6110  Description

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

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

6120  Selection of a Service Delivery Option

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

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

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

6121  Individual Decision

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

6130  Casework Procedures

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

• Section 6200, Service Responsibility Option (SRO);
• Section 6300, Consumer Directed Services (CDS);
• Section 6400, State of Texas Access Reform Plus (STAR+PLUS) Managed Care; and
• Section 6500, Integrated Care Management.

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

6220  SRO Roles and Responsibilities

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

6221  Case Manager Responsibilities

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

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

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

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

In addition, the case manager's responsibilities include:

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

6222  Provider Responsibilities

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

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

6223  Individual Responsibilities

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

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

6230  Casework Procedures

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

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

6231  Initial Authorization of Services

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

6232  Monitoring

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

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

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

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

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

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

6233  Procedures for Ongoing Cases

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

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

6310  Description

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

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

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

See Section 6332.2, Calculation of the Annual Service Plan.

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

6311  Risks and Advantages of the CDS Option

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

6311.1 Risks Associated with CDS

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

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

6311.2  Advantages of CDS Service Delivery

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

• has more control over who provides services and the service delivery schedule;
• can offer the attendant(s) benefits such as bonuses, vacation pay, sick pay and insurance;
• can control the final rate of pay for attendant(s) within the unit rate as a maximum and the federal minimum wage;
• can decide how many back-up attendants are necessary and hire them; and
• has control over the training of attendant(s).

6320  Roles and Responsibilities

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

6321  Individual Responsibilities

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

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

Required Employer Responsibilities

§41.201 — Employer Responsibilities.

(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 to be 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.

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

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

The Designated Representative

§41.201 — Employer Responsibilities.

(a)

If an employer appoints a DR to assist with employer responsibilities:

(1)

a criminal conviction check must be completed on the person as described in §41.225 of this chapter (relating to Criminal Conviction History Checks);

(2)

registry checks must be made as described in §41.227 of this chapter (relating to Required Registry Checks);

(3)

the appointment of an eligible person must be documented by the employer on Form 1720, Appointment of a Designated Representative; and

(4)

the appointment of a DR must be terminated if the DR does not maintain eligibility required in paragraphs (1) and (2) of this subsection.

(b)

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

§41.109 — Enrollment 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 DR signs an agreement to perform employer functions on behalf of the CDS individual. He or she remains the employer of record and assumes liability. The CDSA assists the individual in completing the forms for designation of the DR. The DR may not be hired as the personal attendant.

6322  Case Manager Responsibilities

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

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

6323  Agency Responsibilities

§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)

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

(b)

A CDSA must obtain employer-agent status with the Internal Revenue Service, the Texas Workforce Commission, and any other appropriate government agencies within the time frame established by each agency.

(c)

The CDSA must perform all required employer-agent responsibilities required by government agencies that regulate the relationship between the employer-agent (the CDSA) and the employer (the individual or the LAR) and maintain an original or a copy of each form required to document compliance.

(d)

The CDSA must:

(1)

maintain a copy of required forms and reports that the CDSA files with or receives from government agencies; and

(2)

within 30 calendar days after receipt, provide a copy of each form and report to the employer.

(e)

The CDSA must enter into a service agreement provided by DADS with each of the employer's service providers before issuing the initial payment for services to the service provider.

(f)

The CDSA must accept the designated portion of the program service rate or a designated fee established by the Health and Human Services Commission as payment in full for FMS delivered.

(g)

The CDSA must maintain originals or copies of records to document compliance with this section.

(h)

The CDSA must not provide FMS and case management services to the same individual in accordance with §41.301 of this chapter (Contracting as a Consumer Directed Services Agency).

§41.317 — CDSA Reports. A CDSA must:

(1)

compile a report in accordance with the format provided by DADS addressing each service delivered through the CDS option, including the actual number of hours or units of service delivered;

(2)

provide the report no less than quarterly, and monthly if requested, to:

(A)

the employer or DR; and

(B)

the case manager or service coordinator; and

(3)

provide a copy of the report to DADS, upon request by a DADS representative.

The Consumer Directed Services Agency (CDSA) also performs the following services for the individual:

• registers the individual as an employer and provides assistance in completing forms required to obtain an employer identification number (EIN) from federal and state agencies;
• prepares and distributes payroll at least twice a month;
• conducts criminal history checks of applicants when requested by the individual; and
• pays out-of-home respite providers.

6330  Casework Procedures

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

6331  Presentation of the CDS Option

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

§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 ... 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 ... 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 ... or designee must comply within five working days after receipt of the request.

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

6331.1  Individual Decision

§41.109(c) — Enrollment in the CDS Option.

