Form Es-3161 - Notification Of Kancare/hcbs/mfp/wh/work Services Changes/updates
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1STATE OF KANSAS
ES-3161
NOTIFICATION OF KANCARE/HCBS/MFP/WH/WORK SERVICES
DEPARTMENT OF HEALTH AND ENVIRONMENT
Rev. 01-13
DIVISION OF HEALTH CARE FINANCE
CHANGES/UPDATES
TO: _____________________________________________________________ FROM: ___________________________________________________________
ADDRESS: ______________________________________________________
ADDRESS: ________________________________________________________
______________________________________________________
________________________________________________________
I. CONSUMER INFORMATION
Name: ______________________________________________________________________________________________________________________________
Case Number (if known): ________________________ KanCare ID No.: ________________________
Address Change: _____________________________________________________________________________________ Date: ________________________
Responsible Person or Contact Change: ___________________________________________________________________ Date: ________________________
II. KANCARE INFORMATION CHANGES (to be completed by DCF eligibility staff)
____ Review Complete: ____ Approved/Denied ____ Working Healthy/WORK – Temporary Unemployment Plan Needed
Review Effective Date: ________________________ Next Review Due:: ________________________ Date Last Employed: ________________________
____ HCBS/MFP Client Obligation Change: $ ____________ Effective: ________________________
Reason For Unemployment: __________________
$ ____________ Effective: ________________________
__________________________________________
____ KanCare Case Closed Effective: ________________________ Reason For Closure: _______________________________________________________
____ HCBS/MFP Client Employed – Possible Working Healthy/WORK Eligibility
____ Other: _______________________________________________________________________________________________________________________
Comments: ________________________________________________________________________________________________________________________
III. HCBS/MFP/WORK SERVICE CHANGES (to be completed by Case Manager or WORK Manager)
____ HCBS/MFP/WORK Services Review Complete: ____ Approved ____ Denied Effective Date: ________________________
____ Level of Care Waiver Change To: ___________________________
Effective Date: ________________________
____ Monthly Cost of Care Change To: $ _________________________
Effective Date: ________________________
____ HCBS/MFP/WORK Services Terminated: Effective Date: ________________________ Reason: ____________________________________________
____ Medical Bills For Client Obligation (bills attached)
____ Entered Nursing Facility: Date Entered: ________________________ Facility: __________________________________________________________
Anticipated Length of Stay: _________________ Stay is: ____ HCBS Covered Respite Care ____ Temporary Care ____ Permanent/Undetermined
____ Other: ________________________________________________________________________________________________________________________
Comments: _________________________________________________________________________________________________________________________
IV. WORKING HEALTHY INFORMATION (to be completed by Benefit Specialist)
____ Temporary Unemployment Plan Information: ____ Plan Developed ____ Client Failed to Comply – Reason: ___________________________________
____ Premium Repayment: ____ Agreement Signed – Date Received: ________________________
____ Other: ________________________________________________________________________________________________________________________
Comments: _________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________ Attachments: ____ Yes ____ No
DCF Eligibility Worker Signature
Date
_______________________________________________________________________________________________________
HCBS/MFP/Working Healthy/WORK Authorized Agent Signature
Date
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