Work Opportunities Reward Kansans

Transcription

1 KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL Work Opportunities Reward Kansans

2 Part II WORK OPPORTUNITIES REWARD KANSANS PROVIDER MANUAL Introduction Section BILLING INSTRUCTIONS Introduction to the CMS-1500 Claim Form... Submission of Claim... BENEFITS AND LIMITATIONS Copayment... Assessment... Benefit Plans... Medicaid Appendix Procedure Codes and Nomenclature... A-1 Forms CMS-1500 WORK Assessment Instrument

3 PART II WORK OPPORTUNITIES REWARD KANSANS PROVIDER MANUAL Issued 7/07 This is the provider specific section of the manual. This section (Part II) was designed to provide information and instructions specific to Work Opportunities Reward Kansans (WORK) providers. It is divided into three subsections: Billing Instructions, Benefits and Limitations, and Appendices. Part I of the provider manual consists of five parts: General Information, General Benefits, General Billing, General Special Requirements, and General Third Party Liability (TPL). Part I contains information that applies to all providers, including WORK providers. The Billing Instructions subsection gives instructions for completing and submitting the billing forms applicable to WORK services. The Benefits and Limitations subsection defines specific aspects of the scope of WORK services allowed within the Kansas Medical Assistance Program (KMAP). The Appendix subsection contains information concerning procedure codes. The appendix was developed to make finding and using procedure codes easier for the biller. The Forms subsection contains forms specific to WORK providers. For detailed program information regarding WORK services, refer to the WORK Program Manual. A copy of the WORK Program Manual may be obtained by contacting the Kansas Health Policy Authority (KHPA) WORK Program Manager. HIPAA Compliance As a KMAP participant, providers are required to comply with compliance reviews and complaint investigations conducted by the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required by the Department during its review and investigation. Access to Records Kansas Regulation K.A.R requires providers to maintain and furnish records to KMAP upon request. Providers must also supply records to the Department of Health and Human Services upon request. The provider is required to supply records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's office upon request from such office as required by the Kansas Medicaid Fraud Control Act, K.S.A to , inclusive, as amended. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review, or investigation, including the relevant questioning of the provider s employees. The provider shall not charge a fee to retrieve and copy documents and records related to compliance reviews and complaint investigations. i

4 SUMMARY WORK OPPORTUNITIES REWARD KANSANS Issued 7/07 In September 2006, KHPA, the single Medicaid state agency, received approval from the Centers for Medicare & Medicaid Services (CMS) of a State Plan Amendment (SPA) submitted under Section 6044 of the Deficit Reduction Act of 2005, State Flexibility in Benefit Packages. The SPA provides a package of services, including assessment, personal assistance services, independent living counseling, and assistive services for beneficiaries with developmental disabilities, physical disabilities, and traumatic brain injury. CMS also approved the use of the cash and counseling model, allowing a direct cash payment to beneficiaries who choose to act as their own fiscal manager. This Medicaid State Plan package of services is titled WORK: Work Opportunities Reward Kansans. KHPA expects the number of people with severe cognitive and physical disabilities who enter the workforce will increase if personal assistance and related services are provided at a sufficient level in the home, at work, and in the community. KHPA also hopes that beneficiaries will increase the number of hours worked, increase their income, and self-report better health-related outcomes and an improved quality-of-life as a result of the combination of Working Healthy and WORK. KHPA believes that WORK, combined with the benefits of Working Healthy, will encourage greater participation in Ticket-to-Work Work Incentives Improvement Act (TWWIIA) programs, thereby further promoting employment of people with significant disabilities. KHPA believes that the cash and counseling model is the next logical step for promoting adult self-sufficiency, community integration, and employment. WORK goes a step beyond beneficiary direction, which Kansas already practices in its Home and Community Based Services (HCBS) programs, and allows beneficiaries to truly control their services through person-centered planning, management of their own funds, and the choice of how best to obtain services in the most costeffective way. In addition to supporting employment efforts, WORK is designed to provide eligible enrollees with optimum control of their lives by allowing them to purchase personal assistance services that will meet their unique needs using a monthly cash allocation, determine whether to use the services of an independent living counselor or manage their care independently, decide whether to use a Fiscal Management Service or manage their funds independently, and choose providers with whom they feel the most comfortable rather than have to use mandated providers based on disability and geographical location. KHPA staff designed WORK in conjunction with beneficiaries who will eventually enroll in the program, advocates, community providers, and Social and Rehabilitations Services (SRS) staff. ii

