Form H1700-1, Individual Service Plan

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Documents

Effective Date: 9/2017

Instructions

Updated: 9/2017

Purpose

This form is used to:

  • record the identifying information of the STAR+PLUS Home and Community Based Services (HCBS) program applicant/member;
  • record or update the member's individual service plan (ISP), including:
    • ISP effective period;
    • services to be provided; and
  • serve as a worksheet to compute estimated annual cost of waiver service for the member.

Procedure

When to Prepare

This form is completed by the STAR+PLUS HCBS program service coordinator each time:

  • an applicant's/member's eligibility is assessed for the program;
  • there is a change in the member's service plan; or
  • the annual reassessment of the ISP is completed.

Number of Copies

Maintain an original form for the case record or the electronic version.

Transmittal

The managed care organization (MCO):

  • maintains the original/electronic Form H1700-1 in the member's case file; and
  • posts Form H1700-1 on TxMedCentral in the appropriate MCO ISP folder.

Note: It is not necessary to post changes to ISPs.

Form Retention

Each MCO must keep Form H1700-1 according to the retention requirements found in all Medicaid Managed Care contracts and federal regulations. Keep all originals/electronic copies of this form in the member's folder/electronic record for five years after services are terminated.

Supply Source

This form is found on the Texas Health and Human Services website.

Detailed Instructions

1. Group Code — Enter "19."

2. Medicaid No. — Enter the applicant's/member's nine-digit Medicaid number as shown on the Texas Integrated Eligibility Redesign System (TIERS) files, or on the Your Texas Benefits card. If the Medicaid number is pending, leave blank.

3. Member Name — Enter the applicant's/member's full name (last, first, middle initial) as shown.

4. Plan Code — Enter the plan code of the MCO that the member is enrolled in.

5. Effective Date —

  • For an "Initial ISP" – Enter the start date of STAR+PLUS HCBS program services. This is always the first of the month with the following exceptions:
    • For applicants entering the STAR+PLUS HCBS program via the Money Follows the Person(MFP)/Demonstration process, enter the start date of STAR+PLUS HCBS program services as the first date of the month in which the applicant discharges from the nursing facility; or
    • For applicants entering the STAR+PLUS HCBS program via the transition process, enter the start date of STAR+PLUS HCBS program as the first date of the month following the applicant's 21st birthday.
  • For an "ISP Change" – Enter the date that the change indicated on the form takes effect. The MCO does not post ISP changes, but maintains the change ISPs in the member's folder.
  • For a "Reassessment" on an ISP – Enter the date after the end date of the current ISP.

6. ISP Dates — Enter the "from" and "to" dates for this ISP period. For an initial ISP, the "from" date is the same as the effective date, and the "to" date is a year minus a day after the "from" date. For reassessments, the "from" date is the first day after the day the previous ISP ended, and the "to" date is a year minus a day from the "from" date. The "from" date is always the first day of the month for initials and reassessments.

7. Date of Birth — Enter the date of the applicant's/member's birth. Use eight digits in month, day, year sequence (mmddyyyy).

8. Social Security No. — Enter the applicant's/member's nine-digit Social Security number.

9. County — Enter the three-digit county code for the county in which the applicant/member resides.

10. Type Authorization — Indicate the type of authorization by placing an "X" in the appropriate box.

  • Initial (new) – Check this box when enrolling an applicant/member.
  • ISP Change – Check this box to revise the ISP. Check this box when a change is made to the ISP within the current ISP effective period.
  • Reassessment – Check this box to renew the member's enrollment period for another year.
  • QIT – Check this box if the authorization is a Qualified Income Trust.

11. Enrolled From — Indicate the applicant's type of living arrangement by placing an "X" in the appropriate box.

If the member is enrolled in a Medicaid waiver using the Money Follows the Person option, use Service Authorization System (SAS) Code 12, Rider 37/28 (Facility to Community).

12. Living Arrangement after Entry into STAR+PLUS HCBS Program — Indicate the type of living arrangement for the member after entry into the waiver by placing an "X" in the appropriate box.

13. RUG — Enter the Resource Utilization Group (RUG) level assigned to the applicant/member. This can be found in SAS or in the Long Term Care (LTC) online portal. If the member is ventilator dependent and qualifies for the partial or full ventilator supplemental payment, mark the box at the bottom of Form H1700-1 for partial or full ventilator use.

14. CDS — This is to indicate whether the specific service is provided under the Consumer Directed Services (CDS) option. Place an "X" in the box beside any appropriate service category authorized for the applicant/member.

Example: Place an "X" in Column 14-CDS, for Service Category Nursing Services RN.

15. Service Category — This is a listing of services available. Place an "X" in the box beside any appropriate service category authorized for the applicant/member.

16. Vendor ID No — Enter the nine-digit number assigned to the assigned MCO .

17. Est. Annual Service — Enter the estimated annual service units for each service indicated.

Do not enter estimated annual service units for adaptive aids, medical supplies, minor home modifications or specification fees. Enter daily units, not hourly units, for in-home and out-of-home respite services. Round fractions to the next higher whole unit.

18. Unit Rate — Enter the established unit rate for each service indicated.

Do not enter the unit rate for adaptive aids, medical supplies, minor home modifications, requisition fees and specification fees.

19. Estimated Annual Cost — Enter the estimated annual cost for each service authorized.

Calculate the estimated annual cost by multiplying the estimated annual service units times the service unit category rate.

If the estimated cost of a service is being reduced, the cost listed must be equal to or greater than the total cost for which payment has already been made.

When there is a provider change and the member has received services from the original provider, add the estimated or actual cost of the services already provided by the original provider to the estimated annual cost for services from the new provider to ensure the member does not exceed his ISP cost limit.

Total Est. Waiver Costs — Calculate the estimated annual cost from each service to arrive at the total estimated waiver costs.

Complete the items at the bottom of the page:

Ventilator Use — If the annual cost limit includes the add-on cost for full or partial ventilator use, mark the appropriate box for 6 — 23 hours of ventilator use or 24 hours of continuous ventilator use. Leave boxes blank if there is no ventilator use.

Service Coordinator — Enter the STAR+PLUS HCBS program service coordinator's name.

Annual Cost Limit — Enter the annual cost limit used in development of this page.

MCO Name — Enter the managed care organization name.