Form 3621, CLASS/CFC — Individual Plan of Care

Effective Date
11/2019
Document
Document
3621.pdf (144.18 KB)

 

Instructions

Updated: 10/2018

 

PURPOSE

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

Revision, termination or transfer individual plans of care (IPCs), which include the CFC option services, will require use of this form. The new 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/individual;
  • enroll, revise, renew, transfer or terminate an individual'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 individual;
  • register the individual's IPC in the Service Authorization System (SAS);
  • transfer to another CLASS/CFC agency of choice;
  • document the addition or termination of consumer directed services (CDS) through CLASS or CFC; and
  • terminate an individual from the CLASS/CFC program. CFC services can still be sought through managed care.

 

PROCEDURE

When to Prepare

This form is required and completed by the case manager each time:

  • an applicant's initial eligibility is assessed for the CLASS program, which requires an enrollment IPC;
  • there is a need for revision in the individual'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
  • an individual is no longer eligible for the CLASS program, which requires a termination IPC.

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

Number of Copies

A copy of all completed/signed/dated IPC forms must be provided by the case manager to all members of the service planning team, other CLASS service provider agencies, as applicable, individual/LAR, and others as defined by the individual/LAR.

Transmittal

The case manager files the completed/signed/dated form in the applicant's/individual's case record.

The case manager submits a copy of the completed form to HHSC state office for data entry into SAS of enrollment IPCs, IPC revisions, IPC renewals, IPC terminations. The case manager must mail completed/signed/dated forms to the following address:

Texas Health and Human Services Commission
CLASS Waiver Program, Mail Code W-521
P.O. Box 149030
Austin, TX 78714-9030

Form Retention

Keep this form according to record retention requirements documented in the CLASS Provider Manual.

 

Detailed Instructions

1. Name of Individual (Last, First, MI) — Enter the applicant's/individual's legal name (last, first, middle initial) as shown on his/her Medicaid Identification or Social Security card, or the full name as provided by the applicant/individual/LAR.

2. Social Security No. — Enter the applicant's/individual's nine-digit Social Security number.

3. Medicaid No. (9 digits) — Enter the applicant's/individual's nine-digit Medicaid number as shown on his Medicaid Identification. If the applicant does not have a Medicaid number at the time of the initial intake, leave this field blank.

4. DOB (MM/DD/YYYY) — Enter the date of the applicant's/individual's birth, using eight digits, following the month, day, year (mm/dd/yyyy) sequence.

5. Mailing Address of Individual (Street and/or P.O. Box, City, State, ZIP Code) — Enter the applicant's/individual's residence, mailing and/or post office address (city, state and ZIP Code) in the CLASS catchment area.

6. County Name — Enter the name of the county in which the applicant/individual resides.

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

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

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

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

  • For an Enrollment IPC, the “From” date is the negotiated start date of services as determined by the service planning team. 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, 2013, and To date is Aug. 31, 2014.
    • From date is Sept. 1, 2013, and To date is Aug. 31, 2014.
  • For a Renewal IPC, the From date is the first day after the day the previous IPC ended, and the To date is a year minus a day after the From date.
  • Example:
    • From date is Sept. 1, 2014, and To date is Aug. 31, 2015.

11. Effective Date

  • For an Enrollment IPC, enter the negotiated start date of services as determined by the service planning team.
  • For an IPC revision to add a new service category, add CFC services, or to change an existing CLASS or CFC service category, enter the negotiated start date as determined by the service planning team.
  • 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 individual is authorized to receive CLASS or CFC services through the individual’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, 2013 , through Aug. 31, 2014 = 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, 2013 , through Aug. 31, 2014 = 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 type of living arrangement of the applicant/individual. Codes and descriptions of living arrangements are as follows:

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 = Texas Department of Family and Protective Services

13. For HHSC Use Only (Initial and Date) — Do not enter any information in these boxes. For HHSC use only.

14a. Authorization Type — Indicate the type of authorization by placing an X in the appropriate box. Mark one box only as follows:

  • Enrollment IPC — Mark this box to enroll a new applicant.
  • IPC Revision — Mark this box to revise the IPC within the current IPC effective period.
  • IPC Renewal — Mark this box to renew the individual's enrollment period/services for another year.
  • Termination Code — Mark this box to terminate the individual’s services.
Termination/
Computer Code
Rule Citation Reason for Termination
in Rule Language
Program Affected
Advance Notice to Individual
01 §45.406 (a)(3) The individual leaves the state for more than 180 days and HHSC does not grant an extension.

CLASS and CFC

Y
04 §45.406 (a)(2) The individual is admitted for more than 180 consecutive calendar days to in an institution, as outlined in TAC §45.406 (a) (2) and HHSC has not extended the individual’s suspension in accordance with §45.404(d) of this division.
CLASS and CFC
Y
06 §45.201 (a)(1) The individual is not financially eligible for Medicaid benefits.
CLASS and CFC
Y
18 §45.201 (a)(5) The individual does not have an IPC cost at or below $114,736.07.
CLASS only. CFC can be sought through managed care.
Y
19 §45.402 (a)(2) The DSAs serving the catchment area in which the individual resides are not willing to provide CLASS Program services to the individual because they have determined that they cannot ensure the individual's health and safety.

