Revision 17-1; Effective June 1, 2017

 

 

5010 Selection of a Service Delivery Option

Revision 17-1; Effective June 1, 2017

 

Service coordinators must present all service delivery options to the applicant/member and/or the legally authorized representative at the initial assessment and each annual reassessment. In addition to the documents described in Section 5221, Advantages of Consumer Directed Services (CDS) Service Delivery Options, the managed care organization (MCO) may use Form 1581, Consumer Directed Services Overview, and Form 1582, Consumer Directed Services Responsibilities, or a document created by the MCO and approved by the Texas Health and Human Services Commission, to assist the member or applicant in making the service delivery decision.

MCOs must obtain a signature on Form 1584, Consumer Participation Choice, indicating the member's choice of option. If, at any time during the year, a current member calls requesting information on service delivery options, the MCO must present the information to the member.

 

5020 Member Decision

Revision 17-1; Effective June 1, 2017

 

The managed care organization (MCO) must keep Form 1584, Consumer Participation Choice, in the member's case record. The MCO must ensure the member understands he may request a service delivery option change at any time by contacting the MCO.

 

5100 Agency Option

Revision 17-1; Effective June 1, 2017

 

 

5110 Description

Revision 17-1; Effective June 1, 2017

 

Under the agency option (AO), the managed care organization-contracted provider is responsible for managing the day-to-day activities of the direct service provider and all business details. Some individuals select the AO because of the simplicity and convenience of receiving services. For example, under AO the agency, not the member, is responsible for:

  • locating qualified attendant(s) to provide services;
  • any negligent acts or omissions by the attendant(s), and liability for those acts;
  • handling all conflicts with the attendant(s);
  • any business details related to service delivery; and
  • training the attendant(s).

 

5200 Consumer Directed Services

Revision 17-1; Effective June 1, 2017

 

 

5210 Overview

Revision 17-1; Effective June 1, 2017

 

The Consumer Directed Services (CDS) option was codified in Section 531.051 of the Government Code and expanded by the 79th Texas Legislature to provide more options for members to direct their long term services and supports. The rules for the CDS option are found in Texas Administrative Code, Title 40, Chapter 41.

CDS is a service delivery option in which a member or legally authorized representative (LAR) becomes the CDS employer of record for certain services. The CDS employer recruits, selects, trains, and supervises service providers and directs the delivery of services available through the CDS option, described in Section 5212, STAR Kids Services Available Under the Consumer Directed Services Option. CDS employers are required to use a financial management services agency (FMSA), contracted with the managed care organization that they choose to provide financial management services (FMS). FMSAs conduct payroll and pay employer federal and state taxes on behalf of CDS employers, and provide orientation and ongoing support for members who choose the CDS option. FMSA roles and responsibilities are explained in more detail in Section 5232, Financial Management Service Agency Responsibilities.

A member or LAR may elect the CDS option if the:

  • member's services offer the CDS option;
  • CDS employer agrees to perform the employer responsibilities required for participation in the CDS option;
  • member or LAR selects an FMSA to provide FMS; and
  • member or LAR has developed and received approval from the service planning team for each required service back-up plan.

 

5211 Consumer Directed Services Definitions

Revision 17-1; Effective June 1, 2017

 

The following words and terms, when used in reference to the Consumer Directed Services (CDS) option, have the following meanings.

Budget — A written projection of expenditures for each service delivered through the CDS option.

Designated representative (DR) — A willing adult appointed by the CDS employer to assist with or perform the employer's required responsibilities to the extent approved by the employer. The DR is not the CDS employer.

Employee — A person employed by the member or legally authorized representative (LAR) through a service agreement to deliver program services and is paid an hourly wage for those services.

Employer — The member or LAR who chooses to participate in the CDS option and is responsible for hiring and retaining service providers to deliver program services.

Employer support services — Services and items needed and allocated in the member's budget for the member or LAR to perform employer and employment responsibilities, such as office equipment and supplies, expenses related to recruiting employees, and other items approved in Texas Administrative Code, Title 40, Part 1, Chapter 41, §41.507.

