Complete Form 2603 for an individual’s initial assessment and for all annual and revision assessments. Completion of Form 2603 is required and:
- is developed through a person-centered planning process;
- occurs with the support of a group of people chosen by the individual or the legally authorized representative (LAR) on the individual's behalf; and
- accommodates the individual’s style of interaction, communication and preferences regarding time and setting.
Form 2603 is used to:
- document findings from the STAR Kids Screening and Assessment Instrument (SK-SAI);
- develop a service plan for services received through the STAR Kids managed care organization (MCO) and, for the STAR Kids Medically Dependent Children Program (MDCP) members, is used to develop an MDCP service plan that falls within the individual’s allowable cost limit;
- document services received through third party sources, such as 1915(c) waivers operated by the Texas Health and Human Services Commission (HHSC) and Texas Department of State Health Services (DSHS);
- identify an individual’s strengths, preferences and unique circumstances;
- identify what is important to the individual;
- identify natural supports available and needed service system supports;
- document preferences for when and how to receive services;
- identify any special needs, requests or considerations for the individual; and
- document and address the individual’s unmet needs.
When to Prepare or Update
Form 2603 must be completed in its entirety following the assessment with the SK-SAI. The form must be updated annually. ISP changes must be documented on Form 2603 during the assessment or reassessment process, and as needed, to reflect any changes related to the individual's medical condition or functional ability throughout the ISP year. ISP changes include, but are not limited to, any changes to services listed on the ISP or any newly identified need that the member or LAR requested, or service coordinator identified during the ISP period. If an individual or their LAR does not know the information requested or refuses to answer, document that on Form 2603.
Each MCO must keep Form 2603 per the retention requirements found in all Medicaid Managed Care contracts and federal regulations. Keep all originals or electronic copies of this form in the individual's folder or electronic record for 10 years after services are terminated.
The MCO must provide a printed or electronic copy of the form to each individual or LAR following any significant update and no less than annually in the format requested. The MCO must provide a copy of the form to providers and others as specified by the individual or their LAR. The MCO must upload the form to the MCO provider portal following the requirements in Uniform Managed Care Manual Chapter 3.32. The MCO must complete the form in plain language that is clear to the individual or their LAR, and it must be furnished in Spanish or languages of other major population groups, if requested.
Form 2603 is designed to complement the SK-SAI. Where appropriate, these instructions note the information which may be copied from appropriate fields on the SK-SAI.
The information contained in this form is obtained through an information-gathering conversation called the discovery process with the individual about their abilities, preferences and goals in line with person-centered planning principles. The service coordinator should make their best effort to communicate with the individual. If the individual cannot participate in the discovery process due to age or disability, the service coordinator can supplement with information from the LAR.
Section I. Individual and Service Coordinator Information
1. Individual Name – Enter the name, as found on Section A, Item 3 of the SK-SAI.
2. Date of Birth – Enter the date of birth, as found on Section A, Item 5 of the SK-SAI.
3. Medicaid No. – Enter the Medicaid number, as found on Section A, Item 13c of the SK-SAI. If the individual does not yet have a Medicaid number, leave blank.
4. Social Security No. – Only complete this information if the individual does not yet have a Medicaid number (i.e., an applicant for MDCP). Enter the Social Security number, as found on Section A, Item 13a of the SK-SAI.
5. Service Coordinator Name – Enter the individual’s named service coordinator’s name. If the individual does not have a named service coordinator, enter the name of the service coordinator helping with this service planning process.
6. Service Coordinator Area Code and Phone No. – Enter the individual's named service coordinator’s area code and phone number. If the individual does not have a named service coordinator, enter the phone number of the service coordinator assisting with this service planning process.
7. Service Coordination Level – Enter the individual’s current service coordination level as Level 1, Level 2 or Level 3.
8. ISP Start Date – Enter the effective date of the ISP. This should match the date submitted on the electronic ISP. Otherwise, enter NA.
9. ISP End Date – Enter the end date of the ISP. This should match the date submitted on the electronic ISP. Otherwise, enter NA.
