Form 6500, DBMD and CFC – Individual Plan of Care (IPC)

Instructions

Updated: 11/2024

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

Purpose

This form is used to:

• record the identifying information of the Deaf Blind with Multiple Disabilities (DBMD) applicant or person;
• enroll, revise, renew or terminate a person's IPC, including:
  • IPC effective period,
  • services to be provided,
  • providers authorized to provide services, including Consumer Directed Services (CDS), and
  • record any services provided through the Community First Choice (CFC) option.
• serve as a worksheet to compute estimated annual cost of DBMD and CFC service(s) for the person.
• register the person's IPC in the Service Authorization System (SAS).
• document the addition or termination of CDS through DBMD or CFC.
• terminate a person from the DBMD and CFC program. CFC services can still be sought through managed care.

Procedure

When to Prepare

The case manager completes this form each time:

• an applicant's or person's initial eligibility is assessed for the DBMD and CFC program;
• the person's plan needs revision or to add CFC services;
• the annual renewal of the IPC is completed; or
• a person is no longer eligible for the DBMD program. A person may still be eligible for CFC through managed care despite losing DBMD eligibility.

The case manager may not use Liquid Paper or correction fluid to correct errors on Form 6500. If there is an error on the form, the case manager must:

• line through the error and insert the correction above the error; and
• initial the correction.

The case manager must send the corrected IPC to the person or legally authorized representative (LAR) and the Financial Management Services Agency (FMSA) if applicable. The DBMD and CFC provider agency and the FMSA must keep all corrected IPCs in the person 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), the FMSA if applicable, the person, LAR and others defined by the person or LAR.

Transmittal

The case manager files the completed, signed and dated Form 6500 in the applicant's or person's case record.

The case manager submits a copy of the completed Form 6500 to HHSC Utilization Review as part of requests for program enrollment, renewal, revision, and termination via the IDD Operations Portal. The case manager may also mail or fax the completed, signed and dated Form 6500 to:

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

Fax Number: 512-438-5135

Form Retention

Each DBMD and CFC provider agency must keep Form 6500 according to the record retention requirements in Texas Administrative Code, Chapter 52, Contracting for Community Services.

Detailed Instructions

Person’s Name Last, First, MI — Enter the applicant's or person's legal name (last, first, middle initial) as shown on the person's Medicaid identification, Social Security card or the full name as provided by the applicant, person or LAR.

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

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

Date of Birth — Enter the date of birth  for the applicant or person. Use eight digits and following the month, day, year sequence.

Mailing Address of Person Street or P.O. Box, City, State, ZIP Code — Enter the applicant’s or person's residence, mailing address or post office box (city, state and ZIP code).

County Name — Enter the name of county where the applicant or person resides. The DBMD and CFC provider must verify the county is within the region the provider is authorized to provide services.

Vendor Name — Enter the name of the DBMD and CFC provider agency providing the identified services(s).

Vendor No. — Enter the seven-digit number assigned to the DBMD and CFC provider agency providing the identified service(s).

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

IPC Effective Period From— Enter the From date for the IPC period in the month, day, year sequence MM/DD/YYYY.

IPC Effective Period To— Enter the To date for the IPC period in the month, day, year sequence MM/DD/YYYY.

Example:
From date is Sept. 1, 2023, and To date is Aug. 31, 2024.

• For an Enrollment IPC, the From date is the negotiated start date of services 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, 2023, and To date is Aug. 31, 2024.
  From date is Sept. 1, 2023, and To date is Aug. 31, 2024.
   
• 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 one day after the From date.

Effective Date —

• For an Enrollment IPC, enter the negotiated start date of services as determined by the SPT.
• For an IPC revision to add a new service category of DBMD or CFC services, or to change an existing service category of DBMD or CFC services, enter the negotiated start date determined by the SPT.
• For a Renewal IPC, enter the first day of the first month after the previous IPC ended.
• For a Transfer IPC, enter the first day of service to be provided by the receiving provider or FMSA.
• For a Termination of the IPC, enter the last date the person is authorized to receive DBMD or CFC services. CFC services may still be pursued through managed care when a person terminates from the DBMD waiver.

