Revision 15-1; Effective September 1, 2015

 

 

 

8100 Agency Option (AO)

Revision 10-0; Effective September 1, 2010

 

 

8110 Description

Revision 10-0; Effective September 1, 2010

 

Under the Agency Option (AO), the managed care organization-contracted 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 member 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).

 

8120 Selection of a Service Delivery Option

Revision 10-0; Effective September 1, 2010

 

All service delivery options are presented to the applicant/member at the initial assessment and each subsequent annual recertification. Use Appendix XVII, It's Your Choice: Deciding How to Manage Your Personal Assistance Services, or a document created by the managed care organization (MCO) and with Health and Human Services Commission approval , 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 options. 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.

 

8121 Member Decision

Revision 10-0; Effective September 1, 2010

 

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

 

8200 Consumer Directed Services

Revision 12-3; Effective October 1, 2012

 

 

8210 Overview

Revision 12-3; Effective October 1, 2012

 

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.

§41.107 — Overview of the CDS Option.

(a) An individual or LAR may elect the CDS option if:

(1) the individual's program offers the CDS option;

(2) one or more program services in the individual's authorized service plan are available for delivery through the CDS option;

(3) the individual or LAR agrees to perform, or to appoint a DR to perform, the employer responsibilities required for participation in the CDS option;

(4) the individual or LAR selects a CDSA to provide FMS; and

(5) the individual or LAR has developed and received approval from the service planning team for each required service back-up plan.

(b) If an individual or LAR elects to participate in the CDS option, the individual or LAR:

(1) selects a CDSA to provide FMS;

(2) with the assistance of the CDSA, budgets funds allocated in the individual's service plan for delivery through the CDS option; and

(3) recruits, screens, hires, trains, manages, and terminates service providers.

(c) An individual or LAR, as the employer, may appoint in writing a willing adult as the DR to assist in performing employer responsibilities.

CDS is a service delivery option in which a member or legally authorized representative (LAR) employs and retains service providers and directs the delivery of HCBS STAR+PLUS Waiver (SPW) personal assistance services and respite services. A member participating in the CDS option is required to use a CDS agency (CDSA) chosen by the member or LAR to provide financial management services (FMS). FMS is assistance to members to manage funds associated with services elected for self-direction. This includes initial orientation and ongoing training related to the responsibilities of being an employer and adhering to legal requirements for employers.

An individual or LAR may elect the CDS option if:

  • the individual's program offers the CDS option;
  • one or more program services in the individual's authorized service plan are available for delivery through the CDS option;
  • the individual or LAR agrees to perform or to appoint a designated representative to perform the employer responsibilities required for participation in the CDS option;
  • the individual or LAR selects a CDSA to provide FMS; and
  • the individual or LAR has developed and received approval from the service planning team for each required service back-up plan.

If an individual or LAR elects to participate in the CDS option, the individual or LAR selects a CDSA to provide FMS. The CDSA assists the individual or LAR with the budgeting of funds allocated in the individual’s service plan for delivery through the CDS option. If requested, the CDSA may also assist with recruiting, screening, hiring, training, managing and terminating service providers.

 

8211 Definitions

Revision 12-3; Effective October 1, 2012

 

§41.107 — Overview of the CDS Option.

(a) An individual or LAR may elect the CDS option if:

(1) the individual's program offers the CDS option;

(2) one or more program services in the individual's authorized service plan are available for delivery through the CDS option;

(3) the individual or LAR agrees to perform, or to appoint a DR to perform, the employer responsibilities required for participation in the CDS option;

(4) the individual or LAR selects a CDSA to provide FMS; and

(5) the individual or LAR has developed and received approval from the service planning team for each required service back-up plan.

(b) If an individual or LAR elects to participate in the CDS option, the individual or LAR:

(1) selects a CDSA to provide FMS;

(2) with the assistance of the CDSA, budgets funds allocated in the individual's service plan for delivery through the CDS option; and

(3) recruits, screens, hires, trains, manages, and terminates service providers.

(c) An individual or LAR, as the employer, may appoint in writing a willing adult as the DR to assist in performing employer responsibilities.

