Legally Responsible Individual forms change

The Legally Responsible Individual (LRI) Extraordinary Justification form, the DMAS 95B “Consumer-Direction Services Management Questionnaire”, and the LRI Plan of Care (DMAS 97AB) are required for the spouse of a Medicaid member or the parent, stepparent, or legal guardian of a Medicaid member under 18 years old who is requesting to become the accepted LRI providing care.

Beginning March 1, 2024, DMAS requires that all service facilitators and agency providers send all applicable forms, directly to the member’s health plan.

This form should be delivered to the member’s care coordinator via secure e-mail or CC fax line (866-920-4097). If the name of the member’s care coordinator is not known, note this on the cover sheet and send to the fax line.

Once consumer directed members have an accepted LRI by the health plan, the provider must submit an updated Employer Agreement form to Public Partnerships, LLC (PPL) (833-772-0991). If you have any questions about this communication, call Anthem HealthKeepers Plus Provider Services at 800-901-0020.