Contents
Steps to Filling Out Map 109 Kentucky
Filling out the Map 109 Kentucky form is an important step in securing waiver services. This form collects essential information about the member, their needs, and the services required. Follow these steps carefully to complete the form accurately.
- Member Information: Write the member's name, sex, Medicaid member ID, and date of birth in the designated spaces.
- Address: Fill in the member's complete address, including street, city, state, zip code, and county.
- Contact Information: Enter the home phone number of the member.
- Case Management/Support Broker: Provide the name and phone number of the case management or support broker agency.
- Guardian Details: If applicable, write the guardian's name, relationship to the member, and phone number.
- Power of Attorney: Fill in the name, relationship, and phone number of the power of attorney, if there is one.
- Representative Information: If applicable, write the representative's name, relationship, and address, along with their phone number.
- Level of Care Certification: Enter the certification number and the dates of certification.
- Primary Caregiver: Fill in the primary caregiver's name, relationship, and contact information.
- Identification of Needs: List the member's needs, outcomes, goals, objectives, and service provider details in the respective sections.
- Support Spending Plan: Complete the sections for both traditional waiver services and consumer-directed services, including service codes, provider names, units, costs, and totals.
- Provider Information: List each provider or employee’s name, number, address, and phone number.
- Clinical Summary: Provide a detailed clinical summary of the member's condition and needs.
- Emergency Back-up Plan: Write an emergency back-up plan if applicable.
- Signatures: Ensure the member or guardian, case manager, and representative sign and date the form where required.
Dos and Don'ts
When filling out the Map 109 Kentucky form, consider the following guidelines:
- Do read the entire form carefully before starting.
- Do ensure all personal information is accurate and up-to-date.
- Do provide complete contact details for all relevant parties.
- Do clearly state the needs and outcomes in the designated sections.
- Do double-check the Medicaid Member ID for accuracy.
- Don't leave any sections blank; fill in all required fields.
- Don't use abbreviations that may cause confusion.
- Don't submit the form without obtaining necessary signatures.
- Don't forget to keep a copy of the completed form for your records.
- Don't rush through the process; take your time to ensure accuracy.
File Breakdown
| Fact Name | Description |
|---|---|
| Form Title | Map 109 is titled "Plan of Care/Prior Authorization for Waiver Services." It is used in Kentucky for Medicaid services. |
| Governing Law | This form is governed by Kentucky Revised Statutes, specifically KRS 205.520 and KRS 205.560, which outline Medicaid services. |
| Purpose | The form is designed to authorize and outline the plan of care for individuals receiving waiver services. |
| Types of Waivers | Map 109 covers various waiver programs, including SCL, HCB, MP, ABI, Traditional, and CDO Blended. |
| Member Information | The form requires detailed member information, including name, Medicaid ID, date of birth, and contact details. |
| Provider Information | It includes sections to list service providers, their contact details, and the services they will provide. |
| Cost Breakdown | The form features a section for a support spending plan, detailing costs associated with services provided. |
| Emergency Backup Plan | A specific section is dedicated to outlining an emergency backup plan for Consumer Directed Options (CDO). |
| Signatures Required | The form requires signatures from the member or guardian, case manager, and representative to validate the information provided. |
Documents used along the form
The Map 109 Kentucky form is essential for individuals seeking waiver services through the Kentucky Medicaid program. Along with this form, several other documents are commonly used to ensure comprehensive care and proper authorization. Here’s a list of those documents, along with brief descriptions of each.
- Medicaid Application Form: This form is used to apply for Medicaid benefits. It collects personal information, financial details, and medical history to determine eligibility.
- Level of Care (LOC) Assessment: This document assesses the individual's needs and determines the appropriate level of care required for services. It helps establish eligibility for specific waiver programs.
- Service Plan: This outlines the specific services the individual will receive, including goals and objectives tailored to their needs. It is essential for coordinating care.
