Form 8578-CFC, Intellectual Disability/Related Condition Assessment for CFC

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Documents

Effective Date: 7/2016

Instructions

Updated: 7/2016

Purpose

Form 8578-CFC is limited to the Community First Choice (CFC) Non-Waiver Eligibility. Apply the general Form 8578, Intellectual Disability/Related Conditions Assessment (ID/RC), to document information for applicants applying for, or individuals enrolled in, an Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions (ICF/IID), or one of the Intellectual/Developmental Disability (IDD) Waiver Programs (i.e., Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Home and Community-based Services (HCS) or Texas Home Living (TxHmL)).

Form 8578-CFC is used by a Local Intellectual and Developmental Disabilities Authority (LIDDA) to document information needed to:

  • recommend an ICF/IID level of care (LOC); and
  • demonstrate compliance with federal utilization review requirements.

Procedure

When to Prepare

Form 8578-CFC is completed with information obtained from the applicant or an interested party on behalf of the applicant when requesting an assessment of LOC for CFC. After an individual has an approved LOC for CFC services, this form is completed for each additional LOC action (i.e., annual reassessments or changes).

Transmittal

Certain information from each completed Form 8578-CFC is entered into the Texas Health and Human Services Commission (HHSC) automated Client Assignment and Registration (CARE) System by a representative from the individual’s LIDDA and is transmitted to the Utilization Management and Review (UMR) CFC Non-Waiver Eligibility unit for review.

Form Retention

The submitting LIDDA must maintain the original of each Form 8578-CFC transmitted and originals of all other applicable forms for six years. The transmitting LIDDA must retain copies for three years past an individual’s 18th birthday, even if the retention period exceeds the normal requirement of six years.

Source of Forms and Information Regarding the ID/RC Assessment

Detailed Instructions

Refer to the following tables describing the fields as displayed on the form.

General Information

Item NameContent
1. Local Intellectual and Developmental Disabilities Authority (LIDDA) NameEnter the legal name of the LIDDA completing the form.
2. LIDDA Component CodeEnter the LIDDA’s component code.
3. LIDDA Mailing AddressEnter the LIDDA mailing address.
80. Managed Care Organization (MCO) or Department of State Health Services (DSHS) NameEnter the name of the MCO chosen by the individual for CFC services or name of DSHS.
81. MCO Component CodeEnter the component code associated with the MCO chosen by the individual for CFC services. If DSHS, leave this field blank.
82. Plan CodeEnter the MCO plan associated with the individual’s county of residence. If DSHS, enter 17.
4. Individual’s Name (Last/First/Middle)Enter the individual's last name, first name and middle name or initial.
10. Individual’s Date of BirthEnter the individual's date of birth in MM-DD-YYYY format.
5. Individual's AddressEnter the individual's current mailing address, including street or P.O. Box, city, state and ZIP code.
11. Social Security No.Enter the individual's nine-digit Social Security number.
8. Medicaid No.Enter the individual's Medicaid number, if known.
73. Client Assignment and Registration (CARE) IDEnter the individual's CARE identification number.

Diagnosis

Item NameContents
19. Primary DiagnosisEnter the individual's current primary diagnosis as determined by a licensed physician or an “authorized provider”, as defined in Health and Safety Code (Sec. 593.004). A primary diagnosis is the condition chiefly responsible for the request for CFC Non-Waiver eligibility.
20. CodeEnter the code of primary diagnosis listed in the International Classification of Diseases (ICD). This code must match the primary diagnosis entered in field 19.
21. Version CodeEnter the ICD version code used for the individual's primary diagnosis.
22. OnsetEnter the onset month and year of the individual's disabling condition current primary diagnosis.
23. Medical Diagnosis/ Second ConditionEnter the medical diagnosis or second condition, as determined by a licensed physician.
24. CodeEnter the diagnostic code matching population in field 23.
25. Version CodeEnter the ICD version code used for the individual's current medical diagnosis or second condition.
26. Psychiatric Diagnosis/ Additional ConditionEnter psychiatric diagnosis or additional condition, as determined by a licensed physician or an "authorized provider", as defined in Health and Safety Code (Sec. 593.004).
27. CodeEnter the diagnostic code matching population in field 26.
28. Version CodeEnter the Diagnostic and Statistical Manual of Mental Disorders (DSM) version used for the individual's psychiatric diagnosis or additional condition.

