Where can more information be found about the Intellectual Disability and Related Condition (ID/RC) Assessment?
Form 8578, Intellectual Disability/Related Condition Assessment, and instructions can be found in the Health and Human Services Commission (HHSC) forms website.
Where can I check on an individual's Level of Need (LON) status? (HCS, TxHmL and ICF/IID only)
After registering an individual in the CARE system, check the following for any Level of Care (LOC)/LON history:
- CARE Screen C68 — Home and Community-based Services (HCS) and Texas Home Living (TxHmL) ID/RC Assessments — Summary HCS; or
- TMHP Form Status Inquiry (FSI) – Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Condition (ICF/IID) ID/RC Assessment
What do some of the various items in the ID/RC mean?
Item #13 — Purpose Code
- Purpose Code 2: Initial/new enrollment means that there is no current ID/RC, or for ICF/IID, the individual has been out of an ICF/IID for more than 180 days.
- Purpose Code 3: Renewal of LOC/LON (may be the same LON or changed). A LON change submitted on a Purpose Code 3 may affect the provider's ability to bill until the LON review is completed. A Purpose Code 3 is valid for 365 days, once approved.
- Purpose Code 4: For HCS, TxHmL and ICF/IID only. Change LON. The date of the data entry of the Purpose Code 4 is the effective date of the requested LON change. The expiration date will remain the same as the current Purpose Code 3 expiration date.
- Purpose Code E: For ICF/IID only. Covers a gap in LOC/LON. Check the 1168 (ICF/IID) or C68 (HCS, TxHmL) screen to see the gap dates. A LON increase will not be authorized on a Purpose Code E.
Item #17 — Level of Care
- The LOC is a determination of eligibility for an individual in either the Medicaid waiver or ICF/IID programs and is determined by the individual’s Primary Diagnosis, IQ score, and Adaptive Behavior Level (ABL). The LOC for individuals with a primary diagnosis of intellectual disability will be LOC I. The LOC for individuals with a primary diagnosis of a related condition will be either LOC I or LOC VIII.
- CLASS and DBMD do consider IQ scores in LOC determination. CLASS and DBMD may only indicate LOC VIII for waiver eligibility or LOC 0 for denial of LOC.
|IQ||<75||N / A|
|ABL||I, II, III, IV||II, III, or IV|
|ABL||II, III, or IV|
Item #19 — Primary Diagnosis
- CLASS and DBMD: Always use the appropriate related condition diagnosis for the individual’s “Primary Diagnosis.”
- HCS, TxHmL and ICF/IID: Always use the diagnosis of intellectual disability (ID) or the appropriate related condition diagnosis for the individual's "Primary Diagnosis."
- ID diagnoses are as follows:
- F70 Mild ID
- F71 Moderate ID
- F72 Severe ID
- F73 Profound ID
- F79 ID, severity unspecified
- ID diagnoses are as follows:
- To be considered a related condition, the individual must have an acceptable diagnosis listed on the International Classification of Diseases (ICD-10-CM) that has been approved by HHSC (PDF format).
Item #33 — Inventory for Client and Agency Planning (ICAP) Service Level (HCS, TxHmL and ICF/IID only)
- The ICAP Service Level, Item #33, must match the requested LON, Item #18, unless a request for a LON increase for medical or behavioral reasons is made. Use the chart below to calculate the LON.
|LON||Service Level||Service Score|
|5||4, 5, 6||40-69|
|1||7, 8, 9||> 70|
- If a CLASS DSA or DBMD program provider uses the ICAP to determine Adaptive Behavior Level (ABL) and LOC, item #33, must match the requested ABL, item #30. Use the chart below for ICAP conversion to ABL. CLASS and DBMD eligible ABLs are II, III, and IV.
|Service Level||Adaptive Behavior Level|
4, 5, 6
7, 8, 9
Items #35 - #40 — Level of Need (HCS, TxHmL and ICF/IID only)
- All initial LON assignments during enrollment (PC2) require that supporting documentation be submitted to Program Enrollment Support (PES) for review. For LOC/LON Annual Renewals (PC3): Anytime the LON is different from the last authorized LON, a packet of supporting documentation Form 8603, Level of Need (LON) Review/Increase Cover Sheet must be submitted to Utilization Review (UR).
- If the requested LON (PC3 or PC4) is different from the straight calculated LON from the ICAP score due to behavioral status (ID/RC Assessment item numbers 35—38 are scored with at least 1 (for one “bump” above the ICAP score) or 2 (for an LON 9 request regardless of ICAP score), then supporting documentation must be submitted.
- Any time Item #s 35—38 on the ID/RC has a one, and a behavior increase has not been authorized for the previous ID/RC, a behavior increase LON packet containing the appropriate documentation must be submitted unless the individual has been previously authorized by ICAP as a LON 6 for the preceding year.
- If the requested LON is a 9 (any of Item #s 35-38 have a 2), and a LON 9 was not authorized on the previous ID/RC, then supporting documentation (LON 9 packet) must be submitted.
- If a medical increase is requested (PC3 or PC4), the ID/RC must be marked on Item #40 as a “6” and a packet must be submitted to UR.
- The supporting documentation must be received by UR within seven calendar days of electronic submission of the ID/RC assessment (per the Texas Administrative Code). If no supporting documentation is received within this time period, HHSC will electronically notify the provider that the LON request will not be processed, and the LON assigned will be derived from the previously authorized ICAP Service Level. This will be communicated to the provider electronically in the CARE system.
- Transfers do not require that a new ID/RC assessment be submitted unless the LON changes or the LOC has expired.
Item #48-55 — Physician Evaluation and Recommendation (ICF/IID only)
- A physician evaluation and recommendation are required for all ICF/IID and ID/RCs, except for Purpose Code 4.
- The physician's license number must be verifiable through the Texas Medical Board website (http://www.tmb.state.tx.us/).
- The physician's signature date for Purpose Code 3 must be not more than 60 days before the requested effective date.