Effective Date: 
9/2015

Documents

Instructions

Updated 8/1/2018

PURPOSE

Form 8582, the Texas Home Living program (TxHmL)/Community First Choice (CFC) Individual Plan of Care (IPC), is used by the Texas Health and Human Services Commission (HHSC), TxHmL waiver program providers and Local Intellectual and Developmental Disability Authorities (LIDDAs) to document an individual's TxHmL, CFC, and non-TxHmL/CFC services.

IPC -- Individual plan of care. A written plan that states:
     • The type and amount of each TxHmL program service and each CFC service, except for CFC support management, to be provided to an person during an IPC year
     • The services and supports to be provided to the person through resources other than TxHmL program services or CFC services, including natural supports, medical services and educational services
     • If a person will receive CFC support management
     • Is authorized by HHSC 

Form 8582 The Individual Plan of Care must be completed in accordance with Texas Administrative Code, Title 40, Part 1, Chapter 9, Subchapter N, Texas Home Living Program and Community First Choice, §9.558 Individual Plan of Care and §9.568 Revisions and Renewals of Individual Plans Care, Levels of Care, and Levels of Need for Enrolled Individuals.

PROCEDURE

When to Prepare

The IPC is developed in the following events:
     • Enrollment – After members of the service planning team (SPT) develop a person-directed plan (PDP) for an applicant, the service coordinator and the applicant or LAR develop the proposed enrollment IPC based on the PDP. When the person has chosen a program provider, the service coordinator             (SC) must review the proposed enrollment IPC with the selected program provider to negotiate and finalize the proposed enrollment IPC. Prior to the applicant's service begin date, the LIDDA must provide to the selected program provider and FMSA, if applicable, a copy of the enrollment IPC approved         by HHSC. 
     • Renewal – Annually, and before the expiration of an IPC, the SPT and the program provider review and revise the PDP and IPC to determine if individual outcomes and services previously identified remain relevant. The SC, in collaboration with the SPT, revises the PDP and IPC in response to                        changes in the individual’s needs and identified outcomes.
     • Transfer – A transfer IPC is developed by the SPT when someone receiving services from a TxHmL program provider transfers to another TxHmL program provider or is choosing a different service delivery option, either to change from receiving services from the agency option to CDS option or from              CDS option to the agency option.
     • Revision –There are two types of IPC revisions:
           o Revision to change the amount or type of TxHmL or CFC services, including an IPC revision to only add or change a requisition fee.
           o Revision to add or change Support Management Only– This type of IPC revision is used to add or change to Support Management if requested. A person must be receiving CFC services to receive Support Management. 

Submission

The LIDDA SC is responsible for submitting  the proposed enrollment IPC, annual IPC renewals and necessary IPC revisions to HHSC.

Form 

The program provider or CDS employer and the SC or all, must maintain a copy of the completed Form 8582 in the individual's record.

Questions

To inquire about IPC enrollment or transfers related to Form 8582 or instructions call the HHSC Intellectual and Developmental Disability (IDD) Program Eligibility and Support message line at 512-438-2484

To inquire about IPC revisions or renewals related to Form 8582 or instructions, call the HHSC Intellectual and Developmental Disability (IDD) Waivers Utilization and Review message line at 512-438-5055.  

DETAILED INSTRUCTIONS

Before entering an IPC in the Client Assignment and REgistration (CARE) system, the Form 8582 must be completed and signed by the required SPT members. The hard copy of the IPC in the individual’s record on file with the TxHmL provider  or the CDS employer and LIDDA, must match the IPC data entered in CARE.

Page 1

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

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

Client Assignment and Registration (CARE) ID No. — Enter the individual's CARE system identification number (shown in CARE as Client ID).

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

IPC Begin Date — Enter the begin date of the IPC. 

IPC End Date — Enter the date the IPC year ends. The end date of an IPC is 365 days after the IPC begin date. To determine the current begin and end date of an IPC, view CARE screen C62.

IPC Type — Select the IPC type that describes the reason for completing the IPC. Check only one: 

   • Enrollment (Initial) 
   • Revision
   • Annual Renewal
   • Transfer: Contract/Service Delivery Option
   • Revision for Support Management Change Only

Effective Date — Enter the IPC effective date. 

Program Provider Information:

If the individual is self-directing all TxHmL service through the CDS option, skip to the FMSA Information section of these instructions.

If the individual is receiving any TxHmL or CFC services from a program provider, enter the following information:

   • Program Provider — Enter the legal name of the program provider (do not enter the doing-business-as (DBA) name).
   • Component Code — Enter the program provider's component code.
   • Location Code- Enter OHFH (own home family home).
   • Contract No. — Enter the program provider’s contract number.
   • County of Service — Enter the name of the county in which the individual resides.
 

Authorized Units —Enter the requested amount of each TxHmL service to be provided by a program provider for the IPC year. For an IPC revision or for a transfer IPC, enter the total amounts already provided from the IPC begin date through the revision or transfer effective date as well as amounts to be provided from the revision or transfer effective date through the end date of the IPC. 

FMSA Information:

If the individual is not using the CDS option, skip to page 2.

If the individual is self-directing any TxHmL or CFC services through the CDS option, enter the following information:

   • Financial Management Services Agency (FMSA) — Enter the name of the FMSA. 
   • FMSA Contract No. — Enter the contract number for the FMSA connected to the individual.
   • FMSA Component Code — Enter the FMSA's component code.