Cognitive/Adaptive Functioning

Item NameContents
29. Intelligence Quotient (IQ)Enter the individual’s current IQ score, if obtainable. If IQ cannot be ascertained for an individual because of the severity of the disability (such as profound intellectual disability), enter 019.
68. IQ InstrumentEnter the code associated with the IQ instrument used:
01 = Wechsler Intelligence Scale for Children (WISC)
02 = Wechsler Adult Intelligence Scale (WAIS)
03 = Wechsler Preschool and Primary Scale of Intelligence (WPPSI)
04 = Stanford-Binet form LM (S-B LM)
05 = Cattell Intelligence Test Scale
06 = Peabody Picture Vocabulary Test (PPVT)
07 = Beta
08 = Other
09 = WISC (Revised)
10 = WAIS (Revised)
11 = PPVT (Revised)
12 = Slosson Intelligence Test (SIT)
13 = Leiter International Performance Scale (LIPS)
14 = WISC III
15 = WAIS III
16 = LIPS-Revised
17 = S-B 4th
18 = S-B 5th
19 = WISC IV
20 = SIT-Revised
30. ABLEnter the appropriate adaptive behavior level (ABL) code for the individual:
0 = No deficit in adaptive skills
1 = "Mild" deficit in adaptive skills
2 = "Moderate" deficit in adaptive skills
3 = "Severe" deficit in adaptive skills
4 = "Profound" deficit in adaptive skills
69. ABL Instrument and Score

Select the ABL instrument used as follows:

  • Enter an “X” if the instrument was:
    • Vineland,
    • Vineland ABL Standard Score, or
    • Vineland Adaptive Behavior Scales, Second Edition (Vineland-II)
  • Enter the Inventory for Client and Agency Planning (ICAP) service score if ICAP was used.
  • Enter the Scales of Independent Behavior — Revised (SIB-R) RMI score if SIB-R was used.
  • Enter an “X” if other standardized ABL assessment was used.
70. ABL Assessment DateEnter the date the ABL assessment was conducted.
75. Related Conditions Eligibility Screening Instrument
(Required if primary diagnosis is a related condition)		The population in this field must correspond with the total number of Yes responses in Section 4 A.-F on Form 8662, Related Conditions Eligibility Screening Instrument. This field is required for all individuals with a primary diagnosis of a related condition.
13. Purpose Code

Enter the appropriate purpose code associated with the reason for the submission:

  • Purpose Code 2 — Initial Assessment
  • Purpose Code 3 — Annual Reassessment (Renewal)
  • Purpose Code 4 — Off-cycle Reassessment (Change)
  • Purpose Code 5 — MCO Plan Code or LIDDA Change
17. Recommended Level of Care (LOC)

Enter the LOC recommended by the LIDDA:

  • LOC 0 — (enter a zero if recommending LOC denial)
  • LOC I
  • LOC VIII

LIDDA Certification — By signing the form, the representative is certifying that, to the best of the individual’s knowledge, all information on the form is true and that the information represents the individual’s assessment information as currently documented in the record. If the primary diagnosis is a related condition, the representative also certifies that a physician has attested to the primary diagnosis and onset, and the physician’s attestation is documented in the LIDDA's records.

Item NameContents
56. Signature of LIDDA RepresentativeThe LIDDA representative signs the form.
57. Print Full Name of LIDDA RepresentativeEnter the printed full name of the LIDDA representative who signed the form.
58. DateEnter the date the LIDDA representative signature is rendered.

LIDDA Comments — The LIDDA representative provides any additional information or comments not captured in any of the designated fields. 

Requested Begin/End Dates

Item NameContents
59. Begin DateEnter the requested begin date of the LOC recommendation.
60. End DateThis field is auto-populated by the electronic system.
Individual’s NameEnter the individual’s name.
Medicaid No.Enter the individual’s Medicaid number.

For Departmental Use Only

Item NameContents
61. Authorized LOC

HHSC CFC staff must indicate the authorized LOC as follows:

  • LOC 0 — (only used when denying LOC);
  • LOC I; or
  • LOC VIII.
62. Meets Functional / Diagnostic Eligibility

Check all programs for which the individual qualifies:

  • Community First Choice (CFC)
  • Community Living Assistance and Support Services (CLASS)
  • Deaf Blind with Multiple Disabilities (DBMD)
  • Home and Community-based Services (HCS)
  • Texas Home Living (TxHmL)
63. Effective DateEnter the LOC effective date.
64. End DateThis field is auto-populated by the electronic system.
65. Name of ReviewerEnter the name of the HHSC CFC Reviewer.
66. Date ReviewedThis field is auto-populated by the electronic system.

Reviewer Comments — The HHSC CFC reviewer provides any additional information or comments not captured in any of the designated fields.