(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 ..., complete the following forms:

(1)

Form 1582, Consumer Directed Services Responsibilities;

(2)

Form 1583, Employee Qualification Requirements;

(3)

Form 1584, Participation Choice for Consumer Directed Services;

(4)

Form 1585, Acknowledgement of Responsibility for Consumer Directed Services, or Form 1733, Employer and Employee Acknowledgement of Exemption from Nursing License for Certain 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.

Form 1582, Consumer Directed Services Responsibilities, includes the following sections:

• Responsibilities of the Individual in Consumer Directed Services (CDS),
• Responsibilities of the Case manager and CDS Agency,
• Risks versus Advantages,
• Individual Self-Assessment.

Assist the individual in completing the individual self-assessment. If the individual wants to proceed and meets the criteria, present Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the CDS Option. Also present Form 1583, Employee Qualification Requirements.

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

6331.2  Selection of the Consumer Directed Services Agency

The Department of Aging and Disability Services (DADS) case manager or the individual may go to the DADS website for a choice list of Consumer Directed Services Agencies (CDSAs). The list, which allows individuals to search for CDSAs by county, can be accessed at: www.dads.state.tx.us/providers/CDS/index.cfm.

Under the CDS menu, select CDS Agencies and a list of DADS programs will appear. Select the appropriate program. On the top of the page is a drop-down list of Texas counties. After selecting a county, click the button labeled "Search for CDSAs." This will create a list of CDSAs serving the selected county.

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

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

6332  Initial Authorization of Services

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

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

§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.

During the initial home visit, applicants who choose CDS must select a CDS provider. The individual signs the regional contract list indicating his provider selection.

Once an eligibility determination is made, authorize services on Form 2101, Authorization for Community Care Services. Note in the comments section that the applicant is a CDS individual. Send Form 2065-A, Notification of Community Care Services, to the applicant as notification of eligibility.

6332.1  Pre-Enrollment Requirements

§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, Participation Choice for Consumer Directed Services, 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 case manager ... must provide the following documentation to the CDSA:

(a)

Form 1584;

(b)

the individual's authorized service plan.

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

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

The individual must contact the Consumer Directed Services Agency (CDSA) to request training and transition planning. Send Form 1584, Consumer Participation Choice, to the CDSA to notify it that the individual has selected the agency and will contact it to schedule CDS training. Request that the provider advise by Form 2067, Case Information, when the training and transition planning are complete.

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

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

6332.2  Calculation of the Annual Service Plan

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

Note: In this example, the $9.50 amount is a fictitious number used for demonstration purposes only. The current CDS service rate can be accessed at the following Health and Human Services Commission website: www.hhsc.state.tx.us/rad/long-term-svcs/.

In addition to the budgeted ASP, the case manager will authorize a CDS monthly administrative fee using Service Code 63V. The current rate can be found at the website above.

Consumer Directed Services Agency (CDSA) Procedures

The case manager sends the CDSA:

• Form 2067, Case Information; and
• Form 1584, Consumer Participation Choice.

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

Once the individual has contacted the agency, the CDSA:

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

6332.3  Monitoring CDS Service Initiation

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

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

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

6332.4  Responsibility for Responding to Questions

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

Note: If an individual asks the case manager a question related to CDS that falls under the CDS Agency (CDSA) purview to answer, the case manager must refer the individual to the CDSA rather than attempting to answer the question himself or contacting the CDSA for the individual. If the case manager has a general non-individual specific question about the CDS option, the case manager must contact the regional CDS liaison rather than contacting a CDSA. If the regional CDS liaison cannot answer the question, he or she will forward the question to state office.

6333  Service Initiation Directly into CDS for PHC or CAS

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

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

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

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

6333.1  Authorizing CDS for Ongoing Individuals

Use the appropriate Service Authorization System code(s) created for use with the Consumer Directed Services (CDS) option, as provided in Section 6332.2, Transfers and Consumer Directed Services (CDS).

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

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

6333.2  Transfers and Consumer Directed Services (CDS)

The individual has the right to:

• transfer to a different CDS Agency (CDSA);
• elect to receive services through the Service Responsibility Option (SRO); or
• request a transfer back to the Agency Option (AO) at any time.

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

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

See Section 6333.4, Annual Recertification, for instructions on updating the ASP when transferring to another CDSA.

Transfer to Another CDSA

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

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

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

Transfer to the AO or the SRO

§41.407 — Termination of Participation in the CDS Option.

(a)

An employer may request voluntary termination of participation in the CDS option and receive services through a program agency provider at any time. The termination must last at least 90 calendar days.

