PURPOSE

This form is used by STAR+PLUS Support Unit (SPSU) staff to:

• record information on a managed care waiver applicant pertinent to the nursing assessment and the development of the individual service plan (ISP);
• authorize the pre-enrollment home health assessment of a managed care waiver applicant by the managed care organization (MCO);
• provide verification of qualifying institutional stays for the Money Follows the Person Demonstration (MFPD) to the MCO; and
• authorize payment to the MCO for the assessment.

This form is used by the health plan nurse or other MCO staff person completing the assessment for the MCO to:

• document results of the assessment; and
• report assessment results to the SPSU.

After functional eligibility is met, this form is used by Medicaid Eligibility for the Elderly and People with Disabilities (MEPD) staff to provide financial eligibility documentation to the SPSU.

PROCEDURE

When to Prepare

SPSU staff prepare Section A., Referral/Assessment Authorization, to request the MCO assessment.

Upon receipt of Form 3676-MC, the MCO must date stamp the form. The health plan nurse completes Section B., Waiver Assessment Report, and returns the form to the SPSU within 45 days of the date specified in Item 15 or by date agreed upon.

SPSU staff complete Section C., Eligibility Factors, after receiving the completed MN and LOC assessment and the ISP attachments, Form 3671-1 and Forms 3671-2, as appropriate, from the MCO.

Section D., Financial Eligibility, is completed by MEPD staff.

Copies/Transmittal

After completion of Section A.:

• send the original to the authorized MCO; and
• keep a copy in the case folder.

After Section B. is completed and returned, SPSU staff complete Section C. and:

• send the original to MEPD; and
• keep a copy in the case record.

Record Retention

SPSU staff must keep all originals of this form on file for five years after services are terminated. The provider must keep copies of the completed forms in the consumer's case record three years after case closure. The interim copies of this form (for example, the copy retained by SPSU staff pending the completion of the health plan assessment by the MCO) do not need to be retained after the receipt of the completed form.

Supply Source

This form may be found on the DADS and HHSC websites.

DETAILED INSTRUCTIONS

Check the appropriate box to indicate whether the individual is entering managed care as:

• a Supplemental Security Income (SSI) Money Follows the Person (MFP) community transfer;
• a Medical Assistance Only (MAO) Money Follows the Person (MFP) community transfer;
• an MFP individual whose Medicaid status is pending;
• a release from the interest list;
• transfer from the Medically Dependent Children Program (MDCP) or the Comprehensive Care Program (CCP); or
• as a transfer from a specific type program/base plan.

Section A. — Referral/Assessment Authorization

Managed care Support Unit staff complete Items 1 through 25.

1. Applicant's Name — Enter the applicant's name as shown in the System for Applications, Verifications, Eligibility Reports and Referral/Texas Integrated Eligibility Redesign System (SAVERR/TIERS) records, if this information is available.

2. Date of Birth — Enter the applicant's date of birth.

3. Social Security No. — Enter the applicant's Social Security number.

4. Medicaid No. — Enter the applicant's Medicaid number as shown on the SAVERR records, if available.

5. EDG No. (if in TIERS) — For cases worked in TIERS, enter the individual's Eligibility Determination Group (EDG) number.

6. Medicare No. — Enter the applicant's Medicare number.

7. RUG — Enter the applicant's Resource Utilization Group (RUG) value.

8. TPRs (if any) — Enter the name of any non-Medicare third-party resource (TPR), such as private insurance (for example, Blue Cross) that may be used by the MCO to provide services for the applicant.

9. Current Living Address — Enter the home address of the applicant, including city and ZIP code.

10. Area Code and Telephone No. — Enter the area code and telephone number of the applicant.

11. Current Location of Applicant — Check the box indicating the current location of the applicant.

12. Name and Telephone No. of Contact Other Than Applicant — Enter the name of a contact person at the applicant's current location (for example, the name of the nursing facility social worker or the daughter with whom the applicant lives). If the applicant should be contacted directly or lives alone and there is no other authorized or interested party to contact, enter "same" in this box.

13. Living Arrangement if Enrolled in Waiver — Check the box for the applicant's expected living arrangement if enrolled in the managed care waiver program.