- Emergency Back-Up Plan: Required for Consumer Directed Options (CDO), this plan details procedures to follow in case the primary caregiver is unavailable. It ensures continuity of care.
- Provider Agreement: This document is signed between the Medicaid member and the service provider. It outlines the terms of service delivery and responsibilities of both parties.
- Clinical Summary: This summary provides a snapshot of the individual’s medical history, current health status, and any ongoing treatments. It is important for service providers to understand the member's needs.
- Power of Attorney (POA): This legal document grants someone the authority to make decisions on behalf of the individual regarding healthcare and finances. It is crucial for ensuring that the member's wishes are respected.
- Employment Verification Form: For employers seeking to confirm the eligibility of new hires, utilizing the important Employment Verification form resources is crucial for compliance with state laws.
- Guardian Documentation: If the individual has a legal guardian, this document establishes the guardian's authority and responsibilities in managing the member's care.
- Support Broker Agreement: This outlines the relationship and responsibilities between the support broker and the Medicaid member, ensuring clarity in service coordination.
- Budget Plan: This document details the financial aspects of the care plan, including costs for services and how funds will be allocated. It is essential for managing resources effectively.
Understanding these documents will help streamline the process of obtaining the necessary services and support. Each plays a vital role in ensuring that individuals receive the care they need in a timely manner.
Common PDF Forms
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Kentucky Tax Account Number - The 720X form covers parts for both income tax and license tax liabilities.
FAQ
What is the Map 109 Kentucky form used for?
The Map 109 form is a Plan of Care and Prior Authorization document for waiver services in Kentucky. It helps to outline the needs, goals, and services required for individuals receiving Medicaid waiver services, ensuring that they receive appropriate care and support. This form is essential for both initial requests and modifications to existing care plans.
Who needs to fill out the Map 109 form?
The form must be completed for individuals who are applying for or currently receiving Medicaid waiver services in Kentucky. This includes the member, their guardian, and possibly a case manager or support broker who will assist in coordinating the services. Each party plays a role in ensuring that the information is accurate and comprehensive.
What information is required on the Map 109 form?
The form requires detailed personal information about the member, including their name, Medicaid ID, date of birth, address, and contact information. Additionally, it asks for details about the guardian, power of attorney, and the case management agency involved. There is also a section for identifying needs, outcomes, services, and providers, as well as a support spending plan.
How is the support spending plan structured on the Map 109 form?
The support spending plan section is divided into two parts: Traditional Waiver Services and Consumer Directed Services. Each part requires information about service codes, provider names, units of service, costs, and total expenses. This helps to create a clear financial picture of the services being requested and ensures that all costs are accounted for.
What happens after the Map 109 form is submitted?
Once submitted, the form will be reviewed by the appropriate authorities. They will determine whether the plan of care and requested services are approved or denied. A signature from a Quality Improvement Organization (QIO) will indicate the final decision. If approved, services can begin as outlined in the plan.
Can the Map 109 form be modified after submission?
Yes, the Map 109 form can be modified. If there are changes in the member's needs, services, or providers, a modification can be submitted. This ensures that the care plan remains relevant and effective in meeting the member's needs over time.
What should I do if I make a mistake on the Map 109 form?
If you notice a mistake after submitting the form, it’s essential to address it as soon as possible. Contact the case management agency or support broker to discuss the error and determine the best course of action. They can guide you on how to correct the information and submit any necessary amendments.
Is there a deadline for submitting the Map 109 form?
While specific deadlines can vary based on individual circumstances and programs, it’s generally advisable to submit the Map 109 form as soon as possible. Timely submission can help avoid delays in receiving necessary services. Always check with your case manager for any specific timelines related to your situation.
Where can I get assistance with filling out the Map 109 form?
Assistance is available through your case management agency or support broker. They are equipped to help you understand the form and ensure that all necessary information is accurately provided. Additionally, local advocacy groups may offer resources and support for families navigating the Medicaid waiver process.