Financial Management Services (FMS) — Financial management services delivered by the financial management service agency (FMSA) to the member or LAR, as described in Section 5232, Financial Management Service Agency Responsibilities, such as orientation, training, support, assistance with and approval of budgets, and processing payroll and payables on behalf of the member or LAR.

 

Legally authorized representative (LAR) — A person authorized by law to act on behalf of a member, including a parent of a minor, guardian of a minor, managing conservator of a minor or the guardian of an adult.

Service back-up plan — A documented plan to ensure that critical program services delivered through the CDS option are provided to a member when normal service delivery is interrupted or there is an emergency.

 

5212 STAR Kids Services Available Under the Consumer Directed Services Option

Revision 17-1; Effective June 1, 2017

 

STAR Kids services for which the Consumer Directed Services (CDS) option are available are:

  • Community First Choice (CFC) Personal Assistance Services;
  • CFC Habilitation; and
  • Personal Care Services.

The Medically Dependent Children Program waiver services available in the CDS option are:

  • In-home Respite;
  • Flexible Family Support Services;
  • Supported Employment; and
  • Employment Assistance.

STAR Kids members may choose to self-direct any or all services available through the CDS option. The CDS option is available to members living in their own homes or the homes of family members.

All applicants and ongoing members will be assessed for financial and functional eligibility using the STAR Kids Screening and Assessment Instrument (SK-SAI). Choosing the CDS option in no way impacts a member's eligibility for services. Members have the option of having services delivered through a contracted Home and Community Support Services Agency provider using the agency or service responsibility options, or through the CDS option, in which they hire and manage their own employees to provide the services.

Financial management services (FMS), a required service under the CDS option, provides assistance to members to manage funds associated with services elected for self-direction, and is provided by the financial management service agency (FMSA). This includes initial orientation and ongoing training related to the responsibilities of being an employer and adhering to legal requirements for employers. If requested, an FMSA can provide support consultation, which is extra help training, working with, and if necessary, dismissing an employee provided by a support advisor. FMSAs also conduct payroll and pay employer taxes on behalf of the employer. A monthly administrative fee is authorized on the individual service plan and paid to the FMSA for FMS.

 

5220 Advantages and Risks of the Consumer Directed Services Option

Revision 17-1; Effective June 1, 2017

 

The member should consider the advantages and risks associated with the Consumer Directed Services option before choosing to enroll. To assist the member in making an informed choice, information is presented by the service coordinator. See Section 5521 below.

 

5221 Advantages of Consumer Directed Services (CDS) Service Delivery Option

Revision 17-1; Effective June 1, 2017

 

Below are some of the advantages associated with the Consumer Directed Services (CDS) option. The member or legally authorized representative:

  • has more control over who provides services and the days and times the services are delivered;
  • can offer benefits, such as bonuses, vacation pay, sick pay and insurance to the attendants or nurses, in consultation with the financial management service agency (FMSA);
  • can control the final rate of pay for direct service providers within the bounds of the unit rate established by the managed care organization as a maximum and at least $8.00 per hour, or the wage floor established by the Texas Legislature;
  • may be able to recruit eligible service providers, including family members, friends and other persons they know;
  • may be able to appoint someone to assist with employer responsibilities or to perform employer responsibilities;
  • may use some of the budgeted funds to hire a support advisor, if they need assistance above and beyond what the FMSA provides; and
  • train service providers and supervise the services delivered by their service providers.

 

5222 Potential Risks Associated with the Consumer Directed Services Option

Revision 17-1; Effective June 1, 2017

 

Following are some of the potential risks associated with the Consumer Directed Services (CDS) option. The member or legally authorized representative (LAR) is:

