Form 8578-CFC, Intellectual Disability/Related Condition Assessment for CFC

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Documents

Effective Date: 9/2024

Instructions

Updated: 9/2024

Purpose

Form 8578-CFC is limited to the Community First Choice (CFC) Non-Waiver Eligibility. Apply the general Form 8578, Intellectual Disability/Related Conditions Assessment (ID/RC), to document information for applicants applying for, or persons enrolled in, an Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions (ICF/IID) or one of the IDD Waiver Programs.

A Local Intellectual and Developmental Disabilities Authority (LIDDA) uses Form 8578-CFC to document information needed to:

  • recommend an ICF/IID level of care (LOC); and
  • demonstrate compliance with federal utilization review requirements.

Procedure 

When to Prepare

Form 8578-CFC is completed with information obtained from the applicant or an interested party on behalf of the applicant when requesting an assessment of LOC for CFC Non-Waiver. After a person has an approved LOC for CFC Non-Waiver services, this form is completed for each additional LOC action, such as annual reassessments or changes.

Transmittal

Certain information from each completed Form 8578-CFC is entered into the Texas Health and Human Services Commission (HHSC) automated Client Assignment and Registration (CARE) System by a representative from the person’s LIDDA and is transmitted to IDD Program Eligibility and Support (PES) for review.

Form Retention

The submitting LIDDA must maintain the original of each Form 8578-CFC transmitted and originals of all other applicable forms for six years. The transmitting LIDDA must retain copies for three years past a person’s 18th birthday, even if the retention period exceeds the normal requirement of six years. 

Source of Forms and Information Regarding the ID/RC Assessment

Detailed Instructions

Local Intellectual and Developmental Disabilities Authority (LIDDA) Name – Enter the legal name of the LIDDA completing the form.

LIDDA Component Code – Enter the LIDDA’s component code.

LIDDA Mailing Address – Enter the LIDDA mailing address.

Managed Care Organization (MCO) or Department of State Health Services (DSHS) Name – Enter the name of the MCO the person chose for CFC services or name of DSHS.

MCO Component Code – Enter the component code associated with the MCO the person chose for CFC services. If DSHS, leave this field blank.

Plan Code – Enter the MCO plan associated with the person’s county of residence. If DSHS, enter 17.

Person’s Name (Last, First, Middle) – Enter the person’s last name, first name and middle name  or initial.

Person’s Date of Birth – Enter the person’s date of birth in MM-DD-YYYY format.

Person’s Address – Enter the person’s current mailing address, including street or P.O. Box, city, state and ZIP Code.

Social Security No. – Enter the person’s nine-digit Social Security number.

Medicaid No. – Enter the person’s Medicaid number, if known.

Client Assignment and Registration (CARE) ID – Enter the person’s CARE identification number.

Diagnosis

Primary Diagnosis – Enter the person’s current primary diagnosis as determined by a licensed physician or an authorized provider as defined in Health and Safety Code Section 593.004. A primary diagnosis is the condition chiefly responsible for the request for CFC Non-Waiver eligibility. Note: For LOC VIII, a Related Condition as determined by a license physician is required as a Primary Diagnosis.

Code – Enter the code of primary diagnosis listed in the International Classification of Diseases (ICD). This code must match the primary diagnosis entered in field 19.

Version Code – Enter the ICD version code used for the person’s primary diagnosis.

Onset – Enter the onset month and year of the person’s disabling condition current primary diagnosis.

Medical Diagnosis or Second Condition – Enter the medical diagnosis or second condition as determined by a licensed physician.

Code – Enter the diagnostic code that matches population in field 23.

Version Code – Enter the ICD version code used for the person’s current medical diagnosis or second condition.

Psychiatric Diagnosis or Additional Condition – Enter psychiatric diagnosis or additional condition, as determined by a licensed physician or an "authorized provider", as defined in Health and Safety Code (Sec. 593.004).

Code – Enter the diagnostic code that matches population in field 26.

Version Code – Enter the Diagnostic and Statistical Manual of Mental Disorders (DSM) version used for the person’s psychiatric diagnosis or additional condition.

Cognitive or Adaptive Functioning

Intelligence Quotient (IQ) – Enter the person’s current IQ score if qualifying under an LOC I. If qualifying under an LOC VIII or if IQ cannot be ascertained for a person because of the severity of the disability such as profound intellectual disability, enter 019.

