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Effective Date: 
11/2016

Documents

Instructions

Updated: 11/2016

Purpose

This form is used to:

  • record the identifying information of the STAR Kids or STAR Health applicant/member;
  • record or update the member's individual service plan (ISP) for Medically Dependent Children Program (MDCP) services, including:
    • ISP effective period;
    • services to be provided; and
  • serve as a worksheet to compute estimated annual cost of waiver service for the member.

Procedure

When to Prepare

This form is completed by the STAR Kids or STAR Health service coordinator each time:

  • an applicant's/member's eligibility is assessed for the program; or
  • the annual reassessment of the ISP is completed.

Number of Copies

Maintain an original form for the case record or the electronic version.

Transmittal

The managed care organization (MCO):

  • maintains the original/electronic Form 2604 in the member's case file; and
  • posts Form 2604 on TxMedCentral in the appropriate MCO ISP folder.

Note: It is not necessary to post changes to ISPs.

Form Retention

Each MCO must keep Form 2604 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 folder/electronic record for five years after services are terminated.

Supply Source

This form is found on the Health and Human Services Commission (HHSC) website.

Detailed Instructions

  1. Applicant/Member Name — Enter the applicant's/member's full name (last, first, middle initial) as shown.
  2. Date of Birth — Enter the date of the applicant's/member's birth. Use eight digits in month, day, year sequence (mmddyyyy).
  3. Medicaid No. — Enter the applicant's/member's nine-digit Medicaid number as shown on the Texas Integrated Eligibility Redesign System (TIERS) files, or on the Your Texas Benefits card. If the Medicaid number is pending, leave blank.
  4. Social Security No. — Enter the applicant's/member's nine-digit Social Security number.
  5. Enrolled in a Medicaid Waiver? — If the applicant/member is in another waiver program, check the box and enter the waiver name.
  6. ISP Dates — Enter the "from" and "to" dates for this ISP period. For an initial ISP, the "from" date is the same as the effective date, and the "to" date is the end of the month plus one year. For reassessments, the "from" date is the first day after the day the previous ISP ended, and the "to" date is a year minus a day from the "from" date. The "from" date is always the first day of the month for initials and reassessments.

Effective Date — For an "Initial ISP," enter the start date of MDCP services. This is always the first of the month with the following exceptions:

  • For applicants entering MDCP via the Money Follows the Person/Demonstration process, enter the start date of MDCP services as the first date of the month in which the applicant discharges from the nursing facility; or
  • For members transferring to the MDCP waiver, enter the start date of MDCP as the date the individual moves to an MCO Service Area.

For a "Reassessment" on an ISP, enter the date after the end date of the current ISP.

  1. Type of Authorization — Indicate the type of authorization by checking the appropriate box.
  • Initial (new) – Check this box when enrolling an applicant/member.
  • Reassessment – Check this box to renew the member's enrollment period for another year.
  1. County — Enter the three-digit county code for the county in which the applicant/member resides.
  2. Plan Code — Enter the plan code of the MCO that the member is enrolled in.
  3. CDS Option — This is to indicate whether the specific service is provided under the Consumer Directed Services (CDS) option. Check the box beside any appropriate service category authorized for the applicant/member.
  4. Service Category — This is a listing of services available. Check the box beside any appropriate service category authorized for the applicant/member.
  5. Estimated Annual Service Units — Enter the estimated annual service units for each service indicated. Do not enter estimated annual service units for adaptive aids, minor home modifications or transition assistance services. Enter annual service units (not hourly units) for in-home, out-of-home respite services, flexible family support services, employment assistance, and supported employment. Round fractions to the next higher whole unit.
  6. Unit Cost — Enter the established unit cost for each service indicated. Do not enter the unit rate for adaptive aids, minor home modifications, requisition fees and transition assistance services.
  7. Estimated Annual Cost — Enter the estimated annual cost for each service authorized. Calculate the estimated annual cost by multiplying the estimated annual service units times the service unit category rate. If the estimated cost of a service is being reduced, the cost listed must be equal to or greater than the total cost for which payment has already been made. When there is an MCO change and the member has received services from the original MCO, add the estimated or actual cost of the services already provided by the original MCO to the estimated annual cost for services from the new MCO to ensure the member does not exceed his or her ISP cost limit.

Total Estimated Waiver Costs — Calculate the estimated annual cost from each service to arrive at the total estimated waiver costs.

Service Coordinator — Enter the STAR Kids service coordinator's name.

Annual Cost Limit — Enter the annual cost limit used in development of this page.

Managed Care Organization Name — Enter the MCO name.