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

1 – Hospital
2 – Nursing Facility, Non-Rider 28
3 – Community ICF
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 Texas Department of Family and Protective Services

For HHSC Use Only, Initial and Date — Do not enter any information in these boxes.

Authorization Type — Place an X in the appropriate box to indicate the type of authorization. Mark one box as follows:

• Enrollment IPC – Mark to enroll a new applicant.
• IPC Revision – Mark to revise the IPC within the current IPC effective period.
• IPC Renewal – Mark to renew the person’s enrollment period or services for another year.
• Termination Code – Enter the two-digit code, if applicable, from the following.

Type — For a revision IPC, enter the type of revision requested for the service category or categories authorized for each DBMD waiver service. Enter N for New or C for Change in the 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.

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

Mark one box or multiple boxes as applicable:

Service Code — Service codes available through the DBMD program or the CFC option.

Service Category — Service categories available through the DBMD or the CFC program.

Estimated Units — Enter the estimated annual service units for each DBMD or CFC service.

For service categories that do not have an established unit, such as 16 – Minor Home Modification, 41B – Minor Home Modification Requisition Fee, 15 – Adaptive Aids, 41 – Adaptive Aids Requisition Fee, 5A – Dental, 5B – Dental Sedation, leave these fields blank.

For an IPC revision, determine the number of units to be added or deleted from the total number of estimated units to the end of the IPC year.

If the estimated cost of a service is being reduced or terminated, the cost listed must be equal to or greater than the total cost for which payment has been made or billed, plus services delivered but not billed.

Unit Rate — Enter the current established unit rate of each service authorized. For service categories 10 – Habilitation/Day, 10CFC – CFC PAS/HAB, 17 – Residential Habilitation – Hourly, 17E – Chore Services, 37-Supported Employment, 54-Employment Assistance and 45 – Intervener, enter the rate the DBMD provider is authorized under the DADS Rate Enhancement Contract, if applicable.

For service categories that do not have an established unit, such as 16 – Minor Home Modification, 41B – Minor Home Modification Requisition Fee, 15 – Adaptive Aids, 41 – Adaptive Aids Requisition Fee, 5A – Dental, 5B – Dental Sedation, leave these fields blank.

Estimated Annual Cost — The online form calculates this field. If this form is completed manually, 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 an established unit, such as 16 – Minor Home Modification, 41B – Minor Home Modification Requisition Fee, 15 – Adaptive Aids, 41 – Adaptive Aids Requisition Fee, 5A – Dental, 5B – Dental Sedation, enter the dollar amount of the estimated annual cost for each service authorized.

Subtotal — The online form calculates this field. Enter the dollar amount of all authorized services to be provided by the DBMD provider.

Community First Choice (CFC) Services — Enter the estimated annual service units and the current established unit rate for service codes 10CFC and 20CFC.

CFC Subtotal — The online form calculates this field. Enter the dollar amount authorized for CFC services. CFC totals are not reflected in the total estimated cost and do not contribute to the person’s waiver cost ceiling.

Consumer Directed Services (CDS)

Financial Management Services Agency (FMSA) Vendor Name — If applicable enter the name of the FMSA providing the identified service(s).

FMSA Vendor No. — If applicable enter the seven-digit number assigned to the FMSA providing the identified service(s).

Add or Terminate — If applicable place an X in the box to indicate the addition or termination of services through the CDS option.

Type — For an IPC revision, enter the type of revision requested for the service category or categories authorized for each CDS DBMD or CFC waiver service. Enter N for New or C for Change in the 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.

Backup Plan — Place an X in the appropriate box to indicate if the person requires a backup plan for identified CDS DBMD or CFC waiver services.

Mark one box or multiple boxes as applicable:

Service Code —Service codes available through the CDS option in the DBMD or CFC program.

Service Category —Service categories available through the CDS option in the DBMD and CFC program.

Estimated Units — Enter the estimated annual service units for each CDS category.

For an IPC revision, determine the number of units to be added or deleted from the total number of estimated units to the end of the IPC year.

If the estimated cost of a service is being reduced or terminated, the cost listed must be equal to or greater than the total cost for which payment has already been made or billed, plus services delivered but not billed.

Unit Rate — Already provided on the form.