Authorized Units — Enter the requested amount of each TxHmL service to be provided through the CDS option for the IPC year. For an IPC revision or for a transfer IPC, enter the total number amount already provided from the IPC begin date through the revision or transfer effective date as well as the amounts to be provided from the revision or transfer effective date through the end of the IPC.

Page 2

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

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

IPC Begin Date — Enter the begin date.

IPC End Date — Enter the end date.

IPC Effective Date — Enter the effective date.

Are any Services determined as critical, requiring a service back-up plan? — Select Yes or No.

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

Support Management? — Select Yes or No. The effective date of the addition or change must be entered next to the selection. The IPC must be signed and dated by the required SPT members.
To ensure accurate calculations are captured on the hard copy of the IPC, fill in the following fields after entering the IPC into the CARE system. The CARE system auto-calculates these fields based on units/dollars for services entered: 

         • Summary Totals for TxHmL Services
         • Estimated TxHmL Program Provider Annual Total
         • Estimated FMSA Annual Total
         • Estimated IPC Total

CFC Services

CFC Service/CFC CDS Service

I/D — For an existing CFC service, indicate the need to increase or decrease the service by entering I (increase) or D (decrease) in the column next to the service

Authorized Units — Enter the requested amount of each CFC service to be provided by the TxHmL program provider or CFC service provided under the CDS option for the IPC year. For an IPC revision or for a transfer IPC, enter the total amount provided from the IPC begin date through the IPC effective date as well as the total amount to be provided from the IPC effective date through the end date of the IPC.

To ensure accurate calculations are captured on the hard copy of the IPC, complete the following fields after entering the IPC into the CARE system. The CARE system auto-calculates these fields based on units/dollars entered:

     • CFC Annual Total 
     
TxHmL and CFC Annual Combined Total

Non-Waiver Funded Day Activity –If the individual participates in day activities not funded by the TxHmL program, complete this section for each non-waiver funded day activity the individual attends.

    • Name of Day Activity- Enter the name of the non-waiver day activity the individual attends.
    • Address- Enter the address of the non-waiver day activity the individual attends.
    • No. of Hours Per Day- Enter the average number of hours a day the individual attends a non-waiver day activity.
    • No. of Days Per Week- Enter the average number of days per week the individual attends the non-waiver day activity. 
    • Type of Services Provided- Describe types of services provided or what the individual does at the non-waiver funded day activity. 

Educational Services– Complete this section if the individual receives educational services.

   • Name of School- Enter the name of the school the individual attends.
   • Address- Enter the address of the school the individual attends.
   • No. of Hours Per Day- Enter the number of hours per day the individual attends school. 
   • No. of Days
   • Type of Services Provided- Enter services provided in addition to educational services, such as, Physical Therapy, Occupational Therapy.

Non-Waiver Services Provided by Family– Complete this section if non-waiver funded services are provided by family.

    • Type of Service- Enter the type of non-waiver services the individual is receiving or will receive from a family member. 
    • Service Description- Enter a brief description of the non-waiver service that the individual receives from a family member.
    • No. of Hrs Per Day- Enter the average number of hours per day the individual receives a non-waiver service from a family member.
    • No. of Days Per Week- Enter the average number of days per week the individual receives a non-waiver service from a family member.
    • Name of Provider- Enter the name of the family member providing the service.     
    • Relationship to the Individual- Enter the non-waiver service provider’s relationship the individual.

 Page 3

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

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

IPC Begin Date — Enter the date the IPC began or will begin.

IPC End Date — Enter the date the IPC ends.

IPC Effective Date — Enter the effective date.

Services Provided by Other Funding Sources

    Type of Service — Enter a brief description of the type of service the individual is receiving or will receive. This would include any non-TxHmL waiver or CFC services that is provided to the individual.  

    • Name of Provider — Enter the name of the family member or agency providing the service.

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

Service Planning Team Signatures

Signature – Before electronic transmission to HHSC, a person’s IPC must be signed and dated by the required service planning team members indicating agreement that TxHmL and CFC services for the person are not available through other resources, are necessary to prevent institutionalization, assure health and safety, and are based on outcomes on the person-directed plan.

    • LIDDA Service Coordinator — Signature of the SC who coordinated the development of the IPC.
    • Printed Name — Enter the printed name of the SC who signed the IPC.
    • Date — Enter the date the SC signed the IPC.
    • Signature – Individual/LAR — The individual must sign unless there is an LAR, in which case the LAR's signature is required. 
    • Date — Enter the date the individual/LAR signed the IPC. 
    • Signature-FMSA – Signature of the FMSA representative, if an individual chooses the CDS option for any services. The signature of the FMSA is not required.
    • Date- Enter the date FMSA representative signed the IPC

TxHmL Program Provider Agency Name – Enter the legal name of the program provider, if the individual chooses the agency option for any services. Do not enter the doing-business-as (DBA) name.

    • SignatureProgram Provider Representative — Signature of the program provider representative, if the individual chooses the agency option for any services.
    • Printed Name — Enter the printed name of the program provider representative who signed the IPC.

Date — Enter the date the program provider representative signed the IPC. 

HHSC Review and Authorization (if required)

Signature – HHSC Authorized Representative —The HHSC authorized representative signs the form should a utilization review be conducted.
Date —The HHSC authorized representative enters the date the IPC utilization review was completed by the HHSC authorized representative.
 

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