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Documents
Instructions
Updated: 2/2012
Procedure
In the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Waiver Programs, Form 3611, Involuntary Termination of Consumer Directed Services (CDS) Individual Plan of Care (IPC) Cover Sheet, must be completed when approval of involuntary termination from the CDS option is requested from the Texas Health and Human Services Commission (HHSC), Access and Intake, Utilization Management and Review, IDD Waivers Program Enrollment/Utilization Review (PE/UR). This must be done when requesting an individual's involuntary termination from the CDS option.
Detailed Instructions
The local authority staff will complete all the information on Form 3611 and submit to HHSC for review, along with justifications for this action (as per 40 Texas Administrative Code §41.407). A description of justifications is included on the cover sheet.
Program Type (check one) — Mark the appropriate box to indicate the type of program.
Indicate IPC Request (Refer to 40 Texas Administrative Code (TAC) §41.407 for expanded reasons) — Mark the appropriate box to indicate the reason for requesting termination of CDS.
Provider Contact Information
Provider Name — Enter the name of the program provider.
Provider Contact — Enter the name of the person who will act as the contact for the program provider.
Fax Area Code and Telephone No. — Enter the fax area code and telephone number for the person who will act as the contact for the program provider.
Area Code and Telephone No. — Enter the area code and telephone number for the person who will act as the contact for the program provider.
Component Code — Enter the program provider component number.
Contract No. — Enter the contract number for the program provider.
LA Contact Information
LA Name— Enter the name of the LA.
LA Contact — Enter the name of the person who will act as the contact for the LA. The LA contact should be someone who can answer questions about the action being requested.
LA Fax Area Code and Telephone No. — Enter the fax area code and telephone number for the person who will act as the contact for the LA.
LA Area Code and Telephone No. — Enter the area code and telephone number of the person who will act as the contact for the LA.
Individual Information
Individual Name (Last) — Enter the individual's last name.
Individual Name (First) — Enter the individual's first name.
CARE ID No. — Enter the individual's Client Assignment and REgistration (CARE) system identification number.
Medicaid No. — Enter the individual's Medicaid number.
Date of Birth — Enter the individual's date of birth.
Age — Enter the individual's age.
IPC Begin Date — Enter the date the IPC began.
IPC Effective Date — Enter the effective date of the IPC to be reviewed (for renewals, this is the IPC begin date; for revisions and transfers, it is the revision date).
Legally Authorized Representative (LAR) contact information, if applicable. If no LAR, list individual's information — Enter the name, area code and telephone number, as well as the street address, city, state and ZIP Code of the LAR, if there is one. If there is no LAR, enter the individual's information.
Does any correspondence sent to the LAR or individual need to be translated to another language? — Mark the appropriate box and indicate the language needed if other than English.
LA Action
The service coordinator will:
- document the need for the action;
- secure the service planning team members' signatures;
- submit a packet to HHSC Utilization Management and Review, IDD Waivers PE/UR that includes:
- Form 3611, Involuntary Termination of CDS IPC Cover Sheet;
- a copy of the signed IPC indicating the action;
- documentation of the discussion during the service planning team meeting justifying the action; and
- all additional supporting documentation; and
- ensure the IPC reflecting the action is entered in the CARE system.
IDD Waivers PE/UR Action
HHSC IDD Waivers PE/UR will:
- review the documentation submitted by the service coordinator;
- request additional information from the service coordinator, if necessary;
- authorize or not authorize the requested action;
- check the appropriate box regarding the outcome of the review and sign on the line indicated; and
- fax the LA and provider a copy of Form 3611, Involuntary Termination of CDS IPC Cover Sheet, upon completion of the review, along with a copy of the IPC indicating services authorized by the IDD Waivers PE/UR reviewer.
If termination of the CDS option is approved, a certified letter will be mailed to the individual/LAR informing them of their opportunity for a fair hearing.