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

Actively involved — Involvement with an individual that the individual's interdisciplinary team deems to be of a quality nature based on the following:

  • observed interactions of the person with the individual;
  • a history of advocating for the best interests of the individual;
  • knowledge and sensitivity to the individual's preferences, values and beliefs;
  • ability to communicate with the individual; and
  • availability to the individual for assistance or support when needed.

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

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

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 of Record — 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 the member or LAR needs to perform employer and employment responsibilities, such as office equipment and supplies, recruitment and payment of Hepatitis B vaccinations for employees.

Financial Management Services (FMS) — Financial management services delivered by the Consumer Directed Services agency (CDSA) to the member or LAR 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 an HCBS STAR+PLUS Waiver (SPW) member, including a parent, guardian, 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.

 

8212 SPW Services Available Under the CDS Option

Revision 13-2; Effective June 3, 2013

 

The HCBS STAR+PLUS Waiver (SPW) program services available in the Consumer Directed Services (CDS) option are:

  • Personal Assistance Services (PAS)
  • Respite services, including in-home and out-of-home respite;
  • Skilled Nursing;
  • Physical Therapy;
  • Occupational Therapy; and
  • Speech Language Therapy.

SPW 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. The CDS option is not available to members living in Adult Foster Care homes or Assisted Living facilities.

All applicants and ongoing members will be assessed for financial and functional eligibility under the SPW program guidelines currently in use. There is no change in eligibility determination for the CDS applicant/member. Members have the option of having PAS and Respite services delivered through a contracted Home and Community Support Services Agency (HCSSA) provider or by using the CDS option, in which they hire and manage their own employees to provide the services.

Financial Management Services (FMS), assistance to members to manage funds associated with services elected for self-direction, is provided by the CDS agency. This includes initial orientation and ongoing training related to the responsibilities of being an employer and adhering to legal requirements for employers. A monthly administrative fee is authorized on the individual service plan and paid to the CDS agency for FMS.

 

8213 Risks and Advantages of the CDS Option

Revision 10-0; Effective September 1, 2010

 

The member should consider the risks and advantages associated with the Consumer Directed Services (CDS) option before choosing to enroll. To assist the member in making a decision, information is presented by the service coordinator. Refer to Section 8221, Presentation of the CDS Option.

 

8213.1 Risks Associated with the CDS Option

Revision 10-0; Effective September 1, 2010

 

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

  • responsible for locating attendants, back-up attendants or out-of-home Respite providers since there is no Home and Community Support Services (HCSS) provider to fall back on to provide services. The member or LAR may contract with an HCSS provider to provide back-up services, but the HCSS provider is not required to contract with the member or LAR;
  • the employer in the CDS option, and therefore 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 CDS agency (CDSA), the managed care organization, 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 CDSA and HCSS provider are not involved;
  • required to keep certain paperwork to be specified by the CDSA for a required time period. The member or LAR must safely store the documentation for five years or longer;
  • ultimately responsible for payroll taxes owed to the Internal Revenue Service and Texas Workforce Commission, and is liable if the CDSA fails to pay; and
  • responsible for meeting all requirements as an employer and can be held liable for failure to meet those requirements.

 

8213.2 Advantages of CDS Service Delivery Option

Revision 10-0; Effective September 1, 2010

 

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 personal assistance services and Respite 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;
  • can control the final rate of pay for attendants and/or nurses within the bounds of the unit rate as a maximum and federal minimum wage as a minimum;
  • can decide how many back-up attendants are necessary and hire them; and
  • has control over the training of attendants.

 

8214 Member and CDSA Responsibilities

Revision 10-0; Effective September 1, 2010

 

 

8214.1 Member Responsibilities

Revision 10-0; Effective September 1, 2010

 

The member or legally authorized representative (LAR) assumes responsibility as the employer of record.

§41.201 — Employer Responsibilities.

(b) An employer or DR hires and is responsible and liable for a person, contractor or vendor hired to deliver program services.

