The Map 109 Kentucky form is a vital document used by the Commonwealth of Kentucky's Cabinet for Health and Family Services, specifically within the Department for Medicaid Services. This form serves as a Plan of Care and prior authorization for waiver services, ensuring that individuals receive the necessary support tailored to their unique needs. By outlining essential details such as member information, service providers, and care plans, it plays a crucial role in facilitating access to Medicaid services for eligible individuals.
The Map 109 form, officially known as the Plan of Care/Prior Authorization for Waiver Services, is a crucial document for individuals in Kentucky seeking Medicaid waiver services. This form serves multiple purposes, including the initial assessment of needs, the identification of desired outcomes, and the authorization of specific services required by the member. It is designed to be filled out for various residential statuses, such as in-home care, adult foster care, and group homes. Key sections include personal information about the member, such as their name, Medicaid ID, date of birth, and contact details. Additionally, the form requires details about case management agencies, guardians, and power of attorney representatives. It also outlines the level of care certification, service provider information, and a comprehensive support spending plan that details the costs associated with both traditional and consumer-directed services. Each part of the form is essential in ensuring that members receive the appropriate support tailored to their unique needs, ultimately facilitating a smoother process in accessing vital services.
Map 109
Commonwealth of Kentucky
Cabinet for Health and Family Services
(Rev 07/08)
Department for Medicaid Services
PLAN OF CARE/PRIOR AUTHORIZATION FOR WAIVER SERVICES
Initial
30Day Annual Modification
Residential Status
In Home
Family Home Provider
Adult Foster Care Provider
Staffed Residence
Group Home
Type of Waiver Program
SCL
HCB
MP
ABI Traditional
CDO
Blended (CDO/Traditional)
1. MEMBER NAME: __________________________
_______________
___
Sex:
Last
First
MI
MALE
FEMALE
2. MEDICAID MEMBER ID #: ________________________________ 3. DOB: ______________________
4.ADDRESS: ______________________________________________________________________________
Street
_________________________
_____
_________
5. HOME PHONE:________________
City
State
Zip
County
6.CASE MANAGEMENT/SUPPORT BROKER AGENCY (CDO):____________________ ______________
Phone
7.GUARDIAN NAME: _______________________________________ ________________ _____________
Relationship: Phone
8.POWER OF ATTORNEY: _________________________________ ________________ _______________
9.REPRESENTATIVE NAME (CDO ONLY): ___________________________________: ________________
Relationship
10.ADDRESS: _____________________________________________________________________________
11. PHONE:______________________
12.LEVEL OF CARE (LOC) CERTIFICATION NUMBER: _________________
13.LOC CERTIFICATION DATES: FROM: _______________ TO: ____________________
14.PRIMARY CAREGIVER: _____________________________________________ ___________________
15.ADDRESS: _____________________________________________________________________________
16. PHONE:______________________
Page 1 of 5
Member Name: _____________________________ Medicaid Member ID#:__________________________
Identification of Needs/Outcomes/Services/Providers
NEED(S)
OUTCOMES/GOAL(S)
OBJECTIVES/INTERVENTION(S)
SERVICE
PROVIDER NAME/#
CODE
Page 2 of 5
Member Name: ____________________________________ Medicaid Member ID#: ____________________ Date Services Start: ___________
Support Spending Plan
Traditional Waiver Services
Service Code
A
Provider Name and Number
B
Units per
Week
C
Month
D
Cost per
Unit
E
Cost per Week (Column CxE)
F
Total Cost Monthly
(4.6xColumn F)
G
Total Cost per Month
$
Consumer Directed Services
Service
Description of Service
Employee
Units
Hourly
Number of
Sum of
Administrative
Total
Code
Providing the
per
Month (Column
Wage
Hours per
Wages Times
Costs
Monthly
week
D x 4.6)
Hours
I
Amount
H
J
Total Cost
Per Month
Page 3 of 5
Member Name: ______________________________________ Medicaid Member ID #: ______________________
List each provider/employee name, address and telephone number:
Provider/Employee Name
Provider Number Address
Phone Number
Clinical Summary:
_______________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________________________________________
Page 4 of 5
Member Name: _______________________________________________ Medicaid Member ID #: ________________________
Emergency Back-up Plan (CDO only)
___________________________________________________________________________________________________
I certify the information contained above is accurate and that I have made an informed choice when selecting the providers/employees to provide each service.
_______________________________________________________________
________________________
Member/Guardian Signature
Date
Case Manager/Support Broker Signature
__________________
Representative Signature (CDO)
Plan of Care/Support Spending Plan
Approved
Denied
QIO Signature/Title
Page 5 of 5
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