Service Plan – Version 1
July 2023 Page 1 of 12
Service Plan Card/Assessment/Support Plans: Service Plan Form
Service Plan Card Information
Last Name: First Name: M.I.:
Medicaid ID#: Date of Birth:
Staffing Held Date: Verified Date:
Service Start Date: Service End Date:
Service Plan Type: Waiver:
Assessment/Support Plans: Service Plan
Medicaid Long Term Care Disclosures
Member has been informed that they have the right to choose between institutional services or Home
and Community Based Services.
☐
Yes
Member has been informed of the following Home and Community Based Service (HCBS) Waivers they
may be eligible for:
☐ Brain Injury (BI)
☐ Community Mental Health Supports (CMHS)
☐ Developmental Disabilities (DD)
☐ Elderly, Blind, and Disabled (EBD)
☐ Complementary and Integrated Health (CIH)
☐ Supported Living Services (SLS)
☐ Children's Home and Community Based Services (CHCBS)
☐ Children with Life Limiting Illness (CLLI)
☐ Children's Extensive Supports (CES)
☐
Children's Habilitation Residential Program (CHRP)
Was the member provided with fact sheets for the waivers checked above?
☐
Yes
Select Home and Community Based Service (HCBS) waiver program in which member has been
offered services and/or placement.
☐ Brain Injury (BI)
☐ Community Mental Health Supports (CMHS)
☐ Developmental Disabilities (DD)
☐ Elderly, Blind, and Disabled (EBD)
☐ Complementary and Integrated Health (CIH)
☐ Supported Living Services (SLS)
☐ Children's Home and Community Based Services (CHCBS)
☐ Children with Life Limiting Illness (CLLI)
☐ Children's Extensive Supports (CES)
☐ Children's Habilitation Residential Program (CHRP)
☐ N/A
Select:
Select one
Service Plan – Version 1
July 2023 Page 2 of 12
Medicaid Long Term Care Disclosures
Member has been offered services and/or placement in the following programs:
☐ CDASS
☐ Hospital Back Up/Nursing Facility
☐ Intermediate Care Facility for Individuals with Intellectual Disabilities
☐ Long Term Home Health
☐ Nursing Facility
☐
PACE
Was the member provided with fact sheets for the waivers checked above?
☐ Yes
Member has been informed that:
1. Long Term Care Medicaid is the payer of last resort.
2.
I
f the member is covered by third party insurance, they must disclose the name of that insurance.
3. Third party insurance, natural/community resources, and the Medicaid State Plan must be utilized prior
to accessing Long Term Medicaid benefits.
☐
Yes
Member Roles and Responsibilities
Member has been informed of the roles and responsibilities for participation in an HCBS program.
I
agree to participate in the coordination of my services and will be responsible to:
- G
ive accurate information to my case manager regarding my ability to complete activities of daily living.
- Assist in promoting my own independence.
- Cooperate with my providers and case management agency.
- Notify my case manager of changes in my support system, medical condition and living situation
i
ncluding any hospitalizations, emergency room admissions, nursing home placements or Intermediate
Care Facility for Individuals with Intellectual Disabilities (ICF-IID).
- Notify my case manager if I have not received Home and Community Based Services for 30 days or 1
calendar month.
- Notify my case manager of any changes in my care needs and/or problems with services.
- Notify my case manager of any changes that may affect Medicaid eligibility.
- Notify my case manager of any critical incidents that occur.
☐
Yes
Case Manager Roles and Responsibilities
Member has been informed of the HCBS case manager's roles and responsibilities.
The Case Manager agrees to:
- Coordinate needed services.
- Communicate with service providers regarding service delivery, and concerns.
- Review and revise services, as necessary.
- Notify members regarding any change in services.
- Notify members when services are denied, suspended, terminated, or reduced.
- Document, report, and resolve member complaints and concerns.
- Report abuse, neglect, mistreatment, and exploitation to the appropriate authority.