  • responsible for locating attendants or back-up attendants. The member or LAR may contract with a Home and Community Support Services Agency provider to provide back-up services;
  • the employer in the CDS option and assumes all liability. The member or LAR retains control over hiring, managing and firing employees. The persons providing services are not the employees of the financial management service agency (FMSA), the managed care organization (MCO), any state or federal agency or other contracted provider agency. The member or LAR is solely responsible and liable for any negligent acts or omissions as the employer or by the employee, other employees, service providers and the designated representative;
  • responsible for handling all conflicts with the attendant. The FMSA and service coordinator are not involved;
  • not able to change or increase the MCO authorized service hours by paying the attendants less;
  • required to keep certain paperwork to be specified by the FMSA for a required time period. The member or LAR must safely store the documentation for five years or longer;
  • required to understand that while the FMSA is responsible for payroll taxes owed to the Internal Revenue Service and Texas Workforce Commission, the employer is jointly liable if the FMSA fails to pay; and
  • responsible for meeting all state and federal requirements as an employer and can be held liable for failure to meet those requirements.

 

5230 Member and Financial Management Service Agency Responsibilities

Revision 17-1; Effective June 1, 2017

 

 

5231 Member Responsibilities

Revision 17-1; Effective June 1, 2017

 

The member or legally authorized representative (LAR) assumes responsibility as the employer of record. The member and/or his legally authorized representative is responsible for:

  • recruiting, hiring, training, managing and firing direct service providers;
  • setting wages and benefits for direct service providers within funds allocated for services elected for delivery through the Consumer Directed Services (CDS) option;
  • following state and federal laws including the payment of overtime;
  • evaluating each service provider's job performance;
  • approving, signing and submitting time sheets, invoices and receipts to the financial management service agency (FMSA) for payment to direct service providers;
  • providing the FMSA with necessary information to register as the member’s agent with the Internal Revenue Service and the Texas Workforce Commission;
  • having the FMSA verify eligibility of each applicant before hiring or retaining for employment or service delivery;
  • resolving employee and service provider concerns and complaints;
  • maintaining a personnel file on each service provider;
  • developing and implementing back-up service plans for services determined by the individual's planning team to be critical to the individual's health and welfare; and
  • ensuring protection of the individual receiving services and preserving evidence in the event of a Department of Family and Protective Services Adult Protective Services investigation of an allegation of abuse, neglect, or exploitation against a CDS employee, designated representative, FMSA representative, case manager or service.

 

5232 Financial Management Service Agency Responsibilities

Revision 17-1; Effective June 1, 2017

 

Under the Consumer Directed Services (CDS) option, a financial management service agency (FMSA) must:

  • orient and train the employer/designated representative about employer responsibilities for the CDS option to include legal requirements of various governmental agencies;
  • assist and approve budgets for each service to be delivered through CDS;
  • provide assistance in completing forms required to obtain an employer identification number (EIN) from federal and state agencies;
  • conduct criminal history checks and registry checks of applicants;
  • verify each applicant's eligibility with program requirements, including Medicaid fraud exclusions, before an applicant is employed or retained by the employer;
  • register as the employer-agent with the Internal Revenue Service (IRS) and assume full liability for filing reports;
  • pay employer taxes on the CDS employer's behalf, to the IRS and Texas Workforce Commission;
  • receive and process employee time sheets, compute and pay all federal and state employment-related taxes and withholdings, and distribute payroll at least twice a month;
  • receive and process invoices and receipts for payment;
  • maintain records of all expenses and reimbursement and monitor budget;
  • submit claims to the member's managed care organization;
  • provide written summaries and budget balances of payroll and other expenses at least quarterly;
  • prepare and file employer-related tax and withholding forms and reports (this does not include filing personal income tax returns for employees); and
  • provide ongoing training and assistance, as needed or requested.

The FMSA must obtain employer-agent status as defined by IRS Rev. Proc., 2013-39 and perform all responsibilities as required by the IRS and other appropriate government agencies. The FMSA must enter into service agreements with each of the member's direct service providers before issuing payment.

 

5240 Member Choice in the Consumer Directed Services Option

Revision 17-1; Effective June 1, 2017

 

Information about the Consumer Directed Services (CDS) option is presented to the STAR Kids member by the service coordinator. Written and verbal information is shared about the benefits and requirements of the CDS option. The member chooses which services will be delivered through the CDS option and which will be through the agency or service responsibility option.

