Module #2: Informational Pages

Contents

2.1 Individual Information
2.2 Referral Date and Screen Begin Date
2.3 Critical Identifying Information
2.4 Screen Type
2.5 Referral Source
2.6 Child's Basic Information
2.7 U.S. Citizenship and Identity
2.8 Ethnicity/Race
2.9 Interpreter Language Required
2.10 Contact Information
2.11 Child's Medical Insurance
2.12 Primary Care Provider and Type
2.13 Living Situation


2.1 Individual Information

Demographic information collected for the CLTS FS does not determine functional eligibility for long-term support services. "Other" boxes are available in some instances to allow the screener to fill in answers that may not be provided in the drop down boxes. Choices from the drop-down boxes should be used whenever possible.

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2.2 Referral Date and Screen Begin Date

The Referral Date may be used to assess state and local systems for timely responses to families’ requests for screening. The difference between the Referral Date and the Screen Begin Date will be tracked as part of quality improvements to ensure timely responses to requests for screening. This is quality improvement for systems, not individual screeners. For instance, if one county always takes, on average, three weeks longer than other counties, there may be local systems changes they can make to improve their response time.

For County Programs, the Referral Date is the date the screener received the initial request for service from a parent/guardian or another referral source.

The Screen Begin Date is the date of the screener's first face-to-face contact with the child and parent(s).

If some additional information must be obtained, the Screen Completion Date, recorded on the last page of the CLTS FS, will be later than the Screen Begin Date. There is an edit in the program that will generate an error message if the Referral Date entered is more than 60 days prior to the Screen Completion date. This is to cue screeners there may have been a typo error in the dates entered. It is only a cue and will not stop a screener from completing the CLTS FS and getting functional eligibility results.

For Katie Beckett Consultants Only

The details below are specific instructions for the Katie Beckett Consultants only. Other screening agencies could adopt these policies. This policy is specifically detailed to assure consistent interpretation of the referral date per KBP contract requirements.

The Referral Date is the date that a parent/guardian calls to schedule a home visit for functional eligibility determination. The CLTS FS Referral Date is not used as the MA application date.

  • Children's home visits are often delayed by families' need to reschedule, families who never follow through after an initial contact, and families who make contact before they even move into Wisconsin. For these reasons, the definition and use of "Referral Date" needs further clarification, as follows: Use the date the family contacts the screener to schedule a home visit as the Referral Date (whether or not the screener talked to the family directly).

    Example A: A parent leaves you a voice mail message on Monday 7/9/05 saying that they’ve gathered their documentation as you instructed and would like to set up a time for you to come out to their house. On 7/11/05 you call the parent; due to her work schedule, the home visit cannot occur until 7/31/05. You would use 7/9/05 as their Referral Date.

    Example B: A parent calls you in June because they are moving back to Wisconsin and want to apply for KBP. On July 20th, the parent calls again to say they have moved into Wisconsin and would like to schedule the home visit, to occur in the next few weeks. On the CLTS FS, July 20th (not June) is the Referral Date; because that’s the date the parent contacted you to actually schedule the home visit.

    If the family later requests the home visit be re-scheduled, you would then use this 2nd date for the Referral Date.

    Example C: The same mom calls you on 7/28/05 to say that 7/31/05 won’t work after all, as her work schedule was changed unexpectedly. You reschedule the visit to 8/8/05. Now the Referral Date is 7/28/05.


  • If the consultant makes the home visit but it cannot be completed because, e.g., the family is not prepared or the child is not present, use the next "request date" (which may or may not be the date of the unsuccessful home visit) for the referral date.

    Example D: The screener goes to a scheduled home visit on 8/15/05 and finds that the parent and child are gone. The grandmother says they forgot all about your visit. The screener asks the parent to reschedule. On 8/17/05 the parent calls to reschedule. 8/17/05 is now the Referral Date.

    Example E: The screener goes to a scheduled home visit on 8/30/05. The mother is present, but the child is not; the mom seems to have forgotten that the screener needs to meet the child. While the screener is still there, the screener reschedules another home visit. 8/30/05 becomes the new Referral Date.

    Note that in all of these cases, the Referral Date is the date the family requests to schedule a home visit to complete the CLTS FS.

