Revision 17-1; Effective March 15, 2017

 

 

The case worker completes Form 2101 to renew the prior approval process for all ongoing Primary Home Care individuals (including transfer cases) not certified as Community Attendant Services (CAS) individuals. Instructions for items other than numbers 4 and 5, are covered in the instructions for Form 2101 in the Forms and Reports section.

Renewals Item 4 "Begin" date Item 5 "End" date
Renewal — no service plan change NA — Do not send Form 2101. NA — Do not send Form 2101.
Renewal with increase Seven days from date mailed or negotiated date. Leave blank — date remains the same as current authorization.
Renewal with decrease 12 days from the Form 2101 date unless appealed. Leave blank — date remains the same as current authorization.

 

Service plan change between assessments Item 4 "Begin" date Item 5 "End" date
Increase Seven days from the Form 2101 date or negotiated date. Leave blank — date remains the same as current authorization.
Decrease 12 days from the Form 2101 date unless appealed. Leave blank — date remains the same as current authorization.

 

Terminations Item 4 "Begin" date Item 5 "End" date
Loss of Medicaid eligibility Remains unchanged. Last day of month in which individual is determined ineligible for Medicaid.
Other eligibility criteria change (i.e., type of residence, functional eligibility, unmet need) Remains unchanged. 12 days from the Form 2065 date, unless appealed.
Individual or someone in home threatens health or safety of provider Remains unchanged. Date case worker becomes aware of action.