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It explains completion of Part A, Part B, or Part C based on IRS or Department-approved extenuating circumstances, defines “reside” and “premise,” and lists permissible supporting documentation (minimum 1, dated within three months). 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Changes must be documented immediately.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Which parts of the form must be completed for live-in caregiver status?",{"text":68,"@type":64},"Only Part A, Part B, or Part C needs to be completed. Select the applicable definition and provide the most relevant evidence for that definition.",{"name":70,"@type":61,"acceptedAnswer":71},"What supporting documentation is required to establish live-in caregiver status?",{"text":72,"@type":64},"A minimum of 1 permissible supporting document is required, such as shared residency evidence (e.g., state ID showing shared residency), address listed on tax returns, utility or household bills, bank account statements, or Medicaid records. Documentation must be current or dated within the last three months.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},304723,1790080305,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":55,"slug":121},21,"Paper Templates","papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":33,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":26},1374404737137,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Electronic Visit Verification (EVV) Live-in Caregiver Attestation Form  \nInstructions  \nValidity of information on this form must be reviewed and updated by the provider agency or Financial Management Service (FMS) vendor with the member and caregiver annually. Changes must be documented immediately. The provider agency or FMS vendor is responsible for maintaining this form and any relevant evidence for Department verification and auditing. If live-in caregiver status is not valid at any time, the attendant and provider agency or FMS vendor shall collect EVV per state rule. Service dates prior to the completion of this form and required approvals must have a corresponding EVV record. The Department reserves the right to deny or revoke live-in caregiver status for an EVV exemption when information on completed form does not meet Department specification or if information is found to be misrepresented or falsified.  \nOn the attached form, complete all informational fields with the most current and accurate information available. Part A, Part B, or Part C attest to the determination of live-in caregiver status by meeting the criteria of a Federal entity definition or Department approval of extenuating circumstances. Only Part A, Part B, or Part C need to be completed per form. Mark your selection and provide the most relevant evidence for that definition. If attesting to an extenuating circumstance, contact the Department for pre-approval*.“Reside” for Part B means the place of residence or the place used most often for domestic activities outside of work such as sleeping, living, eating, etc. “Premise” for Part B means any property, dwelling, apartment, or structure that the member resides in.  \nPermissible Supporting Documentation (Minimum of 1) :  \nCopy of both state ID’s showing shared residency; address listed on tax returns; automobile registration ; voter registration card, utility or other household bill showing individuals address; bank account statement ; or Medicaid records. All documentation must be current or have a date within the last three months. Other documentation may be used upon Department approval.  \n*Extenuating circumstance exceptions may be approved for time less than one year. Approval of extenuating circumstance may take 2-4 weeks.  \nLive-In Caregiver Attestation Form  \nElectronic Visit Verification (EVV) is a technology solution which electronically verifies visit information to ensure that home or community-based services are delivered to members needing those services by documenting the precise time service begins and ends. Section 12006of the 21st Century Cures Act requires all state Medicaid agencies implement an EVV solution. Federal guidance permits states to exempt live-in caregivers from EVV. This exemption may or may not apply to the parent or family of a member, depending on living arrangement.  \n\n| Caregiver/Member Information |\n| --- |\n| Caregiver Name: |\n| Last 5 digits of Caregiver SSN: |\n| Member Name: |\n| Member Medicaid ID\\#: |\n| Shared Address: |\n| Provider or FMSVendor Information |\n| Provider Agency or FMS Vendor Name: |\n| Medicaid Provider ID: |\n| Provider Agency or FMS Vendor Representative Name: |\n\nA live-in caregiver is a caregiver who permanently or for an extended period of time resides in the same residence as the Medicaid member receiving services. Live-in caregiver status is determined by meeting requirements established by either the U.S. Department of Labor, Internal Revenue Service, or Department-approved extenuating circumstances. Documentation of live-in caregiver status must be collected and maintained by the provider agency. Live-in caregiver status is established by the member/caregiver relationship and only pertains to relationships where documentation has been provided and approved.  \nPart A: IRS Determination 1  \n☐ I declare that I am an individual care provider receiving payments under a qualifying state Medicaid program as defined in IRS notice 2014-7 for care ","cbCaikwM9jPed8Gb","https://ap.wps.com/l/cbCaikwM9jPed8Gb","pdf",223984,"English","# Instructions\n## Live-in Caregiver Attestation Completion\n## Supporting Documentation Requirements\n## EVV Overview and Exemption Rules\n## Caregiver/Member Information Fields\n## Part A: IRS Determination\n## Part B: DOL Determination\n## Part C: Extenuating Circumstances Determination\n## Signature and Approval Sections","[{\"question\":\"How often must the information on the EVV live-in caregiver attestation form be reviewed and updated?\",\"answer\":\"Validity must be reviewed and updated annually by the provider agency or FMS vendor with the member and caregiver. Changes must be documented immediately.\"},{\"question\":\"Which parts of the form must be completed for live-in caregiver status?\",\"answer\":\"Only Part A, Part B, or Part C needs to be completed. Select the applicable definition and provide the most relevant evidence for that definition.\"},{\"question\":\"What supporting documentation is required to establish live-in caregiver status?\",\"answer\":\"A minimum of 1 permissible supporting document is required, such as shared residency evidence (e.g., state ID showing shared residency), address listed on tax returns, utility or household bills, bank account statements, or Medicaid records. Documentation must be current or dated within the last three months.\"}]","Electronic Visit Verification (EVV) - Live-in Caregiver Attestation Form - Instructions | PDF",1789816537]