August 1st, 2021
Information Letter No. 21-32 –Requirements for IPC Submissions for Individuals Requesting Services Funded with General Revenue
This information letter describes the documentation that a CLASS case manager, DBMD program provider, HCS service coordinator, or HCS program provider must submit to HHSC to request the use of general revenue to pay for services above the individual cost limit of a waiver program.
To justify a request to use general revenue when an individual is enrolling in the CLASS, DBMD, or HCS Program or when an individual’s individual plan of care (IPC) is being revised or renewed:
● The individual’s IPC must be electronically transmitted to HHSC using the HHSC Data System.
● The following additional documentation must be submitted to HHSC through the HHSC portal, or by email or regular mail:
An IPC that is identical to the electronically transmitted IPC and contains all required signatures of the service planning team
For an individual in the HCS Program, the person-directed plan and implementation plans for all services included on the IPC
For an individual in the CLASS or DBMD Program, the individual program plan
A current comprehensive nursing assessment by a registered nurse who is employed by or contracts with the CLASS direct services agency, or the HCS or DBMD program provider
Physician orders used by the registered nurse to develop the IPC
If a home and community support services agency will provide the nursing on the IPC, CMS form 485, Home Health Certification and Plan of Care
If a nurse employed by or contracting with an HCS program provider will provide the nursing on the IPC, documentation containing the same information as CMS form 485, signed by a physician
Nursing notes from the two-week period immediately preceding submission of the documentation
Medication administration record sheets from the two-month period immediately preceding submission of the documentation
Records, notes, and orders of a primary care or specialty physician that are relevant to the services on the IPC, including office visit notes documenting the individual’s current medical conditions. Preprinted after-visit instructions and office notes from a nurse, nurse practitioner, or physician assistant do not meet this requirement. Office visit notes must be dated within the 12-month period immediately preceding submission of the documentation.
The following additional documentation, if relevant, may be submitted to HHSC to justify a request to use general revenue when an individual is enrolling in the CLASS, DBMD, or HCS Program or when an individual’s IPC is being revised or renewed:
● Records related to an individual’s health, such as blood sugar levels, bowel movements, seizures, and suctioning
● Hospitalization paperwork and discharge notes from the one-year period immediately preceding the submission of documentation
● Documentation to support unusual or new diagnoses, such as a comatose or vegetative state
● Hospice assessment, if applicable
● Community First Choice Personal Assistance Services/Habilitation Assessment form
● Evidence of a determination of whether to delegate health maintenance activities, as defined in 22 TAC §225.4, and, if delegated, documentation of delegation monitoring, such as nursing notes describing monitoring or training of unlicensed staff
A CLASS case manager, DBMD program provider, HCS service coordinator, or HCS program provider must respond to a request from HHSC for additional information.
When an IPC is being renewed, the documentation described in this letter must be submitted 30-60 days before the effective date of the renewal IPC.
HHSC does not authorize an IPC for which general revenue is requested until a review of the documentation described in this letter is completed by HHSC.
If you have any questions about submitting a request to use general revenue to pay for services above the individual cost limit of a waiver program, please call Utilization Review at: (512) 438-5055.