 

5241 Presentation of the Consumer Directed Services Option

Revision 17-1; Effective June 1, 2017

 

The service coordinator is responsible for offering the Consumer Directed Services (CDS) option to all new STAR Kids members and Medically Dependent Children Program applicants annually, and to current members who are not enrolled in the CDS option and whenever information is requested. The service coordinator:

  • shares an overview of the benefits and responsibilities of the CDS option by reviewing Form 1581, Consumer Directed Services Overview, and Form 1582, Consumer Directed Services Responsibilities;
  • provides a copy of Form 1581 to the applicant/member; and
  • informs the applicant/member of the right to choose service delivery through the agency option or the CDS option.

The service coordinator obtains the member’s or applicant's signature on Form 1581 at the initial contact. The service coordinator signs and dates the form verifying the information was presented to the member or applicant. A copy of Form 1581 is placed in the case record to document that CDS information was shared.

At annual reassessment, the service coordinator provides the member with a copy of Form 1581 and clearly documents in the case record that Form 1581 was shared with the member.

When members request information about the CDS option at other times, the service coordinator must provide CDS information to the member within five business days after receipt of the request. The service coordinator may provide the information by making a home visit or contacting the individual by telephone. If a home visit is not made, the service coordinator obtains the member's signature by mailing Form 1581 to the member with a postage-paid return envelope. The service coordinator signs and dates Form 1581 indicating the information was presented. A copy of Form 1581 is placed in the member's case record to document Form 1581 was shared.

If the member is still interested in participating in the CDS option once the information on Form 1581 is shared, the service coordinator reviews Form 1582. The service coordinator:

  • reviews with the member or legally authorized representative (LAR) the responsibilities, risks and advantages of the CDS option;
  • assists the member, as needed, in completing the Consumer Self-Assessment on Page 4 of Form 1582;
  • obtains the designated representative's (DR's) dated signature if the appointment of a DR is required based on the assessment;
  • obtains the member's or LAR's dated signature on Form 1582; and
  • signs and dates Form 1582.

If an individual or LAR (the employer) is not able to complete the Consumer Self-Assessment, a person appointed by the employer to be the employer's DR must be able to complete the Consumer Self-Assessment for the individual receiving services to participate in the CDS option.

If an employer would like to use a DR, the financial management services agency assists the employer in appointing a DR.

 

5300 Initiating the Consumer Directed Services Option

Revision 17-1; Effective June 1, 2017

 

Once a member and/or his legally authorized representative (LAR) has chosen the Consumer Directed Services (CDS) option, the service coordinator presents a list of contracted financial management services agencies (FMSAs). The individual must select an FMSA to perform CDS financial management services.

If the member or LAR chooses the CDS option, the service coordinator proceeds to 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. The service coordinator:

  • provides Form 1583 information on the additional responsibilities of being an employer in the CDS option and who may or may not be hired in the CDS option;
  • shares Form 1584 indicating the applicant's/member's or LAR's selection of the CDS option;
  • provides Form 1586 information about support consultation;
  • obtains the applicant's/member's or LAR's dated signature on Form 1583, Form 1584 and Form 1586, if applicable; and
  • signs and dates the forms.

The service coordinator develops the member's service plan according to policy and CDS option rules.

 

5310 Declining the Consumer Directed Services Option

Revision 17-1; Effective June 1, 2017

 

If the member or legally authorized representative (LAR) declines or is not ready to select the Consumer Directed Services (CDS) option at any point after Form 1581, Consumer Directed Services Overview, is shared, the service coordinator:

  • obtains the applicant's/member's or LAR's signature on Form 1584, Consumer Participation Choice, indicating his/her selection of the agency option; and
  • signs and dates Form 1584.

The service coordinator must ensure the member understands the CDS option is always available and that the individual may call the service coordinator to request a change to the CDS option at any time.

Form 1584 is signed by the member when a different service delivery option is chosen. The member must wait 90 days before switching to a different service delivery option.

 

5320 Determining the Individual Service Plan

Revision 17-1; Effective June 1, 2017

 

All existing Medicaid eligibility requirements apply in the Consumer Directed Services (CDS) option. CDS is not a different program; it is a service delivery option. The service coordinator completes all forms currently required for STAR Kids services.