CLASS and CFC potentially.

CFC can still be sought if there is another qualified provider which is willing and able to serve the individual.
Y
17 §45.407 (a) The individual or someone in the individual's home refuses to comply with mandatory program requirements, as described in 40 TAC §45.302(1) and (4), including the determination of eligibility and/or the monitoring of service delivery.
CLASS only. CFC can be sought through managed care.
Y
08 §45.201 (a)(4) The individual has not demonstrated a need for habilitation services as determined by the service planning team.
CLASS only. CFC can be sought through managed care.
Y
20 §45.407 (a) Individual refuses to comply with a mandatory participation requirement, as described in 40 TAC §45.302(6) by not paying the required co-payment in a timely manner.
CLASS only. CFC can be sought through managed care.
Y
07 §45.409 (a) An individual or a person in the individual's residence exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy, as described in 40 TAC §45.302(8).
CLASS only. CFC can be sought through managed care.
Y
39 §45.407 (a) The individual or someone in the individual's home engages in criminal behavior in the presence of the service provider or case manager, as described in 40 TAC §45.302(8)(9).
CLASS only. CFC can be sought through managed care.
Y
02 §45.408 (a)(1) The operating agency or its designee has factual information confirming the death of the individual.
CLASS and CFC
N
05 §45.408 (a)(2) The CMA or DSA receives a clear written statement signed by the individual that the individual no longer wishes to have CLASS Program or CFC Program services or gives information that requires termination or reduction in services and indicates that he or she understands that this must be the result of supplying the information.
CLASS only. CFC may be pursued through managed care. If an individual would like to terminate CFC only, an IPC change is needed.
N
36 §45.408(a)(3) The individual's whereabouts are unknown and the post office returns agency or designee mail directed to him or her indicating no forwarding address.
CLASS and CFC
N
39 §45.408 (a)(4) The CMA or DSA establishes that the individual has been accepted for Medicaid services by another state.
CLASS and CFC
N
08 §45.201 (a)2 The individual is determined by HHSC not to meet the diagnostic eligibility criteria for the CLASS Program.
CLASS and potentially CFC. CFC may be available through managed care.
N
37 §45.407 (a) The individual or someone in the individual's home engaging in a pattern of harassment of the case manager or service provider that interferes with the ability to provide CLASS or CFC Program services or acting in a manner that is threatening to the health and safety of the case manager or service provider, as described in 40 TAC §45.302(10) and (11).
CLASS only. CFC can be sought through managed care.
Y

15a. DSA Vendor Name — Enter the name of the CLASS/CFC direct services agency providing the identified service(s).

15b. DSA Vendor No. — Enter the seven-digit number assigned to the CLASS/CFC direct services agency providing the identified service(s).

15c. CMA Vendor Name — Enter the name of the CLASS/CFC case management agency providing the identified service(s).

15d. CMA Vendor No. — Enter the seven-digit number assigned to the CLASS/CFC case management agency providing the identified service(s).

15e. FMSA Vendor Name (if applicable) — Enter the name of the financial management services agency providing the identified service(s).

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

15g. SFSA Vendor Name (if applicable) — Enter the name of the support family services agency providing the identified service(s).

15h. SFSA Vendor No. (if applicable) — Enter the seven-digit number assigned to the support family services agency providing the identified service(s).

15i. TASA Vendor Name (if applicable) — Enter the name of the transition assistance services agency providing the identified service(s).

15j. TASA Vendor No. (if applicable) — Enter the seven-digit number assigned to the transition assistance services agency providing the identified service(s).

16a. Type — Enter the type of revision being requested for the service category/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 — Indicate if the individual requires a backup plan for identified services by placing an X in the appropriate box.

17. Svc. Code — Listing of service codes available through the CLASS or CFC program.

18. Svc. Category — Listing of 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:

For example, if 52 sessions of hippotherapy 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. In addition, 52 units are multiplied by the certified riding instructor rate determined by the certified riding instructor (e.g., $65.00) to equal $3,380.00. 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 (for example, 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 40 TAC §45.613, 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 can be located in the Long-Term Care Bill Code Crosswalk.

22. CFC Support Management — Mark yes or no to indicate if the individual would like Support Management. This service is available to all indviduals receiving 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 case management services. 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 individual or legally authorized representative, 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 support family services and continued family services. 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 from 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 individual’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 individual’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 from 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 from adding 23f. (Waiver Total Estimated Annual Cost) and 24c. (CFC Total Estimated Annual Cost), as applicable.

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

27. Signatures:

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

If the applicant/individual is unable to write his/her name, the applicant/individual may:

  • enter an X as an identifying mark (the X must be witnessed and dated), or
  • enter his/her name via a signature stamp and date.

If the applicant/individual is a minor, the LAR signs.

If an adult applicant/individual has an LAR, the LAR must sign.

The applicant/individual or LAR signs/dates the IPC agreeing 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 agreeing 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 service planning team 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.