  • If the home visit cannot be completed as scheduled due to circumstances beyond the screener's control, e.g., the screener's own illness, or a snowstorm, the parent’s original request date remains as the Referral Date, even though the home visit must be rescheduled.

    The Screen Begin Date is the date of the screener's first face-to-face contact with the child and parent. This date also establishes the date of application for Medicaid.


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2.3 Critical Identifying Information

Date of Birth
Enter the child's date of birth in MM/DD/YYYY format, as in 01/01/2002. The "/" must be entered between the field elements. CLTS FS programming will not allow dates to be entered that make the applicant more than 22 years old. The person should be referred for an adult screen in this instance. The date of birth must be earlier than the screen begin date.

Pseudo Social Security Number
The only time a certified screener should select to use a Pseudo Social Security Number (SSN) is when the child does not have an actual SSN issued at the time of the home visit (e.g., newborn infants). Do not use a Pseudo SSN simply to enter a screen prior to learning the child's actual SSN.

When a Pseudo SSN is used, the child's identifying information does not go through the MCI clearance. Therefore, if you have a SSN but question the accuracy of it, use the SSN provided to you and then the MCI can check to see if it is a match to another SSN listed for the child.

If a previous screener used a Pseudo SSN and you now have the child's actual SSN, please make the necessary correction in two places. First, uncheck the Pseudo SSN box on the Individual Information page and then edit the SSN on that page.

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2.4 Screen Type

The screener will select one option when completing the CLTS FS. There are three screen type options from which to choose:

Initial Screen—The first CLTS FS completed for a child interested in accessing long-term support services is an initial screen. An initial screen is used when a child has been in a program already but this is the first time a CLTS FS is being completed for them. An initial screen can also be used for a child who has had a previous screen and a screener needs to complete another screen but neither "Change of Condition" nor "Annual Re-screen" conditions apply.

Annual Screen—An annual/recertification screen required as long as a child is enrolled in the KBP, Medicaid Home and Community-Based Services Waivers, FSP, or COP. This type of screening is required annually.

Change of Condition—At any time when a child's physical, emotional or living condition changes significantly they may request and/or receive additional screenings.

Reminders when using EDIT on the CLTS Functional Screen
When you EDIT a screen, you must change a number of items on the CLTS Functional Screen, in addition to the items you are editing, including:

Individual Information Page:

  • Screen Begin Date: the date you received additional information that led you to change the screen.
  • Screener Name: especially when the previous screen was completed by a different certified screener.

Screen Time Page:

  • Screen Completion Date: the date you completed the new, edited screen.
  • Face to Face Contact with Person: if a new home visit was completed.
  • Collateral Contacts: contacts with parents or others who provided the additional information.
  • Paper Work: the time it took to complete the edits on the screen.
  • Travel Time: if applicable.

If the child has aged into a new age group for the ADL/IADLs and Social Skills questions, be prepared to answer those questions accordingly before selecting CALCULATE ELIGIBILITY.

You need to recalculate eligibility when you are done editing the screen so that your information can be considered in the child's functional eligibility results.

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2.5 Referral Source

Select from the drop down box to indicate who contacted the screening agency to refer this person for a Screen. The CLTS FS is designed to determine functional eligibility for children; therefore, we are seeking the referral source that recommended that the family contact the screener agency. Use parent as the referral source if no other person prompted them to contact the screener. If another parent provided the referral to this family, then it is also appropriate to select "parent" from the drop-down options. If no referral was made (e.g., you are doing a recertification screen) select other and write in "recertification".

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2.6 Child’s Basic Information

Primary Contact
Check the Primary Contact box if the person is over 18 years old and is a competent adult (i.e., does not have a court-appointed guardian). If guardian of person proceedings are in process do not check this box. Write a note about pending guardianship in the Notes field.

Title
If the child has a "Jr." or "IV", or other suffix added to their name, list this in the Last Name box, following their last name.

Name
If the child has a title such as "Jr." or "IV", list this in the Last Name box, following their last name.

Street Address/City/State/Zip/Phone Number
Enter the child’s "permanent residence" address. For transient persons, enter the address they lived at the most in the last six months.