- Provide member with the critical incident definition and explain process of notifying case manager of
critical incidents that occur.
☐
Yes
Service Plan – Version 1
July 2023 Page 3 of 12
Complaint Process
Member has been informed of their right to file a complaint regarding Medicaid HCBS services.
☐ Yes
Member has been provided contact information to file this complaint. While it is encouraged for a
member to begin the process with contacting their case manager, they have been informed that they
have the right to file a complaint with any of the contacts provided.
☐
Yes
Appeal Rights
Member has been informed that during the course of each long-term care certification and Service
Planning period, if there is a reduction, termination or denial of services, they will be provided a
Notice of Action form with their appeal rights and instructions for filing an appeal for a Medicaid Fair
Hearing with the Office of Administrative Courts.
☐
Yes
Member has been informed that if there has been a reduction, termination, or denial of a service(s),
and they did not receive a Notice of Action, they may ask for the notice with their appeal rights.
☐
Yes
Member has been informed of the contact information for the Office of Administrative Courts: 1525
Sherman Street, 4th Floor, Denver, CO 80203. Phone Number (303) 866-2000.
☐
Yes
Service and Provider Choice
Member has been informed of:
- T
heir choice of available long term care programs and services
- The availability and right to select among qualified providers
- Their right to change providers at any time
- Providers have the right to accept or deny the request for services
- Any potential conflict of interest
☐ Y
es
Member has been offered or given a resource list of qualified providers.
☐
Yes
Type of Choice
Other:
Statement of Agreement
Statement of Agreement
☐ Me
mber/Guardian indicates that they are in agreement with the information in the Service Pl
an and
agrees to receive services accordingly.
☐ Member/Guardian acknowledges that they are choosing not to sign the Service Plan agreement. A
Notice of Action will be provided as a result of not signing the Service Plan. * Only check this box if the
Member/Guardian does not sign the Service Plan. A Notice of Action must be generated. * CCBs - C.R.S.
27-10.5-102 (20)(b) * SEPs - 10 CCR 2505-10, 8.526 and 8.552.6
Select:
Service Plan – Version 1
July 2023 Page 4 of 12
Statement of Agreement
Check the following that apply. (At least two signatures are required. One signature must be the
Case Manager.)
☐ Legal Guardian Signature on file
☐ Member’s Signature of file
☐ Additional Legal Guardian Signature on file
☐ Case Manager Signature on file
Date Service Plan was signed.
Service Plan Participants
The following individuals (Name, Title) participated in the development of this plan (You must address
service planning participants, both name and title required. Case Manager must be listed as a plan
participant.)
Name
Title
Unpaid Supports
Is there Unpaid Support/Provider?
If member enrolled in an HCBS Waiver program an Unpaid Support must be added or NO UNPAID SUPPORTS
must be selected.
☐ Yes
☐
No Unpaid Supports
Unpaid Support Service
Unpaid Support Provider
Frequency
Service Plan – Version 1
July 2023 Page 5 of 12
Third Party Resources
Are there Third-Party Resources?
If member enrolled in an HCBS Waiver program a Third-Party Resource must be added or NO THIRD-PARTY
RESOURCES must be selected.
☐ Yes
☐ No Third-Party Resources
Select Third Party Resource
☐ Adult Protective Services
☐ Benefits/Assisted Payments
☐ Child Protective Services
☐ Dental
☐ Food Stamps
☐ LEAP
☐ Legal Services
☐ Meals
☐ Money Management
☐ Optical Services
☐ Rehabilitation Services
☐ Senior Companion
☐ Subsidized Housing
☐ Transportation
Other, specify:
Provider:
Frequency:
Select Third Party Resource
☐ Adult Protective Services
☐ Benefits/Assisted Payments
☐ Child Protective Services
☐ Dental
☐ Food Stamps
☐ LEAP
☐ Legal Services
☐ Meals
☐ Money Management
☐ Optical Services
☐ Rehabilitation Services
☐ Senior Companion
☐ Subsidized Housing
☐
Transportation
Other, specify:
Provider:
Frequency:
Service Plan – Version 1
July 2023 Page 6 of 12
State Plan Benefits
Are there State Benefits?
