS-2653) to document that spenddown is met to the DHS FCRC. Based on the information in the HFS-2653, DHS FCRC staff should mark the individual as "spenddown met with no split bill" for up to 12 months. The individual is then approved for Medicaid and receives a MediPlan card.

Important Note: For individuals enrolled in a DD waiver, DHS and HFS have an automated, centralized process to keep people in spenddown met status based on a file transfer of waiver cost information once the initial form is processed.

However, this paper HFS-2653 continues to be necessary for:

  • Individuals who are receiving countable non-waiver developmental disabilities services.
  • New waiver individuals to put the individual in spenddown met status initially (it takes at least three months for the centralized process to begin).
  • Waiver individuals for whom the automated central process does not work.

General Instructions

Eligible Populations

The HFS-2653 may be used for individuals who have a spenddown obligation because of too much income or assets and who are receiving one or more of the following Developmental Disability services (whether or not the individual is enrolled in a Medicaid waiver for individuals with developmental disabilities):

  1. Developmental Training (DT)
  2. Supported Employment (SEP)
  3. Adult Day Care
  4. Child Group Home
  5. Community-Integrated Living Arrangement (CILA)
  6. Community Living Facility (CLF)
  7. Home Individual Program (HIP)
  8. Special Home Placement (SHP)
  9. DD Home-Based Support Services (HBS)

Time Frames

Update the paper HFS-2653 as needed for eligible individuals who are not updated by the centralized file transfer (see above important note).

Always notify the DHS FCRC immediately if there are changes in either the countable services received or the monthly service charges for those services.

Specific Instructions To Complete Form

  1. TO: Fill in the name and address of the DHS FCRC that serves the individual.
  2. FROM: Fill in the name and address of the provider of countable services.
  3. RE: Fill in the name and address of the individual who is or will be receiving countable services. This is the address where the individual is living or will live while receiving the services.
  4. CASE NUMBER: Print the HFS Medicaid Case Number (Note: The case number is not the RIN) for the individual. If a Case Number has not been assigned, print the date that application for Medicaid benefits was made.
  5. INITIAL NOTICE/CHANGE OF INFORMATION: Check whichever box is appropriate. Check only one box.
  6. EFFECTIVE/ANTICIPATED EFFECTIVE DATE OF SERVICE: Fill in the date that the person first started or is expected to start receiving countable services from your agency documented on the form. If the exact date is not known and the person has received services for at least three months prior to the date on which the form is completed, put in the approximate date. If the individual has received services for less than three months, the effective date must be exact.
  7. TERMINATION DATE OF SERVICE: Enter the anticipated date that the client will cease to need the listed amount of service. This is the date that these service charges will no longer be used to meet spenddown, unless the central file transfer or another HFS-2653 submitted to the DHS FCRC continues the spenddown met status.
  8. REMARKS: (at bottom of form) Include any clarifications or notes that may help the caseworker at the DHS FCRC enter the information correctly.
  9. SIGNATURE, TITLE, PHONE OF THE PERSON COMPLETING THE FORM: (at bottom) The form should be signed by the case manager, the manager of the residence, the program director, or the Home-Based Support Services Service Facilitator. Include the date and the title and telephone number of the person completing the form.

Division of Developmental Disabilities Services

  1. DD CILA Services

    Check the box for COMMUNITY-INTEGRATED LIVING ARRANGEMENT (CILA) SERVICES. (This includes all types of licensed CILA programs - DD program codes 60D, 61D, 65H).

    Estimated Monthly Cost: Only the costs of residential habilitation, developmental training, supported employment, adult day care, at home day program and Individual Service and Support Advocacy (ISSA) may be used to meet a spenddown obligation. Do not use costs for capital, support, occupancy, room and board, clothing, school, regular work or any other day program.

    1. Program 60D - Rate Model CILA

      The CILA individual rate sheet may include the daily residential Medicaid waiver claiming rate. Multiply this claiming rate by 365, then divide by twelve to get the monthly residential cost. You may also add DT, SEP, Adult Day Care, At Home Day Program, Temporary Intensive Staffing and ISSA costs, if necessary.

      Alternatively, you can subtract the annual Room and Board cost from the Annual Residential Topline Rate to get the annual program cost. Divide the annual program cost by twelve to get the monthly countable residential costs for spenddown.

      The monthly amount for spenddown is not the amount the individual or family pays toward the cost of care.

    2. Program 65H - Intermittent CILA

      Use the hourly rate times the monthly average number of hours of service. You may also add DT, SEP, Adult Day Care, and ISSA costs, if necessary.

    3. Program 61D - Purchase of Service CILA

      Minimum amounts and how to calculate the monthly cost are detailed in the In-Home/Remedial Care Services (Residential) section below.

  2. Community Habilitation Services (Non-Residential)

    This category is for people receiving DD Home-Based Support Services (HBS) or receiving only a waiver day program - Developmental Training (DT), Adult Day Care and Supported Employment (SEP).

    • Check the box for COMMUNITY HABILITATION SERVICES (NON-RESIDENTIAL).  Estimated Monthly Cost: The provider may use actual payment rates times the average monthly number of hours of service
    • The maximum monthly cost for full-time attendance for each day program effective October 1, 2007 without a rate add-on:
      • DT (DD program codes 31A and 31U) $952
      • Rate add-ons and Temporary Intensive Staffing are also countable
      • Individual SEP services (DD program codes 390, 39U, 36U)  $1,194
      • Group/clustered SEP (DD program codes 390, 39G, 36G)  $1,066
      • Adult Day Care (DD program code 35U) $795

      The cost documented on the HFS-2653 may never exceed the actual cost of services received.

  3. In-Home/Remedial Care Services (Residential)

    This category is for people receiving Child Group Home, HIP, SHP or CLF services (Codes 17D, 68D, 41D, and 67D)

    1. Check the box for IN-HOME/REMEDIAL CARE SERVICES (RESIDENTIAL)
      • If NOT in a DD waiver, check the space for REMEDIAL CARE SERVICES: (NON-WAIVER)
      • If enrolled in a DD waiver, check the space for IN-HOME CARE (WAIVER)

      Estimated Monthly Cost: Only the costs of residential habilitation, developmental training, supported employment, adult day care, at home day program and Individual Service and Support Advocacy (ISSA) may be used to meet a spenddown obligation. Do not use costs for capital, support, occupancy, room and board, clothing, school, regular work or any other day program.

      The monthly amount for spenddown is not the amount the individual or family pays toward the cost of care.

      Only the program component (also known as the Medicaid waiver claiming rate) of the residential Child Group Home/CILA/HIP/SHP/CLF rate may be used to meet a Medicaid spenddown obligation.

      To calculate the countable cost, add the costs for each service the individual receives:

      Monthly residential program amount (excluding room & board) is the DT/SEP, Adult Day Care services (up to the maximum) added to the ISSA (Program 50D) equals the estimated monthly cost

For convenience, you may use the following FY2009 statewide monthly program amounts instead of calculating the amount for each specific individual:

  • Child Group Home (Program 17D)$3,435
  • CILA (Program 61D)$1,385
  • CLF (Program 67D)$ 870
  • HIP (Program 68D)$2,092
  • SHP (Program 41D)$1,052

IMPORTANT NOTE:  If using the above minimum amounts is not enough to meet the individual's spenddown obligation, you may use your agency's actual Medicaid waiver claiming rate. Your business office may know this rate or you may contact the Bureau of Community Reimbursement at (217) 782-0632 to get the actual claiming rate.