Estimated Annual Cost — The online form calculates this field. If this form is completed manually, enter the dollar amount of the estimated annual cost for each CDS category authorized. To calculate the estimated annual cost for service categories with established unit rate(s), multiply the estimated units by the unit rate.

CDS Subtotal— If applicable the online form calculates this field. Enter the dollar amount authorized for services to be provided through the CDS option. The CDS subtotal does not include the dollar amount authorized for Service Code 57V, Support Consultation. The employee of record is responsible for procurement of services.

CFC CDS Services — If applicable enter the estimated annual service units and the current established unit rate of each service authorized.

CFC CDS Subtotal — If applicable the online form calculates this field. 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 total estimated cost and do not contribute to the person’s waiver cost ceiling.

Transition Assistance Services (TAS)

TAS Vendor Name — If applicable enter the name of the TAS agency providing the identified service(s).

TAS Vendor No.— If applicable enter the seven-digit number assigned to the TAS agency providing the identified service(s).

Type — Enter the type.

Service Code —Service codes available through TAS.

Service Category —Service categories available through TAS.

Estimated Units — Enter the estimated annual service units for each TAS category. Service Code 53 does not have an established unit rate and the field should be left blank.

Unit Rate — Enter the current established unit rate for each TAS category authorized. Service Code 53 does not have an established unit rate and the field should be left blank.

Estimated Annual Cost — The online form calculates this field. If this form is completed manually, enter the dollar amount of the estimated annual cost for each TAS category 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 Code 53, enter the dollar amount of the estimated annual cost.

TAS Subtotal — If applicable the online form calculates this field. Enter the dollar amount authorized for TAS. This amount includes the combined total for transition assistance services and the TAS agency fee. This service is only available for an applicant enrolling in the DBMD program.

CFC Support Management — Select Yes or No.

Subtotal — The online form populates this field. Enter the dollar amount of the DBMD Subtotal from the Subtotal box on Page 1 of Form 6500.

CDS Subtotal — If applicable the online form populates this field. Enter the dollar amount of the CDS Subtotal on Page 2.

TAS Subtotal— If applicable the online form populates this field. Enter the dollar amount of the TAS Subtotal on Page 2.

CFC Subtotal — The online form populates this field. Enter the dollar amount of the CFC Subtotal on Page 1.

CFC CDS Subtotal — The online form populates this field. Enter the dollar amount of the CFC Subtotal from the CFC Subtotal box on Page 2.

CFC Total — The online form populates this field. Add the dollar amount of the CFC Subtotal, the dollar amount of the CFC CDS Subtotal, to determine the total cost of all CFC services.

Total Estimated Annual Waiver Cost — The online form calculates this field.  Add the dollar amount of the Subtotal, the dollar amount of the CDS Subtotal, and the TAS Subtotal if applicable to determine the total cost of all waiver services.

CFC and Waiver Total Estimated Annual Cost — The online form calculates this field.  Add the dollar amount of the CFC Total and the dollar amount of the Total Estimated Annual Waiver Cost to determine the total cost of all services.

Service Planning Team (SPT) Signatures and Date — The applicant, person or LAR signs and dates the completed form. If the applicant or person is unable to write their name, the applicant or person 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 has an LAR, the LAR must sign and date the form.

By signing Form 6500, the applicant, person or LAR agree to the service plan for:

• an enrollment IPC,
• a renewal IPC,
• an IPC revision, or
• IPC termination.

The person is not required to sign and date the IPC when services are being terminated unless the termination is being made at the person's request.

Case Manager and Date — The case manager signs and dates the form to certify the identified services are appropriate to meet the needs of the applicant or person in the community and to prevent institutional placement.

Provider Representative and Date — An employee of the provider agency who attends the SPT meeting, such as a nurse or direct service provider with knowledge of the applicant or person can sign and date the form. A nurse or program director is required to participate in the SPT.

Other and Date — Other members of the SPT sign and date the form. An FMSA employee may sign and date the form.

Other and Date — An authorized FMSA representative signs and dates the form to acknowledge the FMSA received IPC.

Note: The SPT representatives verify the accuracy of the information on the IPC Pages 1 and 2, the estimated units and estimated costs for services to be delivered by the DBMD providers.

DBMD and CFC Program Contact and Date — The HHSC DBMD and CFC program contact signs and dates the form when approval is granted.