TX HHS Form 1024. Individual Status Summary

Form 1024, titled Individual Status Summary, is an official Texas Health and Human Services document used to justify situations where an individual’s services exceed established cost limits under certain Medicaid waiver programs. The form must be completed by a Registered Nurse (RN) and plays a critical role in documenting health, safety, and service necessity considerations for individuals receiving long-term services and supports.

This form is typically required when an Individual Service Plan (ISP) or Individual Plan of Care (IPC) goes beyond the standard cost cap and additional justification is needed to continue services in the community rather than in an institutional setting.

Purpose and When This Form Is Required

Form 1024 is used to explain why an individual’s projected cost of services exceeds program limits and why those services remain medically and socially necessary. It helps state agencies evaluate whether continued community-based care is appropriate and compliant with Medicaid waiver requirements.

The form is usually required when:

• The ISP or IPC exceeds the program’s cost limit.
• Specialized services are required due to complex medical or safety needs.
• Community-based care is being maintained instead of placement in a nursing facility or state-supported living center.

If services remain within cost limits, Form 1024 is generally not required.

Programs Covered by Form 1024

This form applies to individuals enrolled in the following Texas Medicaid waiver and managed care programs:

• Home and Community-based Services (HCS)
• Texas Home Living (TxHmL)
• Community Living Assistance and Support Services (CLASS)
• Deaf Blind with Multiple Disabilities (DBMD)
• STAR+PLUS Home and Community Based Services (HCBS)

Who Must Complete the Form

Form 1024 must be completed by a Registered Nurse (RN). The RN provides clinical and functional justification for services, based on direct knowledge of the individual’s condition and care needs.

The form also involves coordination with:

• IDD Waiver Program Provider Representatives
• LIDDA Service Coordinators
• Managed Care Organization (MCO) Service Coordinators
• STAR+PLUS MCO Medical Directors (authorization section)

Section-by-Section Explanation

Individual and Program Information

This section captures identifying details such as name, Medicaid number, date of birth, service area, program enrollment, cost limit, and projected cost of services. Accuracy here is essential to ensure the form is associated with the correct individual and waiver program.

Provider and Coordinator Details

Contact information for the IDD Waiver Program Provider, LIDDA Service Coordinator, and MCO Service Coordinator is required. These parties are involved in planning, oversight, and authorization of services.

Health and Safety Questions

This core section explains:

• Which specific services are causing the cost limit to be exceeded.
• Why these services are medically or functionally necessary.
• Which services cannot be provided in a nursing facility or state-supported living center.
• Whether community resources or informal supports are available and being used.
• Why alternative programs or living arrangements were considered but not utilized.

Legally Authorized Representative (LAR)

If the individual cannot make decisions independently, this section documents whether a legally authorized representative exists and what steps are being taken if one has not yet been appointed.

Backup and Permanency Planning

For individuals enrolled in 1915(c) waivers, the form requires a contingency plan if the primary caregiver becomes unavailable. This helps ensure continuity of care and protects the individual’s health and safety.

Additional Information and Signatures

The RN may include any relevant information not captured elsewhere. The form must be signed by the RN and, when applicable, by the authorizing STAR+PLUS MCO Medical Director.

Common Mistakes to Avoid

• Providing vague explanations instead of specific service-related justifications.
• Failing to explain why services cannot be provided in an institutional setting.
• Leaving sections about community resources or alternative options incomplete.
• Missing RN signature or medical director authorization.

Practical Tips for Completing Form 1024

• Use clear, concise language when explaining medical or safety needs.
• Link each high-cost service directly to a documented health or functional requirement.
• Coordinate with service coordinators to ensure consistency with the ISP or IPC.
• Attach supporting documentation if referenced in explanations.

Real-Life Examples of When This Form Is Used

• An individual with complex medical needs requires specialized nursing services that exceed the HCS cost limit.
• A TxHmL participant needs additional behavioral supports to remain safely in the community.
• A caregiver becomes unavailable, and expanded services are required while a permanency plan is implemented.

Documents Commonly Attached

• Individual Service Plan (ISP) or Individual Plan of Care (IPC)
• Clinical assessments or nursing notes
• Documentation of explored alternative services or placements
• Legal paperwork supporting LAR status, if applicable

Frequently Asked Questions

When is Form 1024 required?

It is required when an individual’s services exceed the cost limit under an applicable waiver or managed care program.

Who completes and signs the form?

A Registered Nurse completes and signs the form, with authorization from the MCO Medical Director when required.

Is this form used for all Medicaid programs?

No, it applies only to specific Texas waiver and STAR+PLUS programs.

Does exceeding the cost limit automatically result in denial?

No, the form provides justification for continued services when properly documented.

Are alternative services required to be explored?

Yes, the form requires documentation of alternative programs, resources, and living arrangements.

Micro-FAQ

• Purpose: Justifies services exceeding cost limits.
• Who files: Registered Nurse.
• Programs: HCS, TxHmL, CLASS, DBMD, STAR+PLUS HCBS.
• Attachments: ISP, IPC, clinical documentation.
• Authorization: RN and MCO Medical Director.

Related Forms

• Individual Service Plan (ISP)
• Individual Plan of Care (IPC)
• Medicaid Waiver Program Applications
• LAR Designation Forms

Form Details

• Form Name: Individual Status Summary
• Form Number: 1024
• State: Texas
• Programs: Medicaid Waiver and STAR+PLUS
• Revision Date: October 2024