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Effective Date: 
3/2018

Documents

Instructions

Updated: 3/2018

Purpose

This form is used to:

  • record the identifying information of the STAR+PLUS Home and Community Based Services (HCBS) program applicant or member and Qualified Income Trust (QIT) trustee;
  • serve as a worksheet to identify services to be purchased through copayment from an applicant's or members QIT;
  • document the agreement of a STAR+PLUS HCBS program applicant, member, legally authorized representative (LAR) or authorized representative (AR) to ensure the trustee pays the QIT copayment and his or her understanding that failure to pay the copayment will result in termination of STAR+PLUS HCBS program sevices and Medicaid benefits; and
  • document the acknowledgement of the trustee that the QIT copayment must be paid to service providers, and failure to pay will result in termination of service.

Procedure

When to Prepare

This form is completed by the managed care organization (MCO) each time:

  • an applicant with a QIT is assessed for eligibility for the STAR+PLUS HCBS program;
  • there is a change in the applicant's or member's individual service plan (ISP) that will impact payment from the QIT;
  • the annual reassessment of the ISP is completed on a member with a QIT who is required to pay a copayment; or
  • changes in the amount available for copayment have been calculated.

Number of Copies

An original form for the MCO; a copy for the applicant, member, LAR or AR; a copy for the provider(s) authorized to deliver services; a copy for the trustee; and copies for individuals authorized by the member to receive a copy.

Transmittal

The original form is filed in the applicant's or member's case record maintained by the MCO.

Following each revision of this form, the MCO will maintain the original in the individual's case record and mail copies to the applicant, member, LAR or AR, provider(s), trustee and individuals authorized by the member to receive a copy.

Form Retention

The MCO must keep this form according to the retention requirements found in the STAR+PLUS Handbook. The MCO must keep all originals of this form in the applicant's or member's case record for five years after STAR+PLUS HCBS program services are terminated.

Detailed Instructions

Applicant/Member Name — Enter the applicant's or member’s full name (last, first and middle initial).

Medicaid No. — Enter the applicant's or member’s nine-digit Medicaid number.

Trustee Name  — Enter the name of the QIT's trustee.

Total QIT Copayment Amount Available Monthly — Enter the total amount of the QIT copayment that is available for use in purchasing services. This amount is provided by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist.

Trustee Mailing Address — Enter the mailing address of the QIT's trustee.

Services Purchased Through QIT Copayment

Specific Service Purchased with QIT Copayment — Enter the name of the specific service(s) to be purchased through the QIT copayment. For example, enter personal assistance services (PAS), nursing, assisted living (AL), adult foster care (AFC), etc.

QIT Copayment Amount — Enter the dollar amount of the monthly QIT copayment available to be used to purchase the service (for example, $200). If more than one service is purchased, the QIT Copayment Amount for the second service will be the copayment amount remaining after purchase of the first service. The amounts entered in the QIT Copayment Amount column should never total more than the Total QIT Copayment Amount Available Monthly.

Service Unit Rate — Enter the MCO's established unit rate for each service purchased.

Units Purchased — Enter the estimated monthly units to be purchased with the copayment for each service listed. Calculate the estimated monthly units by dividing the monthly copayment amount by the unit rate and round down to the next lower half unit. For service categories, adaptive aids and fee, minor home modifications and fee, and medical supplies and fee, enter the estimated monthly cost for these services to be purchased through the copayment.

Amount of Copayment Paid to Provider for ServiceEnter the monthly amount of QIT copayment that will be paid to the service provider(s). Multiply the Units Purchased by the Service Unit Rate. For some service categories, adaptive aids and fee, home modifications and fee, and medical supplies and fee, enter the monthly cost. For AFC and AL, enter the calculated copayment amount.

Copayment Agreement and Signatures The applicant, member, LAR or AR must sign and date Form 1578 each time the form is completed. If the applicant or member is unable to write his name, the applicant or member enters an X as an identifying mark. This X must be witnessed and dated.

The QIT trustee must also sign and date the form in acknowledgement of the responsibilities of the trustee and that services will be terminated if the appropriate copayments are not paid from the QIT.

The MCO must sign and date the form after the applicant, member, LAR or AR, any witnesses and the trustee sign the form.