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Effective Date: 
9/2017

Documents

 

Instructions

9/2017

 

Purpose

This form is used to:

  • record the applicant's/member's choice to receive the STAR+PLUS Home and Community Based Services (HCBS) program as an alternative to nursing facility care;
  • document the applicant's/member's or authorized representative’s acceptance of the individual service plan (ISP); and
  • document certification of the waiver service plan developed and approved by the managed care organization (MCO).

 

Procedure

When to Prepare

The MCO service coordinator initiates the completion of this form for:

  • initial assessment;
  • ISP change; or
  • annual reassessment.

Number of Copies

The original/electronic Form H1700-2 is posted to the MCO's ISPXXX folder in TxMedCentral and the MCO keeps a copy in the member’s case record. Copies are forwarded to the member and the authorized representative, if applicable.

Form Retention

The MCO keeps Form H1700-2 according to the retention requirements found in all Medicaid Managed Care contracts and federal regulations. Keep all originals/electronic copies of this form in the member's case record for five years after services are terminated.

Supply Source

This form is found on the Texas Health and Human Services website.

 

Detailed Instructions

1. Applicant/Member Name — Enter the name of the applicant or member as entered on Form H1700-1, Individual Service Plan (Pg. 1).

2. Medicaid or Applicant Social Security No. — Enter the nine-digit Medicaid number as entered on Form H1700-1. If the applicant does not have a Medicaid number, enter the Social Security number.

3. Effective Date — Enter the effective date as entered on Form H1700-1.

4. MCO Nurse Certification — The MCO service coordinator signs to certify the applicant/member was assessed to establish eligibility in the STAR+PLUS HCBS program. The MCO service coordinator also certifies that medical need for STAR+PLUS HCBS program services was established and documented on Form H1700–A, Rationale for STAR+PLUS HCBS Program Services. Non-STAR+PLUS HCBS program services that will be provided to the applicant/member by non-HCBS program resources and coordinated by the MCO are documented on Form H1700-B, Non-STAR+PLUS HCBS Program Services. The MCO service coordinator is required to sign for initial assessment, ISP changes and annual reassessment.

Freedom of Choice — The applicant/member or authorized representative must sign to acknowledge freedom of choice to choose between a nursing facility or home and community based services.

The applicant's/member's or authorized representative's signature is obtained at:

  • initial assessment;
  • ISP changes; and
  • annual reassessment.

The MCO service coordinator obtains the applicant's/member or authorized representative’s signature during the initial and reassessment visit. If the applicant/member is unable to write his name, the applicant/member enters an "X" as an identifying mark. This "X" must be witnessed by the MCO service coordinator and the date entered.

Acknowledgment and Acceptance of the Individual Service Plan

For initial assessment, ISP changes and annual reassessment, the Acknowledgement and Acceptance of the Individual Service Plan (ISP) box is checked.

The applicant's/member's or authorized representative’s signature providing acknowledgment is required for:

  • initial assessment;
  • ISP changes; and
  • annual reassessment.

For initial assessment, ISP changes and annual reassessment, the MCO service coordinator obtains the applicant's/member's or authorized representative’s signature on the final approval line acknowledging acceptance of the proposed service plan. Once the applicant/member or authorized representative signs the form, if any changes are made to the service plan, the service coordinator must obtain a written or verbal approval of the change within seven business days of the effective date of change. This change must be documented on Form H1700-2 below the final approval line and include the date and the name of the person who provided the verbal approval. The MCO service coordinator must obtain the approval prior to certification.

MCO Certification — The MCO service coordinator signs to certify the proposed ISP was developed, reviewed and approved by the MCO prior to implementation to show the MCO's determination that waiver services are necessary as an alternative to institutionalization and are appropriate to meet the needs of the applicant/member in the community. The service coordinator signs at the time of:

  • initial assessment;
  • ISP changes; and
  • annual reassessment.

At initial assessment, for ISP changes and annual reassessment, the service coordinator signs this section after all ISP forms are signed by the appropriate team members and informal support, and after all other Form H1700-2 signatures/verbal agreements are obtained and documented.