Form 8658, Enhanced Community Coordination (ECC) Designated Funds Request and Authorization

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Documents

Effective Date: 1/2024

Instructions

Updated: 3/2024

Purpose

The local intellectual and developmental disability authority (LIDDA) uses this form to request Enhanced Community Coordination (ECC) Designated Funds. ECC Designated Funds are for people who need help and are transitioning or diverting from a nursing facility, state supported living center, or large or medium intermediate care facility for people with an intellectual disability or related conditions to the Home and Community-based Services (HCS) Program. These funds are a one-time benefit for people receiving ECC services up to 365 days after transition or diversion to the HCS Program. Review the LIDDA Handbook and the PASRR Handbook for more information.

Use this form to:

  • record the person’s essential or special needs for ECC Designated Funds;
  • provide estimated amounts for items and services; and
  • authorize the designated LIDDA to purchase items and services.

Waiver, non-waiver, third-party, community resources, Transition Assistance Services (TAS), and Supplemental Transition Services (STS) must be accessed or be denied before ECC Designated Funds are provided.

Procedure

When to Prepare

The LIDDA staff and the person receiving services or legally authorized representative (LAR) complete this form when a need is identified that has not been covered by other resources during a transition or diversion to the HCS waiver program.

Submission

Form 8658 is sent to IDD Money Follows the Person (MFP) for approval before any purchases are made. IDD MFP staff sends the approved form to the LIDDA contact.

Purchase and Delivery of ECC Items or Services

The LIDDA coordinates, purchases and delivers the items and services listed on the authorized ECC Designated Funds form. Once items and services are delivered, the signature of the person or LAR confirms the items and services were received. The LIDDA staff provides a completed and signed copy of the form to the person or LAR and the HCS provider.

Form Retention

The LIDDA staff and the HCS program provider must keep Form 8658 in the person’s record per HHSC records retention requirements.

Detailed Instructions

Person’s Name — Enter the name of the person receiving services.

CARE ID — Enter the person's CARE ID number.

Transition or Diversion — Select Transition or Diversion.

Request Date — Enter the date the form was completed.

Current Facility — For transitions, enter the name of the facility where the person currently lives. Do not enter only the type, such as NF or SSLC. Enter N/A for diversions.

Facility Address — For transitions, enter the address of the current facility. Enter N/A for diversions.

Facility Phone No. — For transitions, enter the current facility's phone number. Enter N/A for diversions.

Proposed Date of Transition or Diversion — Enter the date the person plans to transition or divert to the HCS waiver program.

Planned HCS Provider — Enter the name of the planned HCS provider the person chose.

Planned Community Address — Enter the address of the planned home or HCS provider home where the person plans to move in the community, if known.

Provider Contact — Enter a contact name for the planned HCS Provider.

Provider Contact Phone No. — Enter the phone number of the planned HCS provider contact.

LIDDA Requesting Funds — Enter the name of the LIDDA requesting the ECC Designated Funds.

LIDDA Contact — Enter the name of the LIDDA staff that should be contacted about this request for ECC Designated Funds.

LIDDA Contact Phone No. — Enter the LIDDA contact's phone number.

LIDDA Contact Email — Enter the LIDDA contact's email.

Planned Residential Setting — Select setting that applies: Own home or family home, three-person home, four-person home or host home/companion care.

Designation of Funds

Each cell in the table must be completed to the best of the LIDDA staff’s knowledge. Items and services identified and approved on this form are the only items and services that will be reimbursed using the LIDDA’s allocated ECC funds on their approved contractor form. If there are no allocated ECC funds listed on the current contractor form, a contractor form revision must be provided with this request.

Note: ECC Designated Funds are a one-time benefit of up to $2,500 for people diverting or transitioning to the HCS waiver program. Funds must be preapproved, or they will not be reimbursed.

Designation of Funds table — In this section, the HCS service planning team carefully reviews any of the person’s existing plans for moving to the community and assesses if the person needs help to address barriers not covered by other funding sources.

Sample (PDF)

Essential Needs 

To address an immediate need or gap of service that presents a barrier to success in the community.

Security Deposit — Enter security deposits for residential, utility and other services. In the "Description" box, enter the name and address of the residence, utility company or phone company. Security deposits may be paid as long as the:

  • payment is specifically for a security deposit and not rent;
  • apartment is in the person's name;
  • payment is for a one-time expense;
  • amount of the payment is no more than the equivalent of two months’ rent; and
  • security deposit is required to lease an apartment or home and to establish utility services for the home.

