SECTION: 11 Adult Protective Services

Transcription

1 STATE OF ALASKA DEPARTMENT OF HEALTH & SOCIAL SERVICES SENIOR AND DISABILITIES SERVICES POLICY & PROCEDURE MANUAL SECTION: 11 Adult Protective Services Number: Page: SUBJECT: ADULT PROTECTIVE SERVICES GENERAL RELIEF ASSISTED LIVING HOME CARE PROGRAM APPROVED: TBD DATE: TBD Title Adult Protective Services General Relief Assisted Living Home Care Program Purpose To describe the eligibility for the program and eligibility determination process To describe benefit application, waitlist, renewal, and termination To describe the roles and responsibilities of program stakeholders Policy Purpose of Program The SDS General Relief Assisted Living Home Care (herein after referred to as General Relief or GR) program provides temporary financial assistance to eligible adults for assisted living home services. The goal of the program is to assist the adults receiving GR benefits to obtain the level of care they could receive in their own home and to live in the least restrictive possible setting. General Relief is a payer of last resort and is utilized only after all other resources are exhausted. Eligibility An applicant must meet the eligibility criteria, as outlined in regulations 7 AAC and 510, and submit a complete application with documentation supporting the eligibility criteria and need for assisted living home care. Application Applications will be reviewed for eligibility when a complete application is received. A complete application includes at a minimum: the Demographic Information Sheet, Application Narrative, Income and Resource Form with supporting documentation (for most people this will be the three most recent months of bank statements), the General Relief Contract, Physician s Report, and any necessary releases of information. Applicants with a legal decision maker must also attach the paperwork appointing the legal decision maker that identifies the decisions they may make on behalf of the applicant. People claiming zero income or who are likely to qualify for Adult Public Assistance and do not already have it must submit confirmation of applying for this program. All applicants must also submit an application to Social Security, SSI, Medicaid, and Adult Public Assistance within 30 days of applying for the General Relief Program and also for any other state federal personal or community based benefit programs for which they may qualify If information is missing or unclear, the application will be given a status of pending and a letter will be sent by the General Relief Unit requesting the information needed to determine eligibility. If the missing information is not received within 20 days, the application will be denied. If a waitlist is in effect, the application approval date is one item used to rank applicants. It is very important to submit a complete application and respond quickly to requests for information. Eligibility Determination Applications will be processed by the earliest date placed in the eligibility queue. There is no expedited or emergency eligibility determination process.

2 STATE OF ALASKA DEPARTMENT OF HEALTH & SOCIAL SERVICES SENIOR AND DISABILITIES SERVICES POLICY & PROCEDURE MANUAL SECTION: 11 Adult Protective Services Number: Page: SUBJECT: ADULT PROTECTIVE SERVICES GENERAL RELIEF ASSISTED LIVING HOME CARE PROGRAM APPROVED: TBD DATE: TBD Once a complete application is received, the General Relief Unit has 30 days to make an eligibility determination. This timeline is suspended when placed in pending status for more information from the applicant. If information is missing or unclear, the application will be given a status of pending and a letter sent requesting the information needed to determine eligibility. If the missing information is not received within 20 days, the application will be denied. Applicants will be notified of their application being approved or denied by letter sent from the General Relief Unit. If a waitlist is in effect, an applicant may be approved for placement on a waitlist for benefits. Applicants who are denied may request a fair hearing if they feel that they should not have been denied benefits. The denial letter contains the information about the procedure to follow to request a fair hearing. Waitlist If the Division of Senior and Disabilities Services determines that the program does not have adequate funding to serve both existing individuals receiving GR benefits and new applicants, it will establish a waitlist for new applicants approved for benefits until funding is available. Funding availability will be reviewed monthly when a waitlist is in effect. Waitlisted applicants will be separated into preference categories and within those categories, ordered by the date a complete application was approved for the waitlist. The first preference category is vulnerable adults in need of protective placement by Adult Protective Services, the second preference category is individuals who will be discharged directly from an institution for mental disease, a Department of Corrections facility, a hospital or long term care facility and the third and third and final tier is all other applicants. If funding becomes available, waitlisted applicants will be selected based on preference category and then by the earliest date of the waitlist approval letter. Once all waitlisted applicants from the first category have been processed, then applicants in the second category will be processed and once the second category has been processed, then applicants in the third category will be processed. Preference category will always have priority over waitlist approved date. At the time an applicant is the first person on the waitlist, the General Relief program will attempt to contact the applicant, the referral agency, listed legal decision maker, and additional contacts listed on the application to attempt to notify the applicant that benefits are available. The applicant will have 20 days to respond to the General Relief Program to confirm he or she is still in need of the benefit. If the applicant is still eligible and wishes to receive the benefit, an approval letter will be issued. After 20 days with no response from any contact person or if the applicant declines the benefit, GR will remove the application from the waitlist, note the declining of benefits or lack of response and deny benefits. If the applicant has been on the waiting list for more than 60 days, additional documentation may be requested to verify the applicant still qualifies for the program before the applicant receives approval for benefits. Benefits Provided The General Relief program will pay for a portion of up to 6 months of assisted living home care fees for applicants who are approved to receive the benefit, up to the maximum daily rate approved for that person. The person s income is taken

3 STATE OF ALASKA DEPARTMENT OF HEALTH & SOCIAL SERVICES SENIOR AND DISABILITIES SERVICES POLICY & PROCEDURE MANUAL SECTION: 11 Adult Protective Services Number: Page: SUBJECT: ADULT PROTECTIVE SERVICES GENERAL RELIEF ASSISTED LIVING HOME CARE PROGRAM APPROVED: TBD DATE: TBD into account and all countable income and resources will be applied to pay for the cost of care, minus any exemptions and personal needs allowance. Upon approval for benefits, the General Relief Unit will create a calculation sheet that identifies the authorized dates of use, approved daily rate, the portion of the daily rate paid for by the State of Alaska and the portion of the daily rate the approved applicant is responsible to pay directly to the home. The two payments combined may not exceed the approved daily rate. Changes in income or resources while a person is applying for or receiving GR must be reported to the GR program and may change the benefit amount paid by both the State of Alaska and the approved applicant/resident. If an approved applicant/resident receives a windfall amount such as a Social Security payback or sale of property, they are responsible to payback the General Relief Program the amount that would be due based on the new resource or income calculations during the dates the GR benefits were used and the dates income was earned or resource was available. The minimum daily rate will not be paid for days the resident is absent from the home, except for short absences preapproved by the GR unit. Augmented rates may be requested for the reasons listed in regulation 7AAC Documentation of need is required to be supplied by the requesting agency or applicant/resident. Residents who are receiving services through another agency, organization, or program provided in an assisted living home are not eligible for an augmented rate. Residents may not also receive augmented rates restricted to those residents working with a Division of Behavioral Health grantee as described in 7 AAC Augmented rates will not be paid for any day the resident is not in the home, whether or not the absence is approved. Use of Benefits Applicants who are approved for General Relief Benefits have 60 days to begin using the benefits. It is the applicant s responsibility to find an Assisted living Home that can meet their care needs and share the information contained in the application with the prospective assisted living home. An Assisted Living Home has the choice to enter into a contract or not based on their ability to care for the described needs and their existing responsibility to care for other residents in the Assisted Living Home. Prior to accepting a resident, it is recommended that ALHs ask for a copy of the approval letter from GR and the calculation sheet with the date payment is authorized. The ALH may have the potential resident sign a Release of Information and the GR Unit can send a current approval letter and calculation sheet or will notice the home the person does not have GR benefits. Once an Assisted Living Home has been selected and the prospective resident moves in, the resident and the ALH must notify the General Relief Program no later than ten days after the move in date. General Relief benefits may only be used to pay for assisted living home services with assisted living homes who have an active State of Alaska Assisted Living Home License and a current General Relief Provider Agreement with the Division of Senior and Disabilities Services. The General Relief program cannot pay a home that is not licensed and a current SDS General Relief provider. General Relief cannot back-date the provider agreement approval date.

