TX HHS Form 1025. Request for Information Medicare Advantage Coordination

Form 1025, titled Request for Information – Medicare Advantage Coordination, is an official Texas Health and Human Services Commission (HHSC) document used to verify community-based services received by an individual. The form plays a coordination role between HHSC, managed care plans, service providers, and relocation coordinators when an individual is receiving, resuming, or transitioning community services, including cases involving nursing facilities.

This form is most often used in the context of Medicaid programs and Medicare Advantage coordination, particularly when determining eligibility, continuity of care, or service reinstatement.

Purpose of the Form

The primary purpose of Form 1025 is to formally confirm which HHSC community services an individual currently receives or is eligible to resume. It serves as a verification tool to support care coordination, especially during transitions between institutional care and community-based services.

The form is commonly required when:

• An individual moves from a nursing facility back into the community
• Service delivery needs to be confirmed for a managed care plan
• HHSC staff must verify active or prior community services
• Multiple agencies are coordinating benefits and care plans

Who Can Complete and Submit Form 1025

Form 1025 may be completed and signed by an authorized requestor, such as:

• HHSC staff members
• Service coordinators or relocation coordinators
• Managed care plan representatives
• Authorized agency staff involved in service delivery

The individual receiving services does not typically complete this form themselves.

Explanation of Key Sections

Individual and Service Information

This section identifies the individual whose services are being verified. It includes the person’s name, Medicaid number, Social Security number, date of birth, address, county, and contact details. Accurate identification is critical to avoid delays or incorrect service determinations.

Community Services Selection

The form lists multiple HHSC community programs. The requestor must check all services currently received or relevant to the request, such as:

• Medically Dependent Children Program (MDCP)
• Primary Home Care (PHC)
• Community Attendant Services (CAS)
• Family Care (FC)
• Home Delivered Meals (HDM)
• Emergency Response Services (ERS)
• Special Services to Persons with Disabilities (SSPD)
• Adult Foster Care (AFC)
• Assisted Living / Residential Care (AL/RC)
• STAR+PLUS services

Managed Care and Provider Details

If the individual is enrolled in STAR+PLUS or receives services through a Home and Community Support Services Agency (HCSSA), this section captures plan names, agency names, and contact phone numbers to support inter-agency communication.

Nursing Facility Transition Request

This portion is used when an individual is currently in a nursing facility but requests to resume community services. It supports relocation and transition planning under HHSC guidelines.

Signatures and Verification

The requestor must sign and date the form. HHSC staff complete the response portion, confirming verified services and providing official validation.

Legal and Regulatory Context

Form 1025 is governed by Texas Medicaid and HHSC administrative rules related to community-based services, managed care coordination, and transitions from institutional settings. Verification of services is required to ensure compliance with state and federal Medicaid regulations and to prevent duplication or interruption of benefits.

Without proper verification, services may be delayed, denied, or incorrectly authorized.

Practical Tips for Completing the Form

• Double-check Medicaid and Social Security numbers for accuracy
• Clearly mark all applicable services to avoid incomplete verification
• Include correct contact information for plans and agencies
• Ensure all required signatures are provided before submission

Common Mistakes to Avoid

• Leaving service checkboxes blank or incomplete
• Using outdated agency or plan contact information
• Missing signatures or dates
• Submitting the form without confirming current service status

Real-Life Use Scenarios

• An individual leaving a nursing facility needs confirmation of community services before discharge
• A STAR+PLUS plan requests verification of services for care coordination
• An HHSC relocation coordinator confirms eligibility for resumed home-based services

Documents Commonly Attached

• Care transition or relocation documentation
• Managed care plan correspondence
• Service authorization records

Frequently Asked Questions

When is Form 1025 required?

It is required when HHSC or a managed care plan needs official verification of community services.

Is this form used by individuals directly?

No, it is completed by authorized staff or coordinators.

Does the form approve services?

No, it verifies existing or prior services for coordination purposes.

Is Form 1025 required for STAR+PLUS members?

Yes, when service verification is needed as part of care coordination.

Can the form be faxed?

Yes, fax information is included for official submission.

Micro-FAQ

• Purpose: Verify HHSC community services.
• Who files: Authorized HHSC or agency staff.
• Deadline: As required for coordination or transition.
• Attachments: Service or transition records.
• Submitted to: Texas HHSC.

Related Forms

• HHSC STAR+PLUS Service Authorization Forms
• Community Services Eligibility Forms
• Nursing Facility Transition Documentation

Form Details

• Form Name: Request for Information – Medicare Advantage Coordination
• Form Number: 1025
• Issued By: Texas Health and Human Services Commission (HHSC)
• Region: Texas
• Revision Date: June 2011