Revision 17-6; Effective June 28, 2017

 

 

6100  Agency Option (AO)

Revision 17-1; Effective March 15, 2017

 

 

6110  Description

Revision 17-1; Effective March 15, 2017

 

Under the Agency Option (AO), the provider is responsible for managing the day-to-day activities of the attendant and all business details. Most individuals select the AO model because of the simplicity and convenience of receiving services. For example, under AO the individual is not responsible for:

  • locating qualified attendant(s) to provide services;
  • any negligent acts or omissions by the attendant(s), nor liable for those acts;
  • handling all conflicts with the attendant(s);
  • any business details related to service delivery; and
  • training the attendant(s).

 

6120  Selection of a Service Delivery Option

Revision 17-1; Effective March 15, 2017

 

All service delivery options are presented to the applicant/individual at the initial assessment and each subsequent annual recertification. Use Appendix XXXI, It's Your Choice: Deciding How to Manage Your Personal Assistance Services, to assist the individual or applicant in making his service delivery decision.

Obtain a signature on Form 1584, Consumer Participation Choice, and Form 2307, Rights and Responsibilities, indicating the individual's choice of options. The individual's signature on Form 2307 is acknowledgement of the presentation of all service delivery options. It is not necessary to complete Form 1584 at subsequent recertifications unless the individual changes his choice of service options.

If, at any time during the year, a current individual calls requesting information on service delivery options, present the information to the individual at that time.

 

6121  Individual Decision

Revision 17-1; Effective March 15, 2017

 

Maintain Form 1584, Consumer Participation Choice, in the individual's case record. Make sure the individual understands that he may request a service delivery option change at any time by contacting the case worker.

 

6130  Casework Procedures

Revision 17-1; Effective March 15, 2017

 

Casework instructions throughout the handbook assume that the individual has selected the Agency Option (AO) for service delivery, with the exception of:

No special procedures are necessary for the AO. Consult the above-referenced sections if the applicant or individual requests another service delivery option.

 

6200  Service Responsibility Option (SRO)

Revision 17-1; Effective March 15, 2017

 

 

6210  SRO Description

Revision 17-1; Effective March 15, 2017

 

The Service Responsibility Option (SRO) is a service delivery option that empowers the individual to manage most day-to-day activities. This includes supervision of the individual providing personal attendant services through:

  • Community Attendant Services (CAS),
  • Family Care (FC), and
  • Primary Home Care (PHC).

The individual decides how services are provided. It leaves the business details to a provider agency of the individual's choosing. See Appendix XXXI, It's Your Choice: Deciding How to Manage Your Personal Assistance Services, for a comparison of all available service delivery option features.

 

6220  SRO Roles and Responsibilities

Revision 17-1; Effective March 15, 2017

 

Form 1582-SRO, Service Responsibility Option Roles and Responsibilities, specifies the roles and responsibilities assigned to the individual, provider and case worker. They receive and sign Form 1582-SRO indicating their agreement to accept the SRO responsibilities.

 

6221  Case Worker Responsibilities

Revision 17-1; Effective March 15, 2017

 

The intake, referral and assessment procedures for the Service Responsibility Option (SRO) are handled in the usual way. The case worker is responsible for:

  • ensuring the individual has an opportunity to make an informed choice by providing an objective and balanced review of the options, and
  • monitoring the quality of services and service delivery.

Once the assessment is complete, the case worker is required to:

  • inform the individual about all options for managing personal attendant services, and
  • review Appendix XXXI, It's Your Choice: Deciding How to Manage Your Personal Assistance Services, with the individual to determine if the SRO is an appropriate choice.

In addition, the case worker's responsibilities include:

  • presenting all service delivery options;
  • documenting the individual's choice on Form 1584, Consumer Participation Choice;
  • explaining SRO rights, responsibilities and resources to the individual;
  • presenting the SRO service provider list and the SRO support consultation provider to the individual;
  • presenting the list of providers that are offering the SRO;
  • making a referral to the provider(s) selected by the individual;
  • processing the individual's request to change service delivery options;
  • redeveloping the service plan when an individual's needs change;
  • serving as a resource if the individual has health or safety concerns, or worries about being taken advantage of by the attendant;
  • convening an interdisciplinary team meeting in instances where the individual:
    • has health and safety concerns,
    • is having difficulty selecting or keeping an attendant, or
    • has other issues relating to services that cannot otherwise be resolved; and
  • monitoring services in accordance with Section 6232, Monitoring.

 

6222  Provider Responsibilities

Revision 17-1; Effective March 15, 2017

 

The provider is the attendant's employer and handles the business details (for example, paying taxes and doing the payroll). The provider also orients attendants to provider policies and standards before sending them to individuals' homes. The Service Responsibility Option (SRO) provider agency will:

  • discuss and negotiate potential back-up plans for those times when the attendant is absent from work;
  • send a maximum of three attendants, including any individuals recommended by the individual, for the individual to review;
  • explain to the selected attendants that the provider is the employer of record and that the individual is the day-to-day worker;
  • provide agency timesheets to the individual and orient the individual to the timesheet submission process, including how frequently timesheets must be completed;
  • receive and process attendant timesheets;
  • send a substitute attendant within the required time frame, ensuring that a break in services:
    • does not occur (for individuals with priority status), or
    • does not extend past 14 days (for individuals without priority status);
  • send new attendants within the required time frame to interview at the individual's request; and
  • orient the individual to the provider's attendant evaluation process, including forms and the schedule for evaluating attendants.

 

6223  Individual Responsibilities

Revision 17-1; Effective March 15, 2017

 

The individual or designated representative (DR) is responsible for most of the day-to-day management of the attendant's activities, beginning with interviewing and selecting the person who will be the attendant. To participate in the Service Responsibility Option (SRO), the individual must be capable of performing all management tasks as described below, or may identify a DR to assist or to perform those management tasks on the individual's behalf. The individual is responsible for:

  • choosing the SRO service delivery option;
  • choosing the SRO service and support provider(s);
  • meeting with the SRO support provider within 14 days of selecting the SRO;
  • coordinating with the provider supervisor as part of the service planning process by:
    • negotiating about the type, frequency and schedule of quality assurance contacts,
    • discussing any concerns about care management,
    • requesting on-site assistance while orienting a new attendant, if desired, and
    • negotiating to develop a back-up plan for when the attendant cannot come to work;
  • selecting personal attendant(s) from candidates sent by the provider (including someone the person recommends to the provider supervisor or someone who has completed the provider pre-employment screen);
  • informing the provider supervisor within 24 hours:
    • of the personal attendant selected,
    • if the attendant gives notice,
    • if the attendant quits, or
    • if the individual wants to dismiss the attendant;
  • training the personal attendant on how to safely perform the approved tasks in the manner desired;
  • supervising the personal attendant;
  • ensuring that the attendant only does the tasks authorized in the service plan and works only the number of hours authorized in the service plan;
  • complying with provider agency payroll and attendant policies;
  • evaluating the attendant's job performance at the time designated by the provider;
  • reviewing, approving and signing provider agency employee timesheets after the attendant completes them;
  • ensuring that employee timesheets are submitted to the provider within the time frames designated by the provider;
  • notifying the provider agency as soon as possible if the personal attendant will be absent and a substitute is needed;
  • taking responsibility for liability risk if the individual or attendant is injured while doing tasks under the individual's training and supervision;
  • using the following complaint procedures:
    • If the provider is not fulfilling the expected responsibilities, address those issues directly with the agency. If the agency and the individual are not able to resolve the concerns/issues, the individual should contact the case worker.
    • If concerns and issues are still not resolved, the individual may select another provider. The individual must contact the case worker to transfer from one agency to another. The case worker will make all the necessary arrangements for the transfer;
  • notifying the case worker and/or provider supervisor of any health or safety concerns or worries about being taken advantage of by the attendant (the individual may, at any time, request an interdisciplinary team (IDT) meeting); and
  • notifying the case worker and provider supervisor if a change to either the Agency Option or Consumer Directed Services is desired. An IDT meeting will be held to plan for the change.

 

6230  Casework Procedures

Revision 17-1; Effective March 15, 2017

 

The Service Responsibility Option (SRO) is not a different service; it is a service delivery option. All financial and non-financial eligibility criteria, including unmet need and "do not hire" policy, continue to apply for each program area. Unless otherwise stated in this section, casework procedures are not impacted by the individual's choice of SRO.

Complete all forms currently required, including the assessment of functional needs on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. Continue to identify any caregivers who are currently providing for the individual's needs. As discussed in Section 2514, Who Cannot Be Hired as the Paid Attendant, current caregivers are designated as individuals who may not be hired as paid attendants for services they are already providing. This information must be clearly explained to the individual, and the individual must be advised that the information will be relayed to the provider.

 

6231  Initial Authorization of Services

Revision 17-1; Effective March 15, 2017

 

The individual's decision to receive services using the Service Responsibility Option (SRO) does not change the manner in which initial services are authorized. See Section 2600, Authorizing and Reassessing Services, for specific information.

 

6232  Monitoring

Revision 17-1; Effective March 15, 2017

 

All monitoring for Service Responsibility Option (SRO) individuals is done according to the mandated schedule for their specific services (see Section 2710, Monitoring Visits and Contacts). When health and safety issues arise:

  • discuss the issues with the agency;
  • talk to the individual to determine if the issues can be resolved; and
  • if the issue cannot be resolved, convene an interdisciplinary meeting.

