All CARE fields must be completed by the provider. (Note: Waiver program providers do not complete the "Physician's Evaluation and Recommendation" section.)
Age at date of onset (Item #22) must be before age 18 to qualify for mental retardation services and before age 22 to qualify for related condition services.
Do not use decimal points in diagnostic code entries.
Moderate mental retardation is coded 318.0, not 318, as 318 is not an acceptable DX code.
IQ (Item #29) must be 69 or below to qualify for a Texas Medicaid program based on a diagnosis of mental retardation.
IQ (Item #29) must be 75 or below with a diagnosis of a related condition to qualify for a Texas Medicaid waiver program under LOC 1 criteria. (Individuals enrolled under OBRA before Sept. 1, 2003, are exempt.)
Inventory for Client and Agency Planning (ICAP) Service Level (Item #33) and Recommended Level of Need (LON) (Item #18) must correlate, unless requesting a behavioral increase (or a Medical increase for individuals enrolled in the Intermedicate Care Facilitiy for Persons with an Intellectual Disability [ICF/ID] program).
Recommended Level of Care (LOC) (Item #17) must be either 1 or 8, depending on the diagnosis.
A "Y" as a response to Behavior Program (Item #34) does not mean that a "1" or "2" is necessary in any of Item #s 35-38.
If any one of Item #s 35-38 contain a "1" or "2," item #34 MUST be answered "Y."
A "1" in any of Item #s 35-38 indicates a request for increase of LON and will force the LON to next higher LON (Item #18), except for LON 6.
A "2" in any of Item #s 35-38 indicates a request for a LON 9 and will force any recommended LON (Item #18) to a "9."
A physician's evaluation and recommendation is not required for waiver programs (Item #s 48-55). However, if any items in this section have information entered, all items must be completed.
For ICF/ID programs, or if the provider does put a physician's signature on the waiver ID/RC:
Physician's responses on Item #s 48-51 MUST be "Y, N, Y, Y" — in that order — or the individual is not eligible for services.
The initial ID/RC must be signed by an M.D. (this includes psychiatrists) or a D.O. For admission to an ICF/ID, the M.D./D.O.'s signature is required. Signature by designee is allowed for subsequent ID/RC assessments. Renewals may be delegated to and advance practice nurse/physician assistant. When delegated, both license numbers are required. The ID/RC must include the physician's license number and the date signed.
The physician's evaluation and recommendation section is still required for ICF/IDs, except when submitting a Purpose Code 4.
Updated: September 5, 2012
