PURPOSE

This form is used to:

• record the needs of the applicant/individual for adaptive aids and medical supplies;
• record the estimated annual cost of adaptive aids and medical supplies for the applicant/individual/member;
• identify services to be provided by the Home and Community Support Service Agency (HCSSA) or managed care organization (MCO)-contracted provider; and
• serve as a worksheet for the initial and ongoing development of the individual service plan (ISP).

PROCEDURE

When to Prepare

This form is completed by the HCSSA or MCO when medical supplies and adaptive aids needs are assessed.

The HCSSA/MCO nurse assessor completes the items on the form based on the instructions below, but may not complete any of the items marked For DADS/MCO Use Only.

The HCSSA/MCO nurse assessor completes items 1, 2, 4-9, 20-22, 30 and 33, and signs and dates the form when completing the pre-enrollment assessment on the Community Based Alternatives (CBA)/1915(c) STAR+PLUS Waiver (SPW) applicant.

The HCSSA/MCO nurse assessor or therapist completes items 1, 2, 4-9, 20-22, 30 and 33, and signs and dates the form when:

• requesting service plan changes during the ISP year or at the time of the coordination of the initial ISP; and
• performing the assessment for the annual service plan revision, if appropriate.

The DADS case manager/MCO completes items 3, 10-19, 23-29, 31-32 and 34, and signs and dates the form when approving:

• the services identified on Form 3671-E completed as part of the pre-enrollment home health assessment;
• service plan changes requested by the HCSSA/MCO-contracted provider during the ISP year or at the time of the coordination of the initial ISP; and
• the services identified on the form following the annual reassessment.

Number of Copies

The original Form 3671-E is placed in the case record. Copies are forwarded to the applicant/individual/member, provider(s) and to each member of the interdisciplinary team (IDT).

Transmittal

The HCSSA/MCO nurse assessor submits the original Form 3671-E to the DADS case manager/MCO service coordinator:

• after completion of the pre-enrollment home health assessment;
• after negotiating for a change in initial service plan at the time of the coordination of the initial ISP;
• when requesting emergency and routine service plan changes; and
• after completion of the annual reassessment, if appropriate.

Documentation of necessity on Form 3671-F, Rationale for Adaptive Aids, Medical Supplies, Dental Services and Minor Home Modifications, or other optional form of documentation explaining why the identified item is necessary and how it relates to the individual's disability or medical condition must be submitted, along with this form, to the DADS case manager/MCO.

When there is a provider change, the DADS case manager/MCO sends a copy of Form 3671-E to the new provider. The provider representative signs Form 3671-2, Individual Service Plan, to acknowledge agreement with the services identified on this form and the other applicable ISP forms.

Form Retention

Each provider must keep a copy of Form 3671-E in the applicant’s/individual's/member’s case record according to the retention requirements found in the Community Based Alternatives (CBA) Provider Manual. The DADS case manager/MCO will keep all originals of this form in the individual's record for five years after services are terminated.

Supply Source

This form is found on the Department of Aging and Disability Services and the Health and Human Services Commission websites.

DETAILED INSTRUCTIONS

The following codes identify the individuals responsible for completing specific items of this form:

(A) HCSSA/MCO nurse assessor;
(B) DADS case manager/MCO; and
(C) HCSSA/MCO-contracted provider representative.

1. Applicant/Individual/Member Name — (A), (C). Self-explanatory.

2. Medicaid No. — (A), (C). Enter the Medicaid number of the applicant/individual/member.

3. Effective Date  — (B). Enter the effective date from Form 3671-1, Individual Service Plan, of the initial ISP, reassessment ISP or ISP change that includes authorization for adaptive aids and/or medical supplies included on this Form 3671-E.

4. DADS Case Manager/MCO Representative — (A), (C). Enter the name of the DADS case manager/MCO representative.

5. Provider Vendor No. — (A), (C). Enter the CBA/SPW vendor number.

Medical Supplies

6. Item Reported — (A), (C). Enter the name of the needed medical supplies used monthly:

• at the time of the pre-enrollment assessment.
• when preparing this form for situations listed in "When to Prepare" in these instructions.

Examples:

"4x4s – 2/pkg. of 24"
"Hydrogen Peroxide – 1 bottle"

7. TPR or Copay for Medical Supplies — (A), (C). Place an X in the appropriate box to indicate whether or not the applicant/individual has third-party resources (TPRs) that will pay for medical supplies or if the CBA/SPW program will be paying the copayment for medical supplies.

