Modified Service Funding Plan Request Instructions
Below you will find instructions for the Modified Service Funding Plan Request (MSFPR) formerly known as the Request for Service Change (RFSC). This request will serve as the official request for funding from the Developmental Disabilities Administration for eligible participants for all service types. The process will be an interim process until the launch of the new Person Centered Plan in LTSS.
Request Urgency:Check applicable box. When a participants health and safety is in immediate jeopardy and the DDA acts quickly to put the appropriate services in place (i.e. a person becomes a danger to themselves or others; they have been abandoned; engaging in aggressive behavior or homeless).
Immediate need:when a participant requires a service to be put in place in order to maintain their health and safety (i.e. in home supports, caregiver passes away establish personal supports in the home, residential services, implement a behavioral plan for the home).
Standard:when a participant makes a general request to modify their current services (i.e. whether they want to discontinue a service, increase their support hours or add a new service).
Cost neutral:when a participant uses their existing funding to transfer into a new services; this is a lateral move from one service to another and it does not require an increase in funding.
- IF a provider completes an existing service adjustment, the CCS should be included.
- IF either a provider or CCS completes the request, the entity (Provider or CCS) is responsible for the completion of the request.
Type of Modified Service Funding Plan Request: Select the appropriate request
Coordinators of Community Services and/or Providers can complete the Modified Service Funding Plan Request for each participant who chooses to receive services through their agencies. After review by the CCS and/or provider the Modified Service Funding Plan Request is submitted to the appropriate Regional Office for consideration.
*Providers please note that the Modified Service Funding Plan Request is a now a “one form” process. There is not a separate service funding plan that is submitted. This process will serve as the sole approval all in one document.
*Be sure to include ratios as applicable.
Provider Initiated:Check applicable box.If initiated by the Provider from the time of the meeting to submission to the RO will have 5 business days to submit.
Coordinator of Community Services Initiated:check applicable box.If initiated by the CCS from the time of the meeting to submission to the RO will have 5 business days to submit.
Once submitted to the RO the Program Team reviews within 7 business days. If additional information is needed RO will reach out to the person completing the request for final approval. The goal is that any request submitted to the RO is reviewed and approved within 20 business days. It is the person completing the request responsibility to respond to the RO within 3 business days of the request for additional information. If a request does not have the completed required information it will not be processed once you submit the required documentation then the 20 days will begin.The 20 business days does not begin unless ALL of the documentation is received.
DateofRequest:List date of request
Annual IP Meeting:List annual IP date; this is the reoccurring plan date for a participants person centered plan.
Name:List individual’s first and last name
Date of Birth:List individual’s date of birth
Address:List individual’s physical address
Phone Number:List individual’s phone number
Email:List individual’s email address
Social Security #: List individual’s social security number
Medical Assistance (MA#):List individual’s MA number
Individual’s preferred method of communication: Check applicable box.
PART I: REQUEST:DDA Program (check one)
Is the service requested a waiver service?Check applicable box
Coordinator of Community Service (CCS)List CCS name and number
Person submitting form (if not CCS):List name of person completing form
Team Meeting Date:Enter date
Does the team have consensus related to this request?Check applicable box.
If “No” has a request for mediation been submitted to the Regional Office?Check applicable box and enter date and explanation in the box.
IP Addendum or Revised IP Attached (If required)check box if applicable
Part 1A: Desired Outcome List the desired outcomes in the box.Desired outcomes identified by an individual are achieved through specified service(s) and action steps that are outlined in the IP to address a need. Individual’s outcomes and needs change which can result in changes to the IP (i.e. increase, decrease, or addition of new services and resources), and therefore a “Modified Service Finding Plan Request.”
Part 1B: Current DDA Authorized Services: complete the applicable boxes enter information as appropriate
Part 1C: Current State Services, Medicaid Services and Natural Supports (CFC services, REM, Medicaid State Plan, etc.). Provide information applicable information in the box and attach additional pages if needed.All current state services need to be indicated to avoid duplication of services.For participants that receives services other that the DDA services will need to be indicated i.e. CFC, REM or MA State Plan etc. which are not indicated in PCIS2.Individuals, with assistance from others (i.e. CCS or provider) if desired, can seek assistance and resources from various sources including natural supports and apply for local, generic, community services; disability programs and services; Medicaid State Plan Services or private insurance; and State and federal programs once the need is identified.