10. ISP Revision Date – Enter the date that the ISP was last revised, if applicable. Otherwise, enter NA.
Section II. Medical Information
Diagnoses and Conditions – Enter information in Section D, Item 1 of the SK-SAI, if applicable.
Medications – Enter information from Section D, Item 2 of the SK-SAI, if applicable.
Hospitalizations in Last 12 Months – Enter information from Section D, Items 17-19 of the SK-SAI, if applicable. Provide the date, reason and plan to prevent readmission.
Specialists – Enter the provider names, provider types, frequency of provider visits, and provider contact information for the individual’s specialist provider. Include all current specialists that are significant to the individual’s care.
Medical Referrals – Enter information from Section Q questions 8 through 10 of the SK-SAI, if applicable. Provide the provider name, provider type, purpose and expiration.
Section III. Preferences, Strengths and Unique Circumstances
1. Strengths – Enter information from Section B, Item 6 of the SK-SAI, if applicable.
2. Hobbies and Interests – Ask about the individual’s hobbies and interests and enter what the individual likes to do in their free time.
3. Community-based Activities – Ask about the community activities the individual participates in and enter that information.
4. Goals – Ask about the individual’s developmental, educational, medical, social, service coordination and other goals. Enter information for both short and long-term goals from Section P, Items 1-2 and Section M, Item 2 of the SK-SAI, if applicable.
5. Who will be directly involved in support planning? – Enter the name and relationship to the individual, preferred method of participation for people who are participating in the service planning process, physical address, mailing address, area code and phone number, and email for each person.
6. Permanency Planning – Make a note, if applicable. Permanency planning is for an individual who is transitioning from a foster care home environment, nursing facility (NF) or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) to the community.
7. Service Preferences – Enter how the individual likes to receive services. This could include a discussion of consumer-directed services and preferences about learning how to do new things.
8. Things Working Well – Enter the services and supports that work well and help the individual stay healthy and remain safe in the community.
9. Things that Could Be Working Better/Barriers – Enter the barriers to receiving necessary care and other issues the individual or LAR might be facing.
10. Family Considerations – Enter information from Section B of the SK-SAI, if applicable.
11. Current Durable Medical Equipment (DME) – Enter information from Section D, Item 20 of the SK-SAI, if applicable. Provide the product type, replacement frequency and concerns/notes.
12. Current Medical Supplies – Enter information from Section D, Item 21 of the SK-SAI, if applicable. Provide the product type, resupply frequency (daily, weekly, monthly or annually) and concerns/notes.
Section IV. Service Planning Considerations
1. Medicaid State Plan Services – Check the box for Medicaid state plan services the individual is receiving or approved to receive, including service or item type, provider type such as home health agency and registered nurse, rationale such as why the service is needed or requested, hours per week if applicable, begin and end date, and if the individual has chosen the Consumer Directed Services (CDS) Option or Service Responsibility Option (SRO), if applicable. Enter information from Section H, Item 5 of the SK-SAI, if applicable.
Make a note if the individual is receiving services through the Early Childhood Intervention (ECI) program. Note: The service coordinator should attach the Individual Family Service Plan (IFSP) that is used in the ECI program to Form 2603, if available.
2. MDCP Services – Check the box for MDCP services the individual is receiving or approved to receive, including service or item type, provider, rationale including why the service is needed or requested, hours per week, begin and end date, and if the individual has chosen the CDS Option or SRO. This list should match the services submitted with the electronic ISP and this information is only applicable to MDCP members and applicants. If the individual is not in MDCP, leave Section IV 2 blank.
MCOs must develop a process to allow for flexible schedules and allow an MDCP member to "bank" respite hours to use at later points in the ISP year.
3. Health home – Document the individual’s utilization of, or interest in, a health home, as defined in Texas Government Code Section 533.00253(a)(2).
4. Value-added Services – Enter the value-added services that the individual is receiving or is approved to receive, including service type, begin and end date, and additional service details.
