Effective Date: 
7/2017

Documents

 

Instructions

Updated: 5/2015

 

Purpose

This form is used to:

  • record the identifying information of the Deaf Blind with Multiple Disabilities (DBMD) applicant/individual;
  • enroll, revise, renew or terminate an individual's IPC, including:
    • IPC effective period,
    • services to be provided,
    • providers authorized to provide services, including Consumer Directed Services (CDS); and
    • record any services provided through the Community First Choice (CFC) option.
  • serve as a worksheet to compute estimated annual cost of DBMD and CFC service(s) for the individual;
  • register the individual's IPC in the Service Authorization System (SAS);
  • document the addition or termination of CDS through DBMD or CFC; and
  • terminate an individual from the DBMD/CFC program. CFC services can still be sought through managed care.

 

Procedure

When to Prepare

This form is completed by the case manager each time:

  • an applicant's/individual's initial eligibility is assessed for the DBMD/CFC program;
  • there is a need for revision in the individual's plan or to add CFC services;
  • the annual renewal of the IPC is completed; or
  • an individual is no longer eligible for the DBMD program. An individual may still be eligible for CFC through managed care despite losing DBMD eligibility.

The case manager may not use Liquid Paper or correction fluid to correct errors on Form 6500. If there is an error on the form, the case manager must:

  • line through the error and insert the correction above the error; and
  • initial the correction.

The case manager must send the corrected IPC to the individual/legally authorized representative (LAR) and the Financial Management Services Agency (FMSA), if applicable. The DBMD/CFC provider agency and the FMSA must keep all corrected IPCs in the individual's case record.

Number of Copies

Copies of all completed, signed and dated IPC forms must be provided by the case manager to all members of the service planning team (SPT), the FMSA (as applicable), individual, LAR and others as defined by the individual/LAR.

Transmittal

The case manager files the completed, signed and dated Form 6500 in the applicant's/individual's case record.

The case manager submits a copy of the completed Form 6500 to state office for data entry into SAS for enrolment IPCs, IPC revisions, IPC renewals and IPC terminations.

The case manager must mail or fax the completed, signed and dated Form 6500 to the following address:

Texas Health and Human Services Commission
DBMD Waiver Program, Mail Code W-521
P. O. Box 149030
Austin, TX 78714-9030

Fax Number: 512-438-5135

Form Retention

Each DBMD/CFC provider agency must keep Form 6500 according to the record retention requirements found in Texas Administrative Code, Chapter 49 (related to contracting for Community Care Services).

 

Detailed Instructions

Name of Individual (Last, First, MI) —Enter the applicant's/individual's legal name (last, first, middle initial) as shown on the individual's Medicaid identification, Social Security card or the full name as provided by the applicant/individual/LAR (enter at the top of each page).

Social Security No. — Enter the applicant's/individual's nine-digit Social Security number.

Medicaid No. (9 digits) — Enter the applicant's/individual's nine-digit Medicaid number as shown on the Medicaid identification. If the applicant does not have a Medicaid number at the time of the initial intake, leave this field blank.

DOB (MM/DD/YYYY) — Enter the date of birth (DOB) for the applicant/individual, using eight digits and following the month, day, year sequence.

Mailing Address of Individual (Street and/or P.O. Box, City, State, ZIP Code) — Enter the applicant’s/individual's residence, mailing address and/or post office box (city, state and ZIP code) in the DBMD provider’s region.

County Name —Enter the name of the county in which the applicant/individual resides. The DBMD/CFC provider must verify that the county is within the region the provider is authorized to provide services.

Vendor Name —Enter the name of the DBMD/CFC provider agency providing the identified services(s).

Vendor No. —Enter the seven-digit number assigned to the DBMD/CFC provider agency providing the identified service(s).

ABL — Enter the adaptive behavior level (ABL) as recorded on the Intellectual Disability/Related Condition (ID/RC) Assessment, Item 30.

IPC Effective Period (MM/DD/YYYY) — Enter the "From" and "To" dates for the IPC period in month, day, year (MM/DD/YYYY) sequence.

Example:

"From" date is Sept. 1, 2010, and "To" date is Aug. 31, 2011.

  • For an Enrollment IPC, the "From" date is the negotiated start date of services as determined by the service planning team. The "To" date is the last day of the previous month of the next year, after the "From" date.