4 STATE OF ALASKA DEPARTMENT OF HEALTH & SOCIAL SERVICES SENIOR AND DISABILITIES SERVICES POLICY & PROCEDURE MANUAL SECTION: 11 Adult Protective Services Number: Page: SUBJECT: ADULT PROTECTIVE SERVICES GENERAL RELIEF ASSISTED LIVING HOME CARE PROGRAM APPROVED: TBD DATE: TBD If an applicant moves in to an Assisted Living Home before being approved for General Relief benefits, the applicant is responsible for full payment to the home up to the date of benefit approval, if benefits are approved. General Relief cannot back-date the approval date. If an applicant is on the waiting list, General Relief payment is not authorized until they are pulled from the waitlist and issued an approval letter. If the General Relief Unit is not noticed of a move-in date within 60 days of approval for the benefit, the benefit case will be closed for non-use unless the General Relief Unit is contacted for a 30-day extension prior to the 60 days ending. Additional documentation may be requested after 60 days to verify the applicant still qualifies for the program. If an additional 30 days pass with no use, the benefit case will be closed and a new application will be required. All approved benefits count toward the total outstanding authorizations and contribute to deciding whether or not a waitlist will begin. General relief benefits that are approved, but go unused should be kept to a minimum. Benefit Renewal General Relief is a temporary benefit program. Benefits will be authorized for up to 6 months and will terminate on the authorized end date unless the resident requests a renewal of benefits. The resident and/or legal decision maker is responsible to turn in a complete renewal application to the GR program 15 days prior to the benefit ending or benefits will be terminated. Sometimes benefits are only approved for one or two months, stating that an application to another program must be completed in order for benefits to be renewed. If this or any other condition applies, the conditions described in the approval letter must also be met before the benefit renewal will be processed. This information is contained in the approval letter. A complete benefit renewal packet includes a minimum of: the Renewal Narrative, Income and Resource Form with supporting documentation, the General Relief Contract, Physician s Report, and a copy of the current ALH contract that outlines the services provided to the individual to support their daily living. Some ALHs may use two separate documents, an ALH contract and a plan of care. If this is the case, both must be submitted. Once a complete renewal application is received, the General Relief Unit has 15 days to make an eligibility determination, including that all benefits have been applied for. If the General Relief Unit is delayed in the determination process, the resident s benefits will continue without interruption through the date benefit determination is made. If a renewal application is denied, benefits will be extended up to 30 days to allow proper noticing to the ALH if the resident chooses to move out. If information is missing or unclear, the renewal application will be given a status of pending and a letter sent requesting the information needed to determine eligibility. If the missing information is not received within 20 days, the application will be denied. Applicants, legal decision maker and the current ALH will be notified of the renewal application being approved or denied by letter. Applicants who are denied may request a fair hearing if they feel that they should not have been denied benefits. The denial letter contains the information about the procedure to follow to request a fair hearing.

5 STATE OF ALASKA DEPARTMENT OF HEALTH & SOCIAL SERVICES SENIOR AND DISABILITIES SERVICES POLICY & PROCEDURE MANUAL SECTION: 11 Adult Protective Services Number: Page: SUBJECT: ADULT PROTECTIVE SERVICES GENERAL RELIEF ASSISTED LIVING HOME CARE PROGRAM APPROVED: TBD DATE: TBD Application Withdrawal/Termination of Benefits If an applicant no longer wants to pursue an application, they can withdraw the application at any time by notifying the General Relief Unit. The GR Unit will follow up with a letter confirming the withdrawal of the application. If an applicant has been approved for benefits, but no longer wishes to use them and has not been placed, they can terminate the benefits at any time by notifying the General Relief Unit. The GR Unit will follow up with a letter confirming the request to terminate benefits. If a resident is currently using General Relief benefits and wishes to be removed from the program, the GR Unit will contact the resident/legal decision maker by phone to confirm the reason for termination and final move out date. The resident is responsible to provide the ALH with adequate notice as outlined in the ALH contract. The GR Unit will follow up with a letter confirming the request to terminate benefits. The General Relief Unit will terminate GR benefits if: information is received and verified that the resident is no longer eligible for the program; the resident is out of ALH placement for more than 30 days; renewal applications and additional information requested are not completed and returned within the timeframes outlined in the written notice; or the resident has died. The GR Unit will follow up with a letter confirming the termination benefits. The General Relief Unit may work with residents and institutional discharge staff to suspend benefits if an absence will be greater than 30 days, but less than 60. Benefits will be reinstated only if the General Relief unit has been kept apprised of the anticipated discharge date and receives discharge plans outlining the resident s care needs identifying a need for ALH care. If a renewal application is due during the institutional stay, the renewal packet must be completed prior to discharge and benefits being reinstated. If an approved applicant or resident s benefits are terminated and they wish to receive General Relief benefits after the termination, they must submit a new complete application packet. The new application will be subject to a waitlist, if in effect. Emergency Placement by Adult Protective Services If Adult Protectives Services determines that a vulnerable adult who is subject or at risk of abuse, neglect self-neglect or exploitation, has no resources for residential care, and is in need of an emergency protective placement; General Relief funding and approved assisted living home providers may be used to support this placement. An APS Supervisor must approve an emergency protective placement, 30 days at a time. General Relief funding for emergency placements may last no longer than 60 days without a complete application packet submitted to the General Relief Program unless the Program Manager of both the General Relief Program and Adult Protective Services Program agree to extend the duration of the emergency placement. This is allowed only when necessary to protect a vulnerable adult from harm and circumstances exist that prevent APS from submitting a General Relief Program Application. Changes in Information The applicant/resident, legal decision maker or anyone acting upon their behalf, and the ALH must report any changes concerning the applicant/resident that may affect their General Relief application or benefits, absence from the home or continued need for the program. This includes but is not limited to: changes in income or resources, changes in eligibility for other programs (such as a waiver), absence from the home, request to terminate benefits, move out or death.

