Medicaid Home and Community-Based Waivers Manual - Appendix A

APPENDIX A: Level of Care

A-1 Adult Long-Term Care Functional Screen, F-00366 (PDF)
A-2 Removed (Children's Long-Term Care Functional Screen)
A-3 QMRP Definition (PDF)
A-4 Removed (Request for Title XIX Care Level Determination)
A-5 Removed (Request for Title XIX Care Level Determination Addendum for Developmentally Disabled Client)
A-6 Removed (COP Functional Screen, F-20823)
A-7 Removed (Brain Injury Waiver Level of Care)
A-8 Level of Care - Grid (PDF)
A-9 Removed (Assessment Tool: LTCFS Supplement, F-20980)
A-10 Institutional Levels of Care: Children's Long-Term Support Programs in Wisconsin  (PDF)


Last Revised: May 11, 2020