Form 3621, CLASS or CFC — Individual Plan of Care

Instructions

Updated: 2/2025

Note: The term person when used in this form refers to an individual per 26 Texas Administrative Code (TAC) Section 259.5.

Purpose

Case management agencies (CMAs) and direct services agencies (DSAs) must use this form for all enrollments, revisions, renewals and terminations. This form is used to record any services provided through the Community Living Assistance and Support Services (CLASS) and the Community First Choice (CFC) option.

Revision, termination or transfer of individual plans of care (IPCs), which include the CFC option services, also require use of this form. The service codes include:

• 10CFC – CFC PAS/HAB
• 10CFV – CDS CFC PAS/HAB
• 48 – Transportation - Habilitation
• 20CFC – CFC ERS
• 48V – Transportation - Habilitation
• 63CFV – CDS CFC FMS
• 57CFV – CFC Support Consultation

This form is used to:

• record the identifying information of the CLASS/CFC applicant or person;
• enroll, revise, renew, transfer or terminate a person's IPC including:
  • IPC effective period,
  • services to be provided,
  • level of care (LOC) effective date, and
  • providers authorized to provide services;
• serve as a handwritten worksheet to compute estimated annual cost of CLASS and CFC service(s) for the person;
• register the person's IPC in the Service Authorization System (SAS);
• transfer to another CLASS or CFC agency of choice;
• document the addition or termination of consumer directed services (CDS) through CLASS or CFC; and
• terminate a person from the CLASS or CFC program. CFC services can still be sought through managed care.

Procedure

When to Prepare

The case manager is required to complete this form each time:

• a person's initial eligibility is assessed for the CLASS program, which requires an enrollment IPC;
• a revision is needed in the person's service plan, including the addition of CFC services;
• there is a change in an agency providing CLASS or CFC services;
• there is a need to add or terminate CLASS or CFC CDS;
• the annual renewal of the IPC is completed; or
• a person is no longer eligible for the CLASS program, which requires a termination IPC.

The case manager must send the corrected IPC to the person, guardian or legally authorized representative (LAR) and to each provider agency affected by the IPC. Each affected provider agency and the person receiving services through the CDS option must keep all corrected IPCs in the person's case record.

Number of Copies

The case manager must provide a copy of all completed, signed and dated IPC forms to all members of the service planning team (SPT), other CLASS service provider agencies as applicable, the person or LAR, and others as defined by the person or LAR.

Transmittal

The case manager files the completed, signed and dated form in the applicant's or person's case record.

The case manager submits a copy of the completed form to HHSC state office for data entry of Enrollment IPCs, IPC Revisions, IPC Renewals or IPC Terminations into SAS. The case manager must mail completed, signed and dated forms to:

Texas Health and Human Services Commission
CLASS Waiver Program, Mail Code W521
P.O. Box 149030
Austin, TX 78714-9030

Form Retention

Keep this form per record retention requirements in the CLASS Provider Manual 7000, Billing/Record Keeping Requirements.

Detailed Instructions

1.  Person’s Name, Last, First, MI — Enter the applicant's or person's legal name as shown on their Medicaid Identification or Social Security card, or the full name as provided by the applicant, person or LAR.

2. Social Security No. — Enter the applicant's or person's nine-digit Social Security number.

3. Medicaid No., nine digits — Enter the applicant's or person's nine-digit Medicaid number as shown on their Medicaid Identification card. If the applicant does not have a Medicaid number at the time of the initial intake, leave this field blank.

4. Date of Birth — Enter the date of the applicant's or person's birth in the month, day, year sequence MM/DD/YYYY.

5. Person’s Mailing Address, Street or P.O. Box, City, State, ZIP Code — Enter the applicant's or person's address in the CLASS catchment area.

6. County Name — Enter the name of the county where the applicant or person lives.

7. ABL — Enter the adaptive behavior level (ABL) recorded on the Intellectual Disability/Related Condition (ID/RC) Assessment, Item 30.

8. Primary DX Code — Enter the applicant's or person's primary diagnosis code on ID/RC, Item 20, ICD 9 Code.

9. LOC Effective Date — Enter the level of care (LOC) effective date on the ID/RC Assessment, Item 63.

10. IPC Effective Period — Enter the From and To dates for this IPC period in the month, day, year sequence MM/DD/YYYY.

• For an Enrollment IPC, the From date is the negotiated start date of services determined by the SPT. The To date is the last day of the previous month of the next year after the From date.
  Examples:
  • From date is Sept. 5, 2024, and To date is Aug. 31, 2025.
  • From date is Sept. 1, 2024, and To date is Aug. 31, 2025.
• For a Renewal IPC, the From date is the first day after the day the previous IPC ended. The To date is a year minus a day after the From date.
  • From date is Sept. 1, 2024, the To date is Aug. 31, 2025.