Because the individual now shares responsibility for service delivery, the case worker, in addition to other monitoring requirements, must monitor the individual's:

  • satisfaction with the SRO, and
  • ability to comply with SRO requirements.

If it is evident that the individual is having difficulty in the management of SRO responsibilities, the case worker will:

  • consult the provider; and
  • advise the individual of the option to transfer back to the agency service delivery option.

 

6233  Procedures for Ongoing Cases

Revision 17-1; Effective March 15, 2017

 

Individuals will be offered the Service Responsibility Option (SRO) option annually, and may request a transfer to the SRO at any time. Additionally, the SRO must be presented to ongoing individuals at each annual reassessment or upon request. If the individual is interested in transferring to the SRO, the individual will sign Form 1582-SRO, Service Responsibility Option Roles and Responsibilities.

Ensure that the individual understands the responsibility he is assuming. Send Form 2067, Case Information, to the provider to advise it of the individual's selection. Notify the provider that that the individual will be contacting it for training. Request that the agency advise the case worker, using Form 2067, when the transition planning is complete. Negotiate a start date with the individual and the provider.

 

6300  Consumer Directed Services (CDS)

Revision 17-1; Effective March 15, 2017

 

 

6310  Description

Revision 17-1; Effective March 15, 2017

 

The Consumer Directed Services (CDS) option gives the individual more control over his or her personal attendant services by making him or her the attendant's employer. The individual hires and manages the attendant(s), and selects a Financial Management Services Agency (FMSA) to do the employee's payroll and federal and state tax payments. The individual also sets the wages and benefits for his or her attendant. See Appendix XXXI, It's Your Choice: Deciding How to Manage Your Personal Assistance Services, for a comparison of available service delivery options.

Staff will encounter terminology that is specific to the CDS option, including the following.

  • Agency Option (AO) — A service delivery option in which the provider manages all aspects of service delivery with input from the individual and case worker.
  • Annual service plan (ASP) — A 12-month plan that identifies:
    • the individual's specific needs;
    • the annual cost of meeting those needs; and
    • how those needs will be met by the individual's employees and the FMSA.

See Section 6332.2, Calculation of the Annual Service Plan. Separate from “service plan” or “service planning,” the term ASP is used to determine the amount of service an individual will receive.

  • Designated representative (DR) — A willing adult appointed by the individual to assist with or perform the individual's required responsibilities to the extent approved by the individual. This individual is not an employee or the legally authorized representative (LAR) and is not paid for his or her services. The DR is not the legally recognized employer.
  • Employee — A person employed by the individual through a service agreement to deliver program services. This individual is paid an hourly wage for those services.
  • Employer — The individual or the LAR who chooses to participate in the CDS option.
  • Financial management services (FMS) — Services delivered by the FMSA to the individual or LAR, such as orientation, training, support, assistance with and approval of budgets, and processing payroll and payables on behalf of the employer.
  • Financial Management Services Agency (FMSA) – An agency contracted by the Texas Health and Human Services Commission (HHSC) to provide financial management to support the delivery of services to CDS individuals.
  • Legally authorized representative (LAR) — A person required by law to act on behalf of an individual who is:
    • for adults, a court-appointed guardian.
    • for individuals under 18 years of age, a parent, adopted parent, step-parent, foster parent or Child Protective Services (CPS). If parental rights have been revoked, the court-appointed guardian must be the LAR.
    • Any mention of the individual applies to the LAR.
  • Service planning team — A term in CDS rules that refers to the interdisciplinary team (IDT). An IDT is a designated group of people who meet when the need arises to discuss service delivery issues. Although other individuals may be asked to participate when needed, the IDT must include:
    • the individual, the individual's representative or both (if there is an LAR, he or she would be a required participant);
    • a provider representative; and
    • an HHSC representative.
  • Service Responsibility Option (SRO) — A service delivery method that gives the individual control over most of his or her attendant services, while leaving the business details to a provider of the individual's choosing.
  • Support consultation — An optional service available to CDS individuals that provides a higher level of assistance and training than what is available through FMS. Support consultation helps the individual meet the employer responsibilities of the CDS option.

 

6311  Risks and Advantages of the CDS Option

Revision 17-1; Effective March 15, 2017

 

Before the individual can make an informed choice regarding service delivery options, it is essential that he or she understand the risks and advantages of the Consumer Directed Services (CDS) option.

 

6311.1 Advantages of CDS Service Delivery

Revision 17-1; Effective March 15, 2017

 

When using the Consumer Directed Services (CDS) option, the individual:

  • has control over who provides services and when services are delivered;
  • can offer the attendant(s) benefits such as bonuses, vacation pay, sick pay and insurance;
  • can control the rate of pay for attendant(s) within the spending limits of the unit rate for the service;
  • can hire backup attendants, if necessary;
  • can train and supervise the attendant(s);
  • can choose a Financial Management Services Agency that will pay attendants and file reports with governmental agencies on their behalf;
  • may appoint someone to assist with employer responsibilities or to perform employer responsibilities for them; and
  • may get additional training and assistance from a CDS support advisor to be a successful employer in the CDS option.

 

6311.2  Potential Risks Associated with CDS

Revision 17-1; Effective March 15, 2017

 

Some of the risks associated with the Consumer Directed Services (CDS) option include:

  • The individual controls hiring, training, managing and firing employees. The attendants are not the employees of the Financial Management Services Agency (FMSA), Texas Health and Human Services Commission (HHSC), any state or federal agency, or other contracted provider. The individual is solely responsible and liable for his or her own negligent acts or omissions, as well as those of the employee(s), service provider(s) and the designated representative.
  • The individual is responsible for handling all conflicts with the attendant. The FMSA or HHSC case worker is not involved.
  • The individual is required to keep certain paperwork, as identified by the FMSA. The individual must safely store the documentation for the length of time specified by the FMSA.
  • The individual is ultimately responsible for payroll taxes owed to the Internal Revenue Service and the Texas Workforce Commission, and is liable for any taxes the FMSA fails to pay.
  • If the individual is unable to find attendants, backup attendants or out-of-home respite providers, there is no home health agency to provide backup services.

 

6320  Roles and Responsibilities

Revision 17-1; Effective March 15, 2017

 

Under the Consumer Directed Services option, the roles and responsibilities of the individual, case worker and provider differ from other service delivery options.

 

6321  Individual Responsibilities

Revision 17-1; Effective March 15, 2017

 

To participate in the Consumer Directed Services (CDS) option, the individual must be:

  • capable of performing all required employer responsibilities upon completion of training and transition planning provided by the Financial Management Services Agency (FMSA), or
  • able to appoint a designated representative (DR) to assist with the responsibilities of being an employer in the CDS option.

Required Employer Responsibilities

An employer is responsible for:

  • service planning with the individual's service planning team;
  • budgeting allocated program funds in the individual's service plan for services to be delivered through the CDS option;
  • determining compensation for service providers within the service rate and spending limits established by the Texas Health and Human Services Commission;
  • recruiting, screening, hiring, and training qualified service providers;
  • managing and terminating service providers; and
  • planning and arranging for backup services.

An employer or DR must hire or retain service providers in accordance with qualifications and other requirements of the individual's program.

Individuals receiving services in the CDS option also have the following responsibilities:

  • reviewing, approving and signing timesheets;
  • submitting employee timesheets, receipts, invoices and employment forms to the FMSA in a timely manner;
  • informing the FMSA of all employees the individual hires, fires or otherwise terminates;
  • resolving employee concerns and complaints;
  • maintaining a personnel file on each employee; and
  • finding appropriate out-of-home respite providers and negotiating a payment rate.

Designated Representative

40 Texas Administrative Code (TAC) §41.205, Employer Appointment of a Designated Representative

40 TAC §41.109(g), Enrollment in the CDS Option

The DR signs an agreement to perform employer functions on behalf of the CDS individual. The individual remains the employer of record and assumes liability. The FMSA can assist the individual in completing the forms for designation of the DR. The DR may not be hired as the personal attendant or be paid for his/her duties.

 

6322  Case Worker Responsibilities

Revision 17-1; Effective March 15, 2017

 

The case worker has specific responsibilities regarding Consumer Directed Services (CDS), which include:

  • explaining and offering the CDS option;
  • reviewing the self-assessment tool (Form 1582, Consumer Directed Services Responsibilities) with the individual to help determine if the CDS option is right for him or her;
  • assessing service needs;
  • coordinating development of the service authorization;
  • presenting the list of Financial Management Services Agencies (FMSAs) participating in the area;
  • informing the individual of his or her rights, responsibilities and resources;
  • redeveloping service authorizations when the individual's needs change;
  • reviewing each quarterly status report received from the FMSA;
  • contacting the FMSA or individual (as appropriate) if there are issues (for example, 50 percent of funds authorized on the annual service plan are already expended on the first quarterly report);
  • being a resource if the individual has health, safety or exploitation concerns; and
  • monitoring and reviewing the individual's satisfaction with the services provided by the FMSA.

 

6322.1  Casework Procedures

Revision 17-1; Effective March 15, 2017

 

Consumer Directed Services is not a service; it is a service delivery option. All financial and non-financial eligibility criteria must be met in order to receive personal attendant services. In addition to the procedures specified in the following sections, customary casework procedures apply.

