Form 3608, Individual Plan of Care (IPC) – Home and Community-based Services

Effective Date: 7/2014

Availability

PDF: 3608.pdf

Instructions

Updated: 2/2014

PURPOSE

Form 3608 is used by Texas Department of Aging and Disability Services (DADS) staff, Home and Community-based Services (HCS) waiver program providers and local authorities (LAs) to document an individual's HCS and non-HCS services.

PROCEDURE

When to Prepare

The IPC is developed during the IPC meeting by:

  • the service planning team (SPT), which consists of the individual or legally authorized representative (LAR), the service coordinator (SC) and any other person invited by the individual/LAR; and
  • the program provider.

In most instances, an IPC meeting is necessary to develop the IPC. An IPC meeting occurs when the SPT and the provider meet in person or by telephone to review the individual's person-directed plan (PDP) and to discuss and identify necessary units of HCS and non-HCS services to support PDP outcomes. The IPC is developed at the following events:

  • Enrollment – The initial IPC is completed by the LA. An LA staff person develops the proposed initial IPC after developing the individual's PDP. When the individual has chosen a program provider, an LA SC, the individual/LAR and the provider hold an IPC meeting to negotiate and finalize the initial IPC.
  • Renewal – An annual IPC renewal is completed by the program provider before the current IPC expires. The provider and the SPT hold an IPC meeting to develop the annual IPC renewal based on the PDP.
  • Transfer – A transfer IPC is developed by the SC when an individual changes to another HCS contract or chooses a different service delivery option (meaning Consumer Directed Services (CDS) is added or removed as a service delivery option). The SPT and the receiving program provider hold an IPC meeting to develop a transfer IPC.
  • Revision – An IPC revision is completed by the program provider. There are three types of IPC revisions:
    • Revision to reflect PDP change – This type of IPC revision is used when adding or deleting an HCS service, or when increasing/decreasing an existing service that requires a new PDP outcome. Both of these situations require the SPT and the provider to hold an IPC meeting.
    • Revision to increase/decrease an existing HCS service – This type of IPC revision is used when the increase or decrease of the existing HCS service is associated with an existing outcome in the current PDP. This situation does not require the SPT and the provider to hold an IPC meeting.
    • Revision to add/change a requisition fee only – This type of IPC revision is used when only a dental, adaptive aid or minor home modification requisition fee is added or changed on an individual's IPC. This situation does not require the SPT and the provider to hold an IPC meeting nor does it require the provider to obtain agreement from the individual/LAR or SC.

Notes:

  • Consumer Directed Services – If an individual only uses the CDS option and does not have a program provider, the LA is responsible for ensuring that self-directed HCS services are included on the IPC any time an IPC is completed.
  • For more information regarding revisions and IPC meetings, see the IPC section of the HCS Handbook.

Transmittal/Submission

Except for an IPC revision for the emergency provision of services, the LA, program provider or SC enters the completed IPC in the Client Assignment and REgistration (CARE) system in accordance with the instructions in the IPC section of the HCS Handbook. If an individual only uses the CDS option and does not have a program provider, the LA is responsible for entering the IPC into CARE.

For an IPC revision for the emergency provision of services, the program provider faxes the hard copy of the completed Form 3608 to DADS Program Enrollment, along with documentation of:

  • the circumstances that necessitated providing the new HCS service or the increase in the amount of the existing HCS service, and
  • the type and amount of the service provided in response to the emergency.

Form Retention

The program provider and SC must maintain a copy of the completed Form 3608 in the individual's record.

Questions

To inquire about Form 3608 or instructions, call the DADS Intellectual and Developmental Disability (IDD) Waivers Program Enrollment message line at 512-438-5055.

DETAILED INSTRUCTIONS

With the exception of "Totals for CARE Screen C62 (for all services)," Form 3608 must be completed before entering the IPC information into CARE.

Client Identifying Information

Individual Name (Last, First, MI) — Enter the individual's last name, first name and middle initial.

Medicaid No. — Enter the individual's Medicaid number.

IPC Begin Date — Enter the date the IPC year began or will begin. This is the 12-month period starting on the date an initial or renewal IPC begins. (A revised or transfer IPC does not change the begin or end date of an IPC year.)

IPC End Date — Enter the date the IPC year ends (365 days following the IPC begin date). (A provider may view CARE screen C62 to determine an individual's current IPC end date.)

IPC Effective Date — Enter the IPC effective date as described below.

Initial (Enrollment) – The IPC effective date is the same as the IPC begin date. However, the IPC meeting must be held on or before the IPC effective date.

Renewal – The IPC effective date is the same as the IPC begin date. However, the IPC meeting must be held on or before the IPC effective date.

Transfer: Contract/Service Delivery Option – The IPC effective date is the date the individual will begin receiving services from the receiving provider. The IPC meeting must be held on or before the IPC effective date.

Revision to Reflect PDP Change – The IPC effective date must be on or after the date of the IPC meeting.