Example:

11. Effective Date —

• For an Enrollment IPC, enter the negotiated start date of services determined by the SPT.
• For an IPC Revision to add a new service category, add CFC services. To change an existing CLASS or CFC service category, enter the negotiated start date.
• For a Renewal IPC, enter the first day of the first month after the previous IPC ended.
• For a Termination of the IPC, enter the last date the person is authorized to receive CLASS or CFC services through the person’s waiver provider. CFC may be sought through managed care.

Examples:

For an Enrollment IPC, if the IPC begins on the first day of the month, the number of months in the IPC will be 12 months, 52 weeks or 365 days.

• Sept. 1, 2024 through Aug. 31, 2025 is 12 months or 52 weeks. If the IPC begins on any day other than the first day of the month, the IPC is calculated on the total number of calendar days from the start date through the last day of the previous month of the following year.
• Sept. 5, 2024 through Aug. 31, 2025 is 361 days.

For a Renewal IPC, the IPC period will be 12 months or 52 weeks.

12. Enrolled from Code — Enter the code of the applicant’s or person's type of living arrangement. Codes and descriptions of living arrangements are:

1 – Hospital

2 – Nursing Facility, Non-Rider 28

3 – Community ICF-IID

4 – Medicare/SNF

5 – Home

6 – State Institution

7 – Hospice

8 – Private Pay

9 – Other, Unknown

10 – *TDFPS Foster Home Placements Levels 1 and 2

11 – *TDFPS Child Placement Agencies

12 – Money Follows the Person (MFP) (Nursing Facility to Community)

*TDFPS is the Texas Department of Family and Protective Services

13. For HHSC Use Only — Do not enter any information in the Initial or Date boxes, they are for HHSC use only.

14a. Authorization Type — Place an X in the appropriate box to indicate the type of authorization. Only mark one box for:

• Enrollment IPC to enroll a new person.
• IPC Revision  to revise the person’s IPC within the current IPC effective period.
• IPC Renewal  to renew the person's enrollment period and services for another year.
• Termination Code to terminate the person’s services.

15a. DSA Vendor Name — Enter the name of the CLASS/CFC DSA that provides the identified service(s).

15b. DSA Vendor No. — Enter the seven-digit number assigned to the CLASS/CFC DSA that provides the identified service(s).

15c. CMA Vendor Name — Enter the name of the CLASS/CFC CMA that provides the identified service(s).

15d. CMA Vendor No. — Enter the seven-digit number assigned to the CLASS/CFC CMA that provides the identified service(s).

15e. FMSA Vendor Name — Enter the name of the FMSA that provides the identified service(s).

15f. FMSA Vendor No. — Enter the seven-digit number assigned to the FMSA that provides the identified service(s).

15g. SFSA Vendor Name — Enter the name of the SFSA that provides the identified service(s).

15h. SFSA Vendor No. — Enter the seven-digit number assigned to the SFSA that provides the identified service(s).

15i. TASA Vendor Name — Enter the name of the TASA that provides the identified service(s).

15j. TASA Vendor No. — Enter the seven-digit number assigned to the TASA that provides the identified service(s).

16a. Type — Enter the type of revision requested for the service category or categories authorized for each CLASS or CFC service.

Enter N for New or C for Change in this box on the line of the appropriate service category to be added or revised on the IPC.

To delete a service use C.

Do not enter an N or C on an enrollment IPC, renewal IPC or transfer IPC.

16b. Backup Plan — Place an X in the appropriate box to indicate if the person requires a backup plan for identified services.

17. Svc. Code —Service codes available through the CLASS or CFC program.

18. Svc. Category —Service categories available through the CLASS or CFC program.

18a. Req. Fee — Enter the total dollar amount of the requisition fee for each specialized therapy. If hippotherapy is being added to the IPC, only include the total cost of services provided by the riding instructor to calculate the requisition fee.

19. Est. Units — Enter the estimated annual service units for each service. The cost of hippotherapy should be the total number of sessions multiplied by the rate for Occupational Therapy (OT) or Physical Therapy (PT) plus the total number of sessions multiplied by the rate for the certified riding instructor.

Example:

If 52 hippotherapy sessions are added to the IPC and will be provided by the PT, then 52 units are multiplied by the PT rate, $77.43, to equal $4,026.36. The 52 units also are multiplied by the certified riding instructor rate determined by the certified riding instructor, $65 for example, to equal $3,380. This combined cost of $7,406.36 is reflected as the Est. Annual Cost under the service code for hippotherapy, 42E.

For an Enrollment IPC, if the IPC begins on the first day of the month, the number of months in the IPC will be 12 months, 52 weeks or 365 days.

20. Unit Rate — Enter the current established unit rate of each service authorized. For service categories 10, Habilitation, 10A, Habilitation – Delegated, 10CFC, PAS/HAB, 37, Supported Employment and 54, Employment Assistance, enter the rate the DSA is authorized under the Rate Enhancement Contract, if applicable. If hippotherapy is being added to the IPC, the total unit rate must equal the combined unit rate of the riding instructor plus the unit rate of the OT or PT.

21. Est. Annual Cost — Enter the dollar amount of the estimated annual cost for each service authorized. To calculate the estimated annual cost for service categories with established unit rate(s), multiply the estimated units by the unit rate.