 

6322.2  Presentation of the CDS Option

Revision 17-1; Effective March 15, 2017

 

The case worker is responsible for presenting information regarding the Consumer Directed Services (CDS) option to the individual. To assist the individual in making his or her decision, the case worker must carefully present both the advantages and risks associated with the CDS option.

Case workers must follow 40 Texas Administrative Code §41.109, Enrollment in the CDS Option, when presenting the CDS option to an individual.

The case worker thoroughly explains all information on Form 1581, Consumer Directed Services Option Overview, to ensure the individual understands the differences between the CDS and agency options.

 

6323  FMSA Responsibilities

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code (TAC) §41.309, Financial Management Services and Employer-Agent Responsibilities

40 TAC §41.317, CDSA Reports

 

6330  Individual Decision

Revision 17-1; Effective March 15, 2017

 

Case workers must follow 40 Texas Administrative Code §41.109(c)-(e), Enrollment in the CDS Option, to enroll an individual into the Consumer Directed Services (CDS) option using a Community Care for Aged and Disabled program.

To enroll in the CDS option, an individual must complete the following forms:

  • Form 1582, Consumer Directed Services Responsibilities, including Page 4,Consumer Self-Assessment;
  • Form 1583, Employee Qualification Requirements;
  • Form 1584, Consumer Participation Choice; and
  • Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option, if the service is available in the individual's program.

An individual who is not able to complete the self-assessment portion of Form 1582 must appoint a designated representative (DR) in order to participate in the CDS option.

Assist the individual in completing the individual self-assessment. The individual must document he/she is able to meet the following criteria needed to become a CDS employer:

  • Locate attendants for hire in the community;
  • Train and supervise attendants to perform each task on the service plan;
  • Locate and arrange for backup staff and out-of-home respite services, if needed;
  • Handle conflict with attendants; and
  • Be willing to accept additional training or help with employer responsibilities, if needed.

If the individual is not able to meet all of the CDS employer criteria, the individual must appoint a DR to assist with employer responsibilities. See Section 6321, Individual Responsibilities, for more information on the requirements of hiring a DR, if needed.

If the individual wants to proceed and meets the criteria, or has appointed a DR, present Form 1586 and Form 1583.

Whether the individual is or is not interested in the CDS option at the initial presentation, have him or her sign Form 1584. File the form in the individual's case record. Make sure individuals not interested in CDS understand that this option is available at any time, and that he or she must call the case worker to request the CDS option.

 

6331  Selection of the Financial Management Services Agency (FMSA)

Revision 17-1; Effective March 15, 2017

 

The Texas Health and Human Services Commission (HHSC) case worker or the individual may go to the HHSC website for a choice list of FMSA. The list, which allows individuals to search for FMSAs by county, can be accessed at: https://hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/consumer-directed-services-cds.

Under the menu on the left, select “FMS Agencies” and a list of HHSC programs will appear. Select “PHC Consumers.” On the top of the page is a drop-down list of Texas counties. After selecting the individual’s county of residence, click the button labeled "Search." This will create a list of FMSAs serving the selected county. The FMSA’s address does not have to be located in the individual’s county of residence to be able to serve the individual. As long as the FMSA is listed in the program and county list, the individual may select the agency as his/her FMSA. This list can be printed and provided to individuals choosing an FMSA.

FMSAs are not required to provide services to all referred individuals. In rare instances, such as anticipation of contract termination or placement on a vendor or individual hold, an FMSA may not accept individual referrals. FMSAs contract with HHSC to provide financial management services (FMS) to individuals choosing the Consumer Directed Services (CDS) service delivery option. FMS includes employer orientation, assistance with and approval of budgets, and processing payroll and payables on behalf of the employer. An FMSA must make available support consultation services if this service is available in the individual's respective program, and is requested by the individual. Support consultation offers employer training and support beyond the FMS provided by the FMSA.

Applicants and individuals use Form 1584, Consumer Participation Choice, to identify the choice of service delivery option and choice of Home and Community Support Services Agency (HCSSA) or FMSA, as appropriate. A list of FMSAs in each county is available on the HHSC website to assist the applicant or individual in making this choice. If the applicant or individual chooses CDS, the case worker has five working days from receipt of Form 1584 by an individual, or from receipt of Form 1584 and determination of eligibility for an applicant, to provide the required documentation to the selected FMSA. If the selected FMSA is not able to provide services to the applicant or individual, the FMSA must send the case worker written notification stating this, using Form 2067, Case Information. Receipt of written notification will prompt the case worker to offer the applicant or individual another choice of FMSA and to provide the newly selected FMSA with the required documentation, following the same procedures outlined above.

 

6332  Initial Authorization of Services

Revision 17-1; Effective March 15, 2017

 

Before receiving services under the Consumer Directed Services (CDS) option, applicants must:

  • be determined eligible for services; and
  • have a program service plan developed.

Note: Individuals do not have to receive services through the agency option before receiving services through the CDS option – they may go directly to the CDS option.

40 Texas Administrative Code §41.111, Service Planning in the CDS Option

During the initial home visit, provide applicants who choose CDS with the choice list of available Financial Management Services Agencies (FMSAs) for their program and county. After the applicant has made a decision, the applicant must sign the regional contract list indicating his or her FMSA selection.

Once an eligibility determination is made, and pre-enrollment requirements have been met (See Section 6332.1 that follows), authorize services on Form 2101, Authorization for Community Care Services. In the comments section, note the total annual hours at the current rate per hour and the total dollar amount for the annual service plan, as detailed in Section 6332.2, Calculation of the Annual Service Plan. Send Form 2065-A, Notification of Community Care Services, to the applicant as notification of eligibility.

 

6332.1  Pre-Enrollment Requirements

Revision 17-1; Effective March 15, 2017

 

Case workers must follow 40 Texas Administrative Code §41.401, Enrollment Process, to enroll an individual into the Consumer Directed Services (CDS) option.

Form 2101, Authorization for Community Care Service, must include the:

  • hours of service being authorized in the period; and
  • hourly payment rate for the service as specified in Section 6332.2, Calculation of the Annual Service Plan.

The case worker must contact the Financial Management Services Agency (FMSA) to request an initial orientation for the individual and send Form 1584, Consumer Participation Choice, to the FMSA to notify it that the individual has selected the agency. Request that the FMSA advise by Form 2067, Case Information, when the initial orientation is complete.

Once this notification is received, negotiate a CDS begin date with the individual and the FMSA. Send Form 2101, Authorization for Community Care Services, to the individual and the FMSA.

  • Authorize the monthly Financial Management Services (FMS) administrative fee using Service Authorization System Service Code 63V. For Community Attendant Services (CAS) applications and recertifications, the FMS fee must be authorized by the regional nurse. Request authorization for the FMS fee from the HHSC designated regional nurse.
  • Use the appropriate service code below to initiate CDS Services:
    • 17 V – Primary Home Care (PHC)
    • 17 CV – Family Care (FC)
    • 17 DV – CAS

 

6332.2  Calculation of the Annual Service Plan

Revision 17-1; Effective March 15, 2017

 

Consumer Directed Services (CDS) is authorized in the Service Authorization System Wizards (SASW) using an annual service plan (ASP). The case worker assesses the individual's need for services using Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. The ASP amount is calculated using the required weekly service units determined using Form 2060.

 

Note: In this example, the $9.50 amount is a fictitious number used for demonstration purposes only. The current CDS service rate can be accessed at the following Texas Health and Human Services Commission website: http://rad.hhs.texas.gov/long-term-services-supports.

Step 1: An individual is determined eligible for Primary Home Care (PHC), Community Attendant Services (CAS) or Family Care (FC) services, and selects the CDS delivery option.

The individual's needs are assessed at 10 hours of personal attendant services per week.
Step 2: The case worker calculates the ASP by extending the individual's weekly needs over a 53-week period by entering the information in the SASW. SASW will automatically calculate the annual hours and total dollar amount of the ASP.
Step 3: In the comments section for Form 2101, Authorization for Community Care Services, the case worker enters the total annual hours at the current rate per hour = total dollar amount for the ASP.

Example: CDS authorized 10 hours per week for a total of 530 hours of service at $9.50 per hour = $5,035.00 total for the ASP.
Step 4: The case worker prints Form 2101, showing the CDS ASP.

 

In addition to the budgeted ASP, the case worker will authorize a CDS monthly administrative fee using Service Code 63V for PHC and FC cases. For initial and ongoing CAS cases, the case worker must request authorization from the HHSC regional nurse prior to initial and renewal of the services using the CDS option. The current rate can be found at the website above.

Financial Management Services Agency (FMSA) Procedures

The case worker sends the FMSA:

These forms notify the agency that the individual has selected it to deliver CDS administrative services.

Once the case worker has contacted the agency, the FMSA:

  • schedules a face-to-face contact with the individual;
  • provides training to the individual covering all orientation material listed in the CDS rules, 40 Texas Administrative Code, §41.307, Initial Orientation of an Employer;
  • assists the individual in developing a budget for program services;
  • provides information and/or assistance in completing the criminal history and other required registry checks on the potential attendant; and
  • completes all required forms to initiate services under the CDS option.

