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Effective Date: 
6/2017

Documents

Instructions

Updated: 06/2017

Purpose

The purpose of this form is to document the proposed STAR+PLUS Home and Community Based Services (HCBS) also called STAR+PLUS Waiver (SPW) benefits that will be provided to the applicant/member during the Individual Service Plan (ISP) period by the identified non-waiver resource.

This form is completed by the managed care organization (MCO) service coordinator (SC). It is used in the development of the applicant/member's ISP; services listed on this form must be received/delivered within the "From" and "To" dates documented on Form H1700-1 Individual Service Plan - SPW (Pg. 1). The completed form documents the non-waiver resources the applicant/member is anticipated to use during the ISP period, including:

  • Medicare and other payers;
  • Medicaid State Plan Services;
  • MCO Value-Added Services (VAS);
  • Informal and community supports;
  • Services provided in an educational setting.

Procedure

When to Prepare

This form is completed for all STAR+PLUS HCBS program applicant/members at:

  • initial assessment;
  • ISP change- a change in non-STAR+PLUS HCBS program services which results in a change in services on the ISP; and
  • Reassessment.

Form Retention

The MCO must keep a copy of Form H1700-B in the member's case record according to the retention requirements found in the Uniform Managed Care Contract 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 may be found on the HHS website at: https://hhs.texas.gov/laws-regulations/forms

Detailed Instructions

I. Member Information — Enter the following information:

  1. Applicant/Member Name – Enter applicant/member's name  
  2. Medicaid ID or Applicant's Social Security Number – Enter applicant/member's Medicaid number. If the applicant does not have a Medicaid number, enter the Social Security Number.
  3. Assessment Type – check the box indicating the reason for completing this form:
    1. Initial,
    2. ISP change, or
    3. Reassessment.

II. Medicare and Other Payers (include Medicare, VA, TRICARE, private insurance, and other payers) — Enter the following information for each resource listed:

  1. Name of Resource – Enter name of the resource that will provide services to the applicant/member during the ISP period.
  2. Policy No. – Enter policy number for the resource, if available.
  3. Service Type Enter service type provided by the resource. Only include the service categories listed on Form H1700-1.
  4. Hours per week – Enter hours per week the service will be provided. One visit per month would be converted to a weekly number by dividing the visit hour(s) by 4.3. Enter 'N/A' if a service type is ongoing or a one-time delivery.
  5. Service Type Detail – Enter specifics for each service type provided by the resource.

Examples:

  1. Name of Resource: Medicare; Policy No.: 123456789A; Service Type: Medical Supplies (MS); Hours per week: N/A; Service Type Detail: diabetic supplies delivered monthly: lancets, test strips.
  2. Name of Resource: Medicare Advantage Plan XYZ; Policy No.: 123456789A; Service Type: Dental; Hours per week: N/A; Service Type Detail: cleaning and x-rays, member plans to make a dental appointment for next month.

III. Medicaid State Plan Services (include Medicaid Home Health, Day Activity and Health Services [DAHS], and Community First Choice [CFC]) – Enter the following information for each State Plan Service listed:

  1. Name of Resource – Enter name of the resource that will provide services to the applicant/member during the ISP period.
  2. Service Type Enter service type provided by the resource. Only include the service categories listed on Form H1700-1.
  3. Hours per week – Enter hours per week the service is provided. One visit per month would be converted to a weekly number by dividing the visit hour(s) by 4.3. Enter 'N/A' if a service type is ongoing or a one-time delivery.
  4. Service Type Detail – Enter specifics for each service type provided by the resource.

Examples:

  1. Name of Resource: DAHS; Service Type: Nursing; Hours per week: 15 hours; Service Type Detail: nurse to assess, teach, measure blood pressure and report elevation to PCP, and administer medication.
  2. Name of Resource: CFC; Service Type: personal attendant services; Hours per week: 28 hours; Service Type Detail: attendant 4 hours/day, 7 days/week for ADLs (activities of daily living) and IADLs (instrumental activities of daily living). Specific tasks as listed on Form H6516, Community First Choice Assessment.
  3. Name of Resource: Medicaid Home Health; Service Type: Physical Therapy; Hours per week: 3 hours; Service Type Detail: strengthening and increased endurance.

