Form 2603, STAR Kids Individual Service Plan (ISP) Narrative

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Effective Date

9/2022
2603.pdf , 2603-S.pdf

Instructions

Updated: 9/2025

Purpose

Form 2603 complements the STAR Kids Screening and Assessment Instrument (SK-SAI) and must be completed by STAR Kids managed care organizations (MCOs) for an individual’s initial, annual, and revision assessments.

Form 2603 must:

  • be completed for Medically Dependent Children Program (MDCP) members and non-MDCP members;
  • be developed through a person-centered planning process;
  • occur with the support of a group of people chosen by the individual or the legally authorized representative (LAR) on the individual's behalf; and
  • accommodate the individual’s style of interaction, communication, and preferences about time and setting.

Use Form 2603 to:

  • document:
    • an individual’s unmet needs;
    • findings from the SK-SAI;
    • 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);
    • preferences for when and how to receive services;
  • develop:
    • a service plan for services received through the STAR Kids MCO;
    • an MDCP service plan that falls within the individual’s allowable cost limit for MDCP;
  • identify:
    • an individual’s strengths, preferences, and unique circumstances;
    • what is important to the individual;
    • natural supports available;
    • needed service system supports; and
    • any special needs, requests, or considerations for the individual.

Procedure

When to Prepare or Update

Complete Form 2603 after administering the SK-SAI assessment. Update Form 2603 at least annually, after administering the SK-SAI reassessment, and after events specified by HHSC. Form 2603 can be updated throughout the ISP year for ISP changes and to document updates such as the individual's medical condition or functional ability, unmet needs, or goals. Examples of ISP changes are any changes to services listed on the ISP and any newly identified need that the member or LAR requested, or service coordinator identified during the ISP period. Document on Form 2603 if an individual or their LAR does not know the information requested or refuses to answer.

Form Retention

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 at least annually in the format requested;
  • provide a copy of the form to providers and others as specified by the individual or their LAR;
  • upload the form to the MCO provider portal following the requirements in Uniform Managed Care Manual Chapter 3.32;
  • complete the form in plain language that is clear to the individual or their LAR, and furnish it in Spanish or languages of other major population groups, if requested.

Detailed Instructions

The MCO must ensure Form 2603 conveys findings from the SK-SAI. Where appropriate, these instructions note which information may be copied from appropriate fields on the SK-SAI.

Get The MCO can use information-gathering conversation, called the discovery process, to gather information and input for the ISP. In line with person-centered planning principles, the service coordinator should do their best to communicate with the individual about their abilities, preferences, and goals. If the individual cannot participate in the discovery process due to age or disability, the service coordinator can supplement with information from the individual’s LAR.

Section I – Individual and Service Coordinator Information

1. Individual Name – Enter the name on Section A, Item 3 of the SK-SAI.

2. Date of Birth – Enter the date of birth on Section A, Item 5 of the SK-SAI.

3. Medicaid No. – Enter the Medicaid number on Section A, Item 13c of the SK-SAI. If the individual does not have a Medicaid number, leave blank.

4. Social Security No. – Only complete this information if the individual does not have a Medicaid number, such as an applicant for MDCP. Enter the Social Security number on Section A, Item 13a of the SK-SAI.

5. Service Coordinator Name – Enter the name of the individual’s named service coordinator. 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 area code and phone number for the individual's named service coordinator. If the individual does not have a named service coordinator, enter the phone number of the service coordinator helping 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 is required for both MDCP and non-MDCP members.

9. ISP End Date – Enter the end date of the ISP. This is required for both MDCP and non-MDCP members.

10. ISP Revision Date – If this ISP is a revision, enter the date the ISP was revised, . If this is an individual’s first ISP, enter the date the ISP was created.

Section II – Medical Information

Diagnoses and Conditions – Enter information from 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’s name and type, frequency of provider visits, and provider contact information for the individual’s specialist providers. Include all current specialists that are significant to the individual’s care.

Medical Referrals – Enter information from Section Q, Items 8 through 10 of the SK-SAI, if applicable. Enter the provider’s name and 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, interests, and what the individual likes to do in their free time.

3. Community-based Activities – Ask about the community activities the individual participates in.

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 or Transition Planning – Enter information, 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 what helps the individual stay healthy and remain safe in the community.

9. Things that Could Be Working Better or Barriers – Enter the barriers to receive 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 and notes.

12. Current Medical Supplies – Enter information from Section D, Item 21 of the SK-SAI, if applicable. Provide the product type, resupply frequency, such as daily, weekly, monthly or annually, and concerns or notes.

Section IV – Service Planning Considerations

1. Medicaid State Plan Services – Check the box for Medicaid state plan services the individual receives or is approved to receive. Include the service or item type, provider type such as home health agency or registered nurse, rationale for 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) used in the ECI program to Form 2603, if available.

2. MDCP Services – Check the box for MDCP services the individual receives or is approved to receive, including service or item type, provider, rationale 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. This item is only applicable to MDCP members and applicants. If the individual is not in MDCP, leave this item 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 – Explain a health home before asking the individual or LAR about the individual’s use of, or interest in, a health home. Check the appropriate box. Health home is defined in Texas Government Code Section 540.0851(a).

4. Value-added Services – Enter the value-added services the individual receives or is approved to receive. This includes service type, begin and end date, and other service details.

5. Non-capitated Medicaid Services – Enter the non-capitated services the individual receives, including the waiver or program name, service type, hours per week, if applicable, and begin and end date. Refer to STAR Kids Contract Section 8.1.24.8 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 item 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. Educational Services – Enter services the individual receives 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. Only share the IEP with the MCO if the individual or LAR gives their permission. If the family does choose to share the IEP with the MCO, attach the IEP to Form 2603.

7. Non-Medicaid State Program Services – Enter services the individual receives through state programs other than Medicaid, including the program name, service type, hours per week, if applicable, and the begin or end date. Examples include the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) and Supplemental Nutrition Assistance Program (SNAP).

8. Informal or 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 or end date. Include informal supports that are most important to the member. Enter information from Sections B and G of the SK-SAI, if applicable.

9. Is the individual or LAR interested in additional resources to become more involved in the community? – Check the appropriate box. Under Service Type Detail, enter potential referrals to community organizations and resources. Examples include volunteer opportunities at a local food bank and 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 or Needed

Record the services the individual is requesting or needs authorization for 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 the individual has completed. Enter the name of the screening or assessment, the assessor’s name, and assessment date. Examples include a speech therapy evaluation and Child and Adolescent Needs and Strengths (CANS) assessment.

Section VIII – Follow-up Items or Assessment Needs

Record any more follow-up screenings or assessments the member needs. Enter the name of the item, screening, or assessment, and the responsible party or entity completing it. Examples include a speech therapy evaluation and 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 8.1.38.6. Enter the date of the next scheduled contact, method of contact such as phone, email, in-person or mail, and annual reassessment date, and any other comments. Use the comments box to record any request to reduce or refuse service coordination, including if the member or LAR refuses to participate in the assessment or discovery process.

Section X – Signatures and Approval

Inform the individual or LAR about their rights and responsibilities, as described in this section. Ask the individual or LAR if 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 – Individual or 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 shows the service coordinator developed the ISP based on needs and in collaboration with the individual or LAR, and that they reviewed the rights and responsibilities.