6 STATE OF ALASKA DEPARTMENT OF HEALTH & SOCIAL SERVICES SENIOR AND DISABILITIES SERVICES POLICY & PROCEDURE MANUAL SECTION: 11 Adult Protective Services Number: Page: SUBJECT: ADULT PROTECTIVE SERVICES GENERAL RELIEF ASSISTED LIVING HOME CARE PROGRAM APPROVED: TBD DATE: TBD Invoices Businesses that currently have an Assisted Living Home license in good standing with the State of Alaska and an executed General Relief Provider Agreement may submit an invoice to the General Relief Program for payment of clients who have been approved to receive General Relief Benefits and have received ALH services from that business. The invoice must adhere to State of Alaska administrative policies, General Relief Regulations 7 AAC and the General Relief Provider Agreement. A tutorial on how to complete an invoice is available on the GR website. General Relief is responsible to pay only the portion identified to be paid by the program on the calculation sheet for approved applicants during the authorized dates. The ALH is responsible for billing and collecting the client portion of the cost of care. The State of Alaska is not responsible to pay for clients who do not pay their cost of care, for the ALH accepting a client who is not approved for GR benefits or for a client who has lapsed benefits. Invoices will be checked by the General Relief Unit in the SDS database to verify the rate, client, dates of service, and required elements of the invoice are complete and correct. Any invoices with discrepancies will be pulled out of the batch for additional provider inquiry and will take longer to process. Payment Inquiry from the ALH It is the responsibility of the ALH to track invoice submission, processing s and other correspondence from the GR Unit involving residents and payment to be able to submit and track invoices. The ALH is able to sign up for IRIS access to look up payments made to the business. The GR Unit will the ALH to identify that the services have been verified and the invoice has been sent on to be processed for payment. If the information on the submitted invoice and the GR database do not match, the ALH will be ed with a notice that an error needs to be resolved. The GR Unit will not respond to overdue payment inquiries until 30 days have passed beyond the expected processing date. Example: Services are rendered in March. Invoice is submitted by the ALH for payment in April. Payment would be expected about 30 days later in May, if there are no errors. The payment would be considered overdue in June. It is very important that ALHs have adequate reserves to cover this long billing cycle as payments cannot be expedited. Assisted Living Home Licensing rules require 6 months of reserves for this reason. Prior to contacting the GR Unit about payment, the ALH must first locate the invoice and identify the date it was submitted to the GR Unit, review its s to locate the processing notice from the GR Unit to make sure there is not outstanding questions about the invoice that need to be answered, and look up the last IRIS payment made to determine the payment has not been made. When calling or ing about late payments the ALH must have the copy of the invoice submitted and any related correspondence ready to review and discuss with the GR Unit. Authority AS 47.24: Protection of Vulnerable Adults; AS 47.33: Assisted Living Homes; AS 47.25: Public Assistance; 7 AAC : General Relief Assisted Living Home Care; 7AAC 49: Hearings; AS : Procedures for Hearings; 2AAC : Purpose, applicability, and effect of hearing procedures; 7 AAC 75: Licensing of Assisted Living Homes. Definitions

7 STATE OF ALASKA DEPARTMENT OF HEALTH & SOCIAL SERVICES SENIOR AND DISABILITIES SERVICES POLICY & PROCEDURE MANUAL SECTION: 11 Adult Protective Services Number: Page: SUBJECT: ADULT PROTECTIVE SERVICES GENERAL RELIEF ASSISTED LIVING HOME CARE PROGRAM APPROVED: TBD DATE: TBD Adult Protective Services (APS) helps to prevent or stop harm from occurring to vulnerable adults in the State of Alaska. This unit is managed by the Division of Senior and Disabilities Services, which is in the Department of Health and Social Services, which is in the Executive Branch of the State of Alaska. Adult Protective Services Program Manager (APS Manager) is a role within the GR section that has oversight over the APS Staff. The APS Manager addresses concerns unable to be answered by the APS Supervisors and matters that concern policy and general administration of the program. Adult Protective Services Supervisor (APS Supervisor) is a role within the APS section that has oversight over the APS investigators. The APS Supervisor is the primary contact for direct adult protective services and investigative work in their geographic areas of the state. Applicant is a person applying for General Relief benefits. Approved Applicant is a person who has been approved for General Relief benefits, but has not been placed in an assisted living home. Assisted Living Home or ALH for the General Relief Program is a home licensed by the Assisted Living Home Licensing Unit that has entered into a General Relief Provider Agreement for services with the Division of Senior and Disabilities Services. Assisted Living Home Licensing (ALL) licenses, inspects and monitors assisted living homes in the State of Alaska. This unit is managed by the Division of Health Care Services, which is in the Department of Health and Social Services, which is in the Executive Branch of the State of Alaska. Emergency or Protective Placement is a placement made by Adult Protective Services to protect a vulnerable adult that has an open case with APS by arranging for assisted living home services through the GR program to stop or prevent abuse, neglect, self-neglect or exploitation. General Relief Assisted Living Home Care Program (General Relief or GR) provides temporary financial assistance to eligible adults for assisted living home services. General Relief Program Manager (GR Manager) is a role within the GR section that has oversight over the GR Supervisor. The GR Manager addresses concerns unable to be answered by the GR Supervisor and matters that concern policy and general administration of the program. General Relief Program Supervisor (GR Supervisor) is a role within the GR section that has oversight over the Senior Services Technicians. The GR Supervisor determines benefit eligibility and approves payment for services. IRIS is the State of Alaska database that processes vendor payments. Vendors can sign up for portal access to review payments made to their business.

