Form 3608, Individual Plan of Care (IPC) HCS and CFC

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Documents

Effective Date: 10/2024

Instructions

Updated: 10/2024

Note: A person in this form refers to an individual as defined in 26 Texas Administrative Code (TAC) Section 263.3.

Purpose

Texas Health and Human Services Commission (HHSC) staff, Home and Community-based Services (HCS) waiver program providers and Local Intellectual and Developmental Disabilities Authorities (LIDDAs) use Form 3608 to document a person’s HCS, non-HCS and Community First Choice (CFC) services.

Procedure

When to Prepare

The IPC is developed during the IPC meeting by:

  • the service planning team (SPT), which consists of the person or legally authorized representative (LAR), the service coordinator (SC) and anyone invited by the person or LAR; and
  • the program provider.

In most cases, an IPC meeting is necessary to develop the IPC. An IPC meeting occurs when the SPT and program provider meet in person, by videoconference or by phone to review the person’s person-directed plan (PDP) and discuss and identify necessary units of HCS, CFC and non-HCS or CFC services to support PDP outcomes. The IPC is developed at the following events:

  • Enrollment – The LIDDA completes the initial IPC. The LIDDA staff develops the proposed initial IPC after developing the person’s PDP. After a person has chosen a program provider, the LIDDA SC, the person or LAR and the program provider meet to negotiate and finalize the initial IPC.
  • Renewal – The program provider completes an annual IPC renewal  before the current IPC expires. The program provider and the SPT meet to develop the annual IPC renewal based on the PDP.
  • Transfer – The SC develops a transfer IPC when a person changes HCS contract or chooses a different service delivery option, such as when Consumer Directed Services (CDS) is added or removed as a service delivery option. The SPT and the receiving program provider hold an IPC meeting to develop a transfer IPC.
  • Revision – The program provider completes an IPC revision. There are four types of IPC revisions:
    • Revision to reflect PDP change – This type of IPC revision is used when adding or deleting an HCS or CFC service, or when increasing or decreasing an existing service that requires a new PDP outcome. Both situations require the SPT and the program provider to meet to revise the IPC.
    • Revision to increase or decrease an existing HCS or CFC service – This type of IPC revision is used when the increase or decrease of the existing HCS service is associated with an existing outcome in the current PDP. This situation does not require the SPT and the program provider to meet.
    • Revision to add or change a requisition fee only – This type of IPC revision is used when only a dental, adaptive aid or minor home modification requisition fee is added or changed on a person’s IPC. This situation does not require the SPT and the program provider to meet nor does it require the program provider to obtain agreement from the person, LAR or SC.
    • Revision to change CFC support management – This type of  revision is used when CFC support management is added or changed on a person’s IPC. The effective date of the IPC remains the same and this change is not entered into the HHSC data system. All other types of revisions must be entered into the HHSC data system.

Notes:

  • CDS – If a person only uses the CDS option and does not have a program provider, the LIDDA must make sure self-directed HCS or CFC services are included on the IPC any time an IPC is completed.
  • For more information about revisions and IPC meetings, see the IPC section of the HCS Handbook.

Transmittal/Submission

The program provider enters the completed renewal and revision IPCs and the SC enters the completed initial IPC in the HHSC data system per the instructions in the IPC section of the HCS Handbook. If a person only uses the CDS option and does not have a program provider, the LIDDA enters the IPC into the HHSC data system.

For an IPC revision for the emergency provision of services, the program provider faxes the hard copy of the completed Form 3608 to HHSC Intellectual and Developmental Disability (IDD) Utilization Review with documentation of:

  • the circumstances that required providing the new HCS or CFC service or the increase in the amount of the existing HCS or CFC service, and
  • the type and amount of the service provided in response to the emergency.

Form Retention

The program provider and SC must maintain a copy of the completed Form 3608 in the person’s record.

Questions

To learn about Form 3608 or instructions related to an initial (enrollment) or transfer IPC, call the HHSC IDD Program Eligibility and Support message line at 512-438-2484.

To learn about Form 3608 or instructions related to a revision or renewal IPC, call the HHSC IDD Waivers Utilization and Review message line at 512-438-5055.

Detailed Instructions

With the exception of "Estimated Annual Totals (for all services)," Form 3608 must be completed before entering the IPC information into the HHSC data system.

Page 1

Client Identifying Information

Name of Person  — Enter the person’s last name, first name and middle initial.