Part 1D: Other Services Explored to Meet the Desired Outcome.Provide information applicable information in the box and attach additional pages if needed.
Part 1E: Services-please check what service change is needed to achieve the desired outcome and add additional pages as needed. Please indicate services the participant currently receives; to include the services that are being requested in this request.
Part 1F: Specific Description of Proposed Services: Provide information applicable information in the box and attach additional pages if needed.(i.e. indicate the services being proposed such as “awake over night” and details supporting why the service is needed; the duration; how it will be provided). (i.e. ongoing is the services that the participants receives that are recurring).
Projected length of service need:Check applicable box
Projected Start Date:Enter the date. **For a projected start date if there is an instance that this was an emergent situation and services began prior to then indicate the date of the start date; Emergent cases must be preapproved by the Regional Office.
Part 1G: Justification and Documentation:Provide information applicable information in the box and attach additional pages if needed (describe the individual’s current status and reason for new or additional service, including reasons such as health and safety, community integration or increased independence. Note any change in the individual’s current situation that effects their health and safety, level of community integration, or independence.
Documentation Provided– Check all that apply include attachment:
Part 1H: Individual ChoiceCheck applicable box - IF “no” please explain and provide applicable information in the box and attach additional pages;a clear explanation is required. (i.e. when considering restrictive techniques we also need to consider the CMS community settings rule related to rights restrictions and documentation required in the plan).
Part 1G: Signatures: Enter information in the each applicablespace. Note - *My initials above indicate that I agree/disagree with the services and goals that are outlined in this request; and I understand that, as a member of this team, I may request changes at any time.
PART II: REQUEST FOR FUNDING (COST DETAIL)
Only the relevant parts of the detail sheet should be submitted with the request(i.e. if it is residential and personal supports those are the only sheets that should be submitted).
The purpose of the cost detail sheet is to identify the funding, matrix level and the add-ons (add-ons are additional services i.e. awake overnight (AON) or direct supports, supplemental services or one time only add-ons (i.e. respite, transportation, or start-up cost). The CCS, Provider and the Participant, Regional Office (Program Services Team) and Regional Director reviews/signs the COST DETAIL. The Regional Office will continue to complete the approval letter as determined by the effective date of the services requested. This process will continue until we are formally utilized LTSS; once we began utilizing LTSS, the system will generate the approval letters.
Part IIA: Cost Detail-Complete Appropriate Supplemental Form for All requested Services and attach separately (see below attachments).
A-Family Support Services
B-Individual Support Services
C-Personal Support Services
D-Residential Support Services
E-Supportive Employment/Community Learning Services/Day Habilitation Service/Employment Discovery & Customization
F-Modified Service Funding Plan Request Instructions
G-Cheat Sheet for identifying the number of hours in a matrix level
H-Shared Living
Part II: Section A: Cost Detail: Check applicable box.
Consumer: List Consumer’s name
Social Security Number: List Consumer’s SSN
Provider:List Provider’s Name
County: List County
Transported using a wheelchair: List information
Number of operating days: List the number of days.
Base Rate: List rate
Start Date: List date
End Date: List date
Complete Matrix Level: Enter information in appropriate boxes
Complete Rate Components:Enter information in appropriate boxes
Additional Funding Requested: Enter information in appropriate boxes
Start Date: List Date
End Date: List Date
Other Funding Requested: Enter information in appropriate boxes
NOTE: Time Frames for submission
- This process is effective November 1, 2016
- If initiated by the CCS from the time of the meeting to submission to the RO will have 5 business days to submit.
- If initiated by the Provider from the time of the meeting to submission to the RO will have 5 business days to submit.
- Once submitted to the RO the Program Team reviews the request within 7 business days.
- If additional information is needed RO will reach out to the person completing the request for final approval; it is the person completing the request responsibility to respond to the RO within 3 business days of the request for additional information.
- If a request does not have the completed required information it will not be processeduntil the required documentation is received by the RO; once received the 20 business days will begin.
***The goal is that any request submitted to the RO is reviewed and approved within 20 business days***
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DDA Policy: Attachment F Version 11/1/16