For service categories that do not have established rates, such as 5A, 5B, 10B, 15, 16, 41D, 41F, 42A, 42B, 42C, 42D, 42E and 42F, enter the dollar amount of the estimated annual cost for each service authorized.

As noted in 26 TAC Section 259.275(a)(3), the cost of specifications for a minor home modification, SVC 41D, is not to exceed $200.

If hippotherapy is being added to the IPC on the form, the cost of hippotherapy would be the total number of sessions multiplied by the rate for OT or PT plus the total number of sessions multiplied by the rate for the certified riding instructor. This combined cost would be reflected under the service code for hippotherapy, 42E, but would be billed under separate bill codes. The bill codes are in the Long-Term Care Bill Code Crosswalk.

22. CFC Support Management — Mark yes or no to indicate if the person would like Support Management. This service is available to all persons who receive CFC PAS/HAB.

23-25. Summary

Column 1:

23a. DSA Subtotal — Enter the dollar amount of all authorized services to be provided by the DSA. Note: This will be the same dollar amount entered in the corresponding section on Page 1 for DSA Subtotal.

23b. CMA Subtotal — Enter the dollar amount authorized for CMA.

Note: This will be the same dollar amount entered in the corresponding section on Page 2 for CMA Subtotal.

23c. FMSA Subtotal — If applicable, enter the dollar amount authorized for SVC 7V, 8V, 9V, 10V, 11PV, 11AV, 13AV, 13BV, 13CV, 13DV, 37V, 54V, 61V and 63V to be provided through the CDS option. The CDS subtotal does not include the dollar amount authorized for SVC 57V. The person or LAR, as the employer, is responsible for hiring and managing service providers.

Note: This will be the same dollar amount entered in the corresponding section on Page 2 for FMSA Subtotal.

23d. SFS Subtotal — If applicable, enter the dollar amount authorized for SFS and continued family services (CFS).

Note: This will be the same dollar amount entered in the corresponding section on Page 2 for SFS Subtotal.

23e. TAS Subtotal — If applicable, enter the dollar amount authorized for transition assistance services. This amount includes the total transition services and the TASA fee.

Note: This will be the same dollar amount entered in the corresponding section at the top of Page 3 for TAS Subtotal.

23f. Waiver Total Estimated Annual Cost — Enter the total dollar amount by adding 23a. (DSA Subtotal), 23b. (CMA Subtotal), 23c. (FMSA Subtotal), 23d. (SFS Subtotal), and 23e. (TAS Subtotal), as applicable.

Column 2:

24a. CFC Subtotal — Enter the dollar amount authorized for CFC services. CFC totals are not reflected in the waiver total estimated annual cost and do not contribute to the person’s waiver cost ceiling. Note: This will be the same dollar amount entered in the corresponding section on Page 2 for CFC Subtotal.

24b. CFC CDS Subtotal — If applicable, enter the dollar amount authorized for SVC 10CFV and 63CFV to be provided through the CFC CDS option. CFC totals are not reflected in the waiver total estimated annual cost and do not contribute to the person’s waiver cost ceiling. Note: This will be the same dollar amount entered in the corresponding section on Page 2 for CFC CDS Subtotal.

24c. CFC Total Estimated Annual Cost — Enter the total dollar amount by adding 24a. (CFC Subtotal) and 24b. (CFC CDS Subtotal), as applicable.

Column 3:

25. CFC and Waiver Total Estimated Annual Cost — Enter the total dollar amount by adding 23f. (Waiver Total Estimated Annual Cost) and 24c. (CFC Total Estimated Annual Cost), as applicable.

Signatures

By signing below, I certify that I — The case manager must provide the person or LAR Electronic Visit Verification (EVV) rights and responsibilities and afford the person or LAR choice between community based services and services in an institution.

Person or Legally Authorized Representative, Date — The applicant, person or LAR signs and dates the completed form. The person is not required to sign or date the IPC when services are being terminated unless the termination is being made at the person's request.

If the applicant or person is unable to write their name, they may:

• enter an X as an identifying mark, the X must be witnessed and dated, or
• enter their name via a signature stamp and date.

If the applicant or person is a minor, the LAR signs.

If an adult applicant or person has an LAR, the LAR must sign.

The applicant, person or LAR signs and dates the IPC to agree to the service plan for:

• an enrollment IPC,
• a renewal IPC,
• an IPC revision, or
• a transfer IPC between one or more provider agencies.

Case Manager, Date — The case manager signs and dates the form.

DSA Representative, Date — An authorized representative of the DSA signs and dates the form agreeing to provide direct services as authorized on the IPC.

Other, Date — An authorized representative of the FMSA signs and dates the form to agree that the IPC was received by their agency.

CLASS Program Consultant — The CLASS Program consultant who authorizes the IPC signs and dates the form.

Note: The SPT representatives verify the accuracy of the information on the IPC, the estimated units and estimated costs for services to be delivered by the CLASS/CFC providers.