8. Estimated Monthly Cost — (A), (C). Enter the estimated monthly cost of the medical supplies identified in Item 6.

• The HCSSA/MCO nurse assessor enters the estimated monthly cost for the medical supplies listed in the pre-enrollment assessment.
• The HCSSA/MCO nurse assessor or therapist enters the estimated monthly cost of medical supplies when preparing this form for situations listed in "When to Prepare" in these instructions.

Note: If the medical supplies are provided entirely by Medicare or another TPR, write the name of the provider (Example: "Medicare") in the cost column. The items provided by a TPR are not included as a waiver cost, and are included by the case manager on Form 8598, Non-Waiver Services.

If supplies are not provided monthly, enter the frequency of delivery in comments in Item 35. The cost listed in Item 8 must reflect a "monthly" cost. Example: If diapers (1 pkg. @ $12) are delivered weekly, the cost in Item 8 would equal $12 x 4.33 weeks, or $51.96 monthly. If one case of diapers ($120) is delivered every other month, Item 8 would equal $120 divided by two months, or $60. A separate worksheet may be attached, if referenced in Item 43.

9. Subtotal = — (A), (C). Enter the total of the monthly estimated cost by adding all figures in Column 8.

10. Total From Box 9 — (B). Enter the amount from Item 9.

11. No. of Months Left in the ISP Year — (B). Enter the number of months remaining in the current ISP (rounded to the next higher month in all cases, except when the rounding will cause the ISP to exceed the cost limit — in these cases round to the next higher quarter month).

12. Subtotal = — (B). Enter the product of multiplying Item 10 by Item 12.

13. Previously Authorized this ISP Year — (B). Enter the estimated dollar amount of the medical supplies previously authorized this ISP year. The actual cost of items already delivered to the individual/member during the current ISP based on earlier authorization(s) may be entered, if known. In cases of reductions in the service plan, do not include the estimated costs of items that will not be delivered. This amount is taken from the previous Form 3671-E, Item 14, and does not include the $1,000 for interim supplies.

14. Subtotal = — (B). Enter the sum of Items 12 and 13.

15. — Add $1,000 (or lesser amount for individuals close to the ISP cost limit).

16. Subtotal = — Enter the sum of Items 14 and 15. Transfer this amount to Form 3671-1 (in the field for medical supplies).

17. Previously Authorized this ISP Year — (B). Enter the estimated dollar amount of the requisition fees previously authorized this ISP year and prior to Dec. 1, 2011, for medical supplies. This amount is taken from the previous Form 3671-E, Item 22, and does not include the $100 for interim supplies.

18. Subtotal = — Enter the sum of Item 17. Transfer this amount to Form 3671-1 (in the field for requisition fees for medical supplies) prior to Dec. 1, 2011, and this ISP.

19. Medical Supplies Annual Cost — (B). Enter the sum of items 16 and 28. This amount cannot exceed the $1,736 without an exception.

Adaptive Aids and Durable Medical Equipment

20. Item/Type of Equipment — (A), (C). Enter the name of the adaptive aid item/type of equipment needed:

• at the time of the pre-enrollment assessment.
• when preparing this form for situations listed in "When to Prepare" in these instructions.

21. TPR or Copay for Adaptive Aids or DME — (A), (C). Place an X in the appropriate box to indicate whether or not the applicant/individual has TPRs that will pay for adaptive aids or durable medical equipment (DME) or if the CBA/SPW program will be paying the copayment for adaptive aids or DME.

22. Estimated Cost — (A), (C). Enter the estimated cost for each item/type of equipment listed.

Notes:

• If the medical supplies are provided by Medicare or another TPR, write the name of the provider (Example: "Medicare") in the cost column.
• The HCSSA/MCO-contracted provider must request an ISP change to get approval for more monies before delivery of the item if the projected cost of the item exceeds the cost originally estimated and authorized on the ISP.

23. Total Est. Cost — (B). Enter the total of the estimated costs listed in Column 29.

24. Previously Authorized this ISP Year — (B). Enter the estimated dollar amount of the adaptive aids previously authorized this ISP year. The actual cost of items already delivered to the individual/member during the current ISP based on earlier authorization(s) may be entered, if known. In cases of reductions in the service plan, do not include the estimated costs of items that will not be delivered. This amount is taken from the previous Form 3671-E, Item 25, and does not include the $1,000 for interim adaptive aids/medical equipment.

