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Effective Date: 
11/2016

Documents

Instructions

11/2016

Purpose

Form 2603 is required to be completed for a member’s or applicant’s initial assessment and for all annual and revision assessments.  Form 2603:

  • is developed through a person-centered planning process;
  • occurs with the support of  a group of people chosen by the member  and the legally authorized representative (LAR) on the individual's behalf; and
  • accommodates the member’s style of interaction, communication and preferences regarding time and setting.

Form 2603 is used to:

  • document findings from the STAR Kids Screening and Assessment Instrument (SAI);
  • develop a service plan for services received through the STAR Kids managed care organization (MCO) and for the STAR Kids Medically Dependent Children Program (MDCP) members, is used to develop an MDCP service plan that falls within the member’s allowable cost limit;
  • document services received through third party sources, such as 1915(c) waivers operated by the Texas Health and Human Services Commission (HHSC) and Texas Department of State Health Services (DSHS);
  • identify an applicant’s or member's strengths, preferences and unique considerations;
  • identify what is important to the applicant or member;
  • identify natural supports available and needed service system supports;
  • document preferences for when and how to receive services;
  • identify any special needs, requests or considerations for the applicant or member; and
  • document and address the applicant’s or member's unmet needs.

 

PROCEDURE

When to Prepare or Update

Form 2603 must be completed in its entirety following the member’s or applicant's assessment with the STAR Kids SAI. The form is updated annually and for changes related to the member's medical condition and/or functional ability. If a member, applicant or LAR does not know the information requested or refuses to answer, document that on Form 2603.

 

Form Retention

Keep the original of the form in the member's case record. The MCO must provide a printed or electronic copy of the form to each member or the member’s LAR following any significant update and no less than annually. The MCO must provide a copy of the form to the member's providers and other individuals specified by the member or member's LAR. The MCO must give the completed form in the format that the member or member’s LAR requests. The MCO must complete the form in plain language that is clear to the member or the member’s LAR and must be furnished in Spanish or languages of other major population groups, if requested.

 

DETAILED INSTRUCTIONS

Form 2603 is designed to complement the STAR Kids SAI. Where appropriate, these instructions note the information which may be copied from appropriate fields on the SAI.

The information contained in this form is obtained through an information gathering conversation (the discovery process) with the applicant or member about his/her abilities, preferences and goals in line with person-centered planning principles. The service coordinator should make his best effort to communicate with the member. If the member is unable to participate in the discovery process due to age or disability, the service coordinator can supplement with information from the LAR.

 

Section I. Member and Service Coordinator Information

1. Applicant/Member Name Enter the applicant’s or member’s name, as found on Section A, Item 1 of the SAI.

2. Date of BirthEnter the applicant’s or member’s date of birth, as found on Section A, Item 3 of the SAI.

3. Medicaid No. – Enter the applicant’s or member’s Medicaid number, as found on Section A, Item 10c of the SAI. If the individual does not yet have a Medicaid number, leave blank.

4. Social Security No.Only complete this information if the applicant does not yet have a Medicaid number (i.e., an applicant for MDCP). Enter the applicant’s or member’s Social Security number, as found on Section A, Item 10a of the SAI. 

5. Service Coordinator NameEnter the individual’s named service coordinator’s name.  If the individual does not have a named service coordinator, enter the name of the service coordinator assisting with this service planning process.

6. Service Coordinator Area Code and Phone No. – Enter the individual's named service coordinator’s area code and phone number. If the applicant or member does not have a named service coordinator, enter the phone number of the service coordinator assisting with this service planning process.

7. Service Coordination LevelEnter the member's current service coordination level: Level 1, Level 2 or Level 3.

8. Medically Dependent Children Program (MDCP) ISP Start Date This question is only applicable for members receiving MDCP services. Enter the effective date of the MDCP ISP. This should match the date submitted on the electronic ISP. Otherwise, enter N/A.

9. MDCP ISP End DateThis question is only applicable for members receiving MDCP services.  Enter the end date of the MDCP ISP. This should match the date submitted on the electronic ISP.  Otherwise, enter N/A.