8 STATE OF ALASKA DEPARTMENT OF HEALTH & SOCIAL SERVICES SENIOR AND DISABILITIES SERVICES POLICY & PROCEDURE MANUAL SECTION: 11 Adult Protective Services Number: Page: SUBJECT: ADULT PROTECTIVE SERVICES GENERAL RELIEF ASSISTED LIVING HOME CARE PROGRAM APPROVED: TBD DATE: TBD Senior Services Technician (SST) is a role within the GR section that processes and prepares incoming applications and renewals for eligibility determination, invoices for payment and other work delegated by the supervisor. Investigator is a role within Adult Protective Services that investigates allegations of abuse, neglect or exploitation of vulnerable adults and provides protective services for vulnerable adults. Resident is a person who lives in an assisted living home. Vulnerable Adult is a person 18 years of age or older who, because of incapacity, mental illness, mental deficiency, physical illness or disability, advanced age, chronic use of drugs, chronic intoxication, fraud, confinement or disappearance is unable to meet the person s own needs or to seek help without assistance. Responsibilities A. Applicant/Resident is responsible for: 1. Ensuring a complete and correct application is submitted to the GR unit for processing. 2. Applying for all benefits listed in 7 AAC within 30 days of the application for GR 3. Providing additional information to the GR unit as requested to process eligibility. 4. Selecting and contracting with an assisted living home. 5. Paying the client cost of care directly to the assisted living home. 6. Notifying the GR unit of any changes involving themselves that affect eligibility for the program, change in income or a change in address, including move-in, within ten days of the change. 7. Renewing benefits if they are needed past the current authorization date. B. Legal Decision Maker is responsible for: 1. Completing any of the tasks the applicant/resident is responsible for that have been delegated or transferred to the legal decision maker. C. At the request of the Applicant or Legal Decision Maker, the Referring Agency is responsible for: 1. Providing application completion and submission assistance. 2. Collecting and submitting additional information to the GR unit. 3. Assisting with selecting an assisted living home. 4. Applying for all benefits listed in 7 AAC within 30 days of the application for GR 5. Notifying the GR unit of any significant changes involving a resident that affect eligibility for the program, change in income or a change in address, including move-in, within ten days of the change. D. Adult Protective Services Investigator is responsible for: 1. Requesting General Relief funding to support a protective placement 2. Selecting an assisted living home with the vulnerable adult 3. Notifying the GR unit of any changes involving a resident that affect eligibility for the program, change in income or a change in address, including move in. 4. Ensuring a complete and correct application is submitted to the GR unit for processing prior to the end of emergency placement if benefits are still needed. E. Senior Services Technician is responsible for 1. Recording and processing applications for GR benefits to prepare them for eligibility determination. 2. Verifying that the applicant or someone on the applicant s behalf has applied for the benefits listed in 7 AAC (a) within 30 days of the initial application for GR.

9 STATE OF ALASKA DEPARTMENT OF HEALTH & SOCIAL SERVICES SENIOR AND DISABILITIES SERVICES POLICY & PROCEDURE MANUAL SECTION: 11 Adult Protective Services Number: Page: SUBJECT: ADULT PROTECTIVE SERVICES GENERAL RELIEF ASSISTED LIVING HOME CARE PROGRAM APPROVED: TBD DATE: TBD 3. Recording and processing renewal applications for GR benefits to prepare them for eligibility determination. 4. Reviewing and updating reported information changes. 5. Recording and batching invoices for payment and assisting providers with fixing incorrect invoices. 6. Collecting and recording signed provider agreements. 7. Providing notices to program stakeholders as directed by GR Supervisor. 8. Answering basic inquiries about the General Relief program, policies, and forms. 9. Other duties as assigned or delegated by the General Relief Supervisor. F. General Relief Program Supervisor is responsible for: 1. Determining eligibility for General Relief Benefits. 2. Requesting additional documentation or information to supplement an application that does not clearly meet eligibility. 3. Approving correct invoices for payment and assisting providers with fixing incorrect invoices. 4. Providing guidance on complex and urgent case issues that cannot be resolved by an SST. 5. Supervising the Senior Services Technician positions and ensures timely completion of their responsibilities. 6. Assisting Health Program Manager III with other duties as assigned or delegated. G. Health Program Manager III is responsible for 1. Providing guidance on complex and urgent case issues that cannot be resolved by a supervisor. 2. Ensuring the program is following applicable statutes, regulations, policies and procedures. 3. Identifying and implementing program improvements and changes. 4. Supervising the General Relief Program Supervisor position. 5. Completing reports and other assigned duties related to the management of the program. H. Assisted Living Homes are responsible for 1. Maintaining a current State of Alaska Assisted Living Home License and following ALH licensing regulations. 2. Maintaining a current General Relief provider agreement and following the terms of the provider agreement. 3. Developing a care contract with the resident and billing the GR program and the client as outlined in the Calculation Sheet. 4. Providing the services outlined in 7 AAC Notifying the GR unit of any changes involving a resident that affect eligibility for the program, change in income or a change in address within ten days of the change. 6. Maintaining current service and payment paperwork for all GR residents served. I. Assisted Living Home Licensing is responsible for 1. Licensing assisted living homes in the State of Alaska. 2. Investigating complaints and concerns brought forward about licensed assisted living homes. SEE ALSO: Attachment A: Application Attachment B: Renewal Application Attachment C: Calculation Sheet Attachment D: Client Activity Form

10 Attachment A Application for General Relief for Assisted Living Home Care Benefits Program Overview The General Relief Assisted Living Home Care Program helps to pay for Assisted Living Home Care for qualified Alaskans facing extreme financial crisis. This is a temporary benefit program. The General Relief Program is a payer of last resort. Applicants must show that they have tried to obtain all other means of payment including: using their own resources, applying for Adult Public Assistance and Medicaid to pay for necessary Assisted Living Home Care before the General Relief benefit can be used. This is a program paid for through State of Alaska General Funds. The availability of this funding is subject to legislative appropriation. A waitlist will be used when there is not enough funding to serve additional applicants. Full program details including regulations and forms are posted on the Senior and Disabilities Services General Relief Program website ( General Relief staff can be reached at or to answer questions about the program. General Relief Assisted Living Home Care Defined Assisted living care is a range of care which includes more than room and board, but which does not include continuous nursing, medical care, or a secure setting. It encompasses twenty-four hour supportive and protective services in the activities of normal daily living and is provided in a residential environment which encourages independent living to the extent possible for each resident (7 AAC ). Residents may leave the home as they wish and have the right to refuse medication or services. General Relief Eligibility Criteria The Division of Senior and Disabilities Services purchases assisted living care for vulnerable adults who meet the medical, social, and financial eligibility criteria outlined in 7 AAC through 7 AAC ) is 18 years of age or older; 2) is a resident of the State of Alaska; 3) has been assessed for eligibility by a care coordinator or other person approved by the Department of Health and Social Services and: a) has a disability that is attributable to mental retardation, cerebral palsy, epilepsy, autism or another condition closely related to mental retardation that significantly impairs intellectual functioning and adaptive behavior; b) has a hearing, speech, visual, orthopedic, or other major health impairment that significantly impedes participation in the social, economic, educational, recreational, and other activities generally available to the individual s non-impaired peers in the community; or c) has a significant deficit in adaptive behavior in the area of self-care, communication of needs, mobility, or independent living, which may be the result of the aging process, an emotional health disturbance, or alcohol or drug dependence; 6) without assisted living care is subject to, or at risk of, abuse, neglect, self-neglect or exploitation by others; 7) does not have income that exceeds the limits permitted in 7 AAC ; 8) does not have resources that exceed the amount permitted by 7 AAC ; 9) has applied for the cash assistance programs as required by 7 AAC (a); and 10) has applied for and exhausted the use of alternative resources. Page 1 of 11