5 WORK OPPORTUNITIES REWARD KANSANS BILLING INSTRUCTIONS Issued 7/07 Introduction to the CMS-1500 Claim Form WORK providers must use the CMS-1500 claim form (unless submitting electronically) when requesting payment for medical services provided under KMAP. An example of the CMS-1500 claim form is in the Forms section at the end of this manual. The interchange MMIS uses electronic imaging and optical character recognition (OCR) equipment. Therefore, information must be submitted in the correct claim fields to be recognized by the equipment. EDS does not furnish the CMS-1500 claim form to providers. Refer to Section 1100 of the General Introduction Provider Manual. Complete, line-by-line instructions for completion of the CMS-1500 are available in the General Billing Provider Manual. Submission of Claim: Send completed first page of each claim and any necessary attachments to: Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571 Topeka, KS KANSAS MEDICAL ASSISTANCE PROGRAM WORK OPPORTUNITIES REWARD KANSANS PROVIDER MANUAL BILLING INSTRUCTIONS 7-1

6 BENEFITS AND LIMITATIONS COPAYMENT Issued 7/07 WORK services (WORK assessment, assistive services, and independent living counseling) are exempt from copayment requirements. KANSAS MEDICAL ASSISTANCE PROGRAM WORK OPPORTUNITIES REWARD KANSANS PROVIDER MANUAL BENEFITS & LIMITATIONS 8-1

7 BENEFITS AND LIMITATIONS ASSESSMENT Issued 7/07 Assessment Contractor The Assessment Contractor is responsible for the following: Providing initial assessment in a timely manner to determine eligibility for WORK Providing annual reassessments and as-needed assessments if changes are necessary Communicating assessment results to beneficiaries Providing the KHPA Program Manager with assessment results Assisting beneficiaries to develop their Plan for Independence Using the assessment and Plan for Independence to determine the allocation for purchasing services Explaining the methodology used to calculate the allocation to the beneficiary Submitting the assessment results, Plan for Independence, and allocated amount to the KHPA Program Manager Maintaining records for each beneficiary assessed and providing responses to requests for information Providing resource information, including independent living counselors and fiscal management organizations The Assessment Contractor may not provide any other WORK services, including independent living counseling, fiscal management, personal assistance services, or assistive services. Assessment The Assessment Contractor and the beneficiary must use the WORK Assessment Instrument to determine the beneficiary s functional limitations and the WORK services needed to live and work in the community. During the assessment, the beneficiary s functional limitations must be assessed, including the amount of time required to perform activities of daily living, instrumental activities of daily living, and work related activities without assistance during the normal rhythm of his/her day. Based on this information, eligibility for WORK and the allocation for services are determined. Procedure code T1023 must be used to bill for the assessment. See the Forms section for a copy of the WORK Assessment Instrument. KANSAS MEDICAL ASSISTANCE PROGRAM WORK OPPORTUNITIES REWARD KANSANS PROVIDER MANUAL BENEFITS & LIMITATIONS 8-2

8 BENEFITS AND LIMITATIONS BENEFIT PLANS Updated 08/08 KMAP beneficiaries are assigned to one or more KMAP benefit plans. The assigned plan or plans are listed on the beneficiary ID card. These benefit plans entitle the beneficiary to certain services. If there are questions about service coverage for a given benefit plan, refer to Section 2000 of the General Benefits Provider Manual for information on the plastic State of Kansas Medical Card and eligibility verification contact the KMAP Customer Service Center at or Eligibility Criteria The following beneficiaries are eligible for WORK: Beneficiaries eligible for the Working Healthy (KMAP Buy-in Program) and meeting the following qualifications: 16 through 64 years of age Determined disabled by the Social Security Administration Earned income verified by FICA/SECA payments Countable net income no higher than 300 percent of the federal poverty level Assets no higher than $15,000 Kansas resident and Beneficiaries on the Developmentally Disabled, Physically Disabled, and Traumatic Brain Injury waivers, or on the waiting lists for one of these waivers, or meet the same functional limitations as beneficiaries on these waivers and Beneficiaries competitively * employed in an integrated ** setting * Competitively employed is defined as work performed in the competitive labor market on a full- or part-time basis for which individuals are compensated at or above minimum wage, but not less than the customary wage and level of benefits paid a nondisabled individual for the same or similar work. ** Integrated setting is defined as a setting typically found in the community in which individuals with the most severe disabilities interact with nondisabled individuals, other than nondisabled individuals who are providing services for them, to the same extent that nondisabled individuals in comparable positions interact with other persons. KANSAS MEDICAL ASSISTANCE PROGRAM WORK OPPORTUNITIES REWARD KANSANS PROVIDER MANUAL BENEFITS & LIMITATIONS 8-3

