Appendix XXIII, Form 2101 Coverage Dates for Title XIX Services

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Revision 17-1; Effective March 15, 2017

The case worker completes Form 2101 to renew the prior approval process for all ongoing Primary Home Care individuals (including transfer cases) not certified as Community Attendant Services (CAS) individuals. Instructions for items other than numbers 4 and 5, are covered in the instructions for Form 2101 in the Forms and Reports section.

Renewals	Item 4 "Begin" date	Item 5 "End" date
Renewal — no service plan change	NA — Do not send Form 2101.	NA — Do not send Form 2101.
Renewal with increase	Seven days from date mailed or negotiated date.	Leave blank — date remains the same as current authorization.
Renewal with decrease	12 days from the Form 2101 date unless appealed.	Leave blank — date remains the same as current authorization.

Service plan change between assessments	Item 4 "Begin" date	Item 5 "End" date
Increase	Seven days from the Form 2101 date or negotiated date.	Leave blank — date remains the same as current authorization.
Decrease	12 days from the Form 2101 date unless appealed.	Leave blank — date remains the same as current authorization.

Terminations	Item 4 "Begin" date	Item 5 "End" date
Loss of Medicaid eligibility	Remains unchanged.	Last day of month in which individual is determined ineligible for Medicaid.
Other eligibility criteria change (i.e., type of residence, functional eligibility, unmet need)	Remains unchanged.	12 days from the Form 2065 date, unless appealed.
Individual or someone in home threatens health or safety of provider	Remains unchanged.	Date case worker becomes aware of action.