11 Attachment A Application for General Relief for Assisted Living Home Care Benefits Checklist The application will not be reviewed for eligibility until it is complete or thirty days have elapsed, whichever is sooner. To decrease the amount of time it takes to review the application, please ensure all of the following items are complete and submitted as part of the same packet. Demographic Information or Electronic Inquiry Form in Harmony (1 page) Application Narrative or Electronic Inquiry Form in Harmony (2 pages) Income and Resource Form or Electronic Inquiry Form in Harmony (1 page) o Attach the most recent three months of bank statements o Applicants claiming $0 income or are likely to qualify for Adult Public Assistance will be required to attach confirmation of applying for Adult Public Assistance. The GR application will not be considered complete without this confirmation. o General Relief will check the EIS database to verify public benefits and application General Relief Contract (2 pages) o Must be signed by the Applicant and Legal Decision Maker (if applicable) o If there is a Legal Decision Maker, attach a copy of that document Physician s Report (2 pages) o Must be dated within 3 months of this application. Release of Information as needed (2 pages) o This is needed for General Relief to discuss the application with someone other than the applicant, referrer, or legal decision maker. o Submit one release per person/agency Note: A TB clearance is no longer required. If information is missing or unclear, the application will be given a status of pending and a letter sent requesting the information needed to determine eligibility. If the missing information is not received within 20 days, the application will be denied. When a waitlist is in effect, the approval date is used to rank applicants. It is very important to submit a complete application and respond quickly to requests for information. Once GR benefits are approved, share a copy of this application with the ALH for placement. Complete Applications can be sent to: Senior and Disabilities Services, General Relief Assisted Living Home Care Program 550 West 8 th Avenue, Anchorage, AK Fax: DSM: general.relief@direct.dhss.akhie.com General Relief staff can be reached at or to answer questions about the application. Page 2 of 11

12 Attachment A Application for General Relief for Assisted Living Home Care Benefits Referrer Contact Information If someone other than the applicant is assisting with the application, complete this section. Salutation: First Name: Last Name: Suffix: Title: Relationship to Applicant: Agency Name: Provider ID: Mailing Address Suite/Apt.: City: State: Zip Code: Phone work: Phone cell: Other: Fax: DSM: Applicant Demographic Information First Name: Middle Initial: Last Name: Suffix: Mailing Address Suite/Apt.: City: State: Zip Code: Physical Address City: Current Location: (hospital/my home/friend s house/etc.) Phone home: Phone cell: Phone work: DOB: Gender: Marital Status: Primary Language: Second Language: Ethnicity: Tribe (if any): Health Insurance/Benefits (list all that apply Ex. IHS, VA, Medicaid): Where has the Applicant lived in the past 12 months? (Check all that apply) Own Home/With Family Assisted Living Home Rented Apartment/Home Skilled Nursing Facility Group Home Shelter Homeless, not in a shelter Jail/Prison Psychiatric Facility Page 3 of 11

13 Attachment A Application for General Relief for Assisted Living Home Care Benefits Crisis Stabilization Unit Residential Treatment Boarding Home Application Narrative Applicant Last Name: Applicant First Name: Describe why Assisted Living Home Care is needed: Describe what independent living, supportive housing or in-home services have already been tried: Describe the services and supervision needed: Expected duration and goals of placement: Page 4 of 11

14 Attachment A Application for General Relief for Assisted Living Home Care Benefits Application Narrative cont. Applicant Last Name: Applicant First Name: Placement History: Significant Behavior Information: (Routine, strengths, likes/dislikes, problems areas, safety issues): Who will help the applicant with the application for benefits listed in 7 AAC , additional paperwork or renewals after placement? Name: Relationship to Applicant: Mailing Address: Phone: When a waitlist is in effect, who should GR contact to notify of benefit availability if we cannot locate the applicant after contacting the applicant, legal decision maker and referrer? Name: Relationship to Applicant: Mailing Address: Phone: Name: Relationship to Applicant: Mailing Address: Phone: Page 5 of 11

15 Attachment A Application for General Relief for Assisted Living Home Care Benefits Income and Resources Worksheet Not all Income and Resources are counted toward eligibility, but must be disclosed. Please enter $0 and note N/A in comments if this income or resource type does not apply. Source of Income Source Name Estimated Monthly Amount Social Security/SSDI $ SSI $ Public Assistance $ Veteran's Benefits $ Senior Benefits $ Native Dividends $ Other Dividends/Interest $ Pension $ Other Income $ Other Income $ Other Income $ Total $ Comments Resource Name of Bank/Resource Details Estimated Value Comments Checking Account Balance $ Savings Account Balance $ Burial Fund $ Second Home $ Land (non-tribal) $ Second Vehicle $ RV $ 4-wheelers/motorcycles, etc. $ Stocks, Bonds, Investments $ Whole Life Insurance $ Expected settlement windfall or back pay $ Other Resource $ Total $ If an applicant is approved for General Relief benefits and income or resources are later discovered that can be applied to the cost of care, the Department will recalculate the client cost of care for any month that income or resource was available to them and retroactively bill the resident for the additional amount owed. This is most common in a windfall situation where multiple months of past earned benefits are paid out in a lump sum. If income or resources are discovered to be available to Page 6 of 11

16 Attachment A Application for General Relief for Assisted Living Home Care Benefits the resident on an ongoing basis above the allowed amounts, the client may no longer be eligible for the General Relief Program. Physician s Report The Physician s Report must be complete and signed by a physician, physician s assistant or advanced nurse practitioner; substitutions are not allowed. Attach additional information as needed. Applicant Information Applicant Last Name: Applicant First Name: Date of Birth: Height: Weight: Medical History and Current Medical Problems Primary Diagnosis (please add ICD-10): Secondary Diagnosis (please add ICD-10): Chronic Conditions (include behavioral health): Medication Prescribed Dosage Prescribed to treat: Instructions/comments Applicant requires the following assistance with medication (Circle): No Assistance Reading Label Reminder to take Supervision Administering Meds Assistive Devices, Technology, Equipment or Special Diet Used Hearing impaired? No or Yes - Describe: Vision impaired? No or Yes - Describe: Mobility impaired? No or Yes - Describe: Page 7 of 11

