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Effective Date: 
5/2021

Documents

 

Instructions

Updated: 5/2021

 

Purpose

Form 1024 is used to document the waiver benefits that result in an Individual Service Plan (ISP) or Individual Plan of Care (IPC) exceeding the assigned cost ceiling and to establish the medical need and rationale for these items or services. Form 1024 documents all additional resources and supports that have been explored and are anticipated to be used by the individual during the plan year.

Form 1024 is to be completed by the managed care organization (MCO) service coordinator, the Local Intellectual and Developmental Disability Authority (LIDDA) service coordinator or the 1915 (c) waiver program provider case manager when an ISP or IPC exceeds the assigned cost ceiling for:

  • The STAR+PLUS Home and Community Based Services (HCBS) program;
  • Home and Community-based Services (HCS);
  • Community Living Assistance and Support Services (CLASS);
  • Deaf Blind and Multiple Disabilities (DBMD); or
  • Texas Home Living (TxHmL).

 

Procedure

When to Prepare

Form 1024 is prepared by the MCO, LIDDA service coordinator or the 1915(c) waiver program provider case manager for any of the following General Revenue submissions:

  • initial assessment;
  • annual reassessment; or
  • when an individual has a change in condition that causes an already approved IPC to require a revision that will put the plan over the cost ceiling.

Form Retention

The MCO must keep a copy of Form 1024 in the member's case record according to the retention requirements found in all Medicaid Uniform Managed Care Contracts (UMCC), HCS or TxHmL Handbooks, CLASS Provider Manual, DBMD Program Manual and federal regulations.

For the STAR+PLUS HCBS program, keep all originals and electronic copies in the member's case record for five years after services are terminated.

For HCS and TxHmL, keep all originals and electronic copies for at least seven years; for CLASS, refer to the Provider Manual for retention requirements.

 

Detailed Instructions

Individual Name — Enter the name of the individual.

Medicaid No. — Enter the individual’s Medicaid number.

CARE or Unique ID No. — If the individual is enrolled in HCS, enter the individual’s Client Assignment and Registration (CARE) Identification number; if CARE has transitioned out of use, enter the Unique ID number assigned to the individual by Texas Medicaid & Healthcare Partnership (TMHP). Enter N/A if no CARE or Unique ID number exists.

Date of Birth — Enter the individual’s date of birth using the mm/dd/yyyy format.

Service Area — Enter the managed care service area the individual resides in. If the individual is not enrolled in HCBS, enter N/A. Link to service areas: https://hhs.texas.gov/sites/default/files//documents/services/health/medicaid-chip/programs/managed-care-service-areas-map.pdf

Waiver Cost Limit — Enter the assigned cost limit. For the STAR+PLUS HCBS program, enter the cost ceiling associated with the assigned Resource Utilization Group (RUG) value, found in STAR+PLUS Handbook Appendix X, STAR+PLUS HCBS Cost Limits. For HCS, enter the cost ceiling associated with the assigned Level of Need (LON). For CLASS, DBMD or TxHmL, enter the cost ceiling assigned with the specific waiver program.

Projected Cost of Services — Enter the estimated cost of the medically necessary services the individual requires during the plan year, located on the ISP or IPC.

Waiver Program — Enter the waiver program the member is currently enrolled in and include any 1915(c) waiver programs [HCS, CLASS, DBMD, TxHmL or Medically Dependent Children Program (MDCP)]. If the member is enrolled in STAR+PLUS, indicate if they are currently receiving services from HCBS.

IDD Waiver Program Provider Representative (if applicable) — Enter the name of the Intellectual and Developmental Disabilities (IDD) waiver case manager responsible for coordinating provider services for the individual.

IDD Waiver Program Provider Phone No. (if applicable) — Enter the telephone number for the waiver case manager (more than one contact number can be provided).

IDD Waiver Program Provider Email (if applicable) — Enter the email address for the waiver case manager.

LIDDA Service Coordinator (if applicable) — Enter the name of the LIDDA service coordinator responsible for coordinating services for the individual.

LIDDA Service Coordinator Phone No. (if applicable) — Enter the telephone number for the LIDDA service coordinator (more than one contact number can be provided).

LIDDA Service Coordinator Email (if applicable) — Enter the email address for the LIDDA service coordinator.

Managed Care Organization (MCO) Service Coordinator (if applicable) — Enter the name of the MCO service coordinator responsible for coordinating services for the individual.

MCO Service Coordinator Phone No. (if applicable) — Enter the telephone number for the MCO service coordinator (more than one contact number can be provided).

MCO Service Coordinator Email (if applicable) — Enter the email address for the MCO service coordinator.

 

Individual Health and Safety

1. Which services are causing the Individual Service Plan (ISP) or Individual Plan of Care (IPC) to exceed the cost limit and why are they necessary? — Enter any services listed on the ISP/IPC that are causing the plan to exceed the assigned cost limit. Explain why the individual requires these services.

2. Identify and explain any services noted in Question 1 that could not be provided in a nursing facility or state supported living center. — Enter specific information detailing what needs the individual has that can’t be provided in a nursing facility or state supported living center. Be specific and detail service with interventions, frequency, etc. Note: A determination to request the use of General Revenue funding for the cost of services exceeding the assigned cost limit is based on whether an individual’s health and safety needs cannot be met in an institution, such as a nursing facility or a state supported living center.

3. Are there any community resources, informal supports and service options available to the individual? Are these being utilized? If not, explain. — Enter any services or supports that will be provided by an identified non-waiver or nonpaid resource. This could include family members or friends providing nonpaid care, services provided at school (until the age of 22), community groups such as the Texas Ramp Project or their church, or service options such as Medicaid Home Health, Day Activity and Health Services (DAHS) and Community First Choice (CFC).

4. Have other agency programs, community resources, service options, or alternative living arrangements been explored or considered? If available, explain why they are not being utilized. — Enter any non-waiver services or supports that have been explored or considered and why these services or supports were deemed not to be appropriate to meet the individual’s needs.

 

Caregiver Status for Own Home or Family Home Setting

1. What impact would the provision of informal support to the individual have on the primary caregiver/family? What barriers, if any, are there to providing informal support? — Enter how the provision of any increased informal support to the individual will impact the primary caregiver/family. Include factors such as financial status/stability, ability to care for others in the home or health status of the primary caregiver.

2. Provide any relevant information not already captured on this form. — Enter any other relevant information that would explain why General Revenue funding is necessary.

Service Coordinator/Case Manager Name — Enter the name of the service coordinator or case manager who filled out the form and include any licensure.

Signature — The service coordinator or case manager signs the form.

Date — Enter the date the form was completed and signed by service coordinator or case manager.

Authorizing MCO Medical Director Name — Enter the name of the MCO medical director who has reviewed the request for General Revenue and authorizes the request submission.

Signature — The MCO medical director who has reviewed the request for General Revenue and has authorized the request submission signs the form.

Date — Enter the date the form was signed by the MCO medical director.