(c) An employer is responsible for:

(1) service planning with the individual's service planning team;

(2) budgeting allocated program funds in the individual's service plan for services delivered through the CDS option;

(3) determining compensation for service providers within the service rate and spending limits established by the Health and Human Services Commission;

(4) ensuring that employees and contractors are paid for services delivered based on an hourly rate;

(5) recruiting, screening, hiring and training qualified employees;

(6) recruiting, screening and retaining qualified contractors;

(7) managing and terminating service providers; and

(8) planning and arranging for back-up services.

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

The member or LAR must agree to accept financial management services from the selected Consumer Directed Services agency (CDSA). The individual or LAR must obtain an employer identification number from applicable government agencies and may request assistance from the CDSA to meet the requirements. The member or LAR must provide the information needed for the CDSA to register as the member's agent with the Internal Revenue Service and other appropriate government agencies.

 

8214.2 CDSA Responsibilities

Revision 10-0; Effective September 1, 2010

 

§41.309 — Financial Management Services and Employer-Agent Responsibilities.

(a) A CDSA must provide FMS to an employer or DR, including:

(1) providing initial orientation as described in §41.307 of this chapter (relating to Initial Orientation of an Employer);

(2) providing ongoing training, assistance, and support for employer-related responsibilities;

(3) verifying qualifications of applicants before services are delivered;

(4) monitoring continued eligibility of service providers;

(5) approving and monitoring budgets for services delivered through the CDS option;

(6) managing payroll, including calculations of employee withholdings and employer contributions and depositing these funds with appropriate agencies;

(7) complying with applicable government regulations concerning employee withholdings, garnishments, mandated withholdings and benefits;

(8) preparing and filing required tax forms and reports;

(9) paying allowable expenses incurred by the employer;

(10) providing status reports concerning the individual's budget, expenditures, and compliance with CDS option requirements; and

(11) responding to the employer or DR as soon as possible, but at least within two working days after receipt of information requiring a response from the CDSA, unless indicated otherwise in this chapter.

The Consumer Directed Services agency (CDSA) must obtain employer-agent status and perform all responsibilities as required by the Internal Revenue Service and other appropriate government agencies. The CDSA enters into service agreements with each of the individual's service providers before issuing payment.

A CDSA may not provide financial management services (FMS) and case management services to the same individual.

The CDSA must accept the designated program service fee established by the Health and Human Services Commission as payment in full for providing FMS.

 

8220 Member Choice in the CDS Option

Revision 12-3; Effective October 1, 2012

 

Information about the Consumer Directed Services (CDS) option is presented to the HCBS STAR+PLUS Waiver (SPW) member by the service coordinator. Written and verbal information is shared about the benefits and requirements of the CDS option. The member chooses to have personal assistance services and Respite services delivered though the CDS option or the agency option.

 

8221 Presentation of the CDS Option

Revision 10-0; Effective September 1, 2010

 

§41.109 — Enrollment in the CDS Option.

(a) At the time of an individual's enrollment in a DADS program that offers the CDS option, and at least annually thereafter, a case manager, service coordinator, or other person designated by the individual's program must:

(1) provide written materials on the CDS option to the individual or LAR;

(2) meet with and provide the individual or LAR with an oral explanation of the CDS option specific to the individual's program; and

(3) complete Form 1581, Consumer Directed Services Option Overview.

(b) An individual or LAR may request that a case manager, service coordinator, or other person designated by the individual's program provide additional oral and written information to the individual or LAR regarding the CDS option or assist with enrollment in the CDS option at any time. The case manager, service coordinator, or designee must comply within five working days after receipt of the request.

(c) An individual or LAR declining participation in the CDS option may at any time elect to participate in the CDS option while receiving services through a DADS program that offers the CDS option.

(d) An individual or LAR who decides to participate in the CDS option must, with assistance from a case manager or service coordinator, complete the following forms:

(1) Form 1582, Consumer Directed Services Responsibilities …

The service coordinator is responsible for presenting the Consumer Directed Services (CDS) option annually to all new applicants and ongoing 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 Option;
  • 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.

For initial applications, the service coordinator obtains the 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 applicant. A copy of Form 1581 is placed in the case record to document that CDS information was shared.

For annual redeterminations, 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.

The service coordinator must discuss the CDS option, as well as differences in service delivery and payment options, and allow the individual the opportunity to choose between delivery of services through the agency option or the CDS option.