17 Attachment A Application for General Relief for Assisted Living Home Care Benefits Special Diet needed? No or Yes - Describe: Medical Equipment or devices used? No or Yes - Describe: Applicant Last Name: Applicant First Name: Functional Assistance Required Frequency of Assistance Extent of Assistance Type Independent Occasional Often Always Minimum Moderate Maximum Bathing Dressing Grooming Toileting Eating Transferring Safety Allergies? No or Yes - Describe: Disoriented? No or Yes - Describe: Memory Problems? No or Yes - Describe: Using drugs or alcohol? No or Yes - Describe: At risk of causing harm to self or others? No or Yes - Describe: Other Significant Information: Typical Services Provided by Assisted Living Home Level of Care An assisted living home provides housing, utilities, food and offers onsite assistance with activities of daily living in a group residential setting. Residents are not required to accept medication or offered care and may leave the home as desired. Assisted living home care does not provide continuous nursing care, medical care, or a secure setting. General Relief does not pay for additional services to supplement ALH care. Recommendation for Care: Page 8 of 11

18 Attachment A Application for General Relief for Assisted Living Home Care Benefits Physician/PA/ANP Signature: Date: Printed Name: Phone: Mailing Address: Zip: General Relief Contract Applicant Last Name: Applicant First Name: Applicant/ Legal Decision Maker initial each item and sign below I am applying for the General Relief Assisted Living Home Care Benefit because I need Assisted Living Home Care and have no other way to pay for this service. A waitlist to receive benefits may be in effect, depending on authorized funding and the number of people using the program. If I am on the waitlist for benefits and my name is pulled off of the waitlist to receive benefits, the General Relief Program will attempt to contact me, any named legal decision maker, the person who helped me fill out the application for GR, and the two additional people listed on the General Relief Application to notify me of my approval to begin receiving benefits. If the GR Program does not hear back from me, my legal decision maker, service provider or named contacts within 20 days, my application will be closed. The General Relief benefit can be used at any Assisted Living Home that has a current provider agreement with the SDS General Relief program. The General Relief program cannot pay a home that is not licensed and a current SDS General Relief provider and cannot back date a provider agreement. If I move in to an Assisted Living Home before I am approved for General Relief benefits, I am responsible for full payment to the home up to the date I am approved for benefits. General Relief does not back-date the approval date. It is my responsibility to find an Assisted living Home that can meet my care needs. An Assisted Living Home has the choice to enter into a contract or not with me based on their ability to care for my needs and their existing responsibility to care for other residents in the Assisted Living Home. I am responsible to make payment of my client share of the daily rate to the contracted Assisted Living Home. The General Relief program will create a Calculation Sheet that shows how much I pay and how much the State of Alaska pays. If my income or resources change, I must contact General Relief to make adjustments to how much I pay. Page 9 of 11

19 Attachment A Application for General Relief for Assisted Living Home Care Benefits The money that is paid by the State of Alaska to cover my cost of care will be reimbursed by me when retroactive and other sources of eligible income or resources become available to me. This amount will not be more than the amount the State has paid for my cost of care. This money will be paid to the Division of Senior and Disabilities Services and remitted to the General Relief Program. Call to find out amount. General Relief Contract cont. If approved, benefits will last 1-6 months dependent on need. If benefits are still needed after that time period, a complete renewal packet must be turned in to the GR program 15 days prior to the benefit ending or benefits will be terminated. If I terminate my General Relief benefits, I will have to reapply to receive benefits again and may be placed on a waitlist if one is in effect. The funding source is State of Alaska General Funds. The availability of this program is based on annual legislative appropriations. There is a chance each fiscal year that this program could be discontinued. The General Relief Program only provides payment assistance for Assisted Living Home Services as described on the front of this packet. It does not provide case management or monitoring of the care provided. If I am being abused, neglected or exploited by anyone, including ALH staff, or I feel that I cannot manage my own care contracts, benefits, or bills, I should report this to Central Intake right away by calling I cannot be evicted for reporting. To file a complaint about the quality of care, environment or services provided by my ALH, I can call the Long Term Care Ombudsman s Office at or Central Intake at I cannot be evicted for filing a complaint. Applicant Last Name: Applicant First Name: Applicant Signature: Date: Legal Decision Maker (LDM) Last Name: LDM First Name: LDM Signature: Date: Type of Legal Decision Maker: o Guardian Page 10 of 11

20 Attachment A Application for General Relief for Assisted Living Home Care Benefits o o o Conservator Power of Attorney Other: Attach proof of Guardian/Conservator/POA status Page 11 of 11

21 Attachment B Renewal Application for General Relief for Assisted Living Home Care Benefits Program Overview The General Relief Assisted Living Home Care Program helps to pay for Assisted Living Home Care for qualified Alaskans facing extreme financial crisis. This is a temporary benefit program. The General Relief Program is a payer of last resort. Applicants must show that they have tried to obtain all other means of payment including: using their own resources, applying for Adult Public Assistance and Medicaid to pay for necessary Assisted Living Home Care before the General Relief benefit can be used. This is a program paid for through State of Alaska General Funds. The availability of this funding is subject to legislative appropriation. A waitlist will be used when there is not enough funding to serve additional applicants. Full program details including regulations and forms are posted on the Senior and Disabilities Services General Relief Program website ( General Relief staff can be reached at or to answer questions about the program. General Relief Eligibility Criteria The Division of Senior and Disabilities Services purchases assisted living care for vulnerable adults who meet the medical, social, and financial eligibility criteria outlined in 7 AAC through 7 AAC ) is 18 years of age or older; 2) is a resident of the State of Alaska; 3) has been assessed for eligibility by a care coordinator or other person approved by the Department of Health and Social Services and: a) has a disability that is attributable to mental retardation, cerebral palsy, epilepsy, autism or another condition closely related to mental retardation that significantly impairs intellectual functioning and adaptive behavior; b) has a hearing, speech, visual, orthopedic, or other major health impairment that significantly impedes participation in the social, economic, educational, recreational, and other activities generally available to the individual s non-impaired peers in the community; or c) has a significant deficit in adaptive behavior in the area of self-care, communication of needs, mobility, or independent living, which may be the result of the aging process, an emotional health disturbance, or alcohol or drug dependence; 6) without assisted living care is subject to, or at risk of, abuse, neglect, self-neglect or exploitation by others; 7) does not have income that exceeds the limits permitted in 7 AAC ; 8) does not have resources that exceed the amount permitted by 7 AAC ; 9) has applied for the cash assistance programs as required by 7 AAC (a); and 10) has applied for and exhausted the use of alternative resources. Residents who are currently receiving General Relief Benefits must Complete a Renewal Application 15 days prior to their benefit authorization end date to continue these benefits according to 7 AAC The assistance may be continued, adjusted, suspended or terminated based on the information received. If a Renewal Application is not received within 15 days of the last day benefits are approved, the benefit may be interrupted. If no Renewal Application is received, benefits will be terminated. Page 1 of 10