5. Non-capitated Medicaid Services – Enter the non-capitated services that the individual is receiving, including the waiver or program name, service type, hours per week , if applicable, and begin and end date. Refer to STAR Kids Contract Section 188.8.131.52 for a list of Medicaid non-capitated services. This category includes services received through HHSC and DSHS waiver programs, such as Community Living and Support Services, Deaf Blind with Multiple Disabilities, Home and Community-based Services, Texas Home Living, and Youth Empowerment Services. Do not include Medicaid services provided through School Health and Related Services (SHARS), which are captured in 6., Education Services. Enter information from Section A, Item 30 of the SK-SAI, if applicable.
Make a note if the individual is receiving ECI services and if they are receiving ECI targeted case management or specialized skills training, which are non-capitated ECI services. Note: The service coordinator should attach the IFSP used in the ECI program to Form 2603, if available.
6. Education Services – Enter services the individual is receiving through school, including name, service type, hours per week, if applicable, and begin and end date. Include services received in both the school and home setting, and Medicaid services provided through the SHARS program. Enter information from Section C of the SK-SAI, if applicable. Note: If the member has an individual education plan (IEP) through the school, the IEP is considered confidential and may only be shared with the MCO with permission from the individual or LAR. If the family does choose to share the IEP, attach the IEP to Form 2603.
7. Non-Medicaid State Program Services – Enter services that the individual is receiving through state programs other than Medicaid, including the program name, service type, hours per week (if applicable) and begin/end date. Examples include Women, Infants and Children and Supplemental Nutrition Assistance Program.
8. Informal/Community Supports – Enter other informal or community supports the individual receives, including the name of the services, relationship of the provider to the individual, service type, hours per week, and the begin/end date. Include informal supports that are most important to the member and information from Sections B and G of the SK-SAI, if applicable.
9. Is the individual/LAR interested in additional resources to become more involved in the community? – Check the appropriate box. Under Service Type Detail, provide potential referrals to community organizations, such as volunteer opportunities at a local food bank or participation in a support or advocacy group.
10. Medicare and Other Payers – If the individual has Medicare or another third-party resource that pays for services, list the name of the resource, policy number, service type, hours per week, begin and end date, and other service type details. Examples include Medicare, TRICARE and other third-party payers.
Section V. Authorizations Requested/Needed
Record the services that the individual is requesting or needs authorization based on results from the SK-SAI. Enter the item or service, provider, “from” date and “to” date.
Section VI. Complaints and Appeals Log
Record the individual’s complaints and appeals. Enter the type of complaint or appeal, submission method, date, actions taken, and ultimate resolution.
Section VII. Completed Assessments
Record any assessments that the individual has completed. Enter the screening/assessment name/type, assessor name (if known) and date. Examples include a speech therapy evaluation or Child and Adolescent Needs and Strengths (CANS) assessment.
Section VIII. Follow-up Items or Assessment Needs
Record any additional follow-up screenings or assessments that are needed. Enter the item, screening, assessment and the responsible party or entity completing it. Examples include a speech therapy evaluation or CANS assessment.
Section IX. Service Coordinator Follow-up Schedule
Document the service coordinator follow-up schedule. Individuals must receive in-person and phone contacts per their service coordination level, as described in STAR Kids Contract Section 184.108.40.206. Enter the date of the next scheduled contact, method of contact such as phone, email, in-person or mail, annual reassessment date, and any other comments including the member’s or LAR’s refusal to participate in the assessment, and any request to reduce or refuse service coordination.
Section X. Signature/Approval
Inform the individual or LAR about their rights and responsibilities, as described in this section, and about whether they want to allow changes to Form 2603 without a signature such as over the phone, or if they want to sign off on all changes. Check the appropriate box under Attestation.
Printed Name – Member/LAR, Signature and Date – The individual or LAR prints, signs and dates this section to agree to the attestation.
Printed Name – Service Coordinator, Signature and Date – The service coordinator prints, signs and dates the form. This indicates they developed the ISP based on needs and in collaboration with the individual or LAR, and that they have reviewed the rights and responsibilities.