Form 1680, Texas Money Follows the Person Demonstration Grant (MFPD) Request for Reimbursement

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Documents

Effective Date: 9/2023

Instructions

Purpose

Form 1680 is used by the local intellectual and developmental disability authority (LIDDA) for requesting reimbursement of Enhanced Community Coordination (ECC) or Transition Support Team (TST) expenses from the Money Follows the Person Demonstration (MFPD) Grant funds that have been allocated to their LIDDA. All LIDDAs will complete the form for ECC. Only the eight contracted LIDDAs will complete an additional form for TST. LIDDAs must submit Form 1680 on or before the 15th day of the following month in which the expenses occurred. Should a LIDDA have zero expenses for reimbursement, Form 1680 must still be completed and submitted.

Before Entering Information on the Form

Before entering information on the form, you must: 

  • rename the file using "save as"; 
  • use the title “MFP (ECC or TST) Monthly Request for Reimbursement for (Month) – (Name of LIDDA)”; 
  • close the file; and 
  • open the renamed file. 

Detailed Instructions

Money Follows the Person Demonstration Program — Select the MFPD program from the drop-down menu.

Type of Submission — Select the type of submission from the drop-down menu:

  • Original- the initial submission for the Service Month and Year.
  • Revision- corrections to the Original submission.
  • Supplemental- additional costs incurred for a Service Month and Year that were not captured or paid in the Original submission.

Date — Enter the date the form is completed. 

LIDDA Name — Enter the LIDDA name.

Component Code — Enter the LIDDA component code.

Area Code and Phone No. — Enter the phone number of the LIDDA. 

Street Address — Enter the LIDDA’s official business street address.

City — Enter the city of the LIDDA’s official business street address. 

Zip — Enter the zip code of the LIDDA’s official business street address. 

Service Month and Year — Enter the month and year the service was provided.

Contact Person — Enter the name of the LIDDA staff to contact regarding this form.

Area Code and Phone No. — Enter the phone number for the person listed as the Contact Person. 

Budget Categories — These are the approved budget categories for MFPD and are represented on both the ECC and TST Contractor Forms. These are the only categories that can be used, and all expenses must be in the category as justified in the narrative and approved by HHSC/CMS on the Contractor Forms. 

Budget Balance Beginning of Service Month — For each Budget Category, enter the remaining balance for the beginning of the Service Month. This is done by deducting submitted calendar year expenses for each prior month from the total allocated amount to each Budget Category.  Please enter zero (0), if applicable. Do not leave any budget categories blank.

Example: Personnel expense submissions for Jan- March:

Budget CategoryCost Jan.Feb.Mar.
Personnel$36,000 $3,000$3,000$3,000
  • $36,000 is the allocated amount, Cost, on the approved Contractor Form for Budget Category Personnel.
  • $3,000+ $3,000+ $3,000= $9,000, the total amount submitted for reimbursement by the LIDDA for previous months of the calendar year for Budget Category Personnel.
  • $36,000-$9,000= $27,000, the Budget Balance Beginning of Service Month for Personnel entered for April’s service month.  

Enter the category balance for the beginning of the Service Month for:

  • Personnel
  • Fringe Benefits 
  • Travel 
  • Supplies 
  • Subrecipients 
  • Other Direct Costs 
  • Indirect Costs 

Requested Reimbursement — For each Budget Category, enter the amount the LIDDA is requesting for the Service Month. Please enter zero (0), if applicable. Do not leave any budget categories blank. Requests for amounts should not exceed the current remaining balance. An ECC or TST Contractor Form budget revision is required prior to exceeding any Budget Category allocation. Email IDDMFPSupport@hhs.texas.gov for more information. 

Enter the amount the LIDDA is requesting for the Service Month for:

  • Personnel
  • Fringe Benefits 
  • Travel — The requested reimbursement amount for travel on this form should match the amount on the Travel Log for the same Service Month.
  • Supplies 
  • Subrecipients 
  • Other Direct Costs 
  • Indirect Costs — Indirect Cost expenses are limited to no more than 10% of the total program budget. If the amount exceeds the approved amount from the LIDDA’s Contractor Form, it will not be reimbursed.

Total Requested Reimbursement  — The form auto-calculates the total.

Supporting Documentation — By checking the box, the LIDDA is confirming that the following required documentation has been completed and is ready for submission according to documentation instructions.

Financial Officer’s Name — Enter the name of the financial officer who is attesting to the financial information provided in the columns Budget Balance Beginning of Service Month and Requested Reimbursement.

Financial Officer’s Signature — The person identified in Financial Officer’s Name signs the form. 

Date — Enter the date the financial officer signs the form. 

Form Submission — 

  • For Original Submissions: submit this form to IDD Performance Contracts SFTP site with the title “MFP (ECC or TST) Monthly Request for Reimbursement for (Month) – (Name of LIDDA).”
     
  • For Revisions and Supplementals: Submit this form to IDDPerformance.Contracts@hhsc.state.tx.us with the title “MFP (ECC or TST) Monthly Request for Reimbursement for (Month) (Revision or Supplemental)– (Name of LIDDA).”  

Note: If a secure email is needed, an email request for a secure email can be made to the same address.

Questions —