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Effective Date: 
3/2015

Documents

 

Instructions

Updated: 9/2017

 

Purpose

Form H2060-B/H2060-BS is used as a guide for collecting and documenting additional long term services and supports assessment information not captured on Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or the Medical Necessity/Level of Care (MN/LOC).

This form is used by the managed care organization (MCO) assessor to collect information to identify needs to include in care plans, as well as make appropriate referrals for the following services:

  • behavioral health;
  • supported employment;
  • employment assistance;
  • transportation assistance services;
  • assistance with instrumental activities of daily living; and
  • medical condition(s) not previously documented.

When to Prepare or Update

Form H2060-B/H2060-BS is completed in conjunction with Form H2060 to assess or reassess a member's need for or change in functionally necessary state plan personal attendant services, state plan day activity and health services, or STAR+PLUS Home and Community Based Services (HCBS) program.

Form Retention

The MCO must keep Form H2060-B/H2060-BS in the applicant's/member's case record for five years after services are terminated.

Supply Source

This form is found in the STAR+PLUS Handbook.

 

DETAILED INSTRUCTIONS

I. General Information

  1. Name of Applicant/Member Name — Enter the name of the applicant/member.
  2. Medicaid ID No. — Enter the nine-digit Medicaid number of the applicant/member.
  3. Person Responding —Record the name of the person responding to questions.
  4. Relationship (if other than applicant/member) — Enter the relationship of the person responding to the applicant/member.
  5. Assessment Date — Enter the date the form is completed.
  6. Type of Contact — Check the box that indicates the method used to contact the applicant/member: Telephone, Home Visit or Other.
  7. Reason for Contact — Check the appropriate box, indicating the reason the contact was made to the applicant/member: Initial Assessment, Annual Assessment or Change in Services.

II. Assessment

The MCO assessor asks the applicant/member or person responding to the questions in this section. Space is provided to capture additional explanation, if needed.

Item A: List active diagnoses. List the diagnoses for which the applicant/member currently receives treatment.

Items B through G: Ask the applicant/member or person responding to the questions and record the response. Ask additional questions to gain a thorough knowledge of the applicant’s/member’s current medical and functional status.

Items H through J: Ask the applicant/member or person responding to the questions and record the response. Ask additional questions to gain a thorough knowledge of the applicant’s/member’s functional status.

III. Additional Comments and Any Referrals To Be Made:

Enter any additional comments regarding the applicant's/member's medical and/or functional status. Include recommendations for referrals for services or supports identified. Use the comments section if there is not adequate space under a specific question. Note the section and letter of the question being continued.

Signature — Assessor — Sign Form H2060-B/H2060-BS after completing the form.