IV. Value-Added Services – Enter the following information if it is anticipated the applicant/member will use MCO VAS during the ISP period. Include only VAS on the ISP items/services such as Dental Services, Emergency Response Services, Respite, or Home Delivered Meals. VAS are not required to be used prior to waiver service. VAS vary by MCO. The SC is responsible for knowing the VAS applicable for the applicant/member.

  1. Service Type – Enter the service type the applicant/member is anticipated to use during the ISP period.
  2. Service Type Detail – Enter specifics about the service that will be provided. For example, for Respite enter eight hours per year; for Dental enter up to $250 per year for dental checkups, or x-rays and cleaning.

Example:

  1. Service Type: Respite; Service Type Detail:  Irma C., daughter, to use 4 hours respite every Monday between 9/15/16 and 12/15/16 to attend a class.

V. Informal/Community Supports (include Family, Community Organizations) – Enter the following information for each informal support and community support listed.

  1. Name – Enter name of the informal/community supports that will provide services to the applicant/member during the ISP period.
  2. Relationship – Enter the relationship to the applicant/member of the person providing the service. Enter N/A if it is a community organization.
  3. Service Type – Enter the service provided by the resource. Service types include but are not limited to nursing tasks and assistance with activities of daily living and instrumental activities of daily living.
  4. Hours per week – Enter hours per week the service will be provided. One visit per month would be converted to a weekly number by dividing the visit hour(s) by 4.3. Enter ‘N/A’ if a service type is ongoing or a one-time delivery.
  5. Service Type Detail – Enter specifics for each service type provided by the resource.

Examples:

  1. Name: Elizabeth Smith; Relationship: daughter; Service Type: assists with ADLs and IADLs: meal prep and personal care; Hours per week: 15 hours and as needed; Service Type Detail: prepares dinner 5 nights/week and all meals on weekends, shops for member's food, assists member every evening in all tasks related to going to bed.
  2. Name: Albert Green; Relationship: son; Service Type: Nursing and personal care; Hours per week: 1 hour and as needed; Service Type Detail: fills medication boxes weekly and accompanies member to medical appointments.
  3. Name: First Neighborhood Church; Relationship: N/A; Service Type: Home Delivered Meals; Hours per week: N/A; Service Type Detail: volunteer from church to deliver lunch Mon-Thursday every week (excluding holidays).

VI. Services in an Educational Setting (if applicable) — Enter the following information for services provided in an educational setting.

  1. Name – Enter name of the educational facility that will provide services to the applicant/member during the ISP period. For example, enter the name of the school.
  2. Service Type – Enter service type provided by the resource. Service types include but are not limited to nursing and therapies provided in the school setting.
  3. Begin/End Date – Enter begin and end date of the service. The dates must be within the "From" and "To" dates as documented on Form H1700-1, Individual Service Plan. Enter 'unknown' if a begin date is unknown.
  4. Hours per week – Enter the hours per week the service to be delivered. Enter 'N/A' if a service type does not have a frequency or duration. Enter 'unknown' if the duration is unknown.
  5. Service Type Detail – Enter specifics for each type of service provided by the resource.

VII. Signatures

The MCO RN SC prints his or her name, including credentials, and signs and dates this form.

Informal support(s) who agree to perform services/tasks listed in Section V prints his or her name, enters telephone number, signs and dates this form if they are present. For dates, use mm/dd/yyyy format. The MCO is responsible for obtaining these signature(s) to document the informal support’s commitment to be involved in the applicant’s/member’s plan of care. If the person providing the informal support is not present, a verbal agreement to the service/tasks is acceptable. The MCO must document each informal support person's name, telephone number and date of the informal support person's verbal consent on the Informal Support line along with the MCO.