If the member is interested in participating in the CDS option once the information on Form 1581 is shared, the service coordinator reviews Form 1582, Consumer Directed Services Responsibilities. 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 individual self-assessment on Page 4 of Form 1582;
  • records the member's or LAR's choice if he/she is willing and able to participate in the CDS option to designate a representative (DR), or records choice not to participate in the CDS option;
  • assists the member or LAR in selecting and designating the DR, or his/her choice not to participate;
  • obtains the DR's dated signature if the member or LAR chooses to designate a DR;
  • obtains the member's or LAR's dated signature on Form 1582; and
  • signs and dates Form 1582.

Refer to Section 8223, Designated Representative, for procedures related to an individual appointing a DR.

 

8222 Member Choice in the CDS Option

Revision 10-0; Effective September 1, 2010

 

§41.409 — Enrollment in the CDS Option.

(d) An individual or LAR who decides to participate in the CDS option must, with assistance from a case manager or service coordinator, complete the following forms:

(1) Form 1582, Consumer Directed Services Responsibilities

(2) Form 1583, Employee Qualification Requirements;

(3) Form 1584, Consumer Participation Choice;

(4) Form 1585, Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services through Consumer Directed Services, or Form 1733, Employer and Employee Acknowledgement of Exemption from Nursing License for Certain Services Delivered through Consumer Directed Services, if required by the policies of the individual's program; and

(5) 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.

(e) An individual or LAR who elects to participate in the CDS option must complete the self-assessment in Form 1582, Consumer Directed Services Responsibilities, and if applicable, complete any assessment required by the individual's program.

(f) An individual or LAR who is not able to complete the self-assessment must appoint a DR in order to participate in the CDS option.

(g) The person appointed as the DR by the individual or LAR must:

(1) be willing to serve as the individual's or LAR's DR for participation in the CDS option;

(2) be or become actively involved with the individual; and

(3) complete the self-assessment in Form 1582, and any assessment required by the individual's program.

The service coordinator presents the information on Form 1582, Consumer Directed Services Responsibilities, and allows the member or legally authorized representative to choose between the Consumer Directed Services option or the Agency Option.

 

8222.1 Choosing the CDS Option

Revision 12-3; Effective October 1, 2012

 

The service coordinator presents a list of contracted Consumer Directed Services (CDS) agencies (CDSA) and Home and Community Support Services (HCSS) providers. The individual must select:

  • a CDSA to perform CDS financial management services; and
  • an HCSS provider to deliver all other HCBS STAR+PLUS Waiver (SPW) services that are not delivered under the CDS option.

If the member or legally authorized representative (LAR) chooses and is able to participate in the Consumer Directed Services (CDS) option, the CDSA proceeds to Form 1583, Employee Qualification Requirements, and Form 1584, Consumer Participation Choice. The CDSA:

  • 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;
  • obtains the applicant's/member's or LAR's dated signature on Form 1583 and Form 1584, if applicable; and
  • signs and dates the forms.

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

 

8222.2 Declining the CDS Option

Revision 10-0; Effective September 1, 2010

 

If the member or legally authorized representative (LAR) declines or is not ready to select the Consumer Directed Services (CDS) option after Form 1582, Consumer Directed Services Responsibilities, is shared, the service coordinator:

  • obtains the applicant's/member's or LAR's signature on Form 1584 indicating his/her selection of the Agency Option; and
  • signs and dates Form 1584.

The service coordinator must ensure the individual 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.

 

8223 Designated Representative

Revision 10-0; Effective September 1, 2010

 

§41.205 — Employer Appointment of a Designated Representative.

(a) An employer may appoint a willing adult as a DR to assist or to perform employer responsibilities. The employer maintains responsibility and accountability for decisions and actions taken by the DR.

(b) If the employer chooses to appoint or change a DR, the employer must complete DADS Form 1720, Appointment of Designated Representative.

(1) The employer must notify a CDSA by fax or telephone within two working days after the appointment or change of a DR.

(2) If the employer notifies the CDSA by telephone, the employer must fax or mail a copy of Form 1720 to the CDSA within five working days after the appointment or change of a DR.