9 BENEFITS AND LIMITATIONS MEDICAID Issued 7/07 All WORK services require prior authorization through the Plan for Independence process. Assistive Services Assistive services include any item, piece of equipment, product system, or environmental modification, which is used to increase, maintain, or improve independence or employment. Procedure code S5165 must be used to bill for assistive services. Purchase or rental of new or used assistive technology is limited to those items not covered by Medicaid under the State Plan. Examples include, but are not limited to, ramps, lifts, home modifications to increase access, and assistive technology that improves communication and/or mobility in the home and workplace. Assistive services also include any service that directly assists a beneficiary with a disability in the selection, acquisition, or use of assistive technology. Beneficiaries may choose, and designate payment for, the provider of their choice. Such services may not include any services already covered by Medicaid under the State Plan. Environmental modifications may be purchased in rented apartments or homes. Assistive services require prior authorization on the Plan for Independence. The assistive service(s) authorized is based on the beneficiary and his/her situation and must be medically necessary, increase the beneficiary s ability to live independently or maintain employment, and prevent nursing home or other institutional placement. Verification of medical necessity is required. Assistive services have an annual limit of $7,500. Medical necessity refers to a health intervention that meets the following guidelines: Recommended by the treating physician or other appropriate licensed professional (a medical practitioner cannot establish medical necessity outside his/her area of expertise) Has the purpose of treating a medical condition Provides the most appropriate level of service, considering potential benefits and harms to the beneficiary Is known to be effective in improving health outcomes Is cost-effective for the condition being treated when compared to alternative interventions (the usual and customary rate is used when approving assistive services) KANSAS MEDICAL ASSISTANCE PROGRAM WORK OPPORTUNITIES REWARD KANSANS PROVIDER MANUAL BENEFITS & LIMITATIONS 8-4

10 8400. Issued 7/07 Assistive Services (cont.) Assistive services must be included on the Plan for Independence and require the prior authorization of the Program Manager. If approved, the assistive services and cost must be included on the Individualized Budget. Beneficiaries are free to choose any vendor enrolled as a KMAP provider and licensed to provide, or capable of providing, that service. Examples of assistive services include, but are not limited to: Home modifications to increase access, including ramps, grab bars, reducing counter tops, widening doors Lifts Specialty beds (such as hospital), specialty mattresses, mattress covers, bed rails Communication devices Dentures Hearing aids and batteries Low vision aids Insulin pumps and supplies Cost of obtaining and replacing service dogs and other service animals Motorized wheelchairs or scooters, and repairs Medical alert devices (installation and monthly fees) Vehicle adaptations (adaptations only) Items exempted include, but are not limited to: Appliances such as blenders, microwaves, refrigerators, washers, dryers Home renovations not related to accessibility Household items such as air conditioners, humidifiers/dehumidifiers, air purifiers, water purifiers Heating pads, heat lamps, vaporizers Water beds Hot tubs, whirlpool baths Exercise equipment, indoor exercise pools Vehicles KANSAS MEDICAL ASSISTANCE PROGRAM WORK OPPORTUNITIES REWARD KANSANS PROVIDER MANUAL BENEFITS & LIMITATIONS 8-5

