Form 1024, Individual Status Summary

Instructions for Opening a Form

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Documents

Effective Date: 10/2024

Instructions

Updated: 10/2024

Purpose

Use Form 1024:

  • to document the items or services that result in an Individual Service Plan (ISP) or Individual Plan of Care (IPC) exceeding the assigned cost limit;
  • to establish the medical need and rationale for these items or services; and
  • to document all other explored resources and supports that the individual is expected to use during the plan year.

Procedure

When to Prepare

An MCO registered nurse (RN) or provider RN must complete Form 1024 when items or services exceed the assigned cost limit for the following programs:

  • 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).

Form 1024 is prepared when assessed or authorized services put the ISP or IPC over the cost limit:

  • at the initial ISP assessment or enrollment IPC;
  • at the annual ISP reassessment or renewal IPC; or
  • when an individual has a change in condition that:
    • requires a revision, and
    • causes an approved IPC to go over the cost limit.

Form Retention

The managed care organization (MCO) must keep a copy of Form 1024 in the applicant’s, member's or individual's case record. This is per the retention requirements found in all Medicaid Uniform Managed Care Contracts (UMCC), Handbooks, Provider and Program Manuals, and federal regulations.

Detailed Instructions

Name — Enter the name of the applicant, member or individual.

Medicaid No. — Enter the applicant’s, member’s, or individual’s Medicaid number.

Unique ID No. (If applicable) — If the individual is enrolled in HCS, enter the Unique ID number assigned to the individual by Texas Medicaid & Healthcare Partnership (TMHP).

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

Service Area (If applicable) — Enter the managed care service area the applicant, member or individual lives. Find the Managed Care Service Areas here (PDF).

Cost Limit — Enter the assigned cost limit for the applicable program as outlined below:

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

Projected Cost of Services — Enter the estimated cost of the medically necessary items and services the applicant, member or individual requires during the plan year, found on the ISP or IPC.

Program — Check the correct box to show which program the applicant, member or individual is being assessed for or currently receiving services in.

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 phone number for the IDD waiver case manager. more than one contact number can be provided).

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

LIDDA Service Coordinator (if applicable) — Enter the name of the Local Intellectual and Developmental Disability Authority (LIDDA) service coordinator responsible for coordinating services for the individual.

LIDDA Service Coordinator Phone No. (if applicable) — Enter the phone number for the LIDDA service coordinator. You may provide more than one contact number.

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 applicant or member.

MCO Service Coordinator Phone No. (if applicable) — Enter the phone number for the MCO service coordinator. You may provide more than one contact number.

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

Health and Safety

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

2. Identify and explain any items or services noted in Question 1 that could not be provided in a nursing facility or state supported living center. — Enter specific information. Detail what needs the applicant, member or individual has that cannot be provided in a nursing facility or state supported living center. Be specific and include things such as detail services with interventions and frequency. Note: A determination for authorization of items or services that exceed the assigned cost limit is based on whether an individual’s health and safety needs cannot be met in an alternative living arrangement, such as a nursing facility or a state supported living center.

3. Are there any community resources, informal supports, or service options available to the applicant, member, or individual? If yes, are these being utilized? If not, explain. — Enter any services or supports that an identified nonpaid resource provides. This could include family members or friends providing nonpaid care, services provided at school until 22 years old, community groups such as the Texas Ramp Project or 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 yes, explain why they are not being utilized. — Enter any services or supports that have been explored or considered and are available. Explain why these services or supports were deemed not appropriate to meet the applicant’s, member’s or individual’s needs.

5. If the applicant, member, or individual is unable to make decisions for themselves, do they have a legally authorized representative (LAR)?

  • Check Yes if the applicant, member, or individual has a LAR.
  • Check No if they do not have a LAR. Describe if there are plans in place to get LAR status.

6. If the individual is enrolled in a 1915(c) waiver and the current caregiver becomes unavailable to provide care or a place of stay, what is the back up or permanency plan? --- Enter the short or long-term plan for the applicant, member or individual if:

  • the individual is enrolled in HCS, TxHmL, CLASS, or DBMD; and
  • there is a temporary or permanent loss of the primary caregiver.

7. Provide any relevant information not already captured on this form. — Enter any other relevant information to explain why the authorization of items or services over the assigned cost limit is necessary.

Printed Name of Registered Nurse– Enter the name of the RN who completed the form.

Signature – Signature of the RN who completed the form.

Date – Enter the date the RN completed the form.

Printed Name of Authorizing STAR+PLUS MCO Medical Director— Enter the name of the STAR+PLUS MCO medical director who reviewed the request and authorized the request submission. This is required only for STAR+PLUS HCBS applicants or members.

Signature — Signature of the STAR+PLUS MCO medical director.

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