Form 8606, Individual Program Plan (IPP)

Effective Date
06/2015
Document
Document
8606.pdf (117.47 KB)

 

Instructions

Updated: 5/2015

Purpose

This form is used by Community Living Assistance and Support Services (CLASS) and Community First Choice (CFC) to:

  • record the individual's need, goals/objectives and frequency/duration of each service category authorized on Form 3621, CLASS Individual Plan of Care (IPC);
  • justify the total units and cost of each service category authorized on Form 3621;
  • record who will deliver each service to the individual, the location of service delivery, the service start date and the projected completion date/duration of the service; and
  • document any support service(s) provided by family or friends and/or obtained from other non-waiver resources in the community available to provide the service.

Procedure

When to Prepare

Enrollment

The case manager must complete this form within 30 calendar days after receiving notification by the direct services agency (DSA) of HHSC approval of diagnostic eligibility (Form 8578, Intellectual Disability/Related Condition Assessment).

The case management agency (CMA) must complete this form for each CLASS or CFC service listed on the proposed IPC.

Renewal

The case manager completes this form at least 30 calendar days before the effective date proposed by the service planning team.

The CMA must complete this form for each CLASS or CFC service listed on the proposed IPC.

Revision

The case manager completes this form at least 30 calendar days before the effective date proposed by the service planning team.

The CMA must complete this form for each new/revised CLASS or CFC service listed on the proposed IPC.

Transmittal

The case manager retains the completed form and provides a copy to the individual/legally authorized representative (LAR), the DSA of record and/or other service planning team members, as appropriate.

Form Retention

The CMA and DSA must keep this form according to the record retention requirements documented in the CLASS Provider Manual.

Detailed Instructions

Program Type (check one): — Mark the appropriate box to indicate the type of program.

1. Individual — Enter the name of the individual as it appears on the individual's Form 3621.

2. Medicaid No. — Enter the individual's nine-digit Medicaid number as it appears on the individual's Form 3621.

3. Individual Plan of Care (IPC) Effective Date — Enter the IPC effective date as it appears on the individual's Form 3621.

4. IPC Type —Mark the appropriate box to indicate enrollment, renewal or revision. Select only one type.

5. Description of Authorized Service Category or Adaptive Aid/Minor Home Modification — Enter the description and service code for each service category authorized on the individual's Form 3621. For service code 42, list each specialized therapy authorized.

6. Old (for IPC revision only) — Use this section to reflect the services authorization as stated in the IPC before creating this IPC revision.

  • Units – Enter the number of units authorized for each service category on the individual's Form 3621.
  • Cost – Enter the cost of each service category authorized on the individual's Form 3621.
  • Req. Fee – For specialized therapies, include the total sum of the requisition fee [(hourly rate x .10) x total hours]. For adaptive aids and minor home modifications (MHM), include the requisition fee for the amount of the item or service as identified in the HHSC CLASS Program Payment Rates.
  • Specs – Enter the cost of written specifications (if applicable) for adaptive aids costing more than $500 and minor home modifications costing more than $1000.
  • Inspection Fee (MHM Only) – Enter the inspection fee only for minor home modifications
  • Frequency and Duration of Service – Enter the frequency and duration of service for each service category authorized on the individual's Form 3621.

7. Added/Reduced (for IPC change only) — Use this section to reflect the changes in services authorization. Use negative sign (–) to indicate a reduction in services.

  • Units – Enter the number of units authorized for each service category on the individual's Form 3621.
  • Cost – Enter the cost of each service category authorized on the individual's Form 3621.
  • Req. Fee – For specialized therapies, include the total sum of the requisition fee [(hourly rate x .10) x total hours]. For adaptive aids and minor home modifications, include the requisition fee for the amount of the item or service as identified in the HHSC CLASS Program Payment Rates.
  • Specs – Enter the cost of written specifications (if applicable) for adaptive aids costing more than $500 and minor home modifications costing more than $1000.
  • Inspection Fee (MHM Only) – Enter the inspection fee only for minor home modifications.
  • Frequency and Duration of Service – Enter the frequency and duration of service for each service category authorized on the individual's Form 3621.

8. New/Renewal — Use this section to calculate the sum of Old and Added/Reduced to reflect the service authorization as stated on the IPC (for IPC change). Use this section to state the number of service units, cost and requisition fee as reflected on the individual's renewal IPC (for renewal and initial IPC).

  • Units – Enter the number of units authorized for each service category on the individual's Form 3621.
  • Cost – Enter the cost of each service category authorized on the individual's Form 3621.
  • Req. Fee – For specialized therapies, include the total sum of the requisition fee [(hourly rate x .10) x total hours]. For adaptive aids and minor home modifications, include the requisition fee for the amount of the item or service as identified in the HHSC CLASS Program Payment Rates.
  • Specs – Enter the cost of written specifications (if applicable) for adaptive aids costing more than $500 and minor home modifications costing more than $1000.
  • Inspection Fee (MHM Only) – Enter the inspection fee only for minor home modifications.
  • Frequency and Duration of Service – Enter the frequency and duration of service for each service category authorized on the individual's Form 3621.

9. Need for Service — In cooperation with other members of the service planning team, document the individual's need for each service category authorized.

10. Goal(s) — Document individual-centered goal(s) for each service category authorized.

11. Objective(s) — Document measurable objective(s) (task analysis) needed to achieve each goal.

12. Title/Position of Person Responsible — Enter the job title/position of the person responsible for providing each service category authorized.

13. Service Start Date — Enter the anticipated start date for each service category authorized.

14. Projected Completion Date/Duration — Enter the projected completion date/duration of each service category authorized, including, but not limited to, specific time frames.

15. Non-Waiver Resources — Document any support service(s) provided by family or friends and/or obtained from other non-waiver resources in the community available to provide the service.

16. Service Start Date — Enter the anticipated start date for each service category authorized.

17. Projected Completion Date/Duration — Enter the projected completion date/duration of each service category authorized, including, but not limited to, specific time frames.

Signatures — The individual, LAR, case manager and DSA representative sign and date the form certifying that the information documented is complete and accurate, and the service increase is needed by the individual.