11 8400. Issued 7/07 Independent Living Counseling Independent living counseling has an annual cap of 480 units or 120 hours; however, exceptions may be made for beneficiaries who require additional hours. Prior authorization is required to exceed the annual limitation. Beneficiaries are not required to use the maximum number of independent living counseling hours that are available each year. Procedure code T1016 (case management, each 15 minutes) must be used to bill for independent living counseling. Independent Living Counselor Qualifications Independent living counselors must meet the following qualifications: Employed by a Center for Independent Living (CIL), Community Developmental Disability Organization (CDDO) or CDDO affiliate, or a licensed Home Health Agency that is enrolled as a provider of independent living counseling services Have a minimum of one year professional experience providing direct services, including case management (working directly with people with a variety of disabilities) Have a minimum of six months experience working with a disability as recognized by the Rehabilitation Act of 1973 or have an understanding of independent living philosophy with at least 12 hours of standardized training in the history and philosophy of independent living annually provided by a CIL or the State Independent Living Council of Kansas Completed and passed the Web-based independent living counseling examination Completed a two-hour WORK orientation Participate in all state mandated WORK and independent living counseling training to ensure proficiency of the program and services rules, regulations, policies, and procedures set forth by KHPA Independent Living Counselor Responsibilities Each beneficiary may choose an independent living counselor to assist in the development of the Individualized Budget and coordination of services. Beneficiaries are not required to use an independent living counselor if they feel they can manage their services without assistance. Independent living counselors must demonstrate evidence of beneficiary involvement at all stages of services and Individualized Budget development. KANSAS MEDICAL ASSISTANCE PROGRAM WORK OPPORTUNITIES REWARD KANSANS PROVIDER MANUAL BENEFITS & LIMITATIONS 8-6

12 8400. Issued 7/07 Independent Living Counselor Responsibilities (cont.) Independent living counselors may perform any of the following: Assist in the development of, and obtain approval for, the Individualized Budget Assist in accessing Web-based self-direction training Assist beneficiaries to access training and support to develop the skills necessary to self-direct services, organize workplace accommodations, and otherwise meet goals for independent living Assist beneficiaries to locate providers of personal assistance services Assist with interviewing, hiring, supervising, and terminating a personal attendant Assist beneficiaries in determining and locating alternate, cost-effective methods for purchasing services Assist in documenting the need for assistive services and locating providers of assistive services and supports Assist in locating emergency backup care and emergency assistance Assist in planning for, documenting the use of, and setting up a savings account for excess allocated funds Assist beneficiaries who do not want to administer their allocation in locating a fiscal agent Assist beneficiaries who choose to administer their allocation to access mandatory Web-based training and assessment Assist in documenting expenditures and submitting documentation in a timely manner Submit all required paperwork in a timely fashion Offer information and referral for meeting independent living and employment goals Assist beneficiaries to maintain and/or increase independence and employment and access other systems that will enhance independent living or employment Assist workers with negotiating equal employment opportunities and reasonable accommodation needs with employers Assist with locating and maintaining services such as, but not limited to, childcare, transportation, and modifications to homes or vehicles Provide peer support for employment and independent living activities Coordinate the services of beneficiaries who choose not to self-direct their services Monitor and evaluate on a regular basis to ensure beneficiaries are being provided services according to the Plan for Independence/Individualized Budget Communicate any changes in status, needs, or problems to the appropriate KHPA and SRS staff Assist in reporting exploitation and emotional or physical abuse to SRS Adult Protective Services Assist in scheduling reassessments for WORK Assist with disenrolling from the program and accessing an HCBS waiver or waiver waiting list Independent living counselors cannot provide personal services or act as a fiscal agent for beneficiaries for whom they are providing independent living counseling. They may, however, be the employees of an agency that provides personal assistance or fiscal management services for beneficiaries. KANSAS MEDICAL ASSISTANCE PROGRAM WORK OPPORTUNITIES REWARD KANSANS PROVIDER MANUAL BENEFITS & LIMITATIONS 8-7

13 APPENDIX PROCEDURE CODES AND NOMENCLATURE Issued 07/07 The following procedure code represents an all-inclusive list of WORK services billable to KMAP. Procedure codes not listed here are noncovered by KMAP. PROCEDURE CODE S5165 T1016 T1023 NOMENCLATURE Home modifications; per service Case management, each 15 minutes Screening to determine the appropriateness of consideration of an individual for participation in a specified program, project, or treatment protocol, per encounter KANSAS MEDICAL ASSISTANCE PROGRAM WORK OPPORTUNITIES REWARD KANSANS PROVIDER MANUAL APPENDIX A-1

14 FORMS CMS-1500 WORK Assessment Instrument

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16 WORK Work Opportunities Reward Kansans Kansas Personal Assistance Program for Employed Persons With Disabilities Assessment Instrument Kansas Health Policy Authority Kansas Working Healthy Program 900 SW Kansas, Suite 900N Topeka, KS 66612