10. ISP Revision DateThis question is only applicable for members receiving MDCP services.  Enter the date that the MDCP ISP was last revised, if applicable. Otherwise, enter N/A.

 

Section II. Medical Information

Diagnoses and ConditionsEnter information in Section D, Item 1 of the SAI, if applicable.

MedicationsEnter information from Section H, Item 1 of the SAI, if applicable.

Hospitalizations in Last 12 MonthsEnter information from Section D, Items 10-12 of the SAI, if applicable. Provide the date, reason and plan to prevent readmission.

SpecialistsEnter the provider names, provider types, frequency of provider visits, and provider contact information for the individual’s specialist provider. Include all current specialists that are significant to the individual’s care.

Medical ReferralsEnter information from Section Z of the SAI, if applicable. Provide the provider name, provider type, purpose and expiration.

 

Section III. Applicant’s/Member’s Preference, Strengths, and Unique Considerations

1. StrengthsEnter information from Section E, Item 7 of the SAI, if applicable.

2. Hobbies and InterestsAsk the member, applicant, or LAR about the individual’s hobbies and interests and enter what the individual likes to do in his/her free time. 

3. Community-based ActivitiesAsk the member, applicant, or LAR about the community activities the individual participates in and enter that information. 

4. GoalsAsk the member, applicant, or LAR about the individual’s developmental, educational, medical, social, service coordination and other goals. Enter information for both short and long-term goals from Section C, Items 1-2 and Section P, Item 1of the SAI, if applicable.

5. Who does the applicant/member/Legally Authorized Representative (LAR) want to be directly involved in support planning? – Enter the name, relationship to the member/applicant/LAR, preferred method of participation for people who are participating in the service planning process, physical address, mailing address, area code and phone number, and email for each person.

6. Permanency/Transition PlanningMake a note, if applicable. Permanency planning is for an applicant or member who is transitioning from a foster care home environment to out-of-home care.

7. Service PreferencesEnter how the applicant or member likes to receive services. This could include a discussion of consumer-directed services and preferences about learning how to do new things.

8. Things Working WellEnter the services and supports that work well and help the applicant or member stay healthy and remain safe in the community.

9. Things that Could Be Working Better/BarriersEnter the barriers to receiving the care that is needed and other issues the applicant, member or LAR might be facing.

10. Family Considerations Enter information from Section E of the SAI, if applicable.

11. Current Durable Medical Equipment (DME) and SuppliesEnter information from Section D, Items 13-15 of the SAI, if applicable. Provide the product type, replacement frequency and concerns/notes.

 

Section IV. Service Planning Considerations

1. Medicaid State Plan ServicesList Medicaid State Plan services the member is receiving or approved to receive, including service/item type, provider, rationale (i.e., functional deficit, skilled nursing need, promote mental health well-being), hours per week (if applicable), begin/end date, and whether the member has chosen the Consumer Directed Services (CDS) Option or Service Responsibility Option (SRO) (if applicable). Enter information from Section H, Item 6 of the SAI, if applicable.

Make a note if the applicant or member is receiving services through the Early Childhood Intervention (ECI) program. Note: The service coordinator should attach the Individual Family Service Plan (IFSP) that is used in the ECI program to Form 2603, if available.

2. MDCP ServicesList MDCP services the applicant or member is receiving or approved to receive, including service/item type, provider, rationale (i.e., respite, functional/medical deficit, promote independence, enable move to a community based setting), hours per week, begin/end date, and whether the member has chosen the CDS Option or SRO. This list should match the services submitted with the electronic ISP and this information is only applicable to MDCP members and applicants. If the member or applicant is not in MDCP, leave blank.

3. Health home Document the member's utilization of, or interest in, a health home.

4. Value-added ServicesEnter the value-added services that the member is receiving or is approved to receive, including service type, begin/end date, and additional service details.