The individual may return to CDS after the 90-day transfer period has expired by contacting the case manager. All pre-assessment procedures must be completed, including a new Individual Self-Assessment, before the individual is allowed to return to CDS.

Service Resources Available During the Transfer Process

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

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

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

Four situations may necessitate revision of the ASP:

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

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

6333.3.1  Provider Transfer

§41.403(c) — After the receipt of a request to transfer, the case manager ... must:

(1)

process the individual's request to transfer from one CDSA to another CDSA in accordance with the requirements of the individual's program;

(2)

calculate the number of units or amount of funds needed to complete the service plan period based on the individual's current service plan;

(3)

revise the service plan to indicate the number of units or amount of funds calculated in this subsection effective the date of transfer and:

(A)

approve only the units and funds calculated as needed if units and funds remaining in the budget meet or exceed the needed number or units or amount of funds to complete the service period, or approve only the amount remaining in the budget for the period remaining in the individual's service plan.

(B)

provide a copy of the transferring service plan to the receiving CDSA and employer before the effective date of the transfer; and

(4)

provide a copy of the individual's revised service plan to the transferring CDSA, the receiving CDSA, and the employer or DR.

Use the following example when processing Consumer Directed Services Agency (CDSA) transfers.

Note: In this example, the $8.50 amount is a fictitious number used for demonstration purposes only. The current CDS service rate can be accessed at the following Health and Human Services Commission website: www.hhsc.state.tx.us/rad/long-term-svcs/.

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

6333.3.2  Rate Change

Use the following example when processing rate changes.

Note: The $9.00 and $8.50 amounts in this example are fictitious numbers used for demonstration purposes only. The current rate can be accessed at the following Health and Human Services Commission website: www.hhsc.state.tx.us/rad/long-term-svcs/.

6333.3.3  Increase in Service Units

Use the following example when processing increases in service units.

Note: In this example, the $8.50 amount is a fictional number used for demonstration purposes only. The current rate can be accessed at the following Health and Human Services Commission website: www.hhsc.state.tx.us/rad/long-term-svcs/.

6333.3.4  Decrease in Service Units

Use the following example when processing decreases in service units.

Note: In this example, the $8.50 amount is a fictitious number used for demonstration purposes only. The current rate can be accessed at the following Health and Human Services Commission website: www.hhsc.state.tx.us/rad/long-term-svcs/.

6333.4  Annual Recertification

§41.109 (a)(2) — 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 ... must meet with and provide the individual or LAR with an oral explanation of the CDS option specific to the individual's program ....

The Texas Administrative Code mandates that case managers conduct home visits at least annually for all Consumer Directed Services (CDS) individuals.

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

§41.111 — Service Planning in the CDS Option.

(a)

A case manager ... 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.

(b)

A case manager ... 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.

Section 1929(b)(2) of the Social Security Act mandates the annual involvement of a home health agency registered nurse at the initial authorization, and each annual reassessment for all Community Attendant Services (CAS) cases. Under CDS, the individual is responsible for the timely compliance with this requirement.

Because all CDS individuals commence receiving services using the Agency Option, the nursing requirement is already met at the time CDS services begin. Therefore, the nurse's authorization for continued CAS services will not coincide with the annual renewal of the CDS ASP. Individuals must be given the date of the initial nurse's assessment so they can track when the next nursing assessment is due.

The individual obtains the required nursing assessment by contracting with a CAS provider through the CDS Agency (CDSA). If the CDSA does not handle this task itself, it will refer the individual to an individual who is contracted to fulfill this condition of ongoing eligibility. This is part of the administrative cost in the CDS budget, but should not have a significant impact on the overall budget for the year.

6333.5  Ongoing CDS Monitoring

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

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

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

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

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

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

6333.6  Ensuring Individual Health and Safety

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

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

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

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

See Section 6323, Agency Responsibilities, for CDSA responsibilities.

6333.6.1  Voluntary Suspension of the CDS Option

§41.405 – Suspension of Participation in the CDS Option.

(a)

An employer may request voluntary suspension of participation in the CDS option and request that all program services be delivered through a program provider at any time.

(b)

The suspension must last at least 90 days.

(c)

The employer must notify the individual's case manager ... of intent to reactivate participation in the CDS option.

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

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

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

6333.6.2  Involuntary Termination of the CDS Option

§41.407 – Termination of Participation in the CDS Option.

(a)

An individual may be involuntarily terminated from participation in the CDS option in accordance with the requirements of the individual's program.

(b)

FMS and, if applicable, support consultation, are terminated in the individual's service plan when participation in the CDS option is terminated.