17 Kansas Health Policy Authority WORK Work Opportunities Reward Kansans Assessment Date: Assessor Name: I. Information Section Name: Street Address: City: State: Zip: Birth Date: Gender: Social Security Number: Medicaid ID Number: Home Phone: Mobile Phone: Friend/Representative Name: Street Address: City: State: Zip: Numbers of hours of employment each month Page 2 of 21

18 II. Eligibility Section Note: This section is only to verify that eligibility has been established for Working Healthy. (Please check yes or no) 1) Have you been determined to have a disability by Social Security Standards (SSI or SSDI) or Disability DU? 2) Are you currently eligible for the Working Healthy Program (KMAP Buy-in Program)? 3) Are you employed (provide proof that you have paid FICA or SECA [self-employment tax])? 4) Are you a Kansas resident? 5) Are you years of age? Yes No III. Previous Support (Initial Assessment) (Questions 1-5, criteria for Waiver to WORK Services for initial assessment only) (Please check yes or no) Yes 1) Are you currently using HCBS waiver services? If no, skip to Question 4 No 2) Which HCBS waiver? (Please check one) Physical Disability (PD) Developmental Disability (MR/DD) Traumatic Brain Injury (HI) (Please indicate the number of hours) 3) If you are currently using Personal Assistance Services, how many hours of Personal Attendant Care services do you currently qualify for? Hours 4) (Please check yes or no) Yes No Are you currently on a waiting list for HCBS waiver services? If no, skip to Question 6 Page 3 of 21

19 5) Which HCBS waiver waiting list? (Please check one) Physical Disability (PD) Developmental Disability (MR/DD) Traumatic Brain Injury (HI) (Please check yes or no) 6) Yes No Are you currently eligible for but not on a waiver or waiting list? 7) Which waivers are you eligible for? (Please check one) Physical Disability (PD) Developmental Disability (MR/DD) Traumatic Brain Injury (HI) Page 4 of 21

20 IV. Support Assessment for PAS Needs ADLs (Activities of Daily Living (Support can be defined as total or partial support from another person, assistance with setup or prep work for an activity, prompts, and verbal guidance (reminders).) 1) Personal hygiene and grooming Examples include: Bathing Oral care Hair care Shaving a) Can you perform this task without support? Yes No Please check one (If yes, skip to Question 2) b) How much time does it take for you to perform this task without support? (List total number of minutes.) c) How do you currently get this done? (Explain in the space below) d) What could you do if someone were available to assist you? (Explain in the space below) e) If support is needed for this task, briefly describe the amount and frequency of support needed and include an estimate of the weekly and monthly hours of support you would need. Total Weekly hours needed for this activity hours Total Monthly hours (Weekly hours x 4.33 = Monthly hours) Estimated time: minutes daily Page 5 of 21

21 2) Dressing Examples include: Personal care Intellectual support Assistive devices a) Can you perform this task without support? Yes No Please check one (If yes, skip to Question 3) b) How much time does it take for you to perform this task without support? (List total number of minutes.) c) How do you currently get this done? (Explain in the space below) d) What could you do if someone were available to assist you? (Explain in the space below) e) If support is needed for this task, briefly describe the amount and frequency of support needed and include an estimate of the weekly and monthly hours of support you would need. Total Weekly hours needed for this activity hours Total Monthly hours (Weekly hours x 4.33 = Monthly hours) Estimated time: minutes daily Page 6 of 21

22 3) Prosthetic and Orthotic Devices Examples include: Assistance in putting on and removing devices Maintenance and cleaning devices a) Can you perform this task without support? Yes No Please check one (If yes, skip to Question 4) b) How much time does it take for you to perform this task without support? (List total number of minutes.) c) How do you currently get this done? (Explain in the space below) d) What could you do if someone were available to assist you? (Explain in the space below) e) If support is needed for this task, briefly describe the amount and frequency of support needed and include an estimate of the weekly and monthly hours of support you would need. Total Weekly hours needed for this activity hours Total Monthly hours (Weekly hours x 4.33 = Monthly hours) Estimated time: minutes daily Page 7 of 21