IQ Instrument – Enter the code associated with the IQ instrument used for an LOC I. If qualifying under an LOC VIII enter code 21. If qualifying under an LOC

  • 01 = Wechsler Intelligence Scale for Children (WISC) 02 = Wechsler Adult Intelligence Scale (WAIS)
  • 03 = Wechsler Preschool and Primary Scale of Intelligence (WPPSI) 04 = Stanford-Binet form LM (S-B LM)
  • 05 = Cattell Intelligence Test Scale
  • 06 = Peabody Picture Vocabulary Test (PPVT) 07 = Beta
  • 08 = Other
  • 09 = WISC (Revised)
  • 10 = WAIS (Revised)
  • 11 = PPVT (Revised)
  • 12 = Slosson Intelligence Test (SIT)
  • 13 = Leiter International Performance Scale (LIPS)
  • 14 = WISC III
  • 15 = WAIS III
  • 16 = LIPS-Revised
  • 17 = S-B 4th
  • 18 = S-B 5th
  • 19 = WISC IV
  • 20 = SIT-Revised
  • 21 = Not Applicable

ABL – Enter the appropriate adaptive behavior level (ABL) code for the person:

  • 0 = No deficit in adaptive skills
  • 1 = Mild deficit in adaptive skills
  • 2 = Moderate deficit in adaptive skills
  • 3 = Severe deficit in adaptive skills
  • 4 = Profound deficit in adaptive skills

The ICAP Conversion Table below will help determine ABL related to LOC VIII. For LOC I, the LIDDA must use the DID Best Practice Guidelines to assign an ABL. If no limitations are indicated, the ABL should be scored as an ABL 0.

ICAP Conversion Table
Service LevelAdaptive Behavior Level
7, 8, 9I
4, 5, 6II
2, 3III
1IV

ABL Instrument and Score – Select the ABL instrument used:

  • Enter the Vineland Adaptive Behavior Scales (ABC Score) if the Vineland was used.
  • Enter the Inventory for Client and Agency Planning (ICAP) service score if ICAP was used.
  • Enter the Scales of Independent Behavior — Revised (SIB-R) RMI score if SIB-R was used.
  • Enter an X if other standardized ABL assessment was used. Enter name of assessment used under LIDDA Comments section.

ABL Assessment Date – Enter the date the ABL assessment was conducted.

Related Conditions Eligibility Screening Instrument (Form 8662). Required if primary diagnosis is a related condition. – Enter the total number of Yes responses in Section 4 B.1, a-f on Form 8662, Related Conditions Eligibility Screening Instrument. This field is required for all persons with a primary diagnosis of a related condition.

Purpose Code – Enter the appropriate purpose code associated with the reason for the submission:

  • Purpose Code 2 — Initial Assessment
  • Purpose Code 3 — Annual Reassessment (Renewal)
  • Purpose Code 4 — Off-Cycle Reassessment (Change)
  • Purpose Code 5 — MCO Plan Code or LIDDA Change Only

Recommended Level of Care (LOC) – Enter the LOC the LIDDA recommended:

  • LOC 0 — (only use if recommending LOC denial)
  • LOC I (DID required)
  • LOC VIII (DID not required)

LIDDA Certification

By signing the form, the representative certifies, to the best of the person’s knowledge, all information on the form is true and the information represents the person’s assessment information as currently documented in the record. If the primary diagnosis is a related condition, the representative also certifies a physician has attested to the primary diagnosis and onset, and the physician’s attestation is documented in the LIDDA's records.

Print Full Name of LIDDA Representative – Enter the printed full name of the LIDDA representative who signed the form.

Signature of LIDDA Representative – The LIDDA representative signs the form.

Title – Enter the LIDDA representative’s title who signed the form.

Date – Enter the date the LIDDA representative signature is rendered.

LIDDA Comments – The LIDDA representative provides any more information or comments not captured in any of the designated fields.

For LIDDA Use Following HHSC LOC Approval or Denial Only

HHSC Authorized Level of Care – LIDDA staff must indicate the authorized LOC in CARE as follows:

  • LOC 0 (only used if denying LOC)
  • LOC I, or
  • LOC VIII.

Meets Functional and Diagnostic Eligibility – Check if the person qualifies:

  • Community First Choice (CFC)

LOC Effective Date – Enter the LOC effective date listed in CARE.

LOC Expiration Date – Enter the LOC expiration date listed in CARE.

Name or ID of HHSC Reviewer – Enter the name or CARE ID of the reviewer listed in CARE.

Date HHSC Reviewed – Enter the date reviewed listed in CARE.

HHSC Reviewer Comments – Enter the HHSC reviewer comments listed in CARE.