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Effective Date: 
9/2017

Documents

Instructions

Updated: 9/2018

 

Purpose

This form is used by the managed care organization (MCO) service coordinator when assessing members for STAR+PLUS Home and Community Based Services (HCBS) program and Community First Choice (CFC) personal assistance services (PAS) to:

  • serve as a worksheet for the initial and ongoing development of the PAS included in the individual service plan (ISP) or CFC service plan; and
  • record the estimated hours per week of PAS hours for:
    • protective supervision;
    • extension of therapy;
    • delegated nursing tasks and health maintenance activities (HMAs);
    • Consumer Directed Services (CDS) nursing tasks performed by an attendant; and
    • additional PAS services allocated.

Procedure

When to Prepare

The MCO service coordinator must complete this form each time:

  • PAS services are requested when an individual is assessed for eligibility for STAR+PLUS HCBS program or CFC (initial application or annual redetermination); or
  • there is an assessed need for a change in the PAS component on Form H2060/Form H2060-S or Form H6516, Community First Choice Assessment.

Number of Copies

The original Form H2060-A/Form H2060-AS is placed in the case record.

Transmittal

The MCO forwards a copy of Form H2060-A/Form H2060-AS to the contracted provider. Copies are given to the applicant or member, provider(s), (except the emergency response services (ERS) provider), and to each member of the interdisciplinary team (IDT).

Form Retention

The MCO must keep Form H2060-A/Form H2060-AS in the applicant's or member's case records for five years after services are terminated.

Supply Source

This form is found on the HHSC website.

DETAILED INSTRUCTIONS

I. Identifying Information

1. Applicant/Member Name — Enter the name of the applicant or member.

2. Medicaid ID No. — Enter the nine-digit Medicaid identification number for the applicant/member.

3. Date Completed — Enter the date this form is completed.

4. Individual Service Plan (ISP) Effective Date— Enter the effective date from Item 5 of Form H1700-1, Individual Service Plan, for the ISP submitted, which includes the PAS services indicated on Form H2060-A.

5. Service Coordinator Name — Enter the name of the service coordinator completing the assessment.

6. Social Security No. — Enter the applicant's or member's Social Security number.

II. Additional Personal Assistance Services (PAS) Hours Not Identified on Form H2060, Needs Assessment Questionnaire and Task/Hour Guide

Check the "Not Applicable" box if additional PAS hours are not applicable and skip to Section IV, PAS Time Totals.

If applicable, check the "Applicable as Follows" box and complete the following for each PAS identified below (1, 2, 3 and 4). Note: These columns are not used for individuals residing in, or expected to reside in, adult foster care (AFC) or assisted living (AL) settings.

A. Number of Minutes Per Day — Enter the number of minutes per day of service provision necessary to perform each task.

B. Number of Days Per Week — Enter the number of days per week the member's task(s) is required. There is no entry for the Purchased Delegated Nursing Tasks included in Item 3 or for CDS and other delegated nursing tasks to PAS in Item 4.

C. Total Minutes Per Week — Enter the product of multiplying the figure in Column "A" by the figure in Column "B" and enter the result in this column.

D. Comments — Use this space, as necessary, to explain tasks, hours, schedule modifications and any specific provider or applicant/member needs, or to reference any attached documentation.

E. Total PAS Minutes Per Week — Enter the sum of the figures for Items 1-4 in Column C.

1. Protective Supervision — Complete Columns A, B and C (if applicable).

2. Extension of Therapy — Complete Columns A, B and C if providing therapy assistance. Specify type of therapy. The MCO must obtain input/documentation from the provider.

3. Purchased Delegated Nursing Tasks and HMAs — This category of delegated tasks refers only to paid attendants. Enter the number of hours per week for delegated tasks and HMAs to be purchased as PAS hours. The number of weekly hours is obtained by converting the monthly hours to weekly hours dividing the monthly hours by 4.33. The resulting hours per week are rounded to the next higher half hour and entered in Column A for Purchased Delegated Nursing Tasks. The MCO must obtain input/documentation from the provider (RN input for delegated nursing).

4. CDS Nursing Tasks to PAS — For CDS, enter the weekly hours needed for member-directed tasks. Calculate the weekly hours by dividing the monthly hours by 4.33. Round up to the next highest half hour. Multiply by 60 minutes in Column B to calculate the total minutes per week in Column C. Specify in Column D, Comments, as necessary. Form 1585, Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services, is required to be completed for CDS nursing tasks performed by an attendant.

