Effective Date
Instructions
Updated 9/2025
Purpose
Use this form to document the STAR+PLUS Home and Community Based Services (HCBS) program benefits provided to the applicant or member and to establish the medical need and rationale for all items or services included on Form H1700-1, Individual Service Plan. The service coordinator also documents on Form H1700-2 all other resources and supports, available and projected, that the applicant or member will use during the individual service plan (ISP) period.
Procedure
When to Prepare
The managed care organization (MCO) service coordinator completes Form H1700-2, or an alternate form of documentation that includes the same information. Form H1700-2 documents all other resources and supports, available and projected, that the applicant or member will use during the individual service plan (ISP) period. Form H1700-2 is completed at the initial assessment, reassessment or for a change in condition.
Form Retention
The managed care organization (MCO) must keep a copy of Form H1700-2 or any alternate document in the member's case record per the retention requirements found in all Medicaid managed care contracts and federal regulations. Provide a copy of Form H1700-2 to the applicant or member on request. After service termination, the MCO must keep all originals and electronic copies of Form H1700-2 in the member's case record for five years.
Detailed Instructions
Individual Service Plan Dates — MCO staff enter the begin and end date of the ISP using mm/dd/yyyy format. For initial assessments, the MCO must use the ISP dates listed on Form H2065-D, Notification of Managed Care Program Services, received from HHSC Program Support Unit (PSU) staff.
Revision Date — Enter the date the ISP was revised if any changes were made during the ISP period. This line is left blank during the initial assessment and annual reassessment.
Applicant or Member Name — Enter the name of the applicant or member.
Medicaid ID No. or Applicant Social Security No. — Enter the applicant's or member's Medicaid number or Social Security number if a Medicaid number is not available.
Section 1 – Medical Information
Describe why the STAR+PLUS HCBS program item or service is necessary and how it benefits the applicant or member:
Item or Service — Enter the STAR+PLUS HCBS program item or service requested on the ISP by the applicant or member or identified as a need by the service coordinator. Each item or service should be entered on a separate line. More lines may be added, if needed.
Rationale — Enter specific information detailing why the requested STAR+PLUS HCBS program item or service is necessary and exactly how it will benefit the individual medically, functionally or in terms of rehabilitation. The rationale should demonstrate how the member meets waiver eligibility of having an unmet need for waiver services. For paid attendant care, include any nursing tasks or health maintenance activities that have been delegated to the attendant.
Section 2 – Payors
A. Medicare and Other Payors – include Medicare, VA, TRICARE, private insurance and other payors — Enter the following information for each non-Medicaid payor listed.
Resource — Enter the name of the non-Medicaid payor providing services to the applicant or member during the ISP period.
Policy No. — Enter the policy number, if available.
Service Type and Detail — Enter the service provided. Document specific detail of what is included in the service.
Units or Hours per Week — Enter the units or hours per week the service is provided.
Not Applicable Box — Check the Not Applicable box if the applicant or member does not receive services from Medicare or other payors.
B. Medicaid State Plan Services – include Medicaid Home Health, DAHS, and CFC — Enter the following information for each state plan service listed.
Resource — Enter the name of the state plan service to be provided to the applicant or member during the ISP period.
Service Type and Detail — Enter the service provided. Document specific detail of what is included in the service. For paid attendant care, include any nursing tasks or health maintenance activities that were delegated to the attendant.
Units or Hours per Week — Enter the units or hours per week the service is provided.
Not Applicable Box — Check the Not Applicable box if the applicant or member does not receive any Medicaid State Plan Services.
C. Services Provided in an Educational Setting — Enter the information for services provided in an educational setting.
Resource — Enter the name of the educational facility that provides services to the applicant or member during the ISP period.
Service Type and Detail — Enter the service provided. Document specific detail of what is included in the service and the beginning and end date of the service. The dates must be within the From and To dates as documented on Form H1700-1, Individual Service Plan. Enter Unknown for an unknown begin date.
Units or Hours per Week — Enter units or hours per week the service is provided.
Not Applicable Box — Check the Not Applicable box if the applicant or member does not receive services in an educational setting.
D. Value-added Services — Enter the following information if it is anticipated the applicant or member will use MCO Value-added Services (VAS) during the ISP period. Include only waiver benefits offered as VAS items or services such as dental services, emergency response services, respite or home-delivered meals. VAS are not required to be used before waiver service. VAS vary by MCO. The service coordinator is responsible for knowing the VAS applicable for the applicant or member.
Service Type and Detail — Enter the service provided. Document specific detail of what is included in the service.
Units or Hours per Week — Enter units or hours per week the service will be provided.
Not Applicable Box — Check the Not Applicable box if the applicant or member does not receive VAS.
E. Additional Follow-up — Enter any other follow-up referral or assessments needed. A referral can be generated for a specific service or item such as:
- physical therapy, personal care service or durable medical equipment (DME); or
- for an assessment for a service such as a referral for a behavioral health assessment to determine specific services an individual may need.
Item or Service — Enter any other identified item or service the applicant or member was assessed as needing but does not have a current authorization.
Action — Enter the action steps needed for the item or service to be authorized and the party or entity responsible for completing the follow-up or assessment. If no action is needed, enter No action required. Document the reason why.
Not Applicable Box — Check the Not Applicable box if the applicant or member does not have any other follow-up needs.
Section 3 – Follow-up Schedule
Enter the information for the applicant’s or member’s follow-up schedule.
Service Coordinator follow-up schedule — Enter the service coordinator’s plan to follow up and communicate with the applicant or member during the ISP period.
Section 4 – Service Coordinator Comments if Applicable
The service coordinator can provide additional documentation of the applicant’s or member's needs from Section 3 - Follow-up Schedule section in this section. Any other needs and how the needs are met may also be listed. Enter comments relevant to the applicant’s or member’s medical or functional status not documented elsewhere.