23 4) Toileting Examples include: Empty ostomy/urine bag Establish/maintain toileting schedule a) Can you perform this task without support? Yes No Please check one (If yes, skip to Question 5) b) How much time does it take for you to perform this task without support? (List total number of minutes.) c) How do you currently get this done? (Explain in the space below) d) What could you do if someone were available to assist you? (Explain in the space below) e) If support is needed for this task, briefly describe the amount and frequency of support needed and include an estimate of the weekly and monthly hours of support you would need. Total Weekly hours needed for this activity hours Total Monthly hours (Weekly hours x 4.33 = Monthly hours) Estimated time: minutes daily Page 8 of 21

24 5) Medication Management Examples include: Reminders to take medication Check compliance Assist in taking medications a) Can you perform this task without support? Yes No Please check one (If yes, skip to Question 6) b) How much time does it take for you to perform this task without support? (List total number of minutes.) c) How do you currently get this done? (Explain in the space below) d) What could you do if someone were available to assist you? (Explain in the space below) e) If support is needed for this task, briefly describe the amount and frequency of support needed and include an estimate of the weekly and monthly hours of support you would need. Total Weekly hours needed for this activity hours Total Monthly hours (Weekly hours x 4.33 = Monthly hours) Estimated time: minutes daily Page 9 of 21

25 6) Transfer Examples include: Supervision/Minimal assistance Moderate assistance Heavy support/lifting a) Can you perform this task without support? Yes No Please check one (If yes, skip to Question 7) b) How much time does it take for you to perform this task without support? (List total number of minutes.) c) How do you currently get this done? (Explain in the space below) d) What could you do if someone were available to assist you? (Explain in the space below) e) If support is needed for this task, briefly describe the amount and frequency of support needed and include an estimate of the weekly and monthly hours of support you would need. Total Weekly hours needed for this activity hours Total Monthly hours (Weekly hours x 4.33 = Monthly hours) Estimated time: minutes daily Page 10 of 21

26 7) Walking/Mobility/Wheelchair Maneuvering Examples include: Special assistive devices Supervise/Minimal assistance Moderate support Heavy support and lifting Turn and position in chair and/or bed a) Can you perform this task without support? Yes No Please check one (If yes, skip to Question 8) b) How much time does it take for you to perform this task without support? (List total number of minutes.) c) How do you currently get this done? (Explain in the space below) d) What could you do if someone were available to assist you? (Explain in the space below) e) If support is needed for this task, briefly describe the amount and frequency of support needed and include an estimate of the weekly and monthly hours of support you would need. Total Weekly hours needed for this activity hours Total Monthly hours (Weekly hours x 4.33 = Monthly hours) Estimated time: minutes daily Page 11 of 21

27 8) Eating Examples include: Remind/Coax to eat Assistance to cut food Directly feeding a) Can you perform this task without support? Yes No Please check one (If yes, skip to Question 9) b) How much time does it take for you to perform this task without support? (List total number of minutes.) c) How do you currently get this done? (Explain in the space below) d) What could you do if someone were available to assist you? (Explain in the space below) e) If support is needed for this task, briefly describe the amount and frequency of support needed and include an estimate of the weekly and monthly hours of support you would need. Total Weekly hours needed for this activity hours Total Monthly hours (Weekly hours x 4.33 = Monthly hours) Estimated time: minutes daily Page 12 of 21

28 9) Meal planning/preparation/clean up ADLs (Instrumental Activities of Daily Living) Examples include: Development of healthy menu Safe preparation of foods Wash dishes and clean kitchen a) Can you perform this task without support? Yes No Please check one (If yes, skip to Question 10) b) How much time does it take for you to perform this task without support? (List total number of minutes.) c) How do you currently get this done? (Explain in the space below) d) What could you do if someone were available to assist you? (Explain in the space below) e) If support is needed for this task, briefly describe the amount and frequency of support needed and include an estimate of the weekly and monthly hours of support you would need. Total Weekly hours needed for this activity hours. Total Monthly hours (Weekly hours x 4.33 = Monthly hours) Estimated time: minutes daily Page 13 of 21