(c) If an employer decides to revoke the appointment of a DR, the employer must:

(1) complete DADS Form 1721, Revocation of Appointment of Designated Representative; and

(2) provide a copy of the completed form to the CDSA within two calendar days after the effective date of the revocation.

(d) Based on documentation provided by the CDSA of an employer's inability to meet employer responsibilities, the service planning team may recommend that the employer designate a DR to assist with or to perform employer responsibilities.

(e) A DR must not:

(1) sign or represent himself as the employer;

(2) be paid to perform employer responsibilities;

(3) be an employee of the employer;

(4) have a spouse employed by the employer; or

(5) provide a program service to the individual.

The member or legally authorized representative (LAR) has the option of designating a representative to assist with the responsibilities of being an employer in the Consumer Directed Services (CDS) option. The CDS agency assists the member or LAR in selecting a designated representative (DR) and documents the decision on Form 1582, Consumer Directed Services Responsibilities.

The DR signs Form 1582 in agreement to perform employer functions on behalf of the CDS individual. The DR may not be hired as the Personal Assistance Services attendant.

The CDS agency assists the member or LAR in completing the designation of a representative. Form 1720, Appointment of a Designated Representative, is used to appoint a DR. Form 1721, Revocation of Appointment of Designated Representative, is used if the member or LAR elects to participate in the CDS option without the use of a DR.

 

8230 Determining the Individual Service Plan

Revision 15-1; Effective September 1, 2015

 

§41.111 — Service Planning in the CDS Option.

(a) Service planning for an individual who chooses to participate in the CDS option is completed in accordance with the rules and requirements of the individual's program in the same manner as if services are delivered through a program provider. Service planning includes:

(1) determining the individual's needs

(2) determining service levels;

(3) justifying changes to the service plan;

(4) maintaining costs and cost ceilings;

(5) reviewing services; and

(6) obtaining approval for planned services.

(b) A case manager or service coordinator must adhere to rules and requirements of the individual's program and in Subchapter D of this chapter (relating to Enrollment, Transfer, Suspension, and Termination) if the individual's services or a request for services is recommended for:

(1) denial;

(2) reduction;

(3) suspension; or

(4) termination.

(c) A case manager or service coordinator must provide an oral explanation of an action recommended by a service planning team. The procedure for requesting a fair hearing must be provided orally and in accordance with the individual's program requirements.

All HCBS STAR+PLUS Waiver (SPW) financial and non-financial eligibility requirements apply. Consumer Directed Services (CDS) is not a different service; it is a service delivery option. The service coordinator completes all forms currently required for SPW services, including Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H2060-A, Addendum to Form H2060, and Form H2060-B, Needs Assessment Addendum, as applicable.

The member using the CDS option must have a back-up system to assure the provision of all authorized personal assistance 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 8245, Service Back-Up Plans.

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 SPW services, as well as actions that could affect the member's participation in the CDS option.

 

8231 Respite Services

Revision 12-3; Effective October 1, 2012

 

Respite services that provide temporary relief to persons caring for HCBS STAR+PLUS Waiver (SPW) members residing in the community are available through the Consumer Directed Services option. The member may choose to receive respite in his/her own home or in an out-of-home setting.

 

8231.1 In-Home Respite in the CDS Option

Revision 10-0; Effective September 1, 2010

 

In determining the member's needs for services in the individual service plan (ISP), the service coordinator discusses the member's need for Respite services. If the member has a caregiver and Respite is requested, the service coordinator includes the authorization for Respite in the ISP.

In selecting the Consumer Directed Services (CDS) option, the member assumes responsibility for managing in-home Respite as well as Personal Assistance Services (PAS). It is the member's or legally authorized representative's responsibility to advise the CDS agency (CDSA) when Respite hours are used so that the CDSA can bill correctly. The member may use the same attendant for PAS hours and in-home Respite or may hire a different attendant for the in-home Respite.

 

8231.2 Out-of-Home Respite in the CDS Option

Revision 10-0; Effective September 1, 2010

 

Out-of-Home Respite services chosen in the Consumer Directed Services (CDS) option must be authorized on the individual service plan (ISP) based on the particular setting for services. The member may select from the array of settings, including Adult Foster Care, Assisted Living (apartment or non-apartment) or nursing facility. If the member requests that out-of-home Respite be included in the ISP, the service coordinator furnishes the member with information on the contracted facilities available in the area.