Medicaid No. — Enter the person’s Medicaid number.

IPC Begin Date — Enter the date the IPC year began or will begin. This is the 12-month period that starts on the date an initial or renewal IPC begins. A revised or transfer IPC does not change the begin or end date of an IPC year.

IPC End Date — Enter the date the IPC year ends, which is 365 days following the IPC begin date or 366 days during a leap year. A program provider may view the HHSC data system to determine a person’s current IPC end date.

IPC Effective Date — Enter the IPC effective date as described below.

  • Initial (Enrollment) – The IPC effective date is the same as the IPC begin date. The IPC meeting must be on or before the IPC effective date.
  • Renewal – The IPC effective date is the same as the IPC begin date. The IPC meeting must be on or before the IPC effective date.
  • Transfer: Contract or Service Delivery Option – The IPC effective date is the date the person will begin receiving services from the receiving program provider. The IPC meeting must be on or before the IPC effective date.
  • Revision to Reflect PDP Change – The IPC effective date must be on or after the date of the IPC meeting.

Special circumstances about the IPC effective date for an IPC revision are noted below:

  • Residential setting change: If the IPC revision is because of a person changing residential type, the IPC effective date must be the date the person begins receiving the new residential service type. The IPC meeting must be on or before the IPC effective date.
  • Emergency provision of services: If the need for the revision meets the criteria for an emergency provision of services per 26 Texas Administrative Code (TAC) Section 263.302(d), the IPC effective date is the date the emergency service was provided.
  • Revision to increase or decrease an existing HCS or CFC service – The IPC effective date must be on or after the date the program provider notifies the SC of the revision.
  • Revision to add or change requisition fee only – The IPC effective date is the date the program provider completes Form 3608.

Address — Enter the person’s address including the street, city, state, and ZIP code.

Date of Birth — Enter the person’s date of birth.

Age — Enter the person’s age.

Level of Need — Enter the person’s currently authorized level of need.

If the person is receiving any HCS or CFC services delivered by a program provider, enter the following information about the program provider:

  • Program Provider — Enter the name of the program provider.
  • Program Provider Vendor No. — Enter the program provider's four-digit vendor number.
  • Program Provider Contract No. — Enter the contract number for the program provider.

If the person is receiving any HCS or CFC services delivered through the CDS option, enter the following information about the Financial Management Services Agency (FMSA):

  • Financial Management Services Agency (FMSA) — Enter the name of the FMSA. The FMSA is responsible for managing the costs for services provided under the CDS option.
  • FMSA Vendor No. — Enter the FMSA's four-digit vendor no.
  • FMSA Contract No. — Enter the contract number for the FMSA.

Residential Type — Mark the appropriate box to indicate the residential type for the person.

Location Code — Enter the location code the program provider has assigned the person. The location code is OHFH for a person who has a residential type of own home/family home.

County of Service — Enter the name of the county where the person resides.

IPC Type

Check the IPC type that describes the reason for completing Form 3608.

Initial (Enrollment) – IPC meeting required.

Renewal – IPC meeting required.

Transfer: Contract or Service Delivery Option – IPC meeting required.

Revision to Reflect Person-Directed Plan (PDP) Change – IPC meeting required.

If the need for the revision meets the criteria for an emergency provision of services per 26 TAC Section 263.302(d), the provider also checks the Meets Emergency Criteria Section 263.302(d) box.

Revision to add or change requisition fee only – No IPC meeting is required.

Revision to change CFC support management – No IPC meeting is required, but all parties must sign the IPC.

Revision to increase or decrease an existing service – No IPC meeting is required. If this box is checked, the provider states the reason for the increase or decrease.

Non-HCS or CFC Services Provided by Family and Other Funding Sources

Type of Service — Enter a brief description of the services the person is receiving or will receive.

Funding Source — Enter the name of the funding source for the service.

No. of Hours Per Day — Enter the number of hours per day the person participates or will participate in the service.

No. of Days Per Week — Enter the number of days per week the person participates or will participate in the service.

Name of Provider — Enter the name of the person or agency providing the service.

Page 2

HCS Services

Note: Licensed vocational nursing, registered nursing, specialized registered nursing and specialized licensed vocational nursing are the only HCS services that can be delivered through the provider agency option and CDS option at the same time. If a person is receiving nursing services from an HCS provider and through the CDS option, enter the nursing amount requested to be provided by the provider in Provider Services and the nursing service requested to be provided through the CDS Option in Consumer Directed Service (CDS).