The member using the CDS option must have a back-up system to assure the provision of certain or critical authorized CDS services without a service break, even if there are unexpected changes in personnel. The member or legally authorized representative must develop and receive approval from the service coordinator for each required service back-up plan in order to participate in the CDS option. Refer to Section 5326, Service Back-Up Plans.

If the member hires a nurse to provide services, the nurse must operate within the license requirements outlined in the Texas Board of Nursing regulations (Texas Administrative Code, Title 22, Part 11), including registered nurse (RN) or physician oversight, plan of care development for nurses depending on the level of nurse hired, and RN or physician delegation as indicated.

The service coordinator follows program policy when completing denials or terminations, reductions in services and suspensions. The service coordinator must ensure the member fully understands the reasons for actions taken relating to the individual service plan and STAR Kids services, as well as actions that could affect the member's participation in the CDS option.

 

5321 Initiation of and Transition to the Consumer Directed Services Option

Revision 17-1; Effective June 1, 2017

 

Within five business days of receipt of the completed Form 1584, Consumer Participation Choice, existing STAR Kids members who choose the Consumer Directed Services (CDS) option are referred to the financial management services agency (FMSA) they selected to begin the CDS initiation process.

The service coordinator provides the FMSA the following documentation:

  • Form 1584;
  • Form 1582, Consumer Directed Services Responsibilities; and
  • individual service plan and any related addenda.

The service coordinator must provide the FMSA with the authorized schedule of service delivery per day, week, month or other time frame specific to the service if not listed on the above forms.

Members who participate in the CDS option and choose to transfer back to the Agency Option (AO) will not have the choice of returning to the CDS option for at least 90 days. Service coordinators must carefully coordinate transition activities when transitioning members to and from the CDS option.

 

5322 Initiation and Orientation of the Member as Employer

Revision 17-1; Effective June 1, 2017

 

Upon receipt of the Consumer Directed Services (CDS) referral from the service coordinator, the financial management service agency (FMSA) completes the initial employer orientation with the member, legally authorized representative (LAR) and designated representative (DR), if one is appointed, in the member's residence or setting of the member’s choosing. The FMSA provides an overview of the CDS option, including the rules and requirements of applicable government agencies, and the roles of the employer and the FMSA.

The member, LAR and DR, if one is appointed, signs and submits all required forms for participation in the CDS option and returns the forms to the FMSA within five calendar days after the date of initial orientation.

 

5323 Employer and Employee Acknowledgment of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services

Revision 17-1; Effective June 1, 2017

 

If the Consumer Directed Services (CDS) employer is going to assume responsibility for training and supervising an unlicensed service provider to perform certain health related tasks, the financial management service agency (FMSA) assists the member, legally authorized representative (LAR) or designated representative (DR) in completing the employer and employee acknowledgment. Tasks prohibited from delegation are described in the Texas Administrative Code §225.13, Tasks Prohibited From Delegation. The employee acknowledges that, as the person who delivers the service, he/she has not been:

  • denied a license under Chapter 301 or 302, Occupations Code; or
  • issued a license under Chapter 301, Occupation Code, that is revoked or suspended.

The FMSA verifies potential service providers selected by the member, LAR or DR meet provider qualifications and other requirements of the STAR Kids program before the member, LAR or DR hires the service provider.

 

5324 Authorizing Consumer Directed Services

Revision 17-1; Effective June 1, 2017

 

For members new to Consumer Directed Services (CDS), following orientation the member or legally authorized representative (LAR) and financial management services agency (FMSA) notify the service coordinator that CDS services are ready to begin. The service coordinator negotiates a start date for services and revises Form 2604, STAR Kids Individual Service Plan - Service Tracking Tool, and changes the appropriate CDS services authorizations to the FMSA. For ongoing members, the individual service plan year remains the same. The same procedures are followed for any other transfer of agencies.