 

6332.3  Monitoring CDS Service Initiation

Revision 17-1; Effective March 15, 2017

 

All Consumer Directed Services (CDS) cases must be monitored within 30 days of the CDS service delivery start date. In all other situations, CDS cases are monitored in accordance with program guidelines, as described in Section 2700, Service Monitoring, Changes and Transfers. At all mandated contacts, case workers must complete:

  • Form 2314, Satisfaction and Service Monitoring; and
  • Form 2314-C, Consumer Satisfaction Interview — Consumer Directed Services Addendum.

Any service problems noted must be communicated to the Financial Management Services Agency using Form 2067, Case Information. The case worker may recommend that the employee complete Form 1741, Corrective Action Plan, and additional training if necessary. Concerns about fiscal management must be noted and resolved with the agency. Consult the contract manager if the situation involves contract issues.

 

6332.4  Responsibility for Responding to Questions

Revision 17-1; Effective March 15, 2017

 

Due to the involvement of different entities in the provision of Consumer Directed Services (CDS), it is sometimes difficult to determine who is responsible for responding to questions asked by an applicant, individual or the applicant's or individual's family. The contact chart was developed for the HHSC case worker to use when making this determination.

Note: If an individual asks the case worker a question related to CDS that falls under the Financial Management Services Agency (FMSA) purview to answer, the case worker must refer the individual to the FMSA rather than attempting to answer the question himself or contacting the FMSA for the individual. If the case worker has a general non-individual specific question about the CDS option, the case worker must contact the CDS operations specialist rather than contacting the FMSA.

 

CDS Contact Chart
Issue or Question Related to:

 

Contact:

 

  • Service authorization
  • Rates for CDS services (unrelated to wages)
  • Offering the CDS option upon enrollment and annually thereafter
  • CDS backup service plan request and approval
  • Approving or requesting a corrective action plan for an individual who is having difficulty with the CDS option
  • Program rules, including those specifically related to the CDS option
  • Service plan, including related forms
  • Convening all Interdisciplinary Team meetings, including those meetings needed to address CDS issues
  • Change in service delivery option at the individual's request or through involuntary termination of the CDS option
  • Change in FMSA
Case worker contacts state office CDS program specialists at:
CDS@dads.state.tx.us

 

  • Initial CDS orientation
  • Employer-related paperwork
  • Issues with service delivery
  • Ongoing training and support related to employer issues
  • CDS budget
  • Criminal history checks
  • Verification of licensing credentials of potential service providers
  • Payroll withholdings, deposits, reporting, timesheets, receipts, invoices and payment to service providers
  • Budget status report
  • Support consultation
  • Support advisor
Case worker refers individual to FMSA

 

FMSA contacts CDS policy specialist in the Center for Policy and Innovation at CDS@dads.state.tx.us

  • Billing and payment issues
Case worker contacts regional CMS coordinator

 

 

 

6333  Service Initiation Directly into CDS for PHC or CAS

Revision 17-1; Effective March 15, 2017

 

Applicants for Personal Attendant Services (PAS) through Primary Home Care (PHC) or Community Attendant Services (CAS) who choose the Consumer Directed Services (CDS) option may begin services directly in CDS without going through a Home and Community Support Services Agency (HCSSA).

If a PHC or CAS applicant chooses to start services through the CDS option, it is the CDS employer's responsibility to obtain the completed Form 3052, Practitioner's Statement of Medical Need. The employer may be the applicant or the legally authorized representative (LAR). The case worker provides a copy of Form 3052 and Form Instructions to the applicant with a return envelope and instructions on returning the form to the case worker within 14 calendar days. It is the case worker's responsibility to verify that the form is completed. If not, it is returned to the employer for correction or completion. If the applicant is applying for CAS, the case worker will forward the completed Form 3052 to the HHSC regional nurse, upon receipt.

It is the CDS employer's responsibility to get Form 3052 to the practitioner and have it completed and signed by the practitioner. The CDS employer will then send the form to the selected Financial Management Services Agency (FMSA) to complete Part II, Provider's Statement. The FMSA returns the form to the CDS employer, and it is the employer's responsibility to return the form to the case worker. Services will not be authorized until Form 3052 is signed by both the practitioner and the FMSA, is returned, and the applicant meets all eligibility requirements.

All other requirements remain the same, as outlined in Section 6300, Consumer Directed Services. These procedures are also applicable to individuals who are on the CDS option in another program and are transferring to PHC or CAS. This includes individuals on Family Care or Personal Care Services (PCS) through the Comprehensive Care Program (CCP).

 

6333.1  Authorizing CDS for Ongoing Individuals

Revision 17-1; Effective March 15, 2017

 

When the individual receiving services selects the agency option initially and then selects Consumer Directed Services (CDS), he or she will be transitioned to the CDS service delivery option. The case worker must present the official list of all Financial Management Services Agencies (FMSAs) found at the HHSC website: https://hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/consumer-directed-services-cds/fmsa-agencies and the following forms:

  • Form 1581, Consumer Directed Services Option Overview;
  • Form 1582, Consumer Directed Services Responsibilities;
  • Form 1583, Employee Qualification Requirements;
  • Form 1584, Consumer Participation Choice; and
  • Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services Option.

The official list must be used as the FMSAs routinely cover multiple regions. When the CDS employer selects an FMSA, the employer signs Form 1584, indicating the choice to use the CDS option and the selected FMSA.

Use the appropriate Service Authorization System code(s) created for use with the CDS option, as provided in Section 6332.1, Pre-Enrollment Requirements.

Complete Form 2101, Authorization for Community Care Services, to terminate Agency Option services and create another Form 2101 authorizing CDS services. The CDS start date is the date negotiated with the individual and FMSA. Service through the provider agency must be terminated the day before the start date of CDS. There must be no gap in coverage dates.

Send Form 2065-A, Notification of Community Care Services, advising that current services are terminating and CDS services beginning. Time frames in Appendix IX, Notification/Effective Date of Decision, apply.

 

6333.1.1  Different Program Annual Review and Annual Service Plan Dates

Revision 17-1; Effective March 15, 2017

 

If an individual decides to transition to the Consumer Directed Services (CDS) option after being on the agency option, the dates for the CDS annual service plan (ASP) will most likely be different than the date for the program annual review.

The case worker must keep the program annual review date the same if the annual review date and the ASP date are within different months. (The next annual review date will be 12 months from the date of the previous annual review date.)

The case worker must complete a separate service authorization wizard in the Service Authorization System (SAS) at the end of the ASP year to renew the CDS funds for another year. The case worker should enter a reminder on his/her scheduler in SAS to ensure there is no gap in CDS services.

The case worker does not complete a home visit or contact the individual when the ASP reauthorization is due or complete a financial or functional wizard in SAS. The case worker will only complete the authorization wizard in SAS to renew the funds needed for the CDS option. The case worker must send the updated Form 2101, Authorization for Community Care Services, to the individual’s Financial Management Services Agency (FMSA). The case worker will complete the program annual review as usual and ensure the CDS ASP dates remain unchanged.

Note: For Community Attendant Services cases, the case worker must request authorization from the HHSC regional nurse.

Example:

An individual starts Community Care for Aged and Disabled services with the agency option on Jan. 15, 2015. The individual decides in April 2015 to switch to the CDS option. The case worker negotiates a start date with the selected FMSA of April 25, 2015. The effective dates of the ASP are April 25, 2015, through April 24, 2016. The case worker completes the authorization for CDS in accordance with Section 6333.1.

The case worker also enters a scheduler entry set to a few days before April 24, 2016, in order to ensure the CDS funds are renewed for another year. The case worker should already have a scheduler in place to complete the program annual review in January 2016.

In January 2016, the case worker completes the program annual review as usual, in accordance with Section 4447, Reassessment, or Section 4678, Annual Reassessments.

In April 2016 (before April 24), the case worker completes the ASP by running the SAS authorization wizard with new dates of April 24, 2016, through April 24, 2017, to renew the CDS option funds. The case worker sends the updated Form 2101 to the FMSA.

 

6333.2  Transfers and Consumer Directed Services (CDS)

Revision 17-1; Effective March 15, 2017

 

The individual has the right to:

  • transfer to a different Financial Management Services Agency (FMSA);
  • elect to receive services through the Service Responsibility Option (SRO), if available; or
  • request a transfer back to the Agency Option (AO) at any time.

If the individual feels that the current FMSA is not fulfilling the expected responsibilities, he or she can:

  • address those issues directly with the FMSA;
  • contact the case worker if he or she is unable to resolve issues or concerns with the FMSA; and/or
  • select another FMSA to provide CDS services if concerns and issues are still not resolved.

See Section 6333.4, Annual Recertification, for instructions on updating the annual service plan (ASP) when transferring to another FMSA.

Transfer to Another FMSA

If issues with the current FMSA cannot be resolved to the individual's satisfaction, he or she has the right to transfer to another FMSA. Follow procedures outlined in Section 2723, Freedom of Choice, regarding transfer of agencies.

The individual must contact the case worker if he or she decides to transfer from one FMSA to another. The case worker makes all necessary arrangements for the transfer.

See Section 6333.3.1, Provider Transfer, for step-by-step budgeting procedures required when transferring from one FMSA to another.