Nutritional supplements — Nutritional supplements must be deemed medically necessary and require written orders from a prescribing physician. Enter the name and quantity of each requested nutritional supplement in the description section. 

Clothing — Provide the clothing type, quantity, size and color of each item requested in the description section.

Medication — Prescribed medication can be covered with ECC Designated Funds. When a person is transitioning, it can take up to 30 days for the person’s Medicaid to update from facility Medicaid to community Medicaid, which can cause a disruption in the person receiving their prescribed medication. Enter the name and quantity of each requested medication in the description section.

Other — This includes items not covered by other funding sources such as a one-time grocery purchase, books for a vocational training class, uniforms needed for a technical school, safety wear, and moving expenses if the person is moving into their own home.

Subtotal for Essential Needs — This is the total for all entries in this category. When this form is filled out electronically, the subtotal is automatically calculated and entered in this field.

Special Needs

Minor Home Modifications (MHM) — ECC Designated Funds can be requested to address a person’s identified special needs, including MHM, not funded by other sources such as STS, TAS or third-party or community resources like home health and Habitat for Humanity. MHM are services that assess the need to arrange for and provide modifications or improvements to the person's living quarters. 

The LIDDA justification must include:

  • An explanation of how the MHM is necessary to make sure the person’s health, welfare and safety, accessibility or to enable the person to function with greater independence in the person’s home. 
  • For MHM, written specifications and bids, if required. 

Household items — Household needs include basic items to furnish a home. The LIDDA staff must be as specific as possible when describing what items are needed. The description should include size, color, specific types or any other identifying information the person specifies that will help meet the person’s needs.

Transportation for trial visits — ECC Designated Funds can be requested to provide transportation to and from trial visits with HCS community providers while the person is in the nursing facility or diverting from a facility.

Educational tuition assistance for a vocational program — Educational tuition assistance, such as vocational programs through community colleges or technical programs or schools to help the person develop the knowledge or skills to obtain community employment.

Subtotal for Special Needs — This is the total for all entries in this category. When this form is filled out electronically, the subtotal is automatically calculated and entered in this field.

Totals — This is the grand total of all subtotals in the Essential Needs and Special Needs tables. When this form is filled out electronically, the total is automatically calculated and entered in this field. This is the amount that may be authorized to the LIDDA to purchase approved items and expenses. Purchases may not to exceed $2,500.

Person’s Statement and Signature 

Printed Name — Person or Legally Authorized Representative (LAR) — Print the name of the person or LAR.

Signature — Person or LAR — Person or LAR signs in the designated box.

Signature Date — Enter the date the LIDDA staff signed the form.

Printed Name — LIDDA Staff — Print the name of the LIDDA staff that should be contacted regarding this request for ECC Designated Funds.

Signature — LIDDA Staff — The LIDDA staff signs in the designated box.

Signature Date — Enter the date the LIDDA staff signed the form.

Printed Name — Planned HCS Provider — Print the planned HCS provider representative's name.

Signature — Planned HCS Provider — Planned HCS provider representative signs in the designated box.

Signature Date — Enter the date the planned HCS provider representative signed the form.

Form Submission

The LIDDA must name each submitted form with the following naming convention:

  • Rename the file using "save as" and use the following naming convention for each form:
    • Form 8658
    • The person’s last name 
    • The person’s first name 
    • The date of the submission such as Sept. 1, 2023=09012023)

      Example: Form8658SmithBob05012022

The subject line on the email should be “Form 8658”. Scan the completed form and send by encrypted email to IDDMFPSubmissions@hhs.texas.gov. 

Note: If needed, send a request for a secure email to the same address.

Authorization- IDD MFP Use Only

This will be completed by IDD MFP. Once approved, the form will be returned to LIDDA Contact listed on the form.

Confirmation of Receipt of Goods and Services

Signature — Person or Legally Authorized Representative — Person or LAR signs the bottom of the form to acknowledge receipt of items or services.

Signature Date — Enter the date the person or LAR signed the form.

Questions

A LIDDA should contact IDDMFPSupport@hhs.texas.gov for questions or guidance on how to access funds or on the preapproval process.