Form 1048, Summary Sheet for Services to Individuals with IDD in a Nursing Facility

Instructions

Updated: 9/2017

Purpose

A local intellectual and developmental disability authority (LIDDA) uses Form 1048 to request reimbursement for LIDDA specialized services provided to Medicaid eligible individuals with an intellectual or developmental disability (IDD) who are residing in a nursing facility (NF). An LIDDA also uses the form to request reimbursement for service coordination provided to an individual with IDD who has been diverted or transitioned from an NF to a Medicaid waiver program that is not Home and Community-based Services (HCS) or Texas Home Living (TxHmL). The LIDDA is required to provide service coordination for these individuals for one year following the individual’s enrollment in the non-HCS or TxHmL Medicaid waiver program.

Procedure

Form 1048 is used to request reimbursement for all specialized services provided by an LIDDA to all eligible individuals within a particular month.

The description of services is a drop-down field on the form which includes the following reimbursable services:

• Determination of Intellectual Disability Assessment
• Behavioral Support
• Day Habilitation 1 - 2.9 Hours
• Day Habilitation 3+ Hours
• Employment Assistance Per Hour
• Independent Living Skills Training Per Hour
• Non-HCS or TxHmL Service Coordination Face-to-Face
• Supported Employment Per Hour

Transmittal

Email the completed form to IDDPerformance.Contracts@hhsc.state.tx.us.

Detailed Instructions

The following information must be included on the form:

Local Intellectual and Developmental Disability Authority — Enter the name of the LIDDA submitting the form.

Street Address — Enter the street address for the LIDDA submitting the form.

City, State, and ZIP Code — Enter the city, state and ZIP code for the LIDDA submitting the form.

Component Code — Enter the three-digit component code for the LIDDA submitting the form.

Service Month and Year — Enter the calendar month and year the service(s) were provided.

Contact Person — Enter the name of the individual who is responsible for addressing questions regarding this form.

Area Code and Telephone No. — Enter the ten-digit telephone number for the contact person during business hours.

Name of Individual — Enter the last name, first name and middle initial for the individual who received the service.

Local Case No. — Enter the local case number for the individual who received the service.

Description of Service — Select the appropriate service from the drop-down field.

Unit — Enter the number of times the individual was provided the selected services for this service month.

Rate — This field auto populates depending on the service selected.

Total — This field auto calculates depending on the service selected and unit(s) entered.

Services Summary and Total Due — The Total Due field auto calculates depending on the number of services provided for each service category.

Printed Name, Signature and Date — The LIDDA staff who completed the form prints his/her name, signs and dates the form.