29 10) Shopping Examples include: Making list of needed items Selection of items needed Payment and change for items a) Can you perform this task without support? Yes No Please check one (If yes, skip to Question 11) b) How much time does it take for you to perform this task without support? (List total number of minutes.) c) How do you currently get this done? (Explain in the space below) d) What could you do if someone were available to assist you? (Explain in the space below) e) If support is needed for this task, briefly describe the amount and frequency of support needed and include an estimate of the weekly and monthly hours of support you would need. Total Weekly hours needed for this activity hours Total Monthly hours (Weekly hours x 4.33 = Monthly hours) Estimated time: minutes daily Page 14 of 21

30 11) Laundry/Housekeeping Examples include: Laundry Cleaning floors and dusting Cleaning bathroom Remove trash Change linens Make beds Assistive devices a) Can you perform this task without support? Yes No Please check one (If yes, skip to Question 12) b) How much time does it take for you to perform this task without support? (List total number of minutes.) c) How do you currently get this done? (Explain in the space below) d) What could you do if someone were available to assist you? (Explain in the space below) e) If support is needed for this task, briefly describe the amount and frequency of support needed and include an estimate of the weekly and monthly hours of support you would need. Total Weekly hours needed for this activity hours Total Monthly hours (Weekly hours x 4.33 = Monthly hours) Estimated time: minutes daily Page 15 of 21

31 12) Transportation (Going from place to place throughout the community) Examples include: Assistance to use public transportation Scheduling transportation needs a) Can you perform this task without support? Yes No Please check one (If yes, skip to Question 13) b) How much time does it take for you to perform this task without support? (List total number of minutes.) c) How do you currently get this done? (Explain in the space below) d) What could you do if someone were available to assist you? (Explain in the space below) e) If support is needed for this task, briefly describe the amount and frequency of support needed and include an estimate of the weekly and monthly hours of support you would need. Total Weekly hours needed for this activity hours Total Monthly hours (Weekly hours x 4.33 = Monthly hours) Estimated time: minutes daily Page 16 of 21

32 13) Money Management Examples include: Assistance with paying bills Using a budget Assistance with checking account a) Can you perform this task without support? Yes No Please check one (If yes, skip to Question 14) b) How much time does it take for you to perform this task without support? (List total number of minutes.) c) How do you currently get this done? (Explain in the space below) d) What could you do if someone were available to assist you? (Explain in the space below) e) If support is needed for this task, briefly describe the amount and frequency of support needed and include an estimate of the weekly and monthly hours of support you would need. Total Weekly hours needed for this activity hours Total Monthly hours (Weekly hours x 4.33 = Monthly hours) Estimated time: minutes daily Page 17 of 21

33 14) Travel Supports Employment related supports Examples include: Assistance to use public transportation Scheduling transportation needs What supports will allow you to travel to and from work or to meet personal appointments within the work day? (Note: Appointments and travel related to employment are employer s responsibility.) If support is needed, briefly describe the amount and frequency of support needed and include an estimate of the weekly and monthly hours of support you would need. Weekly hours needed for this activity hours Monthly hours (Weekly hours x 4.33 = Monthly hours) Estimated time: minutes daily Page 18 of 21

34 15) Physical Supports in Employment Examples include: Assistance with toileting Assistance with meals Movement within the workplace Assistance with medication needs What supports are necessary to meet personal needs while at work? If support is needed, briefly describe the amount and frequency of support needed and include an estimate of the weekly and monthly hours of support you would need. Weekly hours needed for this activity hours Monthly hours (Weekly hours x 4.33 = Monthly hours) Estimated time: minutes daily Page 19 of 21

35 16) Cognitive Supports in Employment Examples include: Assistance with accessing/receiving job/task accommodations Learning and using specific job skills Interacting with employer/supervisor/co-workers Completing work related tasks with acceptable speed and quality Changing job assignments What supports are necessary to meet cognitive needs while at work? If support is needed, briefly describe the amount and frequency of support needed and include an estimate of the weekly and monthly hours of support you would need. Weekly hours needed for this activity hours Monthly hours (Weekly hours x 4.33 = Monthly hours) Estimated time: minutes daily Page 20 of 21

36 Total Hours of Support Identified Total Number of ADL PAS Hours Pages 5-12 Total Number of IADL PAS Hours Pages Total Number of Employment Related Support Hours Pages Total monthly number of Personal Assistance Hours Requested The times and activities on this form are estimates of the times and activities necessary to support my independence. I participated in the development of this document, and agree that it reasonably reflects my support needs. Beneficiary Signature Date Page 21 of 21