If there is a street address and a PO Box, enter street address and apartment information on line 1, PO Box on line 2, and use the PO Box ZIP Code.

The home telephone number is a required field. If the child has no telephone enter all "zeros" (000) 000-0000.

County/Tribe of Residence and County/Tribe of Responsibility
Select the appropriate county/tribe from the drop down box. Typically these will be the same entry. However, in a few instances, people may live in one county but another county/tribe is responsible for services, costs, and/or protective services. For the purposes of screening, residency is physical presence or the intent to reside. The CLTS FS program will automatically enter county of responsibility to be the same as county of residence. This "default" entry can be overridden if different counties are involved.

Are the child’s parents aware of the legal concerns (e.g. Guardianship, Power of Attorney, and Representative Payee) once the child turns 18 years old?
This is a required field once the child is 16 years of age. It is not necessary to know the family's specific choice when the child reaches 18 years of age, since the intent of the question is whether or not they are considering the issues involved as their child becomes an adult.

Is the applicant a competent adult?
If the person is 18 years or older is listed as their own "Primary Contact" it is assumed that they are a competent adult. If the person does not require guardianship of person, they are considered a competent adult.

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2.7 U.S. Citizenship and Identity

Per Federal regulations, United States citizenship and personal identity must be verified for any child seeking Wisconsin Medicaid eligibility which includes Medicaid funded Waiver services. The CLTS FS has required fields where the screener records the documentation viewed to verify both the child's U.S. citizenship and personal identity.

The U.S. citizenship and personal identity requirement applies to all children applying for or receiving services from a Medicaid funded program which includes the Katie Beckett Program and the Children's Long-Term Support Waivers. The Family Support Program (FSP), Community Options Program (COP) and MH Wrap Around programs do not require citizenship and identity documentation. The Comprehensive Community Services (CCS) program requires participants to be Medicaid recipients prior to service provision so United States citizenship and personal identity will have already been verified through their application to Medicaid.

For more information regarding these procedures, refer to DHS Operational Memo 07-69 Citizenship and Identification Requirements Final Rule Summary (PDF) and Acceptable Citizenship and ID Documentation (PDF).

Screeners must refer to this memo and related charts for clarification on specific, acceptable documentation. In addition, each program for which the CLTS FS determines functional eligibility must adhere to its own citizenship and identity regulations.

For U.S. Citizenship, the screen asks the following questions:

  • Child has documentation to establish U.S. Citizenship. The certified screener will be required to indicate from a drop down menu what documentation was used to verify U.S. Citizenship.

  • Child does not have U.S. Citizenship but does have the following Alien Registration Number per the verified Permanent Resident Card. The certified screener will be required to enter the 9-digit Alien Registration number.

  • Child claims to have U.S. Citizenship or an Alien Registration Number but required documentation was not provided. The certified screener will be responsible for editing this screen once the documentation is available.

  • Child is only seeking eligibility for the Family Support Program, Community Options Program, Comprehensive Community Services, and/or Mental Health Wrap Around Program.

Note that these options are mutually exclusive, that is, only one can be selected. As a result, if a screener is editing or updating a screen where the first item (Child has documentation to establish U.S. Citizenship) has already been selected in the past, it should remain checked even if the current program they are applying for does not require U.S. Citizenship. For example, if a child has previously applied for Katie Beckett Program - Medicaid which requires U.S. Citizenship and the Katie Beckett Program certified screener selected the first option above and then the child applies for the Family Support Program (which does not require U.S. Citizenship), the Family Support Program certified screener should leave the first option selected to not negatively affect the child's eligibility for the Medicaid funded program.

If a Permanent Resident Card and/or Alien Registration Number is the documentation being used for Medicaid eligibility this requires further review. This review of Medicaid eligibility can only be done by a Nurse Consultant for the Katie Beckett Program or by a county Economic Support Unit (ESU) for all other Medicaid programs, such as the CLTS Waivers. Therefore, either the Nurse Consultant's name or the Economic Support Worker's name, plus the date this required eligibility was verified, must also be documented in the final notes section of the CLTS FS.