Provider Service or Consumer Directed Service (CDS) — Self-explanatory.

I or D — For any revisions to increase or decrease an existing HCS service, enter I for the service component that is being increased or D for the service component that is being decreased.

Authorized Units — Enter the requested amount of each provider service or service provided under the CDS option for the IPC year. For an IPC revision or transfer IPC, enter the total number of units already provided and those units to be provided in the future.

Authorized Dollars — Enter the requested dollar amount of each service provided through the CDS option for the IPC year. Multiply the authorized units by the rate of the applicable service for the dollar amount. For an IPC revision, enter the sum of dollar amounts already provided and dollar amounts to be provided in the future.

Are any services determined critical and require a service back-up plan? — Mark Yes or No.

Are any services staffed by a relative or guardian? — Mark Yes or No to indicate if any HCS or CFC services, including services provided through the CDS option, are provided by the person’s relative or guardian.

Page 3

CFC Services

Will the person receive CFC Support Management? — A person may request CFC support management from the HCS program provider or FMSA. Mark Yes if the person’s PDP indicates CFC support management or No if the person’s PDP does not indicate CFC support management.

If revision or change to add CFC Support Management, enter date— If it is an IPC revision to change or add CFC Support Management, enter the date when CFC support management was changed or added. An IPC revision to add CFC support management would not be electronically transmitted to HHSC for authorization. The addition of CFC support management would only be reflected on the hard copy Form 3608.

CFC Provider Service or CFC CDS Service — Self-explanatory.

I or D — For any revisions to increase or decrease an existing CFC service, enter either I for the service component that is being increased or D for the service component that is being decreased.

Authorized Units — Enter the requested amount of each program CFC service to be provided by the HCS program provider or CFC service provided under the CDS option for the IPC year. For an IPC revision or transfer IPC, enter the sum of units already provided and those units to be provided in the future.

Authorized Dollars — Enter the requested dollar amount of each CFC service provided under the CDS option for the IPC year. Multiply the authorized units by the rate of service for the dollar amount. For an IPC revision, enter the sum of dollar amounts already provided and dollar amounts to be provided in the future.

For Certifications Completed During Enrollment and Renewals

Person or LAR was informed upon enrollment of the person’s rights and responsibilities. — The SC checks this box only during an enrollment if the person or LAR, upon enrollment, was informed of the person’s rights and responsibilities.

Person or LAR was informed upon enrollment of the process for filing a complaint and reporting allegation of abuse, neglect or exploitation. — The SC checks this box only during an enrollment if the person or LAR, upon enrollment, was informed of the process for filing a complaint and reporting allegation of abuse, neglect or exploitation.

Person or LAR was informed upon enrollment and annually of the person’s option to transfer to other program providers as chosen by the person as often as desired. — The SC checks this box during enrollment and the program provider checks the box during renewals if the person or LAR was informed of the person’s option to transfer to other program providers as chosen by the person as often as desired.

HCS Program Provider and Person or Legally Authorized Representative (LAR) Signature

Printed Name — Enter the printed name of the program provider representative who is signing the IPC.

Signature – Program Provider Representative — The program provider representative who attended the IPC meeting signs the form.

For an IPC revision that increases or decreases an existing HCS or CFC service and does not require an IPC meeting, enter the name of the provider representative who obtained agreement from the person or LAR.

For an IPC revision that adds or changes a requisition fee only or CFC support management, enter the name of the program provider representative who completed the form.

Date — Enter the date the program provider representative attended the IPC meeting and signed the IPC.

For an IPC revision that increases or decreases an existing HCS or CFC service and does not require an IPC meeting, enter the date the program provider representative obtained agreement from the person or LAR.

For an IPC revision that adds or changes a requisition fee only or CFC support management, enter the date the form was completed.

Printed Name — Enter the printed name of the person or LAR who signed the IPC.

* For an IPC revision that adds or changes a requisition fee only, the printed name of the person or LAR is not entered.

Signature – Person or LAR — The person must sign unless there is an LAR, in which case the LAR's signature is required.

The exception is for an IPC revision that adds or changes a requisition fee only, in which case the program provider enters requisition fee only. *

Date — Enter the date the person or LAR signed the IPC.

