Form 1028, Medically Fragile Group Criteria Certification

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Effective Date

9/2025
1028.pdf

Instructions

Update: 9/2025

Purpose

Use this form to document that an applicant meets the criteria for the medically fragile group under the STAR+PLUS Home and Community Based Services (HCBS) program. This form also serves as an attestation by the managed care organization’s (MCO) medical director that an applicant meets the medically fragile group criteria.

Note: In this form, MCO refers to STAR+PLUS MCOs and Medicare-Medicaid Plans (MMPs).

When to Prepare

The MCO service coordinator or medical director must complete this form when the:

  • MCO determines an applicant is medically fragile; and
  • applicant’s health and safety cannot be protected within the assigned Patient Driven Payment Model for Long-Term Care (PDPM LTC) cost limit.

Form Retention

Each MCO must:

  • keep the Medically Fragile Group Criteria Certification form required by all Medicaid managed care contracts and federal regulations; and
  • store originals and electronic copies of the Medically Fragile Group Criteria Certification form in the applicant's folder or electronic record for five years after services end.

Detailed Instructions

Type of Request – Select one of the following:

  • Initial Submission – Select this if the applicant has never received authorization for the medically fragile group.
  • Annual Reassessment – Select this if the applicant received authorization for the medically fragile group or general revenue group during the most recent State Fiscal Year.

Section 1 – Applicant and MCO Information

Applicant Information. Complete the following fields:

  • Applicant's Name – Enter the full name of the applicant.
  • Applicant's Date of Birth – Enter the applicant’s date of birth.
  • Applicant's Medicaid No. – Enter the Medicaid number for the applicant.

Patient Driven Payment Model for Long-Term Care (PDPM LTC) Value: Enter the PTPM LTC value assigned to the applicant.

MCO Information. Complete the following fields:

  • Name of MCO Staff Completing Form – Enter the name of the MCO staff completing this form.
  • Title of MCO Staff Completing Form – Enter the job title of the MCO staff completing this form.
  • Physician Assigned Primary Medical Diagnosis – Enter only the primary medical diagnosis the applicant’s physician has identified. Do not enter a diagnosis the applicant or authorized representative suggests. Use the applicant’s medical records to complete this section.
  • Has the applicant had a change in medical condition from the previous Individual Service Plan (ISP) year? – Check one of the following:
    • Yes - Select this if the applicant’s medical condition has changed since the last ISP year and the change requires more services.
    • No – Select this if the applicant’s medical condition has not change since the last ISP year.

      If you check Yes, describe the change in the applicant’s medical condition compared to the previous ISP year.

Section 2 – Medically Fragile Group Clinical Criteria

Check any applicable clinical criteria. Fill out the frequency of occurrences in a 24-hour period, unless otherwise noted. Support all criteria with medical documentation such as, nursing notes, ventilator, seizure or suction logs, or medication administration records. Do not use MCO service coordinator-created documents to support any medically fragile group criteria listed below.

  • Tracheostomy (Frequency of Suction) – Select this box if the applicant has a tracheostomy. Enter how many times, on average, an applicant is suctioned by tracheostomy in a 24-hour period.
  • Naso-pharyngeal (Frequency of Suction) – Select this box if the applicant receives suctioning through the naso-pharyngeal route. Enter the average number of suctioning episodes in a 24-hour period. Naso-pharyngeal suctioning may be performed whether or not an applicant has a tracheostomy. A physician must include orders for the naso-pharyngeal suctioning intervention in the applicant’s plan of care.

Ventilator – Select one of the following:

  • Assist and Control (A/C) – Select this if the applicant receives ventilation using A/C settings.
  • Synchronized Intermittent Mandatory Ventilation Settings (SIMV) – Select this if the applicant receives SIMV.

Utilization of Ventilation – Select one of the following:

  • Continuous – Select this if the applicant uses A/C or SIMV ventilation settings continuously over a 24-hour period.
  • Not continuous – Select this if the applicant does not use ventilation continuously. Enter the number of hours per day that ventilation is used.

Continuous Positive Airway Pressure (CPAP), Bi-level Positive Airway Pressure (BIPAP), or Average Volume-Assured Pressure Support (AVAPS) – Select one of the following:

  • Continuous – Select this if the applicant has a tracheostomy and receives continuous therapy using a CPAP, BIPAP, or AVAPS mode for a 24-hour period.
  • Not continuous – Select this if the applicant has a tracheostomy but does not receive CPAP, BIPAP, or AVAPS continuously. Enter the number of hours per day that therapy is provided.

Section 3 – Respiratory Treatments

Complete the following fields:

Nebulizer:

  • Number of scheduled treatments – Enter the number of scheduled nebulizer treatments the applicant receives in a 24-hour period. If an applicant receives more than one type of scheduled nebulizer treatment, record all types.
  • Number of Pro Re Nata (PRN) treatments in a 14-day period – Enter the number of PRN nebulizer treatments the applicant receives over a 14-day period.  Make sure this number matches the dates provided in the submitted nursing notes.

