MISSOURI DEPARTMENT OF SOCIAL SERVICES

FAMILY SUPPORT DIVISION

HOME AND COMMUNITY BASED SERVICES REFERRAL

PARTICIPANT NAME	DCN	PARTICIPANT TELEPHONE NUMBER
SPOUSE NAME	SPOUSE DCN	ALTERNATE TELEPHONE NUMBER
PARTICIPANT ADDRESS	PARTICIPANT COUNTY
FOR FSD USE ONLY
FSD ELIGIBILITY SPECIALIST	TELEPHONE NUMBER	DATE
ADDRESS	EMAIL ADDRESS
COUNTY NAME	FSD LOAD NO.
COMMENTS
PARTICIPANT REFERRED TO DSDS/DESIGNEE FOR Level of Care Determination Authorization for Aged and Disabled Waiver services (HCB) Potential HCB Eligibility/Paper Referral Process
FOR DIVISION OF SENIOR AND DISABILITY SERVICES (DSDS)/ DESIGNEE
DSDS/DESIGNEE NAME	TELEPHONE NUMBER	DATE
ADDRESS	EMAIL ADDRESS
CLAIMANT REFERRED TO FSD FOR Assessment of Assets Application for MO HealthNet
CLAIMANT FOUND BY DSDS/DESIGNEE TO REQUIRE Participant determined eligible for Aged and Disabled Waiver services	EFFECTIVE DATE
CLAIMANT DOES NOT REQUIRE NF Level of Care or Aged and Disabled Waiver services	DATE OF DETERMINATION
COMMENTS
FOR FSD USE ONLY
FSD RESPONSE Approved HCB Rejected for MO HealthNet HCB Ineligible, MHNSD, SLMB, still active or approved Date:
MO 886-2951 (2/2015)	IM-54A

Home and Community Based Services Referral Form (IM-54A) Instructions

PURPOSE: The Home and Community Based Referral (IM-54A) provides a standard form for interagency communication between the Department of Social Services, Family Support Division (FSD) and the Department of Health and Senior Services, Division of Senior and Disability Services (DSDS) and their Designee regarding the Home and Community Based Medicaid program. For information on the HCB Medicaid program requirements see 0820.000.00 ELIGIBILITY BASED ON RECEIPT OF HCB WAIVER SERVICES

NUMBER OF COPIES AND DISPOSITION: The original IM-54A is kept in the file of the originating agency and a copy goes to the receiving agency. The form is returned to the originating agency after a decision has been made, and the receiving agency will retain a copy.

INSTRUCTIONS FOR COMPLETION:

Participant Information:

Enter the participant's name, Departmental Client Number (DCN), telephone number, spouse’s name, spouse’s DCN, alternate phone number, county of residence, and mailing address.

For FSD Use Only:

The FSD Eligibility Specialist (ES) will enter his/her name, telephone number, the date received, office address, ES email address, case carrying county, and ES load number.

Provide any additional information in the "Comments" section that would be beneficial to DSDS when processing this referral.

The FSD Eligibility Specialist will check the "Level of Care Determination" box when referring a brand new Home and Community Based Services participant to DSDS/Designee for a level of care determination. The FSD ES will check the "Authorization for Aged and Disabled Waiver services (HCB)” box when referring a participant currently receiving Home and Community Based Services for continued HCB eligibility. The FSD ES will check the “Potential HCB Eligibility/Paper Referral Process” box when application cannot be approved for other assistance while pending for HCB determination.

NOTE: Checking the LPAI screen in production will assist the ES in ascertaining if the participant has services currently. Service history will appear on the screen with current end dates OR the bottom of the screen will display a message stating that “Client active in HCBS Web Tool”.

When the IM54A is completed by FSD

For NEW referrals - participants not receiving Home and Community Based Services, fax or email the referral to the

HCBS Call Center: (573) 526-2915, hcbscallcenter@health.mo.gov

For redetermination referrals - participants currently receiving Home and Community Based Services, fax or email referral to the Regional Evaluation Team at:

Region 1: (417)895-1341, REV1@health.mo.gov

Region 2: (573)290-5650, REV2@health.mo.gov

Region 3: (314)340-3467, REV3@health.mo.gov

Region 4: (816)889-2004, REV4@health.mo.gov

Region 5: (573)884-4884, REV5@health.mo.gov

Division of Senior and Disability Services HCBS Regional Evaluation Teams map may be found at: http://health.mo.gov/seniors/homecomservices/pdf/BHCS-EvalTeam.pdf

For DSDS/Designee:

The DSDS/Designee will enter his/her name, telephone number, the date received, the office address, and email address of the DSDS/Designee.

Claimant referred to FSD for: Check the appropriate box (Assessment of Assets and/or Application for MO HealthNet) to inform FSD of the purpose of the referral.

Claimant found by DSDS/designee to require: If the participant is eligible for Aged and Disabled Waiver (ADW) services, check the appropriate box and provide the effective date.

Claimant does not require: If the participant does not require NF Level of Care or Aged and Disabled Waiver (ADW) services, DSDS/Designee will place a check in this box and provide the date of determination. (A check mark in this box indicates that the participant is not eligible for MO HealthNet using HCB criteria.)

Provide any additional information in the "Comments" section that would be beneficial to FSD when processing this referral.

FSD Response:

Check the appropriate box after the approval/denial is returned from DSDS to display participant’s eligibility; denied/approved for HCB, denied Medicaid or denied HCB however, eligible for SLMB and Medical Assistance.