It is the responsibility of the member, LAR and the FMSA to ensure that the expenditures for the year remain within the authorized amount. The managed care organization is responsible for timely payment of FMSA claims, submitted on behalf of the CDS employer, as well as for payment of the monthly service fee, which pays the FMSA for its services.

 

5325 Ongoing Requirements

Revision 17-1; Effective June 1, 2017

 

The financial management services agency (FMSA) must send a quarterly expenditure report to the employer and service coordinator and document and notify the managed care organization (MCO) of issues or concerns, including:

  • allegations of abuse, neglect, exploitation or fraud;
  • concerns about the member's health, safety or welfare;
  • non-delivery or extended breaks in services;
  • noncompliance with employer responsibilities;
  • noncompliance with service back-up plans; or
  • over- or under-utilization of services or funds allocated in the member's service plan for delivery of services to the member through the Consumer Directed Services (CDS) option and in accordance with the requirements of the STAR Kids program.

The CDS employer is required to participate in the service planning meetings and provide requested documentation related to services and service delivery. The member or legally authorized representative (LAR) must provide documentation to support any requests for a revision to the individual service plan.

The FMSA may also participate in the member's service planning, if requested by the member, LAR or designated representative, and if agreed to by the FMSA. The MCO and service planning team members, as appropriate, participate in approving back-up plans, developing corrective action plans, if necessary, and recommending suspension or termination of the CDS option. Refer to Section 5326 below.

 

5326 Service Back-Up Plans

Revision 17-1; Effective June 1, 2017

 

The managed care organization (MCO) must discuss with the member, legally authorized representative (LAR) or designated representative (DR) the services delivered through Consumer Directed Services (CDS) that are critical to the member's health and welfare. The MCO must inform the member, LAR or DR to develop a service back-up plan to ensure the health and safety of the member when regular service providers are not available to deliver services, or in an emergency. The member, LAR or DR must develop a back-up plan, and document the plan on Form 1740, Service Backup Plan, to assure the provision of all authorized personal assistance services without a service break.

The member, LAR or DR, with the assistance of the MCO (if needed), completes Form 1740. The service back-up plan must list the steps the member, LAR or DR implements in the absence of the service provider. The service back-up plan may include the use of paid service providers, unpaid service providers such as family members, friends or non-program services, or respite (if included in the authorized service plan). The member, LAR or DR is responsible for implementation of the service back-up plan in the absence of the employee.

Service back-up plans are submitted by the member, LAR or DR to the MCO. The MCO and service planning team, as appropriate, approve the plans as being viable in the event a service provider is absent. The MCO or service planning team must approve each service back-up plan and any revision before implementation by the member, LAR or DR. The MCO approves the service back-up plan by signing, dating and returning a copy of the plan to the member, LAR or DR.

The member, LAR or DR is required to:

  • budget sufficient funds in the CDS option budget to implement a service back-up plan;
  • review and revise each service back-up plan annually;
  • revise a service back-up plan if:
    • the member experiences a problem in the implementation, or
    • there are changes in availability of resources;
  • redistribute funds that are not used in carrying out a service back-up plan; and
  • provide a copy of the initial and revised service back-up plans and budgets to the financial management services agency (FMSA) within five business days after a plan's approval by the service planning team.

The FMSA must assist a member, LAR or DR, as requested to revise budgets, to:

  • meet service back-up plan strategies approved by the member's service planning team;
  • reimburse documented, budgeted, allowable expenses incurred related to implementing service back-up plan strategies; and
  • retain a copy of service back-up plans received from the member, LAR or DR.

 

5327 Corrective Action Plans

Revision 17-1; Effective June 1, 2017

 

The Consumer Directed Services (CDS) employer, meaning the member or legally authorized representative (LAR) or designated representative (DR), must provide written corrective action plans (CAPs) to the person requiring the plan within 10 calendar days after receiving a CAP request. CAPs may be requested in writing by the financial management services agency (FMSA) or managed care organization (MCO).

The written CAP must include the:

  • reason the CAP is required;
  • action to be taken;
  • person responsible for each action; and
  • date the action must be completed.