Special circumstances regarding the IPC effective date for an IPC revision are noted below:

  • Residential setting change: If the IPC revision is due to an individual changing residential type, the IPC effective date must be the date the individual begins receiving the new residential service type. The IPC meeting must be held on or before the IPC effective date.
  • Emergency provision of services: If the need for the revision meets the criteria for an emergency provision of services, as described in 40 Texas Administrative Code (TAC) §9.166(d), the IPC effective date is the date the emergency service was provided. (See Transmittal/Submission section of these instructions for additional requirements related to emergency provision of services and submission of an IPC.)

Revision to increase/decrease an existing HCS service – The IPC effective date must be on or after the date the provider notifies the SC of the revision.

Revision to add/change requisition fee only – The IPC effective date is the date the provider completes Form 3608.

Address (Street, City, State, ZIP) — Enter the individual's address.

Date of Birth — Enter the individual's date of birth.

Age — Enter the individual's age.

Level of Need — Enter the individual's currently authorized level of need.

CARE ID No. — Enter the individual's CARE system identification number.

If the individual is receiving any HCS services delivered by a program provider, enter the following information about the program provider:

  • Program Provider — Enter the name of the program provider.
  • Provider Component Code — Enter the program provider's three-digit component code.
  • Provider Contract No. — Enter the contract number for the program provider.

If the individual is receiving any HCS services delivered through the CDS option, enter the following information about the Financial Management Services Agency (FMSA):

  • Financial Management Services Agency (FMSA) — Enter the name of the FMSA. The FMSA is responsible for managing the costs for services provided under the CDS option.
  • FMSA Component Code — Enter the FMSA's three-digit component code.
  • FMSA Contract No. — Enter the contract number for the FMSA.

Residential Type — Mark the appropriate box to indicate the residential type for the individual.

Location Code — Enter the location code to which the program provider has assigned the individual.

County of Service — Enter the name of the county in which the individual resides.

IPC Type — Check the IPC type that describes the reason for completing Form 3608:

Initial (Enrollment) – IPC meeting required.

Renewal – IPC meeting required.

Transfer: Contract/Service Delivery Option – IPC meeting required.

Revision to Reflect Person-Directed Plan (PDP) Change – IPC meeting required. If the need for the revision meets the criteria for an emergency provision of services, as described in 40 TAC §9.166(d), the provider also checks the "Meets Emergency Criteria §9.166(d)" box.

Revision to increase/decrease an existing service – No IPC meeting is required. If this box is checked, the provider states the reason for the increase or decrease.

Revision to add/change requisition fee only – No IPC meeting is required.

Non-HCS Services Provided by Family and Other Funding Sources

Type of Service — Enter a brief description of the services the individual is receiving or will receive.

Funding Source — Enter the name of the funding source for the service.

No. of Hours Per of Day — Enter the number of hours per day the individual participates or will participate in the service.

No. of Days Per Week — Enter the number of days per week the individual participates or will participate in the service.

Name of Provider — Enter the name of the person/agency providing the service.

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Individual Name (Last, First, MI) — Enter the individual's last name, first name and middle initial (must match information on Page 1).

CARE ID No. — Enter the individual's CARE system identification number (must match number on Page 1).

IPC Begin Date — Enter the date the IPC began or will begin (must match date on Page 1).

IPC End Date — Enter the date the IPC ends (must match date on Page 1).

IPC Effective Date — Enter the effective date of the applicable IPC action (must match date on Page 1).

IPC Service Information

Provider Service/Consumer Directed Service (CDS) — Self-explanatory.

I/D — For any revisions to increase or decrease an existing HCS service, enter either I (service component is being increased) or D (service component is being decreased).

Authorized Units — Enter the requested amount of each provider service or service provided under the CDS option for the IPC year. For an IPC revision or transfer IPC, enter the total number of units already provided as well as those units to be provided in the future.

Totals from CARE Screen C62 (for all services) (To be completed after CARE data entry)

CDS Estimated Annual Total — Enter the estimated annual IPC total cost for all the HCS services provided under the CDS option as shown in CARE.

Program Provider Estimated Annual Total — Enter the estimated annual total IPC cost for all the HCS services to be provided by the program provider as shown in CARE.

IPC Estimated Annual Total — Enter the estimated annual cost of all HCS services (i.e., sum of CDS estimated annual total and program provider estimated annual total). The total amount of an IPC may be found in CARE Screen C02 or C62.

Are any services included on this IPC staffed by a relative or guardian? — Mark the appropriate box to indicate if any HCS services (including through the CDS option) are provided by the individual's relative or guardian.

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Individual Name (Last, First, MI) — Enter the individual's last name, first name and middle initial (must match information on Page 1).

CARE ID No. — Enter the individual's CARE system identification number (must match number on Page 1).

IPC Begin Date — Enter the date the IPC began or will begin (must match date on Page 1).

IPC End Date — Enter the date the IPC ends (must match date on Page 1).

IPC Effective Date — Enter the effective date of the applicable IPC action (must match date on Page 1).