If member enrolled in an HCBS Waiver program a State Plan Benefit must be added or NO STATE PLAN
BENEFIT must be selected.
☐ Yes
☐ No State Plan Benefit
Select State Benefit
☐ Acute Medical
☐ Dental Benefit
☐ Early and Periodic Screening
☐ Hospice
☐ Medical Equipment
☐ Medical Supplies
☐ Medical Transportation
☐ Mental Health
☐ Money Management
☐ Primary Care Physician
☐ Private Duty Nursing
☐ Professional Therapies
☐
Targeted Case Management
Provider:
Frequency:
Select State Benefit
☐ Acute Medical
☐ Dental Benefit
☐ Early and Periodic Screening
☐ Hospice
☐ Medical Equipment
☐ Medical Supplies
☐ Medical Transportation
☐ Mental Health
☐ Money Management
☐ Primary Care Physician
☐ Private Duty Nursing
☐ Professional Therapies
☐ Targeted Case Management
Provider:
Frequency:
Service Plan – Version 1
July 2023 Page 7 of 12
Home Health Benefits
Are there Home Health Benefits?
If member enrolled in an HCBS Waiver program a Home Health service must be added or NO HOME HEALTH
must be selected.
☐ Yes
☐ No Home Health
Service Number
Services
Information Provided by
☐ Applicant/Member
☐ Caregiver
☐ Facility Staff
☐
Medical Record
Funding Source
☐ Medicare
☐ Medicaid
☐
Private Insurance
Home Health service provider available
☐ Yes
☐
No
Service Goal:
Provider
Total Units
Service Start Date
Service End Date
Service Number
Services
Information Provided by
☐ Applicant/Member
☐ Caregiver
☐ Facility Staff
☐
Medical Record
Funding Source
☐ Medicare
☐ Medicaid
☐
Private Insurance
Home Health service provider available
☐ Yes
☐
No
Service Goal:
Provider
Total Units
Service Start Date
Service End Date
Service Plan – Version 1
July 2023 Page 8 of 12
Home Community Based Services
Service:
Start Date:
End Date:
Frequency:
Provider:
# of Units:
Care Plan Goal #:
Backup Designation:
Backup Relation to Member:
Backup Provider/Name:
Backup Effective Date:
Level of Supervision (If applicable):
Awake:
Amount of unsupervised time:
Overnight:
Amount of unsupervised time:
Community:
Amount of unsupervised time:
Day Hab/Vocational:
Amount of unsupervised time:
Comments (Indicate why level of supervision needed):
Service:
Start Date:
End Date:
Frequency:
Provider:
# of Units:
Care Plan Goal #:
Backup Designation:
Backup Relation to Member:
Backup Provider/Name:
Backup Effective Date:
Level of Supervision (If applicable):
Awake:
Amount of unsupervised time:
Overnight:
Amount of unsupervised time:
Community:
Amount of unsupervised time:
Day Hab/Vocational:
Amount of unsupervised time:
Comments (Indicate why level of supervision needed):
Select
Select:
Select:
Select:
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Service Plan – Version 1
July 2023 Page 9 of 12
Home Community Based Services
Service:
Start Date:
End Date:
Frequency:
Provider:
# of Units:
Care Plan Goal # to be attached:
Backup Designation:
Backup Relation to Member:
Backup Provider/Name:
Backup Effective Date:
Level of Supervision (If applicable):
Awake:
Amount of unsupervised time:
Overnight:
Amount of unsupervised time:
Community:
Amount of unsupervised time:
Day Hab/Vocational:
Amount of unsupervised time:
Comments (Indicate why level of supervision needed):
Service:
Start Date:
End Date:
Frequency:
Provider:
# of Units:
Care Plan Goal # to be attached:
Backup Designation:
Backup Relation to Member:
Backup Provider/Name:
Backup Effective Date:
Level of Supervision (If applicable):
Awake:
Amount of unsupervised time:
Overnight:
Amount of unsupervised time:
Community:
Amount of unsupervised time:
Day Hab/Vocational:
Amount of unsupervised time:
Comments (Indicate why level of supervision needed):
Select:
Select:
Select:
Select:
Select
Select:
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Select
Service Plan – Version 1
July 2023 Page 10 of 12
Home Community Based Services
Service:
Start Date:
End Date:
Frequency:
Provider:
# of Units:
Care Plan Goal # to be attached:
Backup Designation:
Backup Relation to Member:
Backup Provider/Name:
Backup Effective Date:
Level of Supervision (If applicable):
Awake:
Amount of unsupervised time:
Overnight:
Amount of unsupervised time:
Community:
Amount of unsupervised time:
Day Hab/Vocational:
Amount of unsupervised time:
Comments (Indicate why level of supervision needed):
Service:
Start Date:
End Date:
Frequency:
Provider:
# of Units:
Care Plan Goal # to be attached:
Backup Designation:
Backup Relation to Member:
Backup Provider/Name:
Backup Effective Date:
Level of Supervision (If applicable):
Awake:
Amount of unsupervised time:
Overnight:
Amount of unsupervised time:
Community:
Amount of unsupervised time:
Day Hab/Vocational:
Amount of unsupervised time:
Comments (Indicate why level of supervision needed):
Select
Select:
Select:
Select:
Select:
Select
Select:
Select:
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Select:
Service Plan – Version 1
July 2023 Page 11 of 12
Home Community Based Services
Service:
Start Date:
End Date:
Frequency:
Provider:
# of Units:
Care Plan Goal # to be attached:
Backup Designation:
Backup Relation to Member:
Backup Provider/Name:
Backup Effective Date:
Level of Supervision (If applicable):
Awake:
Amount of unsupervised time:
Overnight:
Amount of unsupervised time:
Community:
Amount of unsupervised time:
Day Hab/Vocational:
Amount of unsupervised time:
Comments (Indicate why level of supervision needed):
Service:
Start Date:
End Date:
Frequency:
Provider:
# of Units:
Care Plan Goal # to be attached:
Backup Designation:
Backup Relation to Member:
Backup Provider/Name:
Backup Effective Date:
Level of Supervision (If applicable):
Awake:
Amount of unsupervised time:
Overnight:
Amount of unsupervised time:
Community:
Amount of unsupervised time:
Day Hab/Vocational:
Amount of unsupervised time:
Comments (Indicate why level of supervision needed):
Select:
Select:
Select:
Select:
Select
Select
Select:
Select:
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Select:
Service Plan – Version 1
July 2023 Page 12 of 12
Home Community Based Services
Service:
Start Date:
End Date:
Frequency:
Provider:
# of Units:
Care Plan Goal # to be attached:
Backup Designation:
Backup Relation to Member:
Backup Provider/Name:
Backup Effective Date:
Level of Supervision (If applicable):
Awake:
Amount of unsupervised time:
Overnight:
Amount of unsupervised time:
Community:
Amount of unsupervised time:
Day Hab/Vocational:
Amount of unsupervised time:
Comments (Indicate why level of supervision needed):
Service:
Start Date:
End Date:
Frequency:
Provider:
# of Units:
Care Plan Goal # to be attached:
Backup Designation:
Backup Relation to Member:
Backup Provider/Name:
Backup Effective Date:
Level of Supervision (If applicable):
Awake:
Amount of unsupervised time:
Overnight:
Amount of unsupervised time:
Community:
Amount of unsupervised time:
Day Hab/Vocational:
Amount of unsupervised time:
Comments (Indicate why level of supervision needed):
Select
Select:
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Select:
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Select
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