* For an IPC revision that adds or changes a requisition fee only, enter the IPC effective date.

Person or LAR participated by phone on: — Check this box if the person or LAR participated and agreed by phone. Enter date of participation or agreement.

* (1) If the person or LAR participates in person and agrees with the IPC, the person or LAR signs, prints their name and enters the date of the IPC meeting. If the person agrees by phone, the program provider checks the appropriate box and enters the date of agreement. The program provider then copies the form and sends it to the person or LAR for signature. (2) For an IPC revision that adds or changes a requisition fee only, the provider does not need to obtain agreement from the person or LAR and enters requisition fee only on the person’s signature line.

HHSC Review and Authorization if required

Signature – HHSC Authorized Representative — The HHSC authorized representative signs the form should a utilization review be conducted.

Date — The HHSC authorized representative enters the date the IPC utilization review was completed by the HHSC authorized representative.

Page 4

Local Intellectual and Developmental Disability Authority or Service Coordinator (SC) Response to IPC Revision to increase or decrease an existing HCS or CFC Service, IPC Participation and Signature

Local Intellectual and Developmental Disability Authority Name — Enter the name of the LIDDA providing service coordination.

Service Coordinator Response to IPC Revision to Increase or Decrease an Existing HCS or CFC Service

The SC completes this section only if a program provider notes on Page 1 under IPC Type that the IPC revision is to increase or decrease an existing HCS or CFC service and will not require an IPC meeting. In these cases, the SC must respond by completing this section and returning the completed Form 3608 to the program provider.

SC agrees with the IPC revision and no IPC meeting is required. — If the SC agrees that the proposed IPC revision does not require an IPC meeting, the SC checks the first box and signs and prints their name, then returns the completed Form 3608 to the program provider within two business days after the program provider sent it to the SC.

SC determines an IPC meeting is needed. — If the SC determines further discussion is necessary, the SC contacts the provider as soon as possible to discuss concerns. If no consensus can be reached after this discussion, the SC checks the box indicating an IPC meeting is needed, includes a reason an IPC meeting is needed. The SC signs and prints their name and returns the completed Form 3608 to the program provider within two business days after the program provider sent the form to the SC. The SC schedules this IPC meeting to occur as soon as possible, but no later than 14 calendar days after the program provider notifies the SC of the need for a revision.

There may be reasons an SC believes an IPC meeting is needed, including:

  • the SC believes the revision may necessitate a PDP update;
  • the program provider did not give a reason for a change of services;
  • the person or LAR or other SPT member requested a meeting; or
  • the SC has reason to believe the revision is not following the person’s or LAR's wishes.

At the IPC meeting scheduled by the SC, the program provider and the SPT complete a new Form 3608. For the IPC type, the provider checks Revision to Reflect PDP Change. The IPC effective date must be on or after the IPC meeting date.

Service Coordinator IPC Participation

Check the appropriate box to indicate how the SC participated in the IPC meeting as described below:

Service Coordinator was notified — For an IPC revision that increases or decreases an existing HCS or CFC service and does not require an IPC meeting, the program provider checks the Service Coordinator was notified box. The program provider prints the SC's name on the Service Coordinator’s Name line and enters the date this form was submitted to the SC. Submission of this form to the SC serves as notification of an IPC revision that does not require an IPC meeting.

Note: The program provider may notify the SC of the revision before receiving the person’s or LAR's signature.

Service Coordinator participated in the IPC meeting in person — When the SC participates in an IPC meeting in person, the SC checks the Service Coordinator participated in the IPC meeting in person box, prints and signs their name and enters the date of the meeting.

Service Coordinator participated in the IPC meeting by phone — When the SC participates in the IPC meeting by phone or videoconference, the program provider checks the Service Coordinator participated in the IPC meeting by phone box. The program provider prints the SC’s name, writes participated by phone or videoconference on the SC signature line and enters the date of the meeting.

No Service Coordinator participation required — For an IPC revision that adds or changes a requisition fee only, the program provider checks the No Service Coordinator participation required box. The program provider enters requisition fee only in the SC signature line and enters the IPC effective date as the signature date.

Signature – Service Coordinator — The SC that attended the IPC meeting signs the form.

Printed Name — Enter the name of the SC who signed the IPC.

Date — Enter the date the SC signed the IPC.

Refer to the IPC Section 6000 of the HCS Handbook to review required actions following completion of this form.