Transfer to the AO or the SRO

Case workers must follow 40 Texas Administrative Code §41.407, Termination of Participation in the CDS Option, to terminate an individual from the CDS option. The individual may return to CDS after the 90-day transfer period has expired by contacting the case worker. All pre-assessment procedures must be completed, including a new Individual Self-Assessment, before the individual is allowed to return to CDS.

Service Resources Available During the Transfer Process

If the individual is without personal attendant services (PAS) and requires assistance before the transfer can take place, he or she may be able to contract for PAS through the AO or SRO provider using CDS funds. The agency is not required to provide this service, however. The individual must be acquainted with other resources, which are outlined in the training provided by the FMSA.

 

6333.3  Circumstances That Necessitate a Revised Annual Service Plan (ASP)

Revision 17-1; Effective March 15, 2017

 

The ASP specifies an annualized dollar amount that is the maximum the individual can expend during the year. It is the basis for developing a service budget. The individual and the Financial Management Services Agency (FMSA) share responsibility for ensuring annual expenditures remain within the authorized amount.

Four situations may necessitate revision of the ASP:

  • provider transfers,
  • rate changes,
  • an increase in service units,
  • a decrease in service units.

Case workers must use Form 1589, Consumer Directed Services Revision Worksheet, Page 1, to initiate any changes that necessitate a revised ASP. The purpose of Form 1589 is to assist a case worker in obtaining the needed information from an FMSA. The case worker can use the optional second page of Form 1589, Consumer Directed Services Supplemental Calculation Worksheet, to assist in completing the rest of the revision calculation. Case workers must continue to follow instructions to input ASP authorizations into the Service Authorization System, in accordance with Sections 6333.3.1, 6333.3.2, 6333.3.3 and 6333.3.4 that follow.

Changes to the ASP must be made in the order of occurrence. For example, the case worker cannot enter a rate change effective Sept. 1 in the Service Authorization System before making a change in hours that was effective Aug. 15.

 

6333.3.1  Provider Transfer

Revision 17-1; Effective March 15, 2017

 

Case workers must follow Texas Administrative Code §41.403(c), Transfer Process, to transfer an individual from one Financial Management Services Agency (FMSA) to another.

Use the following example when processing FMSA transfers.

Note: In this example, the $10.00 amount is a fictitious number used for demonstration purposes only. The current CDS service rate can be accessed at the following Texas Health and Human Services Commission website: https://rad.hhs.texas.gov/long-term-services-supports.

 

Step 1: The individual requests a FMSA transfer, which will take effect on 07-16-15. The original authorization was for 1,060 hours of service @ $10.00 per hour, for a total of $10,600.00, beginning 01-01-15 and ending 12-31-16.
Step 2: The case worker uses Form 1589, Consumer Directed Services Revision Worksheet, to contact the FMSA to determine the amount of service delivered by the first agency and the amount the FMSA would like to (if any) reserve that the individual is expected to use up to the effective date of the transfer. The FMSA reports that 500 hours, for a total of $5,000.00, was used from 01-01-15 through 06-30-16. The FMSA reserves 40 hours, for a total of $400.00.
Step 3: The case worker calculates the total amount available remaining in the annual service plan (ASP): $5,000.00/500 hours amount used + $400.00/40 hours amount reserved = $5,400.00/540 hours remaining in ASP at the time of the transfer effective date.
Step 4: In the Authorization Wizard, enter a new begin date of 07-16-15. The system will automatically insert an end date of 06-15-16.

 

Manually correct the end date to reflect 12-31-16, and document in Comments: "Provider transfer – Provider A states used units of 500 hours @ $10.00 per hour = $5,000.00 and reserved units of 40 hours @ $10.00 per hour = $400.00. $10,600.00 - $5,400.00 = $5,200.00."
Step 5: The case worker must manually correct the "Auth Unit" fields in both authorizations: 01-01-15 through 07-15-15 should be $5,400.00 and 07-16-15 through 12-31-15 should be $5,200.00.
Step 6: The case worker must manually correct the number of units in box 18 to $5,200.00.

 

The case worker must also authorize Financial Management Services (FMS) Service Code 63V for the gaining provider. The regional nurse authorizes the FMS fee for Community Attendant Services applications and recertifications.

 

6333.3.2  Rate Change

Revision 17-1; Effective March 15, 2017

 

Use the following example when processing rate changes.

Note: The $10.50 and $10.00 amounts in this example are fictitious numbers used for demonstration purposes only. The current rate can be accessed at the following Texas Health and Human Services Commission website: https://rad.hhs.texas.gov/long-term-services-supports.

Step 1: The case worker learns that a rate increase to $10.50 will go into effect on 09-01-15. The original authorization was for 530 hours of service @ $10.00 per hour, for a total of $5,300.00, beginning 02-15-15 and ending 02-14-16.

 

The case worker uses Form 1589, Consumer Directed Services Revision Worksheet, to contact the Financial Management Services Agency (FMSA). The FMSA reports 240 hours, for a total of $2,400.00, was used in the period beginning 02-15-15 and ending 08-15-15. The FMSA reserves 20 hours, for a total of $200.00 for the period between 08-15-15 through 08-31-15. The total used/reserved is $2,600.00.
Step 2: The case worker calculates the amount of time available in the remainder of the annual service plan (ASP): 09/01-30/15, 30 days +
10/01-31/15, 31 days +
11/01-30/15, 30 days +
12/01-31/15, 31 days +
01/01-31/16, 31 days +
02/01-14/16, 14 days =
167 days / 7 days = 23.86 weeks = 24 weeks

Note: When the result of this particular calculation is not a whole number, it is always rounded up to the next whole number.

Step 3: The case worker calculates the difference in the hourly amount:

$10.50 − $10.00 = $0.50

Step 4: The case worker calculates the dollar amount available in the remainder of the ASP: 24 weeks x 10 hours per week x $0.50 = $120.00 increase. $5,300.00 original authorization + $120.00 rate increase amount = $5,420.00 revised ASP amount. $5,420.00 revised ASP amount − $2,600.00 used/reserved amount = $2,820.00 remaining in the ASP.
Step 5: Process the Community Care for the Aged and Disabled Functional Wizard to pull in the new provider rate.
Step 6: Authorization Wizard: Enter a new begin date of 09-01-15. The system will automatically insert an end date of 08-31-16.

Manually correct the end date to reflect 02-14-16, and document in comments, "Unit rate increase – provider states used amount of 260 hours @ $10.00 per hour = $2,600.00."

Step 7: The case worker must manually correct the Service Authorization System Wizard "Auth Unit" fields in both authorizations:

 

02-15-15 through 08-31-15 should be $2,600.00, and
09-01-15 through 02-14-16 should be $2,820.00.

Step 8: Manual correction of Form 2101, Authorization for Community Care Services:

The case worker must manually correct the number of units in box 18 to $2,820.00.

 

6333.3.3  Increase in Service Units

Revision 17-1; Effective March 15, 2017

 

Use the following example when processing increases in service units.

Note: In this example, the $9.50 amount is a fictional number used for demonstration purposes only. The current rate can be accessed at the following Texas Health and Human Services Commission website: https://rad.hhs.texas.gov/long-term-services-supports.

 

Step 1: The individual's condition changes, requiring a three-hour increase in service effective 06-01-15. The original authorization was for 795 hours of service @ $9.50 per hour, for a total of $7,552.50, beginning 04-15-15 and ending 04-14-16.

The individual received 15 hours of service per week beginning 04-15-15 and ending 05-15-15.

Step 2: The case worker uses Form 1589, Consumer Directed Services Revision Worksheet, to contact the Financial Management Services Agency (FMSA). The FMSA  reports 60 units, for a total of $570.00, were used from 04-15-15 through 05-15-15. The FMSA reserves 30 units, for a total of $285.00 to be used from 05-15-15 through 05-31-15. The total used/reserved amount is $855.00.
Step 3: The case worker calculates the amount of time remaining in the annual service plan (ASP).

06/01-30/15 = 30 days +
07/01-31/15 = 31 days +
08/01-31/15 = 31 days +
09/01-30/15 = 30 days +
10/01-31/15 = 31 days +
11/01-30/15 = 30 days +
12/01-31/15 = 31 days +
01/01-31/16 = 31 days +
02/01-29/16 = 29 days +
03/01-31/16 = 31 days +
04/01-14/16 = 14 days =
319 days / 7 = 45.57 weeks = 46 weeks

Note: When the result of this particular calculation is not a whole number, this amount is always rounded up to the next whole number. For example, a result of 45.57 would be rounded up to 46 weeks.

Step 4: The case worker calculates the dollar amount available for the remainder of the ASP.

46 weeks x 3 hours = 138 hours
138 hours @ $9.50 = $1,311.00 increase

$7,552.50 original authorization +
$1,311.00 increase amount for remainder of ASP −
$855.00 already used/reserved =
$8,008.50 partial authorization for the period of 01-01-15 through 04-14-16.

Step 5 The case worker calculates the revised ASP.

$855.00 already used/reserved +
$8,008.50 authorized for remainder of ASP =
$8,863.50 revised annual ASP.

Step 6 The case worker enters a new begin date of 06-01-15 in the Authorization Wizard. The system will automatically insert an end date of 05-31-16.

Manually correct the end date to reflect 04-14-16, and document in comments: "Increase ASP – 138 hours @ $9.50 per hour for remainder of ASP = $1,311.00 increase. Authorized amount for remainder of period = $8,008.50 + $855.00 used/reserved amount = $8,863.50 revised annual ASP."

