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Form H3676 is used by Program Support Unit (PSU) staff to:
- record information pertinent to the nursing assessment and development of the individual service plan (ISP) on a STAR+PLUS Home and Community Based Services (HCBS) program or a Medically Dependent Children Program (MDCP) applicant;
- authorize the managed care organization (MCO) to conduct a pre-enrollment assessment for an STAR+PLUS HCBS program or an MDCP applicant; and
- provide verification of qualifying institutional stays for the Money Follows the Person Demonstration (MFPD) to the MCO.
Form H3676 is used by the MCO nurse or MCO contracted nurse completing the assessment for the MCO to:
- document results of the assessment; and
- report assessment results to the PSU.
When to Prepare
PSU staff complete Section A, Referral/Assessment Authorization, to request the MCO to complete an assessment for the applicant.
Upon receipt of Form H3676, the MCO must date stamp the form. The MCO nurse completes Section B, Waiver Assessment Report, and returns the form to the PSU within 60 days of the date specified in Item 15, Date Form H3676 Posted.
After completion of Section A, PSU staff:
- post the original to TxMedCentral in the authorized MCO's folder; and
- upload a copy to the HHS Enterprise Administrative Report and Tracking System (HEART).
After Section B is completed and posted to TxMedCentral by the MCO, PSU staff upload a copy to HEART.
HEART is the PSU's repository for the electronic case record. Paper copies of Form H3676 are not retained. The MCO must keep copies of the completed forms in the applicant's/member's case record three years after case closure.
This form may be found in the STAR+PLUS or STAR Kids Handbook at www.hhs.texas.gov/laws-regulations/handbooks
PSU staff check the appropriate box to indicate the applicant's/member's status as:
- a Supplemental Security Income (SSI) Money Follows the Person (MFP) transfer to the community (STAR Kids only);
- a non-member Medical Assistance Only (MAO) MFP transfer to the community;
- an MFP applicant whose Medicaid status is pending;
- a release from an interest list (IL) (enter the STAR+PLUS IL number or MDCP IL number);
- transferring from STAR Kids with the Medically Dependent Children Program (MDCP); or
- transferring from STAR Kids with Private Duty Nursing (PDN).
A. Referral/Assessment Authorization — Program Support Unit staff complete Items 1 through 26.
1. Applicant's/Member's Name — Enter the applicant's/member's name, as shown in the Texas Integrated Eligibility Redesign System (TIERS), if this information is available.
2. Date of Birth — Enter the applicant's/member's date of birth.
3. Social Security No. — Enter the applicant's/member's Social Security number.
4. Medicaid No. — Enter the applicant's/member's Medicaid number, as shown on the TIERS records, if available.
5. Medicare No. — Enter the applicant's/member's Medicare number, if available.
6. Resource Utilization Group — Enter the applicant's/member's Resource Utilization Group value.
7. Current Living Address — Enter the address of the applicant/member, including city and ZIP code.
8. Telephone No. with Area Code — Enter the area code and telephone number of the applicant/member.
9. Name of Contact Other Than Applicant/Member — If applicable, enter the name of a person who may assist or represent the applicant/member to apply for the STAR+PLUS HCBS program or MDCP.
10. Telephone No. with Area Code of Other Contact — Enter the area code and telephone number of the other contact.
11. Mailing Address of Other Contact (include City and ZIP Code) — Enter the mailing address of the other contact, including city and ZIP code.
12. Current Location of Applicant/Member — Check the box indicating the current location of the applicant/member: Home, Hospital, Nursing Facility, Adult Foster Care (AFC) or Assisted Living/Residential Care (AL/RC).
13. Living Arrangement, if enrolled in STAR+PLUS HCBS program — Check the box for the applicant's expected living arrangement, if enrolled in STAR+PLUS HCBS program: Home, AFC or AL/RC.
14. Home Address — Enter the address and telephone number of the applicant's/member's home address if this differs from his or her current living address. If the information is the same as the address entered in Item 7 and the telephone number entered in Item 8, enter "same" in this box.
15. Date Form H3676 Posted — Enter the date the form is posted to TxMedCentral.
16. Managed Care Organization (MCO) Selected — Enter the name of the MCO selected by the applicant or the MCO in which he or she is a member, if applicable.
17. MCO Vendor No. — Enter the vendor number for the selected MCO.
18. MCO Contact's Name — Enter the name of the contact at the selected MCO agency.
19. Contact's Telephone No. with Area Code — Enter the area code and telephone number of the contact documented in Item 18.
20. MFP Demonstration 90-Day Qualifying Dates — Enter the dates the applicant/member has resided in an institutional setting, including ongoing stays. Enter “ongoing” in the end date field if the applicant/member is still in the facility. Qualifying facilities include nursing facilities, intermediate care facilities serving persons with intellectual or developmental disabilities or a related condition (including state supported living centers), hospitals or state hospitals.
21a. Relocation Referral Made — Check Yes or No to indicate that a relocation referral was made.
21b. Relocation Specialist — Enter the name of the relocation specialist, if a referral was made in Item 21a.
22a. Telephone No. with Area Code — Enter the relocation specialist's area code and telephone number if a referral was made in Item 21a.
22b. Fax Telephone No. with Area Code — Enter the relocation specialist's fax area code and telephone number if a referral was made in Item 21a.
23. Comments — Enter any relevant comments for communication to the MCO.
24. Program Support Unit Staff Name — The PSU staff member enters his or her name in this field to authorize the MCO to perform the pre-enrollment assessment.
25. Date Completed — Enter the date Section A was completed by PSU staff.
26. Telephone No. with Area Code — Enter the PSU staff member's area code and telephone number.
B. Waiver Assessment Report — The MCO completes Items 27 through 36.
27. Date of Assessment — Enter the date the applicant/member was assessed for STAR+PLUS HCBS program or MDCP services.
28. a. Form H1700-1, Individual Service Plan (ISP) — Check Yes or No to indicate if Form H1700-1 is completed and posted to TxMedCentral.
28. b. STAR Kids ISP - Service Tracking Tool — Check Yes or No to indicate if the STAR Kids ISP - Service Tracking Tool is completed in the electronic 278 transaction and posted to TxMedCentral.
29. Fax Telephone No. with Area Code — Enter the fax area code and telephone number of the staff person who completed Form H1700-1 or Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool.
30. Comments — Enter any relevant comments regarding the applicant's nursing needs.
31. Medical Necessity Approved — Check Yes or No to indicate if the applicant has an approved medical necessity.
32. Community First Choice (CFC) Only Eligible — Check Yes or No to indicate if the applicant has an approved medical necessity but does not meet STAR+PLUS HCBS program functional criteria because needs may be met through the CFC program.
33. MFP Demonstration Participant — Check Yes or No to indicate if the applicant/member is an MFP Demonstration project participant.
34. MCO Staff Name — The MCO contact enters his or her name in this field.
35. Date Completed and Posted — The MCO contact enters the date the form is completed and posted to TxMedCentral.
36. Telephone No. with Area Code — Enter the MCO staff member's direct area code and telephone number.