TX HHS Form H2060. Needs Assessment Questionnaire and Task/Hour Guide

This article explains Form H2060 — Needs Assessment Questionnaire and Task/Hour Guide in plain, practical language. The form is a structured assessment used by Medicaid waiver programs and home- and community-based services systems to measure an applicant’s functional needs and to calculate attendant care, personal assistance, and related service hours. The goal of this guide is to help service coordinators, providers, caregivers and applicants understand each section, avoid common mistakes and complete the assessment accurately so the applicant receives appropriately authorized services.

Purpose and When This Form Is Used

Form H2060 documents the applicant’s ability to perform daily living tasks (bathing, dressing, feeding, toileting, mobility, meal preparation, cleaning, shopping, etc.) and converts those needs into minutes/hours of authorized care. Programs use the completed form to establish priority status, compute Aid & Attendance (A&A) offsets where applicable, and set the weekly authorization for attendant or personal assistance services. Typically a case manager, MCO service coordinator or qualified assessor completes the form during an in-person or telehealth assessment.

Regulatory and Program Context

This assessment is governed by Medicaid program rules, waiver manuals, and state-specific guidance for home- and community-based services. It translates clinical and functional findings into service authorization that aligns with program limits (hour caps, allowable tasks, companion case rules). Requirements—such as who may perform the assessment, documentation standards, rounding rules for minutes, and supervisory approval for exceptions—are defined by the administering state agency or managed care organization (MCO). Always check the current program handbook or agency instructions for your state or plan before finalizing the assessment.

How the Form Is Structured

Form H2060 is divided into three main parts and several calculation and signature sections:

• Part A — Functional Assessment: records impairment scores and flags priority factors.
• Part B — Task/Hour Guide: captures minutes-per-day and days-per-week to calculate minutes per week for each task.
• Part C — Task/Minute and Subtask Guide: provides minute ranges and subtasks by impairment level to justify the time allocated.
• A&A Calculations and Totals: converts Aid & Attendance monetary values to hours and computes final total authorization.
• Signatures and Comments: assessor initials, supervisor approval, and space for clinical notes or variance explanations.

Section-by-Section Explanation

Applicant Identification and Header

This top section records the applicant’s name, Medicaid ID, assessment date and case identifiers. Verify all identifiers—errors here can delay processing.

Part A — Functional Assessment

Part A lists activities of daily living (ADLs) and instrumental ADLs (IADLs) and asks the assessor to code impairment severity (0–3). Priority factors are usually bolded; these help determine eligibility priority. Score honestly based on observation, caregiver report and medical information. If a score is inconsistent with observations, document the reasons.

Part B — Task/Hour Guide

For each task the assessor enters minutes per day and number of days per week, then multiplies to obtain total minutes per week. Common tasks include bathing, dressing, feeding, grooming, toileting, transfers, walking, meal prep, cleaning, laundry, escort, and shopping. Remember to round minutes to 5-minute increments as the instructions require, and to convert total minutes into hours for authorization.

Part C — Task/Minute and Subtask Guide

Part C provides the allowable minute ranges per task for each impairment level and lists subtasks (for example, “laying out supplies,” “standby assistance,” “total assistance”). Use this guide to support why a particular minute value was chosen—check every applicable subtask to justify time requested, especially for minutes outside standard ranges.

Aid & Attendance (A&A) and Deductions

If the applicant receives Aid & Attendance or another monetary offset, the form includes conversion steps: monthly amount → weekly amount → hours to be subtracted from authorized attendant hours. Record calculations clearly and show them on the page indicated; discrepancies here are a frequent source of audit findings.

Totals, Rounding and Limits

The form instructs rounding rules (round up to next five minutes, convert to half-hour units when converting to hours, and apply program caps such as a maximum weekly hour limit). If the authorization is to be less than a minimum threshold, the assessor must document rationale. Supervisory approval is required for exceptions.

Who Should Complete the Form

• Trained service coordinators, case managers or authorized assessors employed by the Medicaid program, MCO, or provider agency.
• Assessments should be based on direct observation and corroborated with medical records, caregiver reports and physician input where appropriate.
• Family members and informal caregivers can provide information but should not be the sole source for impairment scoring without professional oversight.

Common Errors and How to Avoid Them

• Mis-identifying the applicant: double-check Medicaid ID and name to avoid processing delays.
• Under-documenting subtasks: if you request minutes outside standard ranges, list specific subtasks and why they are needed.
• Incorrect rounding: always round to the next 5-minute increment and then convert minutes to hours per the form instructions.
• Failing to account for companion cases: household tasks shared by multiple residents must use companion ranges and be justified.
• Omitting A&A calculations: show conversions and how you derived A&A hours to avoid reconciliation issues later.