(c)

An individual's case manager ... convenes the individual's service planning team concerning issues that may warrant immediate termination of the individual's participation in the CDS option. On review of the information, the service planning team may recommend immediate termination of participation in the CDS option when:

(1)

the individual's health or welfare is immediately jeopardized by the individual's participation in the CDS option;

(2)

an employer or DR has been convicted of an offense under Chapter 32 of the Penal Code or an offense barring employment as listed in the Texas health and Safety Code, §250.006(a) and (b); or

(3)

DADS or another government agency with applicable regulatory authority recommends that participation in the CDS option be immediately terminated.

(d)

If an individual, LAR, or DR does not implement and successfully complete the following steps and interventions, an individual's service planning team may recommend termination of participation in the CDS option in accordance with the individual's program requirements:

(1)

eliminate jeopardy to the individual's health or welfare;

(2)

successfully direct the delivery of program services through CDS;

(3)

meet employer responsibilities;

(4)

successfully implement corrective action plans; or

(5)

appoint a DR or access other available supports to assist the employer in meeting employer responsibilities.

(e)

On receipt of a recommendation for involuntary termination from the CDSA or other party, the individual's case manager ... must:

(1)

provide assistance with accessing supports and developing and implement a corrective action plan related to noncompliance with program and CDS requirements;

(2)

document interventions used by the individual, employer, or DR to eliminate noncompliance with program requirements for delivery or program services through the CDS option; and

(3)

convene the service planning team to:

(A)

consider recommendations related to the individual's participation in the CDS option;

(B)

recommend additional interventions to be implemented by the employer to protect the individual's health and welfare for continued participation in the CDS option; and

(C)

make revisions to the individual's service plan if needed.

(f)

The individual's case manager ... must meet requirements of the individual's program and this chapter for termination of service to include documentation of all proceedings and notices in accordance with the individual's program requirements.

(g)

If the service planning team recommends terminating participation in the CDS option, an individual's case manager ... must document:

(1)

the reasons for the recommendation;

(2)

the conditions and time frame established by the individual's service planning team that the individual must meet prior to re-enrollment in the CDS option;

(3)

justification for any time period for a termination in excess of the minimum 90-day requirement; and

(4)

if applicable, the conditions and time frame specified by a hearing officer as the result of a fair hearing that upholds the termination.

(h)

When an individual's participation in the CDS option is terminated, the case manager ... must take steps and interventions in accordance with the requirements of the individual's program to:

(1)

ensure continuity of delivery of program services that were being delivered through the CDS option; and

(2)

document arrangements made for delivery of program services that were being delivered through the CDS option to be delivered by the individual's program provider or other resources.

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

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

6333.6.3  Re-Enrollment in the CDS Option

§41.409 – Re-enrollment for Participation in the CDS Option.

(a)

Following suspension or termination of participation in the CDS option, an individual or LAR must request re-enrollment in the CDS option by notifying the individual's case manager.

(b)

If an individual or LAR wishes to re-enroll in the CDS option, the case manager ... must:

(1)

review the reason that the individual was suspended or terminated from the CDS option;

(2)

verify that the individual has fulfilled the minimum 90-day period and any conditions specified by the individual's service planning team or a hearing officer, if applicable;

(3)

verify how each issue that contributed to the termination has been resolved; and

(4)

refer the request for re-enrollment in the CDS option to the individual's service planning team and follow requirements of the individual's program, including:

(A)

revising the individual's service plan and re-enrolling the individual in the CDS option upon approval; and

(B)

issuing a denial and providing information related to requesting a fair hearing if the request is not approved.