If the child is seeking a Medicaid funded program (Katie Beckett Program or CLTS Waiver) and the screener does not have documentation of U.S. Citizenship, the following warning will be posted:

  • U.S. Citizenship: You've checked that the child claims to have U.S. Citizenship or an Alien Registration Number but required documentation was not provided. It is your responsibility as a certified screener to change the U.S. Citizenship verification on the functional screen when the required documentation is obtained. If a child is awarded eligibility for a program without the required verification of documentation, your agency is at full risk for the full cost of services for this child without any federal matching funds.

The screen will also have the following pending results:

  • Not eligible due to lack of U.S. Citizenship documentation and verification. Services cannot be provided through this program without required documentation.

"Pending documentation" is available as an option under Identity and can be used when a screener has requested the necessary documentation but has not yet received it. The functional eligibility results will continue to indicate that verification is required.

"Not a Medicaid funded program" is available as an option under Identity. When a screener is completing a screen for The Family Support Program (FSP), Community Options Program (COP), MH Wrap Around or Comprehensive Community Services (CCS) they may select this option. If a screener completes a CLTS FS for a child who already has their identity verified by a previous screener, please do not change that information to "Not a Medicaid funded program", even if the program you are completing a screen for does not require the verification.

Once a child's U.S. citizenship and personal identity has been verified by the proper documentation, it does not need to be verified annually at recertification.

If screeners have further questions regarding verification of U.S. citizenship or personal identity requirements, please contact the Children's Services Specialist for your county or your specific program manager.

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2.8 Ethnicity/Race

ETHNICITY
This is not a required field. If needed, use the following definition to identify the appropriate option:

  • Hispanic / Latino: A person of Mexican, Puerto Rican, Cuban, Central, South American, or other Spanish culture or origin, regardless of race.

RACE
This is not a required field. Please check all boxes that apply. The choices here match federal insurance reporting requirements. If needed, use the following definitions to identify the appropriate option:

  • American Indian or Alaska Native: "American Indian and Alaska Native" refers to people having origins in any of the original people of North and South America (including Central America), and who maintain tribal affiliation or community attachment. It includes people who indicate their race or races as Rosebud Sioux, Chippewa, or Navajo.

  • Asian: Refers to people having origins in any of the original peoples of the Far East, Southeast Asian, or the Indian subcontinent. It includes people who indicate their race or races as "Asian Indian," "Chinese," "Filipino," "Korean," "Japanese," "Vietnamese," or "Other Asian," or as Burmese, Hmong, Pakistani, or Thai.

  • Black or African American: "Black" refers to people having origins in any of the Black racial groups of Africa. It includes people who indicate their race as "Black," African American, Afro-American, Nigerian, or Haitian.

  • Native Hawaiian or Other Pacific Islander: "Pacific Islander" refers to people having origins in any of the original peoples of Guam, Samoa, or other Pacific Islands. It includes people who indicate their race or races as "Native Hawaiian," "Guamanian or Chamorro," "Samoan," or "Other Pacific Islander," or as Tahitian, Mariana Islander, or Chuukese.

  • White: "White" refers to people having origins in any of the original peoples of Europe, the Middle East, or North Africa. It includes people who indicate their race as "White" or as Irish, German, Italian, Lebanese, Near Easterner, Arab, or Polish.

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2.9 Interpreter Language Required

Leave this blank if no interpreter is needed. Select the appropriate language if an interpreter is needed. If "Other," please type in the language needed in the space provided. Human service and health care providers should always obtain interpreters when they are needed. This information will help show the extent of such needs, and will also help long-term care programs better serve consumers whose primary language is not English.

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2.10 Contact Information

Additional Contacts
For children under age 18, at least one "Additional Contact" must be entered. For applicants 18 or over, if "Primary Contact" is not checked for the applicant, then at least one "Additional Contact" must be entered.

Parents must be entered separately as two different contacts. They can both be listed as "Primary Contacts" if that is true. DHS correspondence will be sent to the first Primary Contact listed.