In the CDS option, it is the member's or legally authorized representative's responsibility to make the arrangements with the contracted facility for an out-of-home respite stay. The CDS agency is responsible for the appropriate billing.

 

8240 Initiation of and Transition to the CDS Option

Revision 12-3; Effective October 1, 2012

 

§41.401 — Enrollment Process. The enrollment process is conducted in accordance with §41.109 of this chapter (relating to Enrollment in the CDS Option). Within five working days after receipt of a completed Form 1584, Consumer Participation Choice, by an eligible individual or LAR, or upon receipt of Form 1584 and within five working days after eligibility determination for an applicant applying for program services, a service coordinator or service coordinator must provide the following documentation to the CDSA:

(1) Form 1584;

(2) the individual's authorized service plan;

(3) the individual's plan of care; and

(4) if not provided in paragraph (1)-(3) of this section:

(A) the date the employer may begin incurring expenses to initiate start-up activities and to incur recruitment and hiring expenses;

(B) the date the employer may begin delivery of program services through the employer's service providers;

(C) the number of units, the approved rate, or the amount authorized in the individual's service plan for each service to be delivered through the CDS option;

(D) the total funds authorized for each program service to be delivered through the CDS option; and

(E) the authorized schedule of service delivery per day, week, month, or other time frame specific to the service.

Within five business days after eligibility determination for the HCBS STAR+PLUS Waiver (SPW) program, new applicants who choose the Consumer Directed Services (CDS) option are referred to the CDS agency (CDSA) to begin the initiation process.

Within five business days of receipt of the completed Form 1584, Consumer Participation Choice, ongoing SPW individuals who choose the CDS option are referred to the CDSA to begin the CDS initiation process.

The service coordinator provides the CDSA the following documentation:

  • Form 1584;
  • Form 1582, Consumer Directed Services Responsibilities; and
  • the individual service plan.

The service coordinator must provide the CDSA 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.

Some applicants may have been anticipating the availability of the CDS option and may elect to go directly to the CDS option. The service coordinator must emphasize that the applicant assumes all responsibility for arranging Personal Assistance Services and Respite.

Members who participate in the CDS option and choose to transfer back to the Agency Option 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 applicants/members to and from the CDS option.

 

8241 Initiation and Orientation of the Member as Employer

Revision 10-0; Effective September 1, 2010

 

§41.207 — Initial Orientation of an Employer. Upon choosing to participate in the CDS option, an employer, and the DR, if applicable, must:

(1) complete the initial orientation provided by the CDSA in the residence of the individual;

(2) complete and maintain a copy of Form 1736, Documentation of Employer Orientation, upon completion of the orientation;

(3) complete Form 1735, Employer and Consumer Directed Services Agency Service Agreement, with the following required attachments:

(A) Form 1726, Relationship Definitions in Consumer Directed Services;

(B) as required by the individual's program, Form 1733, Employer and Employee Exemption from Nursing License for Certain Services, or Form 1585, Statement of Responsibilities for Consumer Directed Services; and

(C) Form 1738, Rules Acknowledgment;

(4) submit completed original forms specified in paragraph (3) of this subsection to the CDSA within five calendar days after the date of the initial orientation; and

(5) retain copies of completed documentation required by this section.

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

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

The member and CDSA notify the service coordinator when all initiation activities are complete.

 

8242 Employer and Employee Acknowledgment

Revision 12-3; Effective October 1, 2012

 

The Consumer Directed Services agency (CDSA) assists the member, legally authorized representative (LAR) or designated representative (DR) in completing the employer and employee acknowledgment. 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 CDSA assists the member, LAR or DR in hiring or retaining service providers in accordance with qualifications and other requirements of the HCBS STAR+PLUS Waiver (SPW) program.