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

6410  Program Overview

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

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

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

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

• 1915(b) Waiver – Authority granted to the state of Texas to allow delivery of Medicaid State Plan acute and Long-term Services and Supports (Primary Home Care and Day Activity and Health Services) through a managed care delivery system in specific service areas.
• 1915(c) Waiver – Authority granted to the state of Texas to allow delivery of Long-term Services and Supports that assists individuals to live in the community in lieu of a nursing facility. This is also known as the STAR+PLUS Waiver (SPW).
• Enrollment broker – A contracted entity that assists individuals in selecting and enrolling with an MCO. If requested by the individual, the enrollment broker also may assist in choosing a primary care provider (PCP). Members of STAR+PLUS may request an MCO change at any time by contacting the enrollment broker. The change will be effective the first day of the subsequent month if the request is made before the state cutoff date or the first of the following month if the request is made after cutoff.
• Health and Human Services Commission (HHSC) – The state agency responsible for Medicaid. Some functions related to STAR+PLUS have been delegated to the Department of Aging and Disability Services (DADS).
• MCO – An insurer licensed by the Texas Department of Insurance as a managed care organization in accordance with Chapter 843 of the Texas Insurance Code. MCOs provide Medicaid benefits for individuals who are required to enroll in STAR+PLUS.
• Member – An individual who is enrolled in and receiving services through a STAR+PLUS MCO.
• Plan of care (POC) – A care plan the MCO develops for its members that includes acute care and Long-term Services and Supports. The plan of care is not the same as the individual service plan (ISP) for STAR+PLUS waiver services.
• STAR+PLUS Support Unit (SPSU) – DADS staff who support certain aspects of STAR+PLUS case management, as described in Section 6000, State of Texas Access Reform Plus (STAR+PLUS) Managed Care, of the Case Manager Community Based Alternatives Handbook.
• Texas Medicaid & Healthcare Partnership (TMHP) – The Texas contractor administering Medicaid claims processing and the Medicaid primary care case management services program.
• TexMedCentral – A secure internet bulletin board that the state and the MCOs use to share information.
• Upgrade – An existing STAR+PLUS individual enrolled in the 1915(b) waiver who requests and is granted SPW (1915(c) waiver) services.

6411  Services Available Under the STAR+PLUS Option

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

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

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

STAR+PLUS serves as an insurance policy that will be available if members have a need for LTSS at a future time. See Section 6434, Special Circumstances for Dual Eligible Members, for additional information on dual eligible coverage.

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

Long-term Services and Supports

Additional services are available under a 1915(c) waiver program known as the STAR+PLUS Waiver (SPW) that provides services and supports similar to those available under the Community Based Alternatives (CBA) waiver. While eligibility criteria remain the same, policies and procedures for the SPW differ from CBA policies and procedures. See Section 6000 of the Case Manager Community Based Alternatives Handbook for details.

6412  STAR+PLUS Service Areas

Long-term services and supports provided by STAR+PLUS include Primary Home Care, Day Activity and Health Services and a 1915(c) Medicaid waiver that includes the services provided by the Community Based Alternatives (CBA) waiver. For a complete list of services provided under STAR+PLUS, consult the STAR+PLUS website at: www.hhsc.state.tx.us/Starplus/client_info.html.

STAR+PLUS services are currently available in the following areas:

• Bexar Service Area — Atascosa, Bandera, Bexar, Comal, Goliad, Guadalupe, Karnes, Kendall, Medina and Wilson counties
• Dallas-Tarrant Service Area — Collin, Dallas, Denton, Ellis, Hood, Hunt, Johnson, Kaufman, Navarro, Parker, Rockwall, Tarrant and Wise counties
• Harris/Harris Expansion Service Area — Austin, Brazoria, Chambers, Fort Bend, Galveston, Harris, Liberty, Matagorda, Montgomery, Walker, Waller and Wharton counties
• Jefferson Area — Hardin, Jasper, Jefferson, Newton, Orange, Polk, San Jacinto and Tyler counties
• Nueces Service Area — Aransas, Bee, Brooks, Calhoun, Jim Wells, Kenedy, Kleberg, Live Oak, Nueces, Refugio, San Patricio and Victoria counties
• Travis Service Area — Bastrop, Burnet, Caldwell, Fayette, Hays, Lee, Travis and Williamson counties

6420  STAR+PLUS Members Requesting Non-Medicaid Services

Requirements of the 1915(c) waiver dictate that STAR+PLUS Waiver (SPW) recipients receive all services excluding hospice through the waiver. The CCAD case manager must not authorize any Title XX services for individuals enrolled in HCBS SPW.

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

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

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

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

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

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

http://www.hhsc.state.tx.us/starplus/ComparisonCharts.html.

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

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

In some situations, a STAR+PLUS member or his MCO may request and be granted disenrollment of the member from managed care. Whether the disenrollment is voluntary or involuntary, disenrolled individuals can receive available DADS services (both Medicaid and Title XX) if determined eligible, with the exception of Community Based Alternatives (CBA). There are no CBA contracts in managed care areas.

6430  Transition Between DADS and STAR+PLUS

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

Any application for new long-term services and supports from DADS requires the applicant be sent to the MCO first. This must be coordinated through the STAR+PLUS Support Unit (SPSU).

6430.1  Individuals Moving Into a STAR+PLUS Area

Department of Aging and Disability Services (DADS) may receive notification of a transfer into a STAR+PLUS area in a variety of ways. The individual/responsible party may contact the local DADS office before relocating or after moving. In some cases, a provider may notify DADS that the individual has moved or is planning to move.

When DADS becomes aware of a move, whether planned or not, the usual procedures in Section 2722, Individual Moves and Case Transfