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Effective Date: 
9/2017

Documents

 

Instructions

Updated: 9/2017

 

Purpose

To establish a written agreement between an Adult Foster Care (AFC) provider and an AFC individual/member concerning the following:

  • rights and responsibilities;
  • room and board agreement and other expenses;
  • miscellaneous arrangements;
  • individuals to contact in case of emergency;
  • funeral arrangements; and
  • inventory of the individual's/member's possessions.

 

Procedure

When to Prepare

The case worker/managed care organization (MCO) completes Form 2327 with the assistance of the individual/member and provider before AFC is authorized. Update the form at least annually before the coverage period ends and before recertification of AFC services.

Number of Copies

Complete an original and two copies of Form 2327.

Transmittal

Keep the signed original Form 2327 in the individual's/member's case record. The applicant/individual/member and provider each keep a signed copy.

Form Retention

Keep the form in the individual's/member's case record for three years and 90 days.

 

Detailed Instructions

Individual/Member Name— Enter the individual's/member's name.

Social Security No.— Enter the individual’s/member's Social Security number.

Medicaid No.— Enter the individual’s/member's Medicaid number.

Provider Name— Enter the AFC provider's name.

Address— Enter the address of the AFC home.

Period Covered— Enter the begin and end dates of the period the agreement covers. The suggested period is one year unless renegotiated earlier or unless the individual/member leaves the home.

Monetary Agreement

  1. Enter the monthly amount for room and board and the date payment is due each month. Room and board is an agreed upon amount between the individual/member and the AFC provider. STAR+PLUS Home and Community Based Services (HCBS) program room and board is a set amount determined by the Supplemental Security Income Federal Benefit Rate and the personal needs allowance.
  2. Enter the amount of room and board for the month of entry into the AFC home and the due date.
  3. Enter any additional expenses for which the individual/member and/or provider are responsible.

Miscellaneous Arrangements— Enter the following information:

  • special arrangements agreed upon by the individual/member and provider;
  • special monitoring schedules developed;
  • additional resources used in developing the plan of care;
  • special conditions or rules agreed upon by the individual/member and provider;
  • disposal of individual's/member's personal items;
  • names, addresses, telephone numbers and relationship of individuals to be contacted in an emergency;
  • funeral arrangements; and
  • inventory of the individual’s/member's personal belongings.

Signature— The individual/member (or designee), provider and case worker/MCO representative sign and date the form.