Practical Tips for Accurate Completion

• Perform an in-person assessment whenever possible; observational data is more reliable than self-report alone.
• Use the subtask checklist in Part C to itemize exactly what the attendant will do—this supports the time allocation.
• Document environmental factors (stairs, distance to store, lack of in-home appliances) that justify additional minutes.
• Save copies of the completed form and all supporting documents in the location specified on the form (service delivery records).
• If requesting minutes beyond guideline maximums, include supervisory sign-off and a succinct clinical justification.

Real-Life Examples

• Example 1 — Post-hospital recovery: An older adult recently discharged after hip surgery needs total assistance with transfers and dressing for six weeks. The assessor documents high impairment scores on Transfer and Dressing, selects appropriate subtasks (hands-on assistance, positioning), and assigns time based on the maximum range for impairment score 3.
• Example 2 — Companion household: Two roommates share household tasks; one is the applicant and the other a companion. Cleaning and meal prep minutes use companion ranges; the assessor documents which tasks the companion performs and which require purchased attendant time.
• Example 3 — Cognitive impairment impact: An applicant with short-term memory impairment requires standby assistance for medication and meal reminders. The assessor codes Memory Impairment and includes subtasks for medication prompting and supervision, converting minutes to weekly totals accordingly.

Documents and Evidence to Attach

• Medical records or physician statements supporting functional limitations.
• Recent hospital discharge summaries, therapy notes or durable medical equipment orders.
• Medication lists and caregiver statements describing daily needs.
• Proof of residence details if property layout affects service needs (e.g., stairs, remote location).
• Documentation of Aid & Attendance amounts when applicable.

What Happens After Submission

The completed form is reviewed by the service coordinator’s supervisor and by the authorization unit of the administering agency or MCO. The review verifies calculations, confirms that requested minutes fall within program policy or have proper justification, and issues an approved weekly authorization. If the assessor requests unusual minutes, expect additional review and possible requests for clarification.

Frequently Asked Questions (Extended)

Who can sign and certify this assessment?

A trained service coordinator or qualified assessor designated by the Medicaid program or MCO should sign. Supervisory signatures may be required for variances or exceptions.

How are minutes converted to authorized hours?

Total minutes per week are divided by 60 and rounded up to the next half-hour unit per program instructions; then program caps and any A&A deductions are applied.

Can tube feeding be authorized through this form?

Many programs exclude tube feeding from purchased personal assistance on this form—if tube feeding is present, document the reason and follow program-specific clinical guidance for whether other services (e.g., skilled nursing) are appropriate.

What is a companion case and how does it change calculations?

A companion case occurs when more than one eligible person lives in the same household. Shared household tasks use companion minute ranges; document which tasks are shared and how time is apportioned.

How do I request minutes beyond the guideline maximum?

Provide a clear clinical justification, list all relevant subtasks, document environmental or caregiver limitations, and obtain supervisory approval as required by the program.

Is an in-person visit always required?

Policies vary. In-person assessments are preferred for accuracy, but some programs permit telephonic or telehealth assessments under defined circumstances; follow current agency directives.

Who is responsible for keeping service delivery records?

The provider or authorized legal entity is generally required to maintain service delivery records at the location listed on the form. Keep records available for audits or quality reviews.

Micro-FAQ (Ultra-short Answers for Quick Reference)

• Purpose: Determine functional needs and authorize attendant/personal assistance hours.
• Who files: Assessor/service coordinator on behalf of the applicant.
• When used: For Medicaid waiver and home-based service authorizations and re-evaluations.
• Attachments needed: Medical records, A&A documentation, caregiver statements when applicable.
• Rounding rule: Round minutes to the next five-minute increment.
• A&A effect: Convert A&A monthly amount to weekly hours to subtract from authorization.
• Companion case: Use companion minute ranges for shared household tasks.
• Max limits: Program caps apply; document reasons for exceptions.
• Who approves exceptions: Supervisor or authorization unit as defined by the program.
• Record keeping: Keep signed form and supporting documents at service records location.

Related Forms and Resources

• Care plan and service authorization form used by the administering MCO or state agency
• Medical certification or physician’s orders supporting functional limitations
• Aid & Attendance documentation and benefit statements
• Provider service delivery record templates and timesheets
• Re-evaluation or reassessment request forms

Final Notes and Recommendations

Complete Form H2060 with careful documentation: use Part C subtasks to justify requested time, apply correct rounding rules, and show A&A calculations when relevant. When in doubt, consult the program handbook or authorization unit for the administering Medicaid program or MCO—procedures and allowable minutes can vary by state and waiver type. Maintain copies of all supporting records in the location specified on the form and obtain required supervisory approvals for exceptions.

Form Details

• Form Name: Needs Assessment Questionnaire and Task/Hour Guide
• Form Number: H2060
• Program Use: Medicaid waiver and home- and community-based service assessments (state-administered)
• Edition / Date on Form: November 2014-E