The member, LAR or DR may request assistance in the development or implementation of a CAP from the:

  • FMSA or others, if the plan is related to employer responsibilities; and
  • MCO, if the CAP is related to the Medically Dependent Children Program waiver STAR Kids rules or requirements.

Form 1741, Corrective Action Plan, is used to document the CAP.

 

5328 Budgets

Revision 17-1; Effective June 1, 2017

 

The member, legally authorized representative (LAR), or designated representative (DR) with the financial management service agency (FMSA) develops a budget for each STAR Kids service to be delivered through the Consumer Directed Services (CDS) option based on the projected expenditures allocated in the individual service plan period. The member must budget the monthly amount established by the Texas Health and Human Services Commission for payment of financial management services delivered by the FMSA through the CDS option.

The member, LAR or DR develops an initial and annual budget and receives written approval from the FMSA before implementation of the budget and initiation of service delivery through the CDS option.

The FMSA must provide assistance, as requested or needed, by the member, LAR or DR to develop a budget. The FMSA reviews the member's budgeted payroll spending decisions, verifies the applicable budget workbooks are within the approved budget, and notifies the member in writing of budget approval or disapproval. The FMSA must work with the member, LAR or DR to resolve issues that prevent the approval of budget plans.

The member, LAR or DR must submit budget revisions to the FMSA for approval. Revised budgets cannot be implemented until written approval is received from the FMSA. The FMSA must provide assistance to the member, LAR or DR with budget revisions as requested or needed by the member, validate the budget, and provide written approval to the member, LAR or DR.

The managed care organization evaluates service plan changes requested by the member and participates in the service planning team meetings to resolve issues when the member does not follow the budget or comply with CDS option budget requirements.

 

5400 Service Responsibility Option Description

Revision 17-1; Effective June 1, 2017

 

The Service Responsibility Option (SRO) empowers the member to manage most day-to-day activities. This includes supervision of the individual providing direct services. The member decides how services are provided. The SRO leaves the business details to the member's managed care organization. The rules for the SRO are found in Texas Administrative Code, Title 40, Chapter 43.

 

5410 Service Responsibility Option Roles and Responsibilities

Revision 17-1; Effective June 1, 2017

 

Form 1582-SRO, Service Responsibility Option Roles and Responsibilities, specifies the roles and responsibilities assigned to the member, provider and managed care organization (MCO). The member, provider, and MCO receive and sign Form 1582-SRO indicating their agreement to accept the service responsibility option responsibilities.

 

5411 Managed Care Organization Responsibilities

Revision 17-1; Effective June 1, 2017

 

The intake, referral and assessment procedures for members requesting service delivery through the Service Responsibility Option (SRO) are handled in the usual way. The managed care organizations (MCOs) are responsible for:

  • ensuring the member 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 MCO is required to:

  • inform the member about all options for managing services; and
  • review Form 1582-SRO, Service Responsibility Option Roles and Responsibilities, with the member to determine if the SRO is an appropriate choice.

In addition, the MCO's responsibilities include:

  • presenting all service delivery options;
  • documenting the member's choice on Form 1584, Consumer Participation Choice;
  • explaining SRO rights, responsibilities and resources to the member;
  • presenting the MCO provider list and the support consultation provider to the member;
  • making a referral to the provider(s) selected by the member;
  • processing the member's request to change service delivery options;
  • redeveloping the service plan when a member's needs change;
  • serving as a resource if the member has health or safety concerns, issues involving the attendant or other service-related concerns;
  • convening a service planning team meeting in instances where the member has:
    • health and safety concerns;
    • difficulty selecting or keeping an attendant; or
    • other issues relating to services that cannot otherwise be resolved; and
  • monitoring services in accordance with Section 5422, Monitoring.

 

5412 Agency Responsibilities

Revision 17-1; Effective June 1, 2017

 

The agency contracted with the managed care organization is the attendant's employer and handles the business details (for example, paying taxes and doing the payroll). The agency also orients attendants to policies and standards before sending the attendants to members' homes.