Supplemental Oxygen (O2) – Select one of the following:

  • Continuous – Select this if the applicant receives supplemental oxygen continuously in a 24-hour period.
  • Not Continuous – Select this if the applicant does not receive continuous oxygen. Enter the number of hours oxygen is used and how often it is required in a 14-day period. If using PRN oxygen, ensure the usage matches the dates in the submitted notes.

Intrapulmonary Percussive Ventilation (IPV) – Enter the number of times the applicant receives IPV therapy in a 24-hour period.

Intermittent Positive Pressure Breathing (IPPB) – Enter the number of times the applicant receives IPPB therapy in a 24-hour period.

Cough Assist – Enter the number of times the applicant uses a cough assist or similar machine in a 24-hour period.

Chest Percussion Therapy (CPT) Manual – Enter the number of times the applicant receives manual CPT in a 24-hour period.

Chest Percussion Therapy (CPT) Vest – Enter the number of times the applicant receives vest CPT in a 24-hour period.

Medication Administration – Select all boxes that apply:

  • Enteral Tube – Select this if the applicant received any amount of long term or routine medication through enteral tube.
  • Intravenous (IV) Therapy – Select this if the applicant received long term or routine IV medication in a home setting. Do not include medications administered through a Port or peripherally inserted central catheter (PICC) here.
  • Injections – Select this if the applicant received any injection such as intramuscular or subcutaneous, in the home setting.
  • Port or Peripherally Inserted Central Catheter (PICC) – Select this if the applicant received long term or routine medication by central venous catheter or PICC in a home setting. Do not select this box if the Port or PICC was accessed only for normal saline or heparin flushes.
Nutrition (Enteral Tube Feed)

Enteral Tube Feed – Select one of the following:

  • Continuous – Select this if the applicant receives enteral tube feeds continuously over a 24-hour period.
  • Not Continuous – Select this if the applicant receives enteral tube feeds at scheduled times. Enter the number of scheduled feeds in a 24-hour period. Use this section to show if the feeds are provided by bolus, pump or both.

Total Parenteral Nutrition (TPN) – Select one of the following:

  • Continuous – Select this if the applicant receives Total Parenteral Nutrition (TPN) continuously over a 24-hour period.
  • Not Continuous – Select this if the applicant does not receive TPN continuously. Enter the number of hours per day the TPN is administered.  If TPN is not administered daily, enter how many days per week it is administered.

Seizures – Enter the number of rescue interventions provided during the 14-day period. The number must match the submitted nursing documentation. Include interventions such as use of a bag-valve-mask ventilation, rescue inhalers, supplemental oxygen, or emergency medications like Diastat.

Pressure Sores or Injuries – Select all boxes that apply:

  • Stage I;
  • Stage II;
  • Stage III;
  • Stage IV; or
  • Unstageable

For each stage checked:

  • Enter the number of pressure sores or injuries at Stage I- IV.
  • Enter the number of unstageable sores or injuries.

Ostomy or Catheter – Check all boxes that apply to the applicant:

  • Foley Catheter
  • Intraosseous Catheterization
  • Nephrostomy
  • Suprapubic Catheter
  • Colostomy
  • Ileostomy

Do not check intermittent I/O catheterization if the applicant has a physician’s order but is not currently receiving catheterization.

Dialysis – Check one of the following and enter the number of treatments per week:

  • Hemodialysis – Select if provided in a home or in an outpatient setting.
  • Peritoneal dialysis – Select no matter who performs the dialysis.

Functional Status – Describe the applicant’s ability to perform activities of daily living. Use information documented in the Medical Necessity and Level of Care (MN/LOC), Section GG, Functional Status.

Check one of the following:

  • Dependent – Select this if MN/LOC Section GG shows the applicant was coded as Dependent for half or more of the activities.
  • Substantial/Maximal Assistance – Select this if MN/LOC Section GG shows the applicant required substantial or maximal assistance for half or more of the activities. If coding is evenly split between the two options, select the more dependent level.

Other Related Information – In this section, provide any clinical information that is not included in other sections of this form. Examples include recent hospital admissions or emergency room visits.  Do not repeat information already entered in other parts of the form.

Section 4 – MCO Medical Director Certification and Signature

The MCO medical director must sign the form to confirm:

  • they reviewed all submitted documentation; and
  • the applicant meets the criteria for the medically fragile group as shown on the form.

Complete the following fields:

  • Printed Name of MCO Medical Director – Enter the full name of the medical director who signed the form.
  • Specialty of Signing MCO Medical Director – Enter the medical specialty of the medical director who signed the form.
  • Signature – MCO medical director must sign here.
  • Date – Enter the date the medical director signed the form.
  • Area Code and Phone No. – Enter the phone number of the MCO medical director who signed the form.