Step 7 The case worker must manually correct the "Auth Unit" fields in both authorizations:

04-15-15 through 05-31-15 is $855.00
06-01-15 through 04-14-16 is $8,008.50

Step 8 The case worker must manually correct Form 2101, Authorization for Community Care Services, by correcting the number of units in box 18 to $8,008.50.

 

6333.3.4  Decrease in Service Units

Revision 17-1; Effective March 15, 2017

 

Use the following example when processing decreases in service units.

Note: In this example, the $9.75 amount is a fictitious number used for demonstration purposes only. The current rate can be accessed at the following Health and Human Services Commission website: https://rad.hhs.texas.gov/long-term-services-supports.

 

Step 1: The individual's condition improves, requiring a three-hour decrease in service effective 10-01-15. The original authorization was for 689 hours of service @ $9.75 per hour, for a total of $6,717.75, beginning 02-15-15 and ending 02-14-16.

The individual received 13 hours of service per week beginning 02-15-15 and ending 09-15-15.

Step 2: The case worker uses Form 1589, Consumer Directed Services Revision Worksheet, to contact the Financial Management Services Agency (FMSA). The FMSA  reports 364 units, for a total of $3,549.00, used from 02-15-15 through 09-15-15. The FMSA reserves 26 units for a total of $253.50 from 09-16-15 through 09-30-15. A total amount of $3,802.50 is available for the FMSA on the original annual service plan (ASP).
Step 3: The case worker calculates the amount of time remaining in the ASP. 10/01-31/15 = 31 days +
11/01-30/15 = 30 days +
12/01-31/15 = 31 days +
01/01-31/16 = 31 days +
02/01-14/16 = 14 days =
137 days / 7 = 19.57 weeks = 20 weeks. Note: When the result of this particular calculation is not a whole number, this amount is always rounded up to the next whole number. For example, a result of 19.57 is rounded up to 20 weeks.
Step 4: The case worker calculates the dollar amount available for the remainder of the ASP.

 

20 weeks x 3 hours/week = 60 hours
60 hours @ $9.75 = $585.00 decrease

$6,717.75 original authorization -
$585.00 decrease amount for remainder of ASP -
$3,802.50 already used/reserved =
$2,330.25 partial authorization for the period of 10-01-15 through 02-14-16.
Step 5: The case worker calculates the revised ASP. $3,802.50 already used/reserved +
$2,330.25 authorized for remainder of ASP =
$6,132.75 revised annual ASP.
Step 6: The case worker enters a new begin date of 10-01-15 in the Authorization Wizard. The system will automatically insert an end date of 09-30-16.

Manually correct the end date to reflect 02-14-16, and document in comments: "Decrease ASP – 60 hours @ $9.75 per hour for remainder of ASP = $585.00 decrease. Authorized amount for remainder of period = $2,330.25 + $3,802.50 used/reserved amount = $6,132.75 revised annual ASP."

Step 7: The case worker must manually correct the "Auth Unit" fields in both authorizations:

02-15-15 through 09-30-15 is $3,802.50
10-01-15 through 02-14-16 is $2,330.25

Step 8: The case worker must manually correct Form 2101, Authorization for Community Care Services, by correcting the number of units in box 18 to $2,330.25.

 

6333.4  Annual Recertification

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §41.109 (a), Enrollment in the CDS Option, mandates that case workers conduct home visits at least annually for all Consumer Directed Services (CDS) individuals.

Individual rights requirements apply in CDS the same way they apply to any other service delivery option.

 

6333.4.1  Procedures for the CAS CDS Annual Reassessment

Revision 17-1; Effective March 15, 2017

 

In accordance with 1929(b) of the Social Security Act and the State Plan under Title XIX of the Social Security Act Medical Assistance Program, in the Community Attendant Services (CAS) program, the Consumer Directed Services (CDS) employer can be considered the supervisor for the purposes of completing the CAS annual reassessment.

CAS annual reassessment procedures for an individual utilizing the agency option require the case worker to complete the functional assessment, the Home and Community Support Services Agency (HCSSA) supervisor to document agreement or disagreement with the service plan, and the HHSC regional nurse to authorize services within 12 months of the last authorization. Under the State Plan, the CDS employer may fulfill the role of the HCSSA supervisor in signing the agreement or presenting information when in disagreement with the proposed service plan.

When the case worker conducts the home visit for the annual functional reassessment, the role of the CDS employer for the annual reassessment must be explained to the individual/CDS employer. The case worker advises the individual of the following:

  • The proposed service plan, Form 2101, Authorization for Community Care Services, for the next year will be faxed or mailed to the individual/CDS employer.
  • The individual/CDS employer must review the plan, sign Form 1596, Consumer Directed Services Agreement for the Community Attendant Services Annual Reauthorization, indicating his agreement or disagreement with the proposed plan, and return the form to the case worker within 14 calendar days of receipt to prevent delay in services.

The case worker must schedule the annual reassessment home visit to allow time for all the required steps to be completed within the time frames.

Case Worker Procedures

Within five business days after the functional assessment visit, the case worker faxes or sends the individual/CDS employer a copy of the following forms:

  • Referral Form 2101, with the proposed annualized service plan.
  • Form 1596, to be completed and signed by the individual/employer with the following information:
    • A statement indicating that the proposed annualized service plan has been reviewed and the individual/employer is in agreement; or
    • A statement indicating that the proposed annualized service plan has been reviewed and the individual/employer disagrees with the tasks or hours indicated on the annualized service plan for the reasons listed on Form 1596.

The individual/CDS employer must sign Form 1596 and return it to the case worker within 14 calendar days of receipt. If the individual/CDS employer signs agreement with the annualized service plan, the case worker, within five business days, sends a copy of Form 1596 and Form 2101 to the HHSC regional nurse for the annual authorization.

Disagreement with the Service Plan

If the individual/CDS employer does not agree with the proposed annualized service plan, the reasons must be documented on Form 1596. The case worker must contact the individual/CDS employer to try to resolve the issues and agree upon a plan. If an agreement is reached, the case worker sends Form 1596 and Form 2101 to the HHSC regional nurse for the annual authorization.

If an agreement cannot be reached, the case worker forwards Form 2101 and Form 1596 to the HHSC regional nurse. Within five business days of receipt of Form 2101 and Form 1596, the HHSC regional nurse contacts the individual/CDS employer and case worker to determine if agreement can be reached on the service plan.

The HHSC regional nurse makes the final decision on the service plan. If the negotiation results in a decrease in services for the individual, the effective date must allow time for the individual to receive a 12-day advance notice of the adverse action. The individual/CDS employer has the right to request a fair hearing and appeal the decision.

The HHSC regional nurse makes any necessary changes to Form 2101, noting any negotiated changes in the comments and completes the authorization in the Authorization Wizard. The nurse sends Form 2067, Case Information, notifying the individual/CDS employer and the case worker of the outcome of the negotiation and sends a copy of the authorization Form 2101 to the case worker by mail or electronic mail.

The case worker sends a copy of Form 2101 and Form 2065-A, Notification of Community Care Services, to the individual/CDS employer and sends Form 2101 to the Financial Management Services Agency.

Note: If the CDS annual service plan (ASP) dates are different than the CAS annual review dates, in accordance with Section 6333.1.1, Different Program Annual Review and Annual Service Plan Dates, the case worker must ensure the CDS ASP dates remain unchanged after a CAS annual review is completed.

 

6333.5  Ongoing CDS Monitoring

Revision 17-1; Effective March 15, 2017

 

All monitoring of Consumer Directed Services (CDS) individuals is done according to the mandated schedule for their specific services. See Section 2700, Service Monitoring, Changes and Transfers, for details. Because the individual is now responsible for his or her own service delivery, the case worker's function is to:

  • monitor the individual's satisfaction with the Financial Management Services Agency (FMSA) services; and
  • evaluate the individual's ongoing ability to comply with CDS option requirements.

If it is evident the individual is having difficulty in the management of services under the CDS option, the case worker may consult with the FMSA.

Examples of the individual's inability to manage services include:

  • lack of adequate supervision of the attendant so that necessary services are not being delivered; or
  • misuse of funds so that the annual authorized amount will be expended before the year is over.

The FMSA must provide the budget status report at least quarterly to the individual or designated representative and case worker. If the case worker does not receive the quarterly report, or the individual reports he or she has not received the quarterly report the case worker must follow-up with the FMSA.

 

6333.6  Ensuring Individual Health and Safety

Revision 17-1; Effective March 15, 2017

 

The Financial Management Services Agency (FMSA) and case worker share responsibility for assessing the individual's ability to manage the demands of the Consumer Directed Services (CDS) option. Careful evaluation is necessary to ensure the individual's health and safety are maintained.

As soon as he or she becomes aware of a potential problem, the case worker must:

  • notify the FMSA of any concerns regarding the individual's circumstances or ability to comply with CDS option requirements; and
  • provide supporting documentation about the circumstances or problems noted to the FMSA.

The individual is responsible for informing the FMSA of the assessment date in time for the FMSA to send the case worker a copy of the individual's annual budget.

See Section 6323, FMSA Responsibilities, for FMSA responsibilities.