22 Attachment B Renewal Application for General Relief for Assisted Living Home Care Benefits Checklist The application will not be reviewed for eligibility until it is complete or thirty days have elapsed, whichever is sooner. To decrease the amount of time it takes to review the application, please ensure all of the following items are complete and submitted as part of the same packet. Demographic Information or Electronic Inquiry Form in Harmony (1 page) Application Narrative (1 page) Income and Resource Form (1 page) o Residents claiming $0 income or are likely to qualify for Adult Public Assistance will be required to attach confirmation of applying for Adult Public Assistance. The Renewal Application will not be considered complete without this confirmation. o General Relief will check the EIS database to verify public benefits and application General Relief Contract (2 pages) o Must be signed by the Applicant and Legal Decision Maker (if applicable) o If there is a Legal Decision Maker, attach a copy of that document Physician s Report (2 pages) o Must be dated within 3 months of this application. Copy of the ALH Contract outlining cost of care and services provided. Release of Information as needed (2 pages) o This is needed for General Relief to discuss the application with someone other than the applicant, referrer, or legal decision maker. o Submit one release per person/agency Note: A TB clearance is no longer required. If information is missing or unclear, the application will be given a status of pending and a letter sent requesting the information needed to determine eligibility. When the missing information is not received within 20 days, the review application will be denied and benefits will be terminated. It is very important to submit a complete application and respond quickly to requests for information. Complete Applications can be sent to: Senior and Disabilities Services General Relief Assisted Living Home Care Program 550 West 8 th Avenue Anchorage, AK Fax: DSM: general.relief@direct.dhss.akhie.com General Relief staff can be reached at or to answer questions about the application. Page 2 of 10

23 Attachment B Renewal Application for General Relief for Assisted Living Home Care Benefits Referrer Contact Information If someone other than the applicant is assisting with the application, complete this section. Salutation: First Name: Last Name: Suffix: Title: Relationship to Applicant: Agency Name: Provider ID: Mailing Address Suite/Apt.: City: State: Zip Code: Phone work: Phone cell: Other: Fax: DSM: Who will help the applicant with additional paperwork or renewals after this application is processed? Name: Relationship to Applicant: Mailing Address: Phone: Applicant Demographic Information First Name: Middle Initial: Last Name: Suffix: Mailing Address Suite/Apt.: City: State: Zip Code: Physical Address City: Current Location: (hospital/my home/friend s house/etc.) Phone home: Phone cell: Phone work: DOB: Gender: Marital Status: Primary Language: Second Language: Ethnicity: Tribe (if any): Page 3 of 10

24 Attachment B Renewal Application for General Relief for Assisted Living Home Care Benefits Health Insurance/Benefits (list all that apply Ex. IHS, VA, Medicaid): Page 4 of 10

25 Attachment B Renewal Application for General Relief for Assisted Living Home Care Benefits Application Narrative Applicant Last Name: Applicant First Name: Describe why the need for Assisted Living Home Care continues: Describe what independent living, supportive housing or in-home services have already been tried: Describe the services and supervision needed: Expected duration and goals of placement: Page 5 of 10

26 Attachment B Renewal Application for General Relief for Assisted Living Home Care Benefits Income and Resources Worksheet Not all Income and Resources are counted toward eligibility, but must be disclosed. Please enter $0 and note N/A in comments if this income or resource type does not apply. Source of Income Source Name Estimated Monthly Amount Social Security/SSDI $ SSI $ Public Assistance $ Veteran's Benefits $ Senior Benefits $ Native Dividends $ Other Dividends/Interest $ Pension $ Other Income $ Other Income $ Other Income $ Total $ Comments Resource Name of Bank/Resource Details Estimated Value Comments Checking Account Balance $ Savings Account Balance $ Burial Fund $ Second Home $ Land (non-tribal) $ Second Vehicle $ RV $ 4-wheelers/motorcycles, etc. $ Stocks, Bonds, Investments $ Whole Life Insurance $ Expected settlement windfall or back pay $ Other Resource $ Total $ If an applicant is approved for General Relief benefits and income or resources are later discovered that can be applied to the cost of care, the Department will recalculate the client cost of care for any month that income or resource was available to them and retroactively bill the resident for the additional amount owed. This is most common in a windfall situation where multiple months of past earned benefits are paid out in a lump sum. If income or resources are discovered to be available to the resident on an ongoing basis above the allowed amounts, the client may no longer be eligible for the General Relief Program. Page 6 of 10

27 Attachment B Renewal Application for General Relief for Assisted Living Home Care Benefits Physician s Report The Physician s Report must be complete and signed by a physician, physician s assistant or advanced nurse practitioner; substitutions are not allowed. Attach additional information as needed. Applicant Information Applicant Last Name: Applicant First Name: Date of Birth: Height: Weight: Medical History and Current Medical Problems Primary Diagnosis (please add ICD-10): Secondary Diagnosis (please add ICD-10): Chronic Conditions (include behavioral health): Medication Prescribed Dosage Prescribed to treat: Instructions/comments Applicant requires the following assistance with medication (Circle): No Assistance Reading Label Reminder to take Supervision Administering Meds Assistive Devices, Technology, Equipment or Special Diet Used Hearing impaired? No or Yes - Describe: Vision impaired? No or Yes - Describe: Mobility impaired? No or Yes - Describe: Special Diet needed? No or Yes - Describe: Medical Equipment or devices used? No or Yes - Describe: Page 7 of 10

28 Attachment B Renewal Application for General Relief for Assisted Living Home Care Benefits Applicant Last Name: Applicant First Name: Functional Assistance Required Frequency of Assistance Extent of Assistance Type Independent Occasional Often Always Minimum Moderate Maximum Bathing Dressing Grooming Toileting Eating Transferring Safety Allergies? No or Yes - Describe: Disoriented? No or Yes - Describe: Memory Problems? No or Yes - Describe: Abusing drugs or alcohol? No or Yes - Describe: At risk of causing harm to self or others? No or Yes - Describe: Other Significant Information: Typical Services Provided by Assisted Living Home Level of Care An assisted living home provides housing, utilities, food and offers onsite assistance with activities of daily living in a group residential setting. Residents are not required to accept medication or offered care and may leave the home as desired. Assisted living home care does not provide continuous nursing care, medical care, or a secure setting. General Relief does not pay for additional services to supplement ALH care. Recommendation for Care: Physician/PA/ANP Signature: Date: Printed Name: Phone: Page 8 of 10