 

8243 Authorizing CDS

Revision 13-1; Effective March 1, 2013

 

When the member or legally authorized representative (LAR) and Consumer Directed Services (CDS) agency (CDSA) notify the service coordinator that CDS services are ready to begin, the service coordinator negotiates a start date for services. The service coordinator revises Form H1700-1, Individual Service Plan — SPW (Pg. 1), and changes the Personal Assistance Services and Respite authorizations to the CDSA. 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 CDSA to ensure that the expenditures for the year remain within the authorized amount.

 

8244 CDS Service Planning

Revision 12-3; Effective October 1, 2012

 

§41.215 — Employer Role in the Service Planning Process.

(a) An individual's service planning team consists of persons required or allowed by the individual's program.

(b) An employer must attend and participate in the individual's service planning meeting. An employer's DR may also attend the meeting with approval of the individual or LAR.

(c) An employer or DR must provide documentation related to services, service delivery, and participation in the CDS option when requested by a HMO or service coordinator.

(d) An employer or DR must, when requesting a change in a service or the addition of a service for delivery through the CDS option, provide the service planning team with documentation of circumstances that require a revision to the individual's service plan.

The managed care organization (MCO) and HCBS STAR+PLUS Waiver (SPW) interdisciplinary team (IDT) members make up the service planning team for the member who selects the Consumer Directed Services (CDS) option. The MCO convenes the IDT as required by SPW program policy and obtains approvals as appropriate from IDT members. The MCO and IDT also assist in resolving issues and concerns related to the member's participation in the CDS option.

The CDS agency (CDSA) must document and notify the 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 CDS option and in accordance with the requirements of the SPW program.

The member 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 CDSA may also participate in the member's service planning if requested by the member, LAR or designated representative (DR) and if agreed to by the CDSA. Within three days after receiving a request from the member, LAR, DR, MCO or other involved parties, the CDSA must provide information related to the member's participation in the CDS option.

The MCO and IDT 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 8245 below and Section 8246, Corrective Action Plans.

 

8245 Service Back-Up Plans

Revision 10-0; Effective September 1, 2010

 

§41.217 — Service Back-up Plan.

(a) An employer or DR must develop and document a service back-up plan for each service to be delivered through the CDS option that the individual's service planning team has determined to be critical to the health and welfare of the individual.

(b) An individual's service planning team must describe:

(1) which services are critical; and

(2) the length of time that constitutes a service interruption or an emergency for the individual.

(c) An employer or DR must develop a service back-up plan that:

(1) ensures the provision of services when the employer's regular service provider is not available to deliver the service or in an emergency; and

(2) may include the use of:

(A) paid service providers;

(B) unpaid service providers, such as family members, friends, or non-program services; or

(C) use of respite, if included in the authorized service plan.

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 system 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, Service Backup Plan. 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 interdisciplinary team (IDT), as appropriate, approve the plans as being viable in the event a service provider is absent. The MCO or IDT 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 CDS agency (CDSA) within five business days after a plan's approval by the IDT.

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

  • meet service back-up plan strategies approved by the member's IDT;
  • 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.

 

8246 Corrective Action Plans

Revision 12-3; Effective October 1, 2012

 

§41.221 — Corrective Action Plans.

(a) A written corrective action plan may be required from an employer or DR if the employer or DR:

(1) hires an ineligible service provider;

(2) submits incomplete, inaccurate, or late documentation of service delivery;

(3) does not follow the budget;

(4) does not comply with program requirements related to the CDS option;

(5) does not meet other employer responsibilities.

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

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:

  • CDSA or others, if the plan is related to employer responsibilities; and
  • MCO, if the CAP is related to the HCBS STAR+PLUS Waiver (SPW) rules or requirements.

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

 

8247 Budgets

Revision 12-3; Effective October 1, 2012

 

§41.501 — Budget Development.

(a) The employer or DR, with assistance obtained from the CDSA or others, must:

(1) develop a budget for each program service to be delivered through the CDS option;

(2) project expenditures of funds allocated in the individual's authorized service plan for the effective period of the service plan;

(3) use applicable budget workbooks available through DADS at www.dads.state.tx.us/business/communitycare/cds/CDSforms.html;

(4) request assistance from the CDSA as needed;

(5) submit each budget to the CDSA for review; and

(6) obtain written approval for each budget from the CDSA before initiating services or making purchases for payment.