 

6333.6.1  Responsibilities for HHSC Case Workers in Association with Abuse, Neglect and Exploitation (ANE) Allegations

Revision 17-6; Effective June 28, 2017

 

Responsibilities for HHSC Case Workers

Responsibilities for HHSC case workers in association with ANE investigation procedures specifically for the Consumer Directed Services (CDS) option when a CDS employee, designated representative, or representative of a Financial Management Service Agency (FMSA) is the alleged perpetrator are as follows.

Initial Intake Actions When a CDS Employee or Designated Representative is the Alleged Perpetrator

When the Department of Family and Protective Services (DFPS) receives an allegation of ANE for an individual using the CDS option, Adult Protective Services (APS) will provide the initial intake report to the CDS employer and the individual’s case worker. The case worker must notify the individual’s FMSA of the initial allegation. The case worker is required to hold an interdisciplinary team (IDT) meeting in person or by telephone, within four business days of receipt of the initial report, with the CDS employer to:

  • discuss the actions the CDS employer has taken or will take to protect the individual during the APS investigation, which may include implementing the service backup plan to allow someone other than the CDS employee who is the alleged perpetrator to provide services;
  • inform CDS employers of their responsibilities to protect evidence, such as timesheets and other employee-related documentation; and
  • if appropriate, recommend termination of the CDS option, in accordance with 40 Texas Administrative Code (TAC) §41.407(e).

The case worker documents in writing the responses provided by the CDS employer during the IDT and any actions that have been or will be taken as a result of the allegation pending the outcome of the final investigative report.

Final Report Actions

After the investigation is complete, APS will release a final investigatory report, including findings, to the CDS employer and the case worker. The case worker will convene an IDT meeting in person or by phone, within four business days after receipt of the final report, if there is a confirmed or inconclusive finding of ANE or if concerns and recommendations are included in the report, in which:

  • the IDT discusses the findings or concerns and recommendations;  
  • the case worker documents, in writing, any actions that have been or will be taken by the CDS employer as a result of the findings or concerns and recommendations. (Form 1741, Corrective Action Plan, may be used for this purpose); and
  • if appropriate, the case worker may recommend termination of the CDS option, in accordance with 40 TAC §41.407(e).  

Initial Intake Actions if an FMSA Representative is the Alleged Perpetrator

When DFPS receives an allegation of ANE related to services delivered through the CDS option and an FMSA representative is the alleged perpetrator, APS will provide the initial intake report to the CDS employer and the FMSA of the initial allegation. The FMSA must provide a copy of the initial intake report to the individual’s HHSC regional office within one business day. The HHSC regional director or designee will ensure that the individual’s case worker receives the intake report and a copy of Information Letter 15-83, “ANE Investigation Procedures for the CDS Option in the PHC Program,” as soon as possible.

The case worker will convene an IDT meeting in person or by phone within four business days after receipt of the initial intake report, in which:

  • the IDT discusses the actions the CDS employer has taken or will take to protect the individual during the APS investigation, which may include transferring to a different FMSA; and
  • the case worker documents in writing any actions that have been or will be taken as a result of the allegation, pending the outcome of the final investigative report.

Final Investigation Report

After the investigation is complete, APS will send a final investigation report, including findings, to the CDS employer and to the individual’s FMSA. The FMSA must provide a copy of the final investigation report, within one business day after receipt of the report, to the individual’s HHSC regional office. The HHSC regional director or designee will ensure the final investigative report is given to the case worker as soon as possible.

The case worker will convene an IDT meeting in person or by phone, within four business days after receipt of the final report, if there is a confirmed or inconclusive finding of ANE or if concerns and recommendations are included in the report, in which:

  • the IDT discusses the findings or concerns and recommendations;  
  • the case worker documents, in writing, any actions that have been or will be taken by the CDS employer as a result of the findings or concerns and recommendations. (Form 1741 may be used for this purpose); and
  • if appropriate, the case worker may recommend termination of the CDS option in accordance with 40 TAC §41.407(e).

 

6333.6.2  Voluntary Suspension of the CDS Option

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §41.405, Suspension of Participation in the CDS Option

Voluntary suspensions are rare; examples include (but are not limited to):

  • an individual has turned 18 and no guardian has been appointed (so there is no "employer"); or
  • an individual lacks back-up service delivery options.

For the case worker, a voluntary suspension is handled in exactly the same way that a transfer to another service delivery option would be handled. See Section 6333.2, Transfers and Consumer Directed Services (CDS), for detailed instructions. But, for the Financial Management Services Agency, the provider tasks (as described in Section 6323, FMSA Responsibilities) do not have to be repeated when the individual transfers back to CDS at the end of the 90-day voluntary suspension period. That is not true when the individual simply transfers from, and then back to, CDS.

 

6333.6.3  Involuntary Termination of the CDS Option

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §41.407, Termination of Participation in the CDS Option

The case worker or Financial Management Services Agency (FMSA) representative may observe that an individual is unprepared to meet the demands of managing the details of service delivery. With supporting documentation from the monitoring visit or from the FMSA, the case worker recommends to the individual that he or she voluntarily request to return to the agency option. If he or she does not agree, the case worker, in consultation with the supervisor and the interdisciplinary team (IDT), (see definition under "service planning team" in Section 6310, Description) transfers the individual back to the agency option.

The case worker must carefully document the findings of the IDT, including:

 

Requirement Example
The date, time and location of the meeting The IDT meeting was convened at 2 p.m. on Oct. 15, 2014, at the home of Mrs. Scott.
The names of each participant and their relationship to the individual Present at the meeting were:
  • Ann Scott, the individual;
  • Nancy Albright, the individual's daughter;
  • Angela Jones, FMSA representative;
  • Linda Sullivan, the HHSC case worker; and
  • Nelson Travis, the case worker's supervisor.
The reasons for the recommendation that the individual be involuntarily returned to the Agency Option (AO). Documentation must be specific and detailed

Mrs. Scott was contacted by the FMSA on Oct. 8, 2014, after missing the deadline for submitting employee timesheets. The FMSA is informed that the attendant quit without notice over a week ago; Mrs. Scott has gone without services since that time. The individual did not contact the FMSA or the case worker at the time because she couldn't remember who to call, and couldn't find any of her paperwork.

During the IDT meeting, Mrs. Scott agreed with the assessment that she currently is unable to fulfill the responsibilities of the Consumer Directed Services (CDS) option. However, she expressed a desire to have her daughter serve as the designated representatives (DR), which would enable her to continue using the CDS.

Mrs. Albright was able to stay with the individual the remainder of that week. So the case worker transferred the individual from CDS to AO effective Oct. 22, 2014.

The conditions and time frame established by the IDT that must be met before re-enrollment in CDS All IDT members agree that the individual may return to the CDS option in six months, at which time her daughter has agreed to begin serving as the DR.
Justification for any time period for a termination in excess of the minimum 90-day requirement Mrs. Albright is unable to begin serving as the DR for six months, and the individual is unwilling to allow anyone else to serve that function.
If applicable, the conditions and time frame specified by a hearing officer as the result of a fair hearing that upholds the termination The individual filed an appeal and was accompanied to the hearing by her daughter. During the proceedings, the daughter stated that her situation had changed and that she would be able to begin serving as the DR on Feb. 1. The hearing officer overturned the original decision, specifying that the individual can return to CDS Feb. 1, 2014, provided the daughter is able to assume DR responsibilities at that time.

 

6333.6.4  Re-Enrollment in the CDS Option

Revision 17-1; Effective March 15, 2017

 

40 Texas Administrative Code §41.409, Re-enrollment for Participation in the CDS Option

The individual may request to re-enroll in the Consumer Directed Services option at any time following the mandatory 90-day suspension period.

 

6400  State of Texas Access Reform Plus (STAR+PLUS) Managed Care

Revision 17-1; Effective March 15, 2017

 

 

6410  Program Overview

Revision 17-1; Effective March 15, 2017

 

The 74th Texas Legislature implemented the State of Texas Access Reform Plus (STAR+PLUS) program to create a cost-neutral managed care system that would combine acute care as well as Long-term Services and Supports. The STAR+PLUS program does not change Medicaid eligibility or services. It changes the way Medicaid services are delivered.

The STAR+PLUS program combines acute care and Long-term Services and Supports, such as assisting in an individual's home with daily activities, home modifications, respite (short-term supervision) and personal assistance. These services are delivered through providers contracted with managed care organizations (MCOs). STAR+PLUS provides a continuum of care with a wide range of options and increased flexibility to meet individual needs. The program has increased the number and types of providers available to Medicaid individuals.

Service coordination, available to all members, is the main feature of STAR+PLUS. It is a specialized case management service for program members who need or request it. Service coordination means that plan members, family members and providers can work together to help members get acute care, Long-term Services and Supports, Medicare services for dual eligible individuals and other community support services.

