Form 3608: Texas HCS and CFC Services Individual Plan of Care (IPC)

Enter the Person's Name (Last, First, MI), Medicaid No., IPC Begin Date, IPC End Date and IPC Effective Date.

Enter the Street Address, City, State, ZIP Code, Date of Birth, Age and Level of Need.

Enter the Program Provider, Program Provider Vendor No. and Program Provider Contract No., then the Financial Management Services Agency (FMSA), FMSA Vendor No. and FMSA Contract No.

Under Residential Type, check Host Home/Companion Care, Own Home/Family Home, Supervised Living or Residential Support Services.

Enter the Location Code and County of Service.

Check the IPC type that describes the reason for completing Form 3608.

Initial Enrollment, Renewal, Transfer: Contract or Service Delivery Option, and Revision to Reflect Person-Directed Plan (PDP) Change: IPC Meeting Required.

Check Meets Emergency Criteria Section in 263.302 if the revision is because of an emergency.

Revision to add or change requisition fee only: No IPC meeting is required.

Revision to change CFC support management: No IPC meeting is required, but all parties must sign the IPC.

Revision to increase or decrease an existing Home and Community-based Services (HCS) or Community First Choice (CFC) service: if the increase or decrease requires a new outcome, this option must not be used because the Service Planning Team and provider must meet to revise the PDP. The IPC effective date for an increase or decrease must be on or after the date the provider notified the service coordinator (SC) in writing of the need to increase or decrease a current HCS or CFC service.

Under Non-HCS or CFC Services Provided by Family and Other Funding Sources, enter the Type of Service, Funding Source, No. of Hours Per Day, No. of Days Per Week and Name of Provider.

In HCS Services, enter the Provider, I or D and Authorized Units for each Service.

In the Provider Service I or D* column, for a revision to increase or decrease an existing HCS service, enter I for the service component being increased or D for the service component being decreased.

For Consumer Directed Service (CDS), enter I or D, Authorized Units and Authorized Dollars.

Select respite or in-home respite as appropriate and use the correct service rate to determine the authorized dollar amount. The rates for respite and in-home respite are different.

The service limit for respite and in-home respite combined cannot exceed 300 hours during an IPC year.

Are any services determined critical and require a service back-up plan? Yes or No.

Are any services included on this IPC staffed by a relative or guardian? Yes or No.

Will the person receive CFC Support Management? Yes or No.

If the revision or change is to add CFC Support Management, enter the date.

In CFC Services, enter the CFC Provider, I or D and Authorized Units for each Service.

For CFC CDS Service, enter I or D, Authorized Units and Authorized Dollars.

For certifications completed during enrollment and renewals: Person or LAR was informed upon enrollment of the person's rights and responsibilities.

Person or LAR was informed upon enrollment of the process for filing a complaint and reporting allegation of abuse, neglect or exploitation.

Person or LAR was informed upon enrollment and annually of the person's option to transfer to other program providers as chosen by the person as often as desired.

By signing under HCS Program Provider and Person or Legally Authorized Representative (LAR) Signature, you agree that the HCS or CFC services for this person are necessary to protect the person's health and welfare. You agree these services are not available to the person through any other source, including the state plan, other governmental programs, private insurance or the person's natural supports. You agree these services are the most appropriate type and amount to meet the person's needs, are cost effective and are necessary to enable community integration and maximize independence.

Under HCS Program Provider and Person or Legally Authorized Representative (LAR) Signature, SIGN, then enter the Printed Name and Date.

(1) If the person or LAR participates in person and agrees with the IPC, the person or LAR signs, prints their name and enters the date of the IPC meeting. If the agreement is obtained by phone, the provider checks the box and enters the date of agreement. The provider then sends a copy of the form to the person or LAR for signature.

(2) For an IPC revision that adds or changes a requisition fee only, the provider enters requisition fee only in the person's signature line and enters the IPC effective date as the signature date.

(3) For an IPC revision that documents a change in CFC support management, the program provider obtains the person's or LAR's signature and indicates the date on the form when CFC support management is changed. A copy of the form is sent to the SC for signature. The effective date of the IPC remains the same and this change is not entered into the HHSC data system.

If HHSC Review and Authorization is required, SIGN and enter the Date.

For the LIDDA or SC Response to IPC Revision to increase or decrease an existing HCS or CFC Service, IPC Participation and Signature, enter the LIDDA Name.

Check SC agrees with the IPC revision and no IPC meeting is required, or SC determines an IPC meeting is needed and enter the Reason.

Before checking SC determines an IPC meeting is needed, the SC contacts the provider and discusses any questions or concerns about the requested revisions. After the discussion, if the SC determines an IPC meeting is needed, the SC checks the IPC meeting is needed box, includes the reason for the meeting, signs, prints name and returns this form to the program provider. The SC then schedules a meeting with the person or LAR and the program provider as soon as possible but no later than 14 calendar days.

Under Service Coordinator IPC Participation, check the applicable option: Service Coordinator was notified of IPC revision that increases or decreases an existing HCS or CFC service and does not require an IPC meeting; Service Coordinator participated in the IPC meeting in person; Service Coordinator participated in the IPC meeting by phone; No Service Coordinator participation required; or Requisition Fee only.

For Program provider notified SC, enter the date, then the Printed Name of Service Coordinator and Date.

Under Service Coordinator Signature, SIGN, then enter the Printed Name and Date.

In the Service Coordinator Response to IPC Revision to Increase or Decrease an Existing HCS or CFC Service, return the form to the provider within two business days after the provider submits the notification of needed change to the SC.