    Examples:

    "From" date is Sept. 5, 2009, and "To" date is Aug. 31, 2010.
    "From" date is Sept. 1, 2009, and "To" date is Aug. 31, 2010.

  • For a Renewal IPC, the "From" date is the first day after the day the previous IPC ended, and the "To" date is a year minus one day after the "From" date.

Effective Date

  • For an Enrollment IPC, enter the negotiated start date of services as determined by the SPT.
  • For an IPC revision to add a new service category of DBMD or CFC services, or to change an existing service category of DBMD or CFC services, enter the negotiated start date as determined by the SPT.
  • For a Renewal IPC, enter the first day of the first month after the previous IPC ended.
  • For a Transfer IPC, enter the first day of service to be provided by the receiving provider and/or FMSA.
  • For a Termination of the IPC, enter the last date the individual is authorized to receive DBMD and/or CFC services. CFC services may still be pursued through managed care when an individual terminates from the DBMD waiver.

Enrolled from Code — Enter the code of the type of living arrangement of the applicant/individual. Codes and descriptions of living arrangements are as follows:

1 – Hospital
2 – Nursing Facility (Non-Rider 28)
3 – Community ICF
4 – Medicare/SNF
5 – Home
6 – State Institution
7 – Hospice
8 – Private Pay
9 – Other/Unknown
10 – *TDFPS Foster Home Placements Levels 1 and 2
11 – *TDFPS Child Placement Agencies
12 – Money Follows the Person (MFP) (Nursing Facility to Community)

*TDFPS = Texas Department of Family and Protective Services

For HHSC Use Only (Initial and Date) — Do not enter any information in these boxes.

Authorization Type — Indicate the type of authorization by placing an "X" in the appropriate box. Mark one box only as follows:

  • Enrollment IPC – Mark this box to enroll a new applicant.
  • IPC Revision – Mark this box to revise the IPC within the current IPC effective period.
  • IPC Renewal – Mark this box to renew the individual's enrollment period/services for another year.
  • Termination Code – Enter the two-digit code, if applicable, from the following:
Termination/
Computer Code
Reason for Termination Program Affected
01 The individual leaves the state for more than 180 days or moves to a county in which the DBMD program does not have a program provider to provide services. DBMD and CFC.
02 The operating agency or its designee has factual information confirming the death of the individual. DBMD and CFC.
04 The individual has been legally confined or has resided in an institutional setting for longer than 180 days. DBMD and CFC.
05 The individual requests service termination. DBMD only. CFC may be pursued through managed care. If an individual would like to terminate CFC, only an IPC change is needed.
06 The individual is not financially eligible for Medicaid benefits. DBMD and CFC.
07 The individual threatens the health/safety of the provider. DBMD and potentially CFC. CFC may be available through managed care.
08 The individual does not meet the level-of-care criteria for ICF as identified on the ID/RC. DBMD and CFC.
17 Failure to follow service plan or mandatory participation requirements of the DBMD program. DBMD only. CFC may be pursued through managed care.
18 The individual plan of care exceeds the cost ceiling for the DBMD program. DBMD only. CFC may be pursued through managed care.
19 DBMD providers have refused to serve the individual on the basis of a reasonable expectation that the individual's medical and nursing needs cannot be met adequately in the individual's residence.

DBMD and CFC potentially.

CFC can still be sought if there is another qualified provider which is willing and able to serve the individual.
20 The individual fails to pay his qualified income trust co-payment. DBMD only.
35 The individual is temporarily in a nursing home. This code is used when the individual will be re-opened for the same IPC period and the individual will not require new eligibility. DBMD and CFC.
36 The individual's whereabouts are unknown and the post office returns agency or designee mail directed to the individual indicating no forwarding address. DBMD and CFC.
37 The individual or someone in the individual's home has a substantial and demonstrated pattern of abuse, discrimination or harassment, not related to the individual's disability, of service providers which results in an inability to provide service(s) to the individual. DBMD only. CFC can be sought through managed care.
39 Other. Document the reason and attach the IPC. Potentially either DBMD or CFC, depending on the specific reason.

Type — For a revision IPC, enter the type of revision being requested for the service category/categories authorized for each DBMD waiver service. Enter N for New or C for Change in the box on the line of the appropriate service category to be added or revised on the IPC. To delete a service, use C. Do not enter an N or C on an enrollment IPC, renewal IPC or transfer IPC.