29 Attachment B Renewal Application for General Relief for Assisted Living Home Care Benefits Mailing Address: Zip: General Relief Contract Applicant Last Name: Applicant First Name: Applicant/ Legal Decision Maker initial each item and sign below I am applying for renewal of the General Relief Assisted Living Home Care Benefit because I continue to need Assisted Living Home Care and have no other way to pay for this service. A waitlist to receive benefits may be in effect, depending on authorized funding and the number of people using the program. If I am on the waitlist for benefits and my name is pulled off of the waitlist to receive benefits, the General Relief Program will attempt to contact me, any named legal decision maker, the person who helped me fill out the application for GR, and the two additional people listed on the General Relief Application to notify me of my approval to begin receiving benefits. If the GR Program does not hear back from me, my legal decision maker, service provider or named contacts within 20 days, my application will be closed. The General Relief benefit can be used at any Assisted Living Home that has a current provider agreement with the SDS General Relief program. The General Relief program cannot pay a home that is not a licensed and a current SDS General Relief provider and cannot back date a provider agreement. If I move in to an Assisted Living Home before I am approved for General Relief benefits, I am responsible for full payment to the home up to the date I am approved for benefits. General Relief does not back-date the approval date. It is my responsibility to find an Assisted living Home that can meet my care needs. An Assisted Living Home has the choice to enter into a contract or not with me based on their ability to care for my needs and their existing responsibility to care for other residents in the Assisted Living Home. I am responsible to make payment of my client share of the daily rate to the contracted Assisted Living Home. The General Relief program will create a Calculation Sheet that shows how much I pay and how much the State of Alaska pays. If my income or resources change, I must contact General Relief to make adjustments to how much I pay. The money that is paid by the State of Alaska to cover my cost of care will be reimbursed by me when retroactive and other sources of eligible income or resources become available to me. This amount will not be Page 9 of 10

30 Attachment B Renewal Application for General Relief for Assisted Living Home Care Benefits more than the amount the State has paid for my cost of care. This money will be paid to the Division of Senior and Disabilities Services and remitted to the General Relief Program. Call to find out amount. If approved, benefits will last 1-6 months dependent on need. If benefits are still needed after that time period, a complete renewal packet must be turned in to the GR program 15 days prior to the benefit ending or benefits will be terminated. If I terminate my General Relief benefits, I will have to reapply to receive benefits again and may be placed on a waitlist if one is in effect. The funding source is State of Alaska General Funds. The availability of this program is based on annual legislative appropriations. There is a chance each fiscal year that this program could be discontinued. The General Relief Program only provides payment assistance for Assisted Living Home Services. It does not provide case management or monitoring of the care provided. If I am being abused, neglected or exploited by anyone, including ALH staff, or I feel that I cannot manage my own care contracts, benefits, or bills, I should report this to Central Intake right away by calling I cannot be evicted for reporting. To file a complaint about the quality of care, environment or services provided by my ALH, I can call the Long Term Care Ombudsman s Office at or Central Intake at I cannot be evicted for filing a complaint. Applicant Last Name: Applicant First Name: Applicant Signature: Date: Legal Decision Maker (LDM) Last Name: LDM First Name: LDM Signature: Date: Type of Legal Decision Maker: o Guardian o Conservator o Power of Attorney o Other: Attach proof of Guardian/Conservator/POA status, if not submitted with the prior application. Page 10 of 10

31 State of Alaska Department of Health and Social Services Senior and Disabilities Services Attachment C General Relief Program Calculation Sheet Client Information Client Name: Client DOB: Client Number: ALH DSM: Current ALH Placement: Daily Rate for Client Services Regional Daily Base GR Rate: $ Approved Daily Augmented Rate: $ Total Daily Rate: $ Note: This is the total amount that can be billed for General Relief services per day when client cost of care and General Relief payments are added together. Additional payment beyond this rate may not be collected for this service. If client income or resources change, the total daily rate stays the same, but the amounts the GR program pays and the client pays will change. Notify GR within ten days of an income or resource change to recalculate. Cost of Care - To Be Paid By Client Net monthly income: $ x12 months/365 days Client Daily Rate: $ Note: This is the total daily amount to be collected from the client for cost of care. It is the provider's responsibility to collect the client's cost of care from the client/representative directly. The State is not responsible for client non-payment. Individual clients may have differing amounts of personal spending money since some benefits cannot be counted as income for GR per regulations. Only use the above rate for client billing. Cost of Care - To Be Paid By General Relief Total Daily Rate: $ Client Daily Rate: Minus $ GR Daily Rate: $ Note: General Relief is the payer of last resort. If additional payments are received by the provider from the client or another program, this reduces the amount of the GR Rate for the time period of the income or resource change and may result in the provider needing to pay back the General Relief program. Always notify the GR program of client income or resource changes. Authorization Dates Start Date: End Date: Note: This calculation sheet is only good for this time period. If more than one calculation sheet is created during this time period, this new start date will end the rates of the prior authorization. Renewal paperwork must be submitted 15 days prior to the end date for benefits to continue without interruption. APS Emergency placements will require an initial application to be submitted 10 days prior to the end date. Questions? Please call the General Relief Program at or Changes in income can be reported using the Client Activity Form.

32 State of Alaska Department of Health and Social Services Senior and Disabilities Services Attachment D General Relief for Assisted Living Home Care CLIENT ACTIVITY FORM The GR Program must be notified within ten days of any client changes. Client Last Name: Client First Name: Date of Birth: Name of ALH reporting change: What changed? Check all that apply and explain below o Client moved in Date: o Client was absent from the ALH, but did not move out Date(s) gone: o Client moved to a new GR ALH Date: Name and address of New ALH: o Client moved out, doesn t need/want GR Date: New Address/Location: New Phone Number: o o Income or Resource Change- describe below Request for Augmented Rate describe below, attach supporting documentation Application for APA or Waiver services turned in: Date: For Waiver: Name and contact information for Care Coordinator: Application for Other Benefit(s) turned in For Other Benefit(s): Describe benefit(s) Date: o Client Died Date: Additional Information: (attach more pages as needed) Name of Person Filling out Form: Title: Signature: Date: Send this form to: General Relief Program Division of Senior and Disabilities Services 550 W. 8th Ave. Anchorage, Alaska fax: (907) general.relief@direct.dhss.akhie.com