If there are other nursing tasks to purchase, complete Columns A, B and C and specify the task(s) in Column D, Comments.

5.  Additional PAS Allocated — Complete  Columns A, B and C (if applicable). Additional time over and above the Grand Total Minutes is documented on Form H2060. Form H2060 is a guide and when protective supervision is not appropriate, but the member needs PAS in excess of what Form H2060 calculates, the additional time is entered here. The reason for the additional time is entered in the Comments section.

III. Comments

Use this space for comments in addition to the comments entered above or to continue any explanation started in the II. D. Comments space.
Comments must be entered when making initial referral for assessment to indicate if protective supervision could be required, or would not be required, depending on whether protective supervision has been requested or may be appropriate. Comments are also entered here to support the need for additional PAS, as indicated in Item 5.

IV. PAS Time Totals

The MCO service coordinator completes this section for the initial and reassessment ISP and any time there is a change in Form H2060/Form H2060-S PAS hours.

1. Minutes Per Week from Form H2060 — Enter the total number of minutes from Form H2060/Form H2060-S, if applicable. This field must be completed before referring for initial assessment.

2. Minutes Per Week from this Form H2060-A — Enter the total PAS minutes from this form, Section II, E. (above).

3. Total Minutes Per Week — Enter the sum of the figures in Box 1 and Box 2 to get total minutes per week.

4. Total Hours — Divide the total minutes per week in Box 3 by 60 to determine the hours per week, round to the next higher half hour, and enter the total hours in Box 4.

5. A&A and Third Party Resource (TPR) Hours — Add any Veterans Affairs (VA) Aid and Attendance (A&A) monetary amount (from Form H2060/form H2060-S) to any payments from other TPR, Family and Community Supports (from Form H1700-B, Non- STAR+PLUS HCBS Program Services), and divide monthly total by 4.33 to determine a weekly amount. Divide weekly amount by the PAS hourly rate and enter the total number of weekly hours in Box 5.

6. Adjusted Weekly Hours — Subtract the A&A/TPR hours entered in Item 5 from the weekly total hours entered in Item 4, and enter the remainder in Box 6. Round up to the next higher half hour.

7. Hours Authorized Per Year — Multiply the adjusted weekly hours in Box 6 by the number of weeks remaining in the ISP year and enter the product in Box 7. (To determine the number of weeks remaining in the ISP, divide the number of remaining days by seven and round up to the next higher number. Example: 365 days divided by 7 = 52.14, round to 53 weeks. Round to a two-place decimal if the rounding to the next higher whole number will cause the ISP to exceed the ISP cost ceiling.)

8. Hours Previously Authorized this ISP Year — Enter the number of hours already authorized in the current ISP year that were scheduled to have been delivered before the time of this ISP change, if applicable. If none, enter 0.

9. Estimated Annual PAS Authorization — Enter the sum of the figures in Box 7 and Box 8, rounded up to the next higher hour in this box. This figure should be registered on Form H1700-1, Individual Service Plan, Service Category, Personal Assistance Services.

V. Certification by Interdisciplinary Team Members
The MCO service coordinator signs and dates the form to approve or disapprove the identified PAS services. The MCO service coordinator's signature is required when PAS is requested at initial application/certification, annual redetermination and ISP changes.

The applicant, member or responsible party is not required to sign Form H2060-A/Form H2060-AS at initial application or annual redetermination because his/her signature and participation in the development of the ISP are documented on Form H1700-2, Individual Service Plan. The MCO service coordinator checks the box labeled "Applicant/Individual/Responsible Party and Service Coordinator signatures on Form H1700-2, Individual Service Plan, at initial certification and annual redetermination" to indicate the signatures are included on Form H1700-2.

For ISP changes, the MCO service coordinator discusses the requested change with the applicant's or member's and obtains the applicant's or member's signature or verbal agreement of the requested change. When the MCO service coordinator obtains the applicant’s or member’s or responsible party's decision about the ISP change by telephone, the MCO service coordinator writes "verbally approved" and the date on the signature line. If verbal approval for the change is not appropriate, such as the applicant or member has no telephone or has a cognitive or communication impairment precluding understanding the change over the telephone, the MCO service coordinator makes a home visit to obtain the applicant's or member's approval.

Informal supports providing non-essential tasks of daily living must be documented on the Form H2060/Form H2060-S assessment. Tasks essential to daily living functioning provided by informal support must be documented on Form H1700-B and applicable signatures or verbal agreements obtained on Form H1700-B.