Backup Plan — Indicate if the individual requires a backup plan for identified services by placing an X in the appropriate box.

Mark one box or multiple boxes as applicable:

Service Code —— Listing of service codes available through the DBMD program or the CFC option.

Service Category — Listing of service categories available through the DBMD program or the CFC option.

Estimated Units —Enter the estimated annual service units for each DBMD or CFC service.

For service categories that do not have an established unit (16 – Minor Home Modification, 41B – Minor Home Modification Requisition Fee, 15 – Adaptive Aids, 41 – Adaptive Aids Requisition Fee, 5A – Dental, 5B – Dental Sedation), leave these fields blank.

For an IPC revision, determine the number of units to be added or deleted from the total number of estimated units to the end of the IPC year.

If the estimated cost of a service is being reduced or terminated, the cost listed must be equal to or greater than the total cost for which payment has already been made and/or billed, plus services delivered but not billed.

Unit Rate —Enter the current established unit rate of each service authorized. For service categories 10 – Habilitation/Day,  10CFC –  CFC PAS/HAB, 17 – Residential Habilitation – Hourly, 17E – Chore Services, 37-Supported Employment, 54-Employment Assistance and 45 – Intervener, enter the rate the DBMD provider is authorized under the DADS Rate Enhancement Contract, if applicable.

For service categories that do not have an established unit (16 – Minor Home Modification, 41B – Minor Home Modification Requisition Fee, 15 – Adaptive Aids, 41 – Adaptive Aids Requisition Fee, 5A – Dental, 5B – Dental Sedation), leave these fields blank.

Estimated Annual Cost — The online form will calculate this field. If this form is being completed manually, enter the dollar amount of the estimated annual cost for each service authorized. To calculate the estimated annual cost for service categories with established unit rate(s), multiply the estimated units by the unit rate.

For service categories that do not have an established unit (16 – Minor Home Modification, 41B – Minor Home Modification Requisition Fee, 15 – Adaptive Aids, 41 – Adaptive Aids Requisition Fee, 5A – Dental, 5B – Dental Sedation), enter the dollar amount of the estimated annual cost for each service authorized.

Subtotal — Enter the dollar amount of all authorized services to be provided by the DBMD provider.

Community First Choice (CFC) Services — Enter the estimated annual service units and the current established unit rate for service codes 10CFC and 20CFC.

CFC Subtotal — Enter the dollar amount authorized for CFC services. CFC totals are not reflected in the total estimated cost and do not contribute to the individual’s waiver cost ceiling.

Page 2 of Form 6500

Name of Individual, IPC Effective Period, IPC Effective Date and Medicaid No. — Enter the same information as it appears on Page 1 of Form 6500.

Consumer Directed Services (CDS)

Financial Management Services Agency (FMSA) Vendor Name (if applicable) — Enter the name of the FMSA providing the identified service(s).

FMSA Vendor No. (if applicable) — Enter the seven-digit number assigned to the FMSA providing the identified service(s).

Add or Terminate (if applicable) — Place an X in the box to indicate the addition of services or termination of services through the CDS option.

Type —— For a revision IPC, enter the type of revision being requested for the service category/categories authorized for each CDS DBMD or CFC waiver service. Enter N for New or C for Change in the box on the line of the appropriate service category to be added or revised on the IPC. To delete a service, use C. Do not enter an N or C on an enrollment IPC, renewal IPC or transfer IPC.

Backup Plan —Indicate if the individual requires a backup plan for identified CDS DBMD or CFC waiver services by placing an X in the appropriate box.

Mark one box or multiple boxes as applicable:

Service Code —Listing of service codes available through the CDS option in the DBMD or CFC program.

Service Category —Listing of service categories available through the CDS option in the DBMD/CFC program.

Estimated Units — Enter the estimated annual service units for each CDS category.

For an IPC revision, determine the number of units to be added or deleted from the total number of estimated units to the end of the IPC year.

If the estimated cost of a service is being reduced or terminated, the cost listed must be equal to or greater than the total cost for which payment has already been made and/or billed, plus services delivered but not billed.

Unit Rate — Already provided on the form.

Estimated Annual Cost — The online form will calculate this field. If this form is being completed manually, enter the dollar amount of the estimated annual cost for each CDS category authorized. To calculate the estimated annual cost for service categories with established unit rate(s), multiply the estimated units by the unit rate.

