This is a general outline to follow for the application process. If you are currently working with Department of Human Services (DHS) staff, please contact that person regarding the application process for waiver services.

Apply for the Medicaid (Title XIX) and the MR Waiver at the local DHS office by contacting an Income Maintenance Worker (IM). The IM Worker will secure a payment slot or put the applicant's name on a waiting list. Upon availability of a payment slot, the IM will process the application and refer the consumer to a DHS Service Worker (SW) or a Medicaid case manager (CM). The Service Worker or Medicaid case manager will set up an appointment to complete a service application.

The documentation you may be asked to bring with you to your appointment with the IM Worker will vary from family to family. You may be asked to bring:

*Medical records (psychological testing) *Financial records *Title XIX card or a letter of Medicaid Eligibility, if applicable

The IM Worker may request the consumer to apply for SSI or SSA at the local Social Security office if the consumer is not already receiving this assistance.

The DHS Service Worker or Case Manager will do an assessment which determines if the consumer needs services requiring Intermediate Care Facility (ICF/MR) level of care.

If the consumer does not need ICF/MR level of care, a Notice of Decision (NOD) notifying the consumer of denial will be sent. The consumer has the right to appeal the decision. The process for appealing is explained on the NOD.

An Individual Comprehensive Plan (ICP) will be developed by the interdisciplinary team (IDT) which will include the consumer/family, DHS Service Worker or Case Manager, and may include school personnel, therapist or other professional or support persons.

Please respond immediately to correspondence from an Income Maintenance Worker, Service Worker or Medicaid case manager. This will 'speed up' the application process and assist in communication.

For adults, the HCBS Services Agreement (MA-2172) must be signed by the county of legal settlement CPC Administrator or county designee. For children, no signature is required by the county. However, the HCBS Services Agreement must be sent in with the approval packet.

If the consumer is approved to receive MR Waiver services, the consumer will be notified by the service worker or Medicaid case manager.

FOR MORE INFORMATION PLEASE CALL (515) 281-8061