The agency staff:

  • 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 member, for the member to review;
  • explain to the selected attendants that the agency is the employer of record and the member is the day-to-day manager;
  • provide agency time sheets to the member and orient the member to the time sheet submission process, including how frequently time sheets must be completed;
  • receive and process attendant time sheets;
  • send new attendants within the required time frame to interview at the member's request; and
  • orient the member to the agency's attendant evaluation process, including forms and the schedule for evaluating attendants.

 

5413 Member Responsibilities

Revision 17-1; Effective June 1, 2017

 

The member 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 member must be capable of performing all management tasks as described below, or may identify a DR to assist or perform those management tasks on the member's behalf.

The member is responsible for:

  • choosing the SRO;
  • choosing the SRO service and support provider(s);
  • meeting with the SRO support provider within 14 days of selecting the SRO;
  • coordinating with the agency supervisor as part of the service planning process by:
    • negotiating 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 agency, including someone the person recommends to the agency supervisor or someone who has completed the agency pre-employment screening;
  • informing the agency supervisor within 24 hours:
    • of the personal attendant selected;
    • if the attendant gives notice of his intention to quit;
    • if the attendant quits; or
    • if the member 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 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 agency payroll and attendance policies;
  • evaluating the attendant's job performance at the time designated by the agency;
  • reviewing, approving and signing agency employee time sheets after the attendant completes them;
  • ensuring employee time sheets are submitted to the agency within the time frames designated by the agency;
  • notifying the agency as soon as possible if the personal attendant will be absent and a substitute is needed;
  • taking responsibility for liability risk if the member or attendant is injured while doing tasks under the member's training and supervision;
  • using the following complaint procedures:
    • If the agency is not fulfilling the expected responsibilities, addressing those issues directly with the agency. If the agency and the member are not able to resolve the concerns/issues, the member should contact the managed care organization (MCO).
    • If concerns and issues are still not resolved, the member may select another agency. The member must contact the MCO to transfer from one agency to another. The MCO will make all necessary arrangements for the transfer.
  • notifying the MCO and/or agency supervisor of any health or safety concerns or issues with the attendant (the member may, at any time, request a service planning team meeting); and
  • notifying the MCO and agency supervisor if a change to either the Agency Option or Consumer Directed Services is desired. A service planning team meeting will be held to plan for the change.

 

5420 Managed Care Organization Procedures

Revision 17-1; Effective June 1, 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, managed care organization procedures are not impacted by the member's choice of SRO. Complete all forms currently required and continue to identify any caregivers who are currently providing for the member's needs.

 

5421 Initial Authorization of Services

Revision 17-1; Effective June 1, 2017

 

The member's decision to receive services using the Service Responsibility Option does not change the manner in which initial services are authorized. See Section 3300, Member Service Planning and Authorization, for specific information.

 

5422 Monitoring

Revision 17-1; Effective June 1, 2017

 

All monitoring for Service Responsibility Option (SRO) members is done by the managed care organization (MCO) according to the mandated schedule for its specific services. When health and safety issues arise, the MCO staff will:

  • discuss the issues with the agency staff;
  • talk to the member to determine if the issues can be resolved; and
  • convene a service planning team meeting if the issue cannot be resolved.

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

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

If it is evident that the member is having difficulty in the management of SRO responsibilities, the MCO staff must:

  • consult the agency staff; and
  • advise the member of the option to transfer back to the agency option.

 

5423 Procedures for Ongoing Members

Revision 17-1; Effective June 1, 2017

 

Members must be offered the Service Responsibility Option (SRO) by the managed care organization (MCO) annually, and may request a transfer to the SRO at any time. Additionally, the SRO must be presented to ongoing members at each annual reassessment or upon request. If the member is interested in transferring to the SRO, the member must sign Form 1582-SRO, Service Responsibility Option Roles and Responsibilities.

The MCO must ensure the member understands the responsibility he is assuming. Send Form H2067-MC, Managed Care Programs Communication, to the agency to advise it of the member's selection. Notify the agency the member will be contacting it for training. Request the agency to advise the MCO, using Form H2067-MC, when the transition planning is complete. Negotiate a start date with the member and the agency.