Page 190 - QAP Manual 2020

NCI™ ADULT IN-PERSON SURVEY (IPS) 2020-21

BI-56 What is the funding for supports for this person? (Please obtain this information from a state
data system or official record if possible.) Check ALL THAT APPLY.

□ 1. ICF/IID (Intermediate Care Facility for individuals with intellectual disabilities) Funded
□ 2. Medicaid HCBS Waiver-Funded Services
□ 3. Medicaid State Plan Funded Services
□ 4. Exclusively supported by State Funds (no Medicaid long-term services and supports (LTSS)
and is not receiving Medicaid health care)
□ 5. Exclusively supported by State Funds (no Medicaid long-term services and supports (LTSS)
but is receiving Medicaid health care)
99. Don’t know

BI-57 Does this person currently receive Medicare?

□ 1. No
□ 2. Yes
□ 99. Don’t know

BI-58 What was the date of this person’s last Annual IPP meeting?

An Annual IPP meeting is a meeting in which the individual and those close to him/her
meet with a service coordinator to discuss a plan for supports to help the individual
meet his/her goals. This meeting typically occurs at least once a year.

(MM/DD/YYYY) _______/_______/_______
BI-59 In this person’s IPP, is there a goal to create, expand, strengthen and/or maintain friendships
and relationships?

□ 1. No
□ 2. Yes
□ 99. Don’t know

BI-60 In this person’s IPP, is there a goal to increase this person’s participation in activities in the
community?

□ 1. No
□ 2. Yes
□ 99. Don’t know

BI-61 In this person’s IPP, is there a goal to increase independence or improve functional skill
performance in activities of daily living (ADLs)?

□ 1. No
□ 2. Yes
□ 99. Don’t know

Page 27 of 76