A second Primary Contact (e.g., a second parent) can be listed if s/he has legal responsibility for the child. If they do not have legal responsibility, they can still be listed as "Additional Contacts" but not as a "Primary Contact." A warning box will appear on the Functional Screen reminding the screener to be certain that multiple "Primary Contacts" have legal rights to the child’s records. A second Primary Contact (e.g., a second parent) can be listed if s/he has legal responsibility for the child. If they do not have legal responsibility, they can still be listed as "Additional Contacts" but not as a "Primary Contact." At the bottom of the page, a screener will need to check "I verify that all Primary Contacts have legal right to the person's records."

In cases of joint custody in which one parent does not reside with the child, that parent’s contact information must be included. If the second parent does not have joint custody, this information is optional.

For convenience, the child’s address and home telephone number will auto-fill if the screener selects "parent" as the type of contact. The screener can delete or write over this information if it is not correct for the contacts. If a contact person’s name is not clearly gendered, the screener can note the person’s gender in the Notes section for future reference.

If there is a street address and a PO Box, enter street address and apartment information on line 1, PO Box on line 2, and use the PO Box ZIP Code.

The home telephone number is a required field. If the person has no telephone enter all "zeros" (000) 000-0000.

If a contact person does not have a known address, put the person's name and any additional information the screener has in the note section on this page.

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2.11 Child’s Medical Insurance

Check all Medical Insurance that apply in this section. This information does not affect functional eligibility calculations. BadgerCare, General Assistance Medical (GAM) and MAPP are forms of Medicaid. If the child is on BadgerCare, General Assistance Medical (GAM) or MAPP, enter this information under Medicaid with the number, and put a comment about this information in the Notes section. This is also the procedure to follow for children on SSI and Katie Beckett Program-Medicaid.

"Private insurance" includes employer-sponsored insurances (e.g., an HMO) available as a job benefit. Insurance company name and policy number can be filled in if available, or left blank if not known.

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2.12 Primary Care Provider and Type

This is a required field. The information does not affect functional eligibility. It may eventually be used for state and local systems changes to improve children’s access to primary health care. These data are also required for federal outcome measurements.

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2.13 Living Situation

Where Child Currently Lives
Check one box. If the screener selects "other," type an explanation in the "other" box. Most of the drop down box menu options are self-explanatory. For further clarification:

  • "CBRF" includes "group home."
  • Other IMD = Other Institute for Mental Disease.
  • Residential Care Apartment Complex (RCAC) is what is commonly (or formally) known as "assisted living."

If a family is homeless but the child is under 18 years old and living with their parents, please select "with parents" for their living situation. If they are over 18 years old and homeless, then select "no permanent residence."

If a child is living in a kinship care arrangement, select "with other unpaid family members."

Prefers to Live (if age 18 or over)
Check one box. If the screener selects "other," type an explanation in the "other" box.

For applicants age 18 years and up, this question asks precisely and only for the consumer's own stated preference. It will be used to see if long-term care consumers are living where they want to live and to track changes over time. This question is asking the person's informed preference. Record where the person would like to live - not where anyone else wants them to live, and not where the screener or others think is realistic. 

Screeners must take the time to explain the person's options. The person cannot express a preference if the screener has not informed them of their options first. The screener must take the time to ask questions to help the person articulate her/his preferences. Some people like to live with others; while others highly value having their own space. Screeners should select the answer that most accurately reflects what the person is saying. If a person with developmental disability is telling the screener that she wants "a place of my own," then the screener select the most appropriate selection of "own home or apartment." Do NOT select "someone else's home or apartment" or an "apartment with services" even if that is probably where the person will live. The purpose of this question is to record what the person says, not what the system will provide or what the screener thinks s/he really needs. This question has no bearing on functional eligibility.

If the applicant's preferred living situation is not listed, select "Other" and please type in what the "Other" represents.

Guardian/Family's Preference of Living Arrangement for this Person
This question is only for people age 18 years or over, and accompanies the previous question about the consumer’s preference on where to live. It was added because screeners found completing the "Prefers to Live" too difficult to answer accurately when the guardian or family disagreed with the consumer’s preference. Select the most appropriate option from the drop down box menu. It has no bearing on functional eligibility. 

If the child is not currently living at home, is there a plan to return to home within six months of screening date?
This question affects functional eligibility for some home-and community-based programs as well as the Family Support Program. The question is related to a specific plan to return the child to the home rather than a permanency plan.

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