Overview
The Department of Healthcare and Family Services (HFS) uses income and asset standards to determine whether or not an individual may receive Medicaid Benefits (i.e., Medical, SNAP). Individuals who earn or have too much money have a "monthly spenddown obligation." Before getting a MediPlan card, they must document they have met the spenddown obligation. This documentation is sent to the Department of Human Services (DHS) Family Community Resource Center (FCRC).
The costs of certain DHS-funded developmental disability services may be used to meet an individual's spenddown obligation. Allowable DD-funded services currently include services that meet both of the following criteria:
- A service that is covered under one of the DD Medicaid Waivers, whether or not the individual is enrolled in a DD Waiver.
- A service that is long term and, so it is reasonable to anticipate 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 the 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 benefits 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.
The Notice of DHS Community-Based Services form/HFS-2653 (commonly known as the Spenddown form) must be completed by a provider agency or the Home-Based Services Employer of Record. The Estimated Monthly cost to be filled in on this form can be found on the DHS/DDD Rate sheets, which is the second page of the DDD Award Letter. The provider must forward a copy of the form to the ISC agency. It is the ISC agency's responsibility to provide assistance and information as needed to the provider agency or the Home-Based Services Employer of Record. The ISC is not required to send this form into DHS, but should maintain the Notice of DHS Community-Based Services form/HFS 2653 in the individual's file.
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 Disabilities services (whether or not the individual is enrolled in a DD Medicaid Waiver):
- Community Day Services (CDS)
- Supported Employment (SEP)
- Adult Day Care
- Child Care Institution (CCI)
- Child Group Home (CGH)
- Community-Integrated Living Arrangement (CILA)
- Community Living Facility (CLF)
- Special Home Placement (SHP)
- Supported Living Arrangement (SLA)
- 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 services received or the monthly service charges for those services.
Specific Instructions To Complete the HFS 2653 Form
- TO: Fill in the name and address of the DHS FCRC office or staff person (if known) who serves the individual.
- FROM: Fill in the name and address of the provider of countable services.
- 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.
- 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.
- INITIAL NOTICE/CHANGE OF INFORMATION: Check whichever box is appropriate. Check only one box.
- EFFECTIVE/ANTICIPATED EFFECTIVE DATE OF SERVICE: Fill in the date 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.
- TERMINATION DATE OF SERVICE: Enter the anticipated date the client will cease to need the listed amount of service. This is the date 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.
- REMARKS: (at bottom of form) Include any clarifications or notes that may help the caseworker at the DHS FCRC enter the information correctly.
- 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 Self-Directed Advocate or Employer of Record. Include the date, 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 (24-hour, Host Family/Foster Care, Intermittent, Family Intermittent and Hourly - DD program codes 60D and 65H).
Estimated Monthly Cost: Only the costs of residential habilitation, community day services, supported employment, adult day services, 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, occupancy, room and board, clothing, school, regular work or other day program.
a. Program 60D - Rate Model CILA
The CILA individual rate sheet states the "Total Annual CILA Topline Rate" on the bottom left. You must deduct any "Room & Board" amount specified on the CILA individual rate sheet on the upper right from the Topline CILA Rate. You may also add CDS, SEP, Adult Day Care, At Home Day Program, Temporary Intensive Staffing (DD program code 53R) and ISSA costs, if necessary. To calculate the countable cost the person receives the formula for 60D CILA would be:
The monthly amount for spenddown is not the amount the individual or family pays toward the cost of care.
b. Program 65H - Intermittent CILA
Use the hourly rate times the monthly average number of hours of service. You may also add CDS, SEP, Adult Day Care, and ISSA costs, if necessary. To calculate the countable cost the person receives the formula for 65H CILA would be:
The monthly amount for spenddown is not the amount the individual or family pays toward the cost of care.
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 - Community Day Services (CDS), Adult Day Care and/or 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 a person funded for Home-Based Support Services is:
| Effective |
01/01/2019 |
01/01/2020 |
| Child |
$1,542 |
$1,566 |
| Adult |
$2,313 |
$2,349 |
3. In-Home/Remedial Care Services (Residential)
This category is for people receiving Child Group Home (CGH 17D), Child Care Institution (CCI 19D), Special Home Placement (SHP 41D), Supported Living Arrangement (SLA 42D) or Community Living Facility - CLF services (Codes 67D and 67E)
Check the box for IN-HOME/REMEDIAL CARE SERVICES (RESIDENTIAL)
Estimated Monthly Cost: Only the costs of residential habilitation, community day services, supported employment, adult day services, 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 (CGH)/Child Care Institution (CCI)/Special Home Placement (SHP)/Supported Living Arrangement (SLA)/Community Living Facility (CLF) rate may be used to meet a Medicaid spenddown obligation.
a. Remedial Care Services (Non-Waiver) Estimated Monthly Cost
This sub-category is for the Estimated Monthly Cost for people receiving Non-Waiver services including: Child Care Institution (CCI 19D), Special Home Placement (SHP 41D), Supported Living Arrangement (SLA 42D) or Community Living Facility - CLF services (Code 67E only). To calculate the countable cost the person receives the formula for these supports would be:
Monthly residential program amount (excluding room & board) plus the Community Day Services, Supported Employment, or Adult Day Services equals the Estimated Monthly Cost. The cost of education or "school" is not an eligible cost for children being served in a residential setting.
For convenience, you may use the following statewide monthly program amounts instead of calculating the amount for each specific individual:
- Child Care Institution (Program 19D) $3,435
- CLF - Non-Waiver (Program 67E) $870
- SHP (Program 41D) $1,052
- SLA (Program 42D) $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 residential claiming rate. Your business office may know this rate or you may contact the Bureau of Reimbursement and Program Support at (217) 782-0632 to get the actual claiming rate.
b. In-Home Care Services (Waiver) Estimated Monthly Cost
This sub-category is for the Estimated Monthly Cost for people receiving Child Group Home (CGH 17D), or Community Living Facility - CLF services (Code 67D only). To calculate the countable cost, add the costs the person receives the formula for these supports would be:
Monthly residential program amount (excluding room & board) plus the Community Day Services, Supported Employment or adult day services plus the ISSA equals the Estimated Monthly Cost. The cost of education or "school" is not an eligible cost for children being served in a residential setting.
For convenience, you may use the following statewide monthly program amounts instead of calculating the amount for each specific individual:
- Child Group Home (Program 17D) $3,435
- CLF - Waiver (Program 67D) $870
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 residential claiming rate. Your business office may know this rate or you may contact the Bureau of Reimbursement and Program Support at (217) 782-0632 to get the actual claiming rate.