HCS Program Provider/Individual/Legally Authorized Representative (LAR) Signature

Signature – Provider Representative — The provider representative who attended the IPC meeting signs the form. (For an IPC revision that increases/decreases an existing HCS service and does not require an IPC meeting, enter the name of the provider representative who obtained agreement from the individual/LAR. For an IPC revision that adds/changes a requisition fee only, enter the name of the provider representative who completed the form.)

Printed Name — Enter the printed name of the provider representative who is signing the IPC.

Date — Enter the date the provider representative attended the IPC meeting and signed the IPC. (For an IPC revision that increases/decreases an existing HCS service and does not require an IPC meeting, enter the date the provider representative obtained agreement from the individual/LAR. For an IPC revision that adds/changes a requisition fee only, enter the date the form was completed.)

Signature – Individual/LAR — The individual must sign unless there is an LAR, in which case the LAR's signature is required. The exception is for an IPC revision that adds/changes a requisition fee only, in which case the provider enters "requisition fee only." *

Printed Name — Enter the printed name of the individual or LAR who signed the IPC.* For an IPC revision that adds/changes a requisition fee only, the printed name of the individual or LAR is not entered.

Date — Enter the date the individual/LAR signed the IPC.* For an IPC revision that adds/changes a requisition fee only, enter the IPC effective date.

Individual/LAR participated by phone on: — Check this box if the individual/LAR participated and agreed by phone. Enter date of participation/agreement.

* (1) If the individual/LAR participates in person and agrees with the IPC, the individual/LAR signs, prints his name and enters the date of the IPC meeting. If the individual agrees by phone, the provider checks the appropriate box and enters the date of agreement. The provider then copies the form and sends it to the individual/LAR for signature. (2) For an IPC revision that adds/changes a requisition fee only, the provider does not need to obtain agreement from the individual/LAR and enters "requisition fee only" on the individual's signature line.

DADS Review and Authorization (if required)

Signature – DADS Authorized Representative — The DADS authorized representative signs the form should a utilization review be conducted.

Date — The DADS authorized representative enters the date the IPC utilization review was completed by the DADS authorized representative.

Local Authority/Service Coordinator (SC) Signature

Local Authority Name — Enter the name of the local authority providing service coordination.

Signature – Service Coordinator — The SC signs the form.**

Printed Name — Enter the printed name of the SC who signed the IPC.**

Date — Enter the date the SC signed the IPC.**

** (1) When the SC participates in an IPC meeting in person, the SC signs, prints his name and enters the date on the day of the meeting. (2) When the SC participates in the IPC meeting by phone, the provider writes "participated by phone" on the SC signature line, prints the SC's name and enters the date of the meeting. (3) For an IPC revision that increases/decreases an existing HCS service and doesn't require an IPC meeting, the provider writes "notified SC" on the SC signature line, prints SC's name and enters the date this form was submitted to the SC. (Submission of this form to the SC serves as notification of an IPC revision that does not require an IPC meeting.) (4) For an IPC revision that adds/changes a requisition fee only, the provider enters "requisition fee only" in the SC signature line and enters the IPC effective date as the signature date.

Note: For a revision that increases/decreases an existing HCS service and does not require an IPC meeting in which the individual/LAR agrees by phone, the provider may notify the SC of the revision prior to receiving the individual/LAR's signature.

Service Coordinator Response (For proposed service increase/decrease IPC revisions only)

The SC completes this section only if a provider notes on Page 1 under IPC Type that the IPC revision is to increase/decrease an existing HCS service and will not require an IPC meeting. In these cases, the SC must respond by completing this section and returning the completed Form 3608 to the provider. If an IPC meeting was held, this section is not completed.

SC agrees with the IPC revision. No IPC meeting is required. — If the SC agrees that the proposed IPC revision does not require an IPC meeting, the SC checks the first box and signs and prints his name, and then returns the completed Form 3608 to the provider within two business days after the provider sent it to the SC.

IPC meeting is needed. — If the SC determines further discussion is necessary, the SC contacts the provider as soon as possible to discuss concerns. If no consensus can be reached after this discussion, the SC checks the box indicating an IPC meeting is needed, includes a reason for determining that an IPC meeting is needed, signs and prints his name, and returns the completed Form 3608 to the provider within two business days after the provider sent the form to the SC. The SC is responsible for scheduling the IPC meeting to occur as soon as possible, but no later than 14 calendar days after being notified of the need for a revision from the provider.

There may be reasons why an SC believes an IPC meeting is needed, including:

  • the SC believes the revision may necessitate a PDP update,
  • the provider did not give a reason for a change of services,
  • the individual/LAR or other SPT member has requested a meeting, or
  • the SC has reason to believe that the revision is not in accordance with the individual's/LAR's wishes.

At the IPC meeting scheduled by the SC, the provider and the SPT complete a new Form 3608. For the IPC type, the provider checks "Revision to Reflect PDP Change." The IPC effective date must be on or after the IPC meeting date.

Refer to the IPC section of the HCS Handbook to review required actions following completion of this form.

 

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