Free Interagency Notification Termination of Community Waiver Participation - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-22637 (07/2008)

STATE OF WISCONSIN 42 CFR 431

INTERAGENCY NOTIFICATION TERMINATION OF COMMUNITY WAIVER PARTICIPATION
This form is to be completed by the care manager/support and service coordinator and sent to the Income Maintenance Worker (IMW) when the community waiver participant loses Medicaid community waiver eligibility.

NAME ­ Community Waiver Care Manager/Support and Service Coordinator

Agency

NAME ­ Income Maintenance Worker

County

NAME ­ Community Waiver Participant

Case / ID Number

Social Security Number (Optional)

Reason for Termination No longer meets functional/level of care eligibility No longer resides in eligible living arrangement1 Failed to meet post-eligibility requirements (ISP not signed, cost share payment(s) not made, spenddown not met, etc.) Participant has notified the agency of his/her decision to discontinue program participation Other--Specify: ________________________________________________________________________________

Additional Comments

Date Sent to IMW Date Received by IMW

SIGNATURE ­ CM/S&SC SIGNATURE - IMW

When a waiver participant moves to an ineligible living arrangement, the action of termination of waiver services may be initiated without advance notice (42 CFR 431.213 (c)). This means that the LTSA notice can give an effective termination date shorter than the normally required 10 days. Note that care managers still need to notify the ESA that waiver services are being terminated.

1