25. Subtotal = — (B). Enter the sum of the estimated costs in Items 23 and 24.

26. —  Add $1,000 (or lesser amount for individuals close to the ISP cost limit).

27. Subtotal = — Enter the sum of Items 31 and 32. Transfer this amount to the Form 3671-1 field for adaptive aids.

28. Previously Authorized this ISP Year — (B). Enter the estimated dollar amount of the requisition fee previously authorized this ISP year and prior to Dec. 1, 2011, for adaptive aids or durable medical equipment. This amount is taken from the previous Form 3671-E, Item 37, and does not include the $100 for interim requisition fees.

29. Subtotal = —  Enter the sum of Item 28. Transfer this amount to the Form 3671-1 field for requisition fees for adaptive aids in this ISP and prior to Dec. 1, 2011.

30. Specification Fees — (A), (C). Enter the amount of specification fees for reimbursement to a professional other than the HCSSA/MCO registered nurse (RN) or therapist. These can include specifications for computer assistive technology, augmentative communication devices or environmental controls.

31. Total Spec. Fees — (B). Enter the sum of all specification fees in Column 30. Put this total in the estimated annual cost column for specification fees on Form 3671-1.

32. Adaptive Aids Annual Cost — (B). Enter the sum of Items 27 and 29. This amount cannot exceed $2,050 without an exception.

33. Comments/Schedules/Progress Reports — (A), (B), (C). Enter any comments, schedules for implementation of the items in question or any reports on individual's/member’s progress, as well as reference to pro-rata data for billing medical supplies in monthly increments.

34. Total of Boxes 19 + 32 — (B). Enter the sum of the amounts in Item 19, Medical Supplies Annual Cost, and Item 32, Adaptive Aids Annual Cost. This sum cannot exceed $10,000 unless an exception of the service ceiling cap of $10,000 for the combination of medical supplies and adaptive aids has been granted.

Note: This total is not entered on Form 3671-1. Separate entries are required on the ISP for medical supplies, adaptive aids and fees.

Certification by Interdisciplinary Team Members

The HCSSA/MCO nurse assessor signs and dates the form or after completing the pre-enrollment or annual assessment, if appropriate, when requesting a change to medical supplies and adaptive aids during the ISP year.

The applicant/individual/member/responsible party and HCSSA/MCO-contracted provider representative are not required to sign Form 3671-E at initial application or annual redetermination because their signatures and participation in the development of the ISP is documented on Form 3671-2. The DADS case manager/MCO checks the box labeled "Applicant/individual/member/responsible party and HCSSA/MCO representative signatures on Form 3671-2 at initial certification and annual redetermination" to indicate the signatures are included on Form 3671-2.

The HCSSA/MCO representative signature is not required for ISP changes unless the HCSSA/MCO representative requests a change in the ISP, including situations in which a change to the items, or estimated cost of items, authorized on the ISP is requested.

Note: The HCSSA/MCO representative is responsible for obtaining and maintaining the documentation identified on this form and in the CBA Provider Manual as required for the delivery of this service, such as written bids, bills or receipts showing date and item or service purchased, etc.

The therapist signs on the line labeled "Signature – HCSSA/MCO Representative" and dates the form when the therapist has been involved in the assessment of the need for medical supplies or adaptive aids, an IDT meeting or the delivery of this service as a representative of the HCSSA/MCO-contracted provider.

The DADS case manager/MCO signs and dates the form to approve or disapprove the identified adaptive aids and medical supplies. The DADS case manager's/MCO’s signature is required when adaptive aids and medical supplies are requested at initial certification, annual redetermination and changes.

For ISP changes, the DADS case manager/MCO discusses the requested change with the individual/member and obtains his/her signature or verbal agreement of the requested change. When the DADS case manager/MCO obtains the individual/member/responsible party's decision about the ISP change by telephone, the DADS case manager/MCO writes "verbally approved" and the date on the signature line. If verbal approval for the change is not appropriate (such as if the individual has no telephone or has a cognitive or communication impairment precluding understanding the change over the telephone), the DADS case manager/MCO makes a home visit to obtain the individual's/member’s approval.

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