The member, legally authorized representative (LAR) or designated representative (DR) develops a budget for each HCBS STAR+PLUS Waiver (SPW) 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 Health and Human Services Commission for payment of Financial Management Services delivered by the CDS agency (CDSA) through the CDS option.

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

The CDSA must provide assistance as requested or needed by the member, LAR or DR to develop a budget. The CDSA 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 CDSA must work with the member, LAR or DR to resolve issues that prevent the approval of budget plans.

§41.511 — Budget Revisions and Approval.

(a) An employer or DR must make budget revisions if:

(1) a change to the individual's authorized service plan affects funding for a program service delivered through the CDS option;

(2) a budget has been or will be exceeded before the end date of the service plan;

(3) authorized units, unit rate, or amount of funds allocated have changed;

(4) an amount paid for one or more services, goods or items affects the approved budget;

(5) strategies are added or revisions are made to a service back-up plan;

(6) funds budgeted for a service back-up plan are not used or needed; or

(7) the CDSA, the case manager or service coordinator, the individual's service planning team, or a DADS representative require a revision.

The member, LAR or DR must submit budget revisions to the CDSA for approval. Revised budgets cannot be implemented until written approval is received from the CDSA.

The CDSA 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 interdisciplinary team meetings to resolve issues when the member does not follow the budget or comply with CDS option budget requirements.

 

8300 Service Responsibility Option (SRO) Description

Revision 11-2; Effective June 1, 2011

 

SRO is a service delivery option that empowers the member to manage most day-to-day activities. This includes supervision of the individual providing personal assistance services and respite services.

The member decides how services are provided. SRO leaves the business details to the member's managed care organization. See Appendix XVII, It's Your Choice: Deciding How to Manage Your Personal Assistance Services, for a comparison of all available service delivery option features.

 

8310 SRO Roles and Responsibilities

Revision 11-2; Effective June 1, 2011

 

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 (SRO) responsibilities.

 

8311 MCO Responsibilities

Revision 11-2; Effective June 1, 2011

 

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 personal assistance services and respite services; and
  • review Appendix XVII, It's Your Choice: Deciding How to Manage Your Personal Assistance Services, 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 an interdisciplinary team meeting in instances where the member:
    • 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 8322, Monitoring.

 

8312 Agency Responsibilities

Revision 11-2; Effective June 1, 2011

 

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:

  • discusses and negotiates potential back-up plans for those times when the attendant is absent from work;
  • sends a maximum of three attendants, including any individuals recommended by the member, for the member to review;
  • explains to the selected attendants that the agency is the employer of record and the member is the day-to-day manager;
  • provides agency time sheets to the member and orients the member to the time sheet submission process, including how frequently time sheets must be completed;
  • receives and processes attendant time sheets;
  • sends new attendants within the required time frame to interview at the member's request; and
  • orients the member to the agency's attendant evaluation process, including forms and the schedule for evaluating attendants.

 

8313 Member Responsibilities

Revision 11-2; Effective June 1, 2011

 

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 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 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, address 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 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 an interdisciplinary team meeting); and
  • notifying the MCO and agency supervisor if a change to either the Agency Option or Consumer Directed Services is desired. An interdisciplinary team meeting will be held to plan for the change.

 

8320 Managed Care Organization (MCO) Procedures

Revision 15-1; Effective September 1, 2015

 

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, MCO procedures are not impacted by the member's choice of SRO.

Complete all forms currently required, including the assessment of functional needs on Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H2060-A, Addendum to Form H2060, and Form H2060-B, Needs Assessment Addendum. Continue to identify any caregivers who are currently providing for the member's needs.

 

8321 Initial Authorization of Services

Revision 11-2; Effective June 1, 2011

 

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, Administrative Procedures, for specific information.

 

8322 Monitoring

Revision 11-2; Effective June 1, 2011

 

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:

  • discuss the issues with the agency staff;
  • talk to the member to determine if the issues can be resolved; and
  • convene an interdisciplinary 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.

 

8323 Procedures for Ongoing Cases

Revision 11-2; Effective June 1, 2011

 

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/she 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 2067, when the transition planning is complete. Negotiate a start date with the member and the agency.