14. Home Address if Enrolled in Managed Care Waiver Program — Enter the address (including city and ZIP code) and telephone number of the applicant's current location. If the information is the same as the home address entered in Item 9 and the telephone number entered in Item 10, enter "same" in this box.

15. Date Form 3676-MC Posted — Enter the date the form is being completed.

16. Health Plan Selected — Enter the name of the health plan selected by the consumer, if applicable.

17. MCO Vendor No. — Enter the vendor number for the selected MCO, if applicable.

18. Health Plan Contact's Name — Enter the name of the contact at the selected MCO agency.

19. Contact's Area Code and Telephone No. — Enter the area code and telephone number of the contact documented in Item 18.

20. MFPD 90-Day Qualifying Dates — Enter the dates the individual has resided in an institutional setting, including ongoing stays. Enter “ongoing” in the end date field if the individual is still in the facility. Qualifying facilities include nursing facilities, intermediate care facilities serving persons with mental retardation or a related condition (including state supported living centers), hospitals or state hospitals.

21a. Relocation Referral Made — Check Yes or No to indicate that a relocation referral was made.

21b. Relocation Specialist — Enter the name of the relocation specialist if a referral was made in Item 21a.

22a. Area Code and Telephone No. — Enter the relocation specialist's area code and telephone number if a referral was made in Item 21a.

22b. Fax Area Code and Telephone No. — Enter the relocation specialist's fax area code and telephone number if a referral was made in Item 21a.

23. Signature – Support Unit Staff — The managed care Support Unit staff member signs this form to authorize the MCO to perform the pre-enrollment home health assessment. An electronic signature is acceptable.

24. Date — Enter the date Section A. was completed by managed care staff.

25. Area Code and Telephone No. — Enter the SPSU staff member's area code and telephone number.

Section B. — Waiver Assessment Report

The MCO completes Items 26 through 36.

26. Date of Assessment — Enter the date the consumer was assessed for managed care waiver services.

27. Form 3671-1 Entered — Check Yes or No to indicate if Form 3671-1, Individual Service Plan, is completed and attached.

28. Fax Area Code and Telephone No. — Enter the fax area code and telephone number of the individual who completed Form 3671-1.

29. Comments — Enter any relevant comments regarding the consumer's nursing needs.

30. Risk Criteria Met — Check Yes or No to indicate if the individual meets risk assessment as measured by Form 2333, Nursing Facility Risk Criteria Scoring Form.

31. Medical Necessity Approved — Check Yes or No to indicate if the individual has an approved medical necessity.

32. MFP Demo Participant? — Check Yes or No to indicate if the individual is an MFP demonstration project participant.

33. Signature — The health plan contact signs in the space provided.

34. Date — The health plan contact enters the date the form is signed.

35. Contact's Name — Print the name of the health plan contact.

36. Area Code and Telephone No. — Enter the health plan provider's area code and telephone number.

Section C. — Eligibility Factors

STAR+PLUS Support Unit staff complete Items 37-41 after receiving this form and the ISP attachments from the MCO.

37. ISP approved — Check Yes or No.

38. Risk Criteria Met — Check Yes or No.

39. Approved MN/LOC — Check Yes or No.

40. Date Sent to MEPD — Enter the date the form is being sent to MEPD.

41. Support Unit Staff Name — Enter the name of the person sending the information to MEPD.

Section D. — Financial Eligibility

MEPD staff complete Items 42 through 47 and return the form to the managed care Support Unit.

42. Date Received by MEPD — Enter the date the form is received by MEPD.

43. MEPD Staff BJN — Enter the budgeted job number of the MEPD staff person who receives the form.

44. Financial Eligibility Completed — Check Yes or No to indicate if financial eligibility was completed. If Yes is selected, enter the medical effective date of 14/13 coverage. If No is selected, enter the denial date and the denial code.

45. Area Code and Telephone No. — The MEPD staff person completing Section D. enters his area code and telephone number.

46. Completed By Signature — The MEPD staff person completing Section D. signs the form.

47. Date — The MEPD staff person completing Section D. enters the date.

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