5. Non-capitated Medicaid ServicesEnter the non-capitated services that the applicant or member is receiving, including the waiver or program name, service type, hours per week (if applicable), and begin/end date. Refer to STAR Kids Contract Section 8.1.24.8 for a list of Medicaid non-capitated services. This category includes services received through HHSC and DSHS waiver programs, such as Community Living and Support Services, Deaf Blind with Multiple Disabilities, Home and Community-based Services, Texas Home Living and Youth Empowerment Services. Do not include Medicaid services provided through School Health and Related Services (SHARS), which are captured in 6., Education Services. Enter information from Section C, Item 6 of the SAI, if applicable.

Make a note if the applicant or member is receiving ECI services and if he/she is receiving ECI targeted case management or specialized skills training, which are non-capitated ECI services. Note: The service coordinator should attach the IFSP used in the ECI program to Form 2603, if available.

6. Education Services – Enter services the applicant or member is receiving through school, including name, service type, hours per week (if applicable) and begin/end date. Include services received in both the school and home setting, and Medicaid services provided through the SHARS program. Enter information from Section B of the SAI, if applicable. Note: If the applicant or member has an individual education plan (IEP) through the school, the IEP is considered confidential and may only be shared with the MCO with permission from the member, applicant or LAR. If the family does choose to share the IEP, attach the IEP to Form 2603.

7. Non-Medicaid State Program ServicesEnter services that the member is receiving through state programs other than Medicaid, including the program name, service type, hours per week (if applicable) and begin/end date. Examples include Women, Infants and Children and Supplemental Nutrition Assistance Program.

8. Informal/Community SupportsEnter other informal or community supports the applicant or member receives, including the name of the services, relationship of the provider to the member, service type, hours per week, and the begin/end date. Include informal supports that are most important to the member and information from Section E of the SAI, if applicable.

9. Is the applicant/member/LAR interested in additional resources to become more involved in the community? Check the appropriate box and under Service Type Detail, provide potential referrals to community organizations, such as volunteer opportunities at a local food bank or participation in a support or advocacy group.

10. Medicare and Other PayersIf the member has Medicare or another third party resource that pays for services, list the name of the resource, policy number, service type, hours per week, begin/end date, and other service type details. Examples include Medicare, TRICARE and other third party payers.

 

Section V. Authorizations Requested/Needed

Record the services for which the member is requesting or needs authorization based on results from the SAI. Enter the item/service, provider, from date and to date.

 

Section VI. Complaints and Appeals Log

Record the member's complaints and appeals. Enter the type of complaint/appeal, submission method, date, actions taken, and ultimate resolution.

 

Section VII. Completed Assessments

Record any assessments that the member has completed. Enter the screening/assessment name/type, assessor name (if known) and date. Examples include a speech therapy evaluation or Child and Adolescent Needs and Strengths (CANS) assessment.

 

Section VIII. Follow-up Items or Assessment Needs

Record any additional follow-up screenings or assessments that are needed. Enter the item/screening/assessment  and the responsible party or entity completing it. Examples include a speech therapy evaluation or CANS assessment.

 

Section IX. Service Coordinator Follow-up Schedule

Document the service coordinator follow-up schedule. Members must receive in-person and telephone contacts according to their service coordination level, as described in STAR Kids Contract Section 8.1.38.6.  Enter the date of the next scheduled contact, method of contact (telephone, email, in person or mail), annual reassessment date, and any additional comments. 

 

Section X. Signature/Approval

Inform the member, applicant or LAR about their rights and responsibilities, as described in this section, and about whether they want to allow changes to Form 2603 without a signature (i.e., over the phone), or if they want to sign off on all changes. Check the appropriate box in the Applicant/Member/LAR Attestation.

Printed Name – Member/LAR, Signature and Date – The applicant, member or LAR signs and dates this section to agree to the attestation.

Printed Name – Service Coordinator, Signature and Date – The service coordinator signs and dates the form to indicate he/she developed the ISP based on needs and in collaboration with the member, applicant or LAR, and that he/she reviewed the rights and responsibilities.