Elements of the STAR+PLUS system that are different from traditional service delivery include:

  • 1115 Waiver – Authority granted to the state of Texas to allow delivery of Medicaid State Plan acute, Long-term Services and Supports (Primary Home Care and Day Activity and Health Services) and delivery of Long-term Services and Supports that assists individuals to live in the community in lieu of a nursing facility through a managed care delivery system.
  • Enrollment broker – A contracted entity that assists individuals in selecting and enrolling with an MCO. If requested by the individual, the enrollment broker also may assist in choosing a primary care provider (PCP). Members of STAR+PLUS may request an MCO change at any time by contacting the enrollment broker. The change will be effective the first day of the subsequent month if the request is made before the state cutoff date or the first of the following month if the request is made after cutoff.
  • Texas Health and Human Services Commission (HHSC) – The state agency responsible for Medicaid. HHSC staff receiving a request for STAR+PLUS Waiver services will notify the HHSC Program Support Unit of the request.
  • MCO – An insurer licensed by the Texas Department of Insurance as a managed care organization in accordance with Chapter 843 of the Texas Insurance Code. MCOs provide Medicaid benefits for individuals who are required to enroll in STAR+PLUS.
  • Member – An individual who is enrolled in and receiving services through a STAR+PLUS MCO.
  • Plan of care (POC) – A care plan the MCO develops for its members that includes acute care and Long-term Services and Supports. The plan of care is not the same as the individual service plan (ISP) for STAR+PLUS waiver services.
  • Program Support Unit (PSU) – HHSC staff who support certain aspects of STAR+PLUS case management.
  • Texas Medicaid & Healthcare Partnership (TMHP) – The Texas contractor administering Medicaid claims processing and the Medicaid primary care case management services program.
  • TexMedCentral – A secure internet bulletin board that the state and the MCOs use to share information.
  • Upgrade – An existing STAR+PLUS individual enrolled in the 1915(b) waiver who requests and is granted SPW (1115 waiver) services.

 

6411  Services Available Under the STAR+PLUS Option

Revision 17-1; Effective March 15, 2017

 

Managed care organizations (MCOs) are required to contact all members upon enrollment. If there is a need identified or a request from the member, the MCO will assess the member to determine needs and to develop an appropriate individual plan of care (POC). Because MCOs are at risk for paying for a range of acute care and long term services and supports, there is an incentive to provide innovative, cost-effective care from the outset in order to prevent or delay the need for more costly institutionalization.

STAR+PLUS Medicaid-only individuals are required to choose an MCO and a primary care provider (PCP) in the MCO's network. These individuals receive all services (both acute care and long term service and supports) from the MCO.

Individuals who receive both Medicaid and Medicare (dual eligible) choose an MCO, but not PCP. This is because they receive acute care from their Medicare providers. STAR+PLUS does not impact Medicare services or service delivery in any way. The STAR+PLUS MCO only provides Medicaid Long-term Services and Supports (LTSS) to dual eligible individuals.

STAR+PLUS serves as an insurance policy that will be available if members have a need for LTSS at a future time.

Medicaid-only individuals (those who do not receive Medicare) receive traditional Medicaid acute care services, plus an annual check-up. For these individuals, the cost of acute care services is included in the payment to the MCO. For dual eligible individuals, the MCO payment does not include the cost of acute care.

Long-term Services and Supports

Additional services are available under the STAR+PLUS Waiver (SPW).

 

6420  STAR+PLUS Members Requesting Non-Medicaid Services

Revision 17-1; Effective March 15, 2017

 

Requirements of the 1115 Waiver dictate that STAR+PLUS Waiver (SPW) recipients receive all services excluding hospice through the waiver. The CCAD case worker must not authorize any Title XX services for individuals enrolled in Home and Community-based Services (HCBS) SPW.

For non-waiver recipients on the STAR+PLUS program, participation in a Medicaid managed care program is not sufficient cause for denial of the right to access non-Medicaid services. Non-Medicaid services should be viewed as any other community resource available to a managed care organization (MCO) member.

STAR+PLUS members are entitled to Title XX services if all eligibility criteria are met. However, the case worker must first ensure that approval of the request would not result in a duplication of services.

 Title XX services available to members in the STAR+PLUS program are:

  • Adult Foster Care,
  • Residential Care,
  • Emergency Response Services,
  • Home-delivered Meals, and
  • Special Services to Persons with Disabilities.

Individuals on the STAR+PLUS program requesting Title XX services listed above will continue to be added to any applicable interest list at the time of the request in order to protect the date and time of the request. The case worker must first determine whether or not there is a slot available for the requested service. If not, the individual’s name is added to the appropriate interest list by entering the information in the Community Services Interest List (CSIL) system. Individuals are released from the interest list on a first-come, first-served basis; eligibility determinations are conducted as slots for services become available.

When the member’s name is released from the interest list, the case worker must verify the Managed Care Organization’s (MCO) service array does not include a service equivalent of the Title XX service requested by viewing the STAR+PLUS Program Health Plan Comparison Charts and value-added services on the Health and Human Services (HHSC) website at:

https://hhs.texas.gov/services/health/medicaid-chip/programs/childrens-health-insurance-program-chip/chip-comparison-charts/star/report-cards/starplus.

Value-added services offered by an MCO are extra services approved by HHSC. Value-added services will vary by MCO.

The case worker is no longer required to wait for appeal decisions from MCOs to process requests for Title XX services if the service requested is not a value-added service on the member’s plan. Once released from the Title XX interest list, the case worker verifies the applicant’s MCO does not offer an equivalent service as a value-added service and proceeds with the eligibility determination for the requested Title XX service.

In some situations, a STAR+PLUS member or his MCO may request and be granted disenrollment of the member from managed care. Whether the disenrollment is voluntary or involuntary, disenrolled individuals can receive available HHSC services (both Medicaid and Title XX) if determined eligible.

 

6421  Disenrollment from STAR+PLUS

Revision 17-1; Effective March 15, 2017

 

In some situations, a STAR+PLUS member or his managed care organization (MCO) may request and be granted disenrollment of the member from managed care. Whether the disenrollment is voluntary or involuntary, disenrolled individuals can receive available HHSC services (both Medicaid and Title XX) if determined eligible.

 

6421.1  Disenrollment Due to Health and Safety Issues

Revision 17-1; Effective March 15, 2017

 

When a managed care organization (MCO) requests disenrollment for a STAR+PLUS member due to non-compliance, including behavioral issues, the MCO submits a disenrollment request to the Texas Health and Human Services Commission (HHSC) Health Plan Management (HPM). The HPM team reviews the request to determine if there is sufficient information to send to the HHSC Disenrollment Committee. The Disenrollment Committee reviews the information and determines if disenrollment is appropriate. If so, the STAR+PLUS member is disenrolled from STAR+PLUS.

When an individual on STAR+PLUS personal attendant services or STAR+PLUS Waiver services is disenrolled from STAR+PLUS due to threatening behaviors, the individual may immediately apply with HHSC for services.

HPM will send an email to the HHSC Regional Support and Program Improvement (RSPI) worker advising when a STAR+PLUS member has been disenrolled from STAR+PLUS due to threats to health and safety and will provide information on the nature of the behavioral issues. This is to protect the health and safety of service providers and HHSC staff who will assess the individual for HHSC services. The RSPI worker will send the information to the regional director of the region where the individual lives advising that the individual has been disenrolled from STAR+PLUS and may be calling HHSC to apply for services. The regional director will establish procedures for disseminating this information to staff who perform intakes.

If the individual calls HHSC requesting services, the intake is assigned to a case worker. The intake staff must note in the Comments section on Form 2110, Community Care Intake, this individual has been disenrolled from STAR+PLUS due to threats to health and safety and include all information provided from the regional director.

The case worker conducts the initial interview and assessment according to standard procedures, but during the initial interview the case worker advises the individual:

  • he must comply with program guidelines; and
  • any threatening behavior may result in immediate termination of services.

Unless the individual displays threatening behavior during the initial interview, the case worker proceeds with the application process and authorizes services if the individual meets eligibility requirements. The case worker must issue a written notice to the individual at the initial authorization advising the individual he must comply with service delivery provisions or his services may be terminated immediately on the first report of any behavior that threatens health or safety.

If the HHSC case worker encounters threatening or non-compliant behavior or receives a report from the Home and Community Support Services Agency (HCSSA) or other providers of threatening behavior or non-compliance with services delivery provisions, services are immediately suspended.

The case worker must consult with the supervisor regarding the alleged behaviors. If the supervisor determines the alleged behavior does not warrant termination, the case worker follows the policy in Section 2831, Suspensions Due to Refusal to Comply with Service Delivery Provisions.

If the supervisor agrees the individual is a threat to health or safety, then services are terminated. The case worker sends Form 2065-A, Notification of Community Care Services, to the individual terminating services on the date of the suspension. The case worker cites 40 Texas Administrative Code (TAC) §48.3903 (b) and enters a statement in comments that services are terminated due to threats to health and safety.

The individual has the right to appeal, but services do not continue during the appeal process. The case worker must document the consultation and all other actions in the case record.

 

6430  Transition Between HHSC and STAR+PLUS

Revision 17-1; Effective March 15, 2017

 

Mandatory STAR+PLUS members may continue to receive their current non-Medicaid services from HHSC until the managed care organization (MCO) is able to authorize Medicaid services. Example: A member is able to continue to receive Family Care until the MCO authorizes Primary Home Care (PHC). These members are also entitled to be placed on an interest list for a non-Medicaid service, following policy specified in Section 2230, Interest List Procedures.

Mandatory STAR+PLUS individuals who are not yet enrolled with an MCO will be referred to the Enrollment Broker. Individuals who are already enrolled with an MCO and request PHC or Day Activity and Health Services from HHSC must be advised to contact their MCO.