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Effective Date: 
8/2021

Documents

 

Instructions

Updated 8/2021

 

Purpose

The service coordinator completes Form H1700-2 and the purpose of this form is to document the STAR+PLUS Home and Community Based Services (HCBS) program benefits that will be provided to the applicant or member and establish the medical need and rationale for all items or services included on Form H1700-1, Individual Service Plan. The service coordinator also documents on Form H1700-2 all additional resources and supports available and anticipated to be used by the applicant or member during the individual service plan (ISP) period.

 

Procedure

When to Prepare

Form H1700-2, or an alternate form of documentation that includes the same information, is prepared by the service coordinator at the initial assessment, reassessment or ISP change.

Form Retention

The managed care organization (MCO) must keep a copy of Form H1700-2 or any alternate document in the member's case record according to the retention requirements found in all Medicaid managed care contracts and federal regulations. A copy of Form H1700-2 should be provided to the applicant or member upon request. After service termination, the MCO must keep all originals and electronic copies of Form H-1700-2 in the member's case record for five years.

 

Detailed Instructions

Individual Service Plan Dates — MCO staff enter the begin and end date of the ISP using mm/dd/yyyy format. For initial assessments, the MCO must use the ISP dates listed on Form H2065-D, Notification of Managed Care Program Services, received from Program Support Unit (PSU) staff.

Revision Date — Enter the date the ISP was revised if any changes were made during the ISP period. This line is left blank during the initial assessment and annual reassessment.

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

Medicaid ID No. or Applicant Social Security No. — Enter the applicant's or member's Medicaid number or Social Security number if a Medicaid number is not available.

 

I. Medical Information

Describe why the STAR+PLUS HCBS program item/service is necessary and how it benefits the applicant/member:

Item/Service — Enter the STAR+PLUS HCBS program item or service requested on the ISP by the applicant or member or identified as a need by the service coordinator. Each item or service should be entered on a separate line. Additional lines may be added, if needed.

Rationale — Enter specific information detailing why the requested STAR+PLUS HCBS program item or service is necessary and exactly how it will benefit the individual medically, functionally or in terms of rehabilitation. The rationale should demonstrate how the member meets waiver eligibility of having an unmet need for waiver services. For paid attendant care, include any nursing tasks or health maintenance activities that have been delegated to the attendant.

 

II. Goals — Enter at least one individualized goal important to the applicant or member and the action steps needed to help the person reach the desired goal.  Use a person-centered discovery process to help the applicant or member develop goals based on what is important to them with regard to delivery of their supports and services. Include the applicant’s or member’s support system, as needed.

Note: The most up-to-date information should be captured in this field. If the information captured in this field is documented on another form, document in this section where the information can be found.

 

III. Support System (include family, community organizations, informal support, etc.)

Name/Relationship — Enter the name and the relationship of the person or organization that will provide assistance or services to the applicant or member during the ISP period.

Service/Support Details — Enter the service provided by the person or organization and document specific detail of what is included in the service.

Phone and/or Email Address — Enter the area code and phone number or email address of the contact person or organization.

Units/Hours per Week — Enter the units or hours per week the service will be provided.

Involved in Development of Plan? — Enter Yes if the support system was involved in the development of the plan. Enter No if the support system was not involved in the development of the plan.

N/A box — Check the N/A box if the applicant or member has no caregiver/informal support involvement.

a. Medicare and Other Payers (include Medicare, VA, TRICARE, private insurance and other payers): Enter the following information for each non-Medicaid payer listed.

Resource — Enter the name of the non-Medicaid payer that will provide services to the applicant or member during the ISP period.

Policy No. — Enter the policy number, if available.

Service Type/Detail — Enter the service provided and document specific detail of what is included in the service.

Units/Hours per Week — Enter the units or hours per week the service will be provided.

N/A box — Check the N/A box if the applicant or member does not receive services from Medicare or other payers.

b. Medicaid State Plan Services (include Medicaid Home Health, Day Activity and Health Services [DAHS], and Community First Choice [CFC]): Enter the following information for each state plan service listed.

Resource — Enter the name of the state plan service that will be provided to the applicant or member during the ISP period.

Service Type/Detail — Enter the service provided and document specific detail of what is included in the service. For paid attendant care, include any nursing tasks or health maintenance activities that have been delegated to the attendant.

Units/Hours per Week — Enter the units or hours per week the service will be provided.

N/A box — Check the N/A box if the applicant or member does not receive services in any Medicaid State Plan Services.

c. Services Provided in an Educational Setting: Enter the following information for services provided in an educational setting.

Resource — Enter the name of the educational facility that will provide services to the applicant or member during the ISP period.

Service Type/Detail — Enter the service provided and document specific detail of what is included in the service and the beginning and end date of the service. The dates must be within the "From" and "To" dates as documented on Form H1700-1, Individual Service Plan. Enter “Unknown” if a begin date is unknown.

Units/Hours per Week — Enter units or hours per week the service will be provided.

N/A box — Check the N/A box if the applicant or member does not receive services in an educational setting.

d. Value-added Services (VAS): Enter the following information if it is anticipated the applicant or member will use MCO VAS during the ISP period. Include only waiver benefits that are offered as VAS items/services such as dental services, emergency response services, respite or home-delivered meals. VAS are not required to be used prior to waiver service. VAS vary by MCO. The service coordinator is responsible for knowing the VAS applicable for the applicant or member.

Service Type/Detail — Enter the service provided and document specific detail of what is included in the service.

Units/Hours per Week — Enter units or hours per week the service will be provided.

N/A box — Check the N/A box if the applicant or member does not receive VAS.

e. Additional Follow-up: Enter any additional follow-up referral or assessments needed. A referral can be generated for a specific service or item (i.e., physical therapy, personal care service or DME) or for an assessment for a service (i.e., a referral for a behavioral health assessment to determine specific services an individual may need).

Item/Service — Enter any additional identified item or service the applicant or member was assessed as having a need for but does not have a current authorization.

Action — Enter the action steps needed for the item/service to be authorized and the party or entity responsible for completing the follow-up or assessment. If no action is needed, enter “No action required” and document the reason why.

N/A box — Check the N/A box if the applicant or member does not have any additional follow-up needs.

 

V. Emergency Plan: Enter the following information for the applicant’s or member’s emergency plan.

Describe the details of the emergency plan — Enter specific detail of how the applicant’s or member’s needs will be met in the event of an emergency.

Emergency contacts — Enter the name, relationship, area code and phone number of the person the applicant or member would like to be contacted in the event of an emergency. If the applicant or member does not have a contact, enter “No emergency contact.”

 

VI. Follow-up Schedule: Enter the following information for the applicant’s or member’s follow- up schedule.

Service Coordinator follow-up schedule — Enter the plan for the service coordinator to follow up and communicate with the applicant or member during the ISP period.

 

VII. Service Coordinator Comments (if applicable): The service coordinator can provide additional documentation of the applicant’s or member's needs listed above or any other additional needs and how the needs are met. Enter comments that are relevant to the applicant’s or member’s medical or functional status not documented elsewhere.