Appendix XXIII, Form 2101 Coverage Dates for Title XIX Services

Revision 24-4; Effective Sept. 1, 2024

The caseworker completes Form 2101. This renews the prior approval process for all ongoing Primary Home Care people, including transfer cases, not certified as Community Attendant Services (CAS) people. 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 calendar days from date mailed or negotiated date.	Leave blank — date remains the same as current authorization.
Renewal with decrease	12 calendar 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 calendar days from the Form 2101 date or negotiated date.	Leave blank — date remains the same as current authorization.
Decrease	12 calendar 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 that person is determined ineligible for Medicaid.
Other eligibility criteria change such as type of residence, functional eligibility, unmet need	Remains unchanged.	12 calendar days from the Form 2065 date, unless appealed.
Person or someone in home threatens health or safety of provider	Remains unchanged.	Date caseworker becomes aware of action.