CDS Subtotal (if applicable) — Enter the dollar amount authorized for services to be provided through the CDS option. The CDS subtotal does not include the dollar amount authorized for Service Code 57V, Support Consultation. The procurement of services is the responsibility of the employee of record.

CFC CDS Services (if applicable) — Enter the estimated annual service units and the current established unit rate of each service authorized.

CFC CDS Subtotal (if applicable) — Enter the dollar amount authorized for SVC 10CFV and 63CFV to be provided through the CFC CDS option. CFC totals are not reflected in the total estimated cost and do not contribute to the individual’s waiver cost ceiling.

Transition Assistance Services (TAS)

TAS Vendor Name (if applicable) — Enter the name of the TAS agency providing the identified service(s).

TAS Vendor No. (if applicable) — Enter the seven-digit number assigned to the TAS agency providing the identified service(s).

Type — Enter the type.

Service Code — Listing of service codes available through TAS.

Service Category — Listing of service categories available through TAS.

Estimated Units — Enter the estimated annual service units for each TAS category. Service Code 53 does not have an established unit rate and the field should be left blank.

Unit Rate — Enter the current established unit rate for each TAS category authorized. Service Code 53 does not have an established unit rate and the field should be left blank.

Estimated Annual Cost — The online form will calculate this field. If this form is being completed manually, enter the dollar amount of the estimated annual cost for each TAS category authorized. To calculate the estimated annual cost for service categories with established unit rate(s), multiply the estimated units by the unit rate. For Service Code 53, enter the dollar amount of the estimated annual cost.

TAS Subtotal (if applicable) — Enter the dollar amount authorized for TAS. This amount includes the combined total for transition assistance services and the TAS agency fee. This service is only available for an applicant enrolling in the DBMD program.

CFC Support Management — Select Yes or No.

Subtotal — Enter the dollar amount of the DBMD Subtotal from the Subtotal box on Page 1 of Form 6500.

CDS Subtotal (if applicable) — Enter the dollar amount of the CDS Subtotal on Page 2.

TAS Subtotal (if applicable) — Enter the dollar amount of the TAS Subtotal on Page 2.

CFC Subtotal— Enter the dollar amount of the CFC Subtotal from the CFC Subtotal box on Page 1 of Form 6500.

CFC CDS Subtotal— Enter the dollar amount of the CFC Subtotal from the CFC Subtotal box on Page 2 of Form 6500.

CFC Total — Add the dollar amount of the CFC Subtotal, the dollar amount of the CFC CDS Subtotal, to determine the total cost of all CFC services.

Total Estimated Annual Waiver Cost— Add the dollar amount of the Subtotal, the dollar amount of the CDS Subtotal, and the TAS Subtotal (if applicable) to determine the total cost of all waiver services.

CFC and Waiver Total Estimated Annual Cost— Add the dollar amount of the CFC Total and the dollar amount of the Total Estimated Annual Waiver Cost to determine the total cost of all services.

Service Planning Team (SPT) Signatures and Date — The applicant/individual/LAR signs and dates the completed form. If the applicant/individual is unable to write his name, the applicant/individual may:

  • enter an X as an identifying mark (the X must be witnessed and dated), or
  • enter his name via a signature stamp and date.

If the applicant/individual has an LAR, the LAR must sign and date the form.

By signing Form 6500, the applicant/individual/LAR agree to the service plan for:

  • an enrollment IPC,
  • a renewal IPC,
  • an IPC revision, or
  • IPC termination.

The individual is not required to sign and date the IPC when services are being terminated, unless the termination is being made at the individual's request.

Case Manager and Date — The case manager signs and dates the form to certify that the identified services are appropriate to meet the needs of the applicant/individual in the community and to prevent institutional placement.

Provider Representative and Date — An employee of the provider agency who attends the SPT meeting can sign and date the form (for example, a nurse or direct service provider with knowledge of the applicant/individual). A nurse or program director is required to participate in the SPT.

Other and Date — Other members of the SPT sign and date the form. An FMSA employee may sign and date the form.

Other and Date — An authorized representative of the FMSA signs and dates the form agreeing that the IPC was received by the FMSA.

Note: The SPT representatives verify the accuracy of the information on the IPC, Pages 1 and 2, the estimated units and estimated costs for services to be delivered by the DBMD providers.

DBMD/CFC Program Contact and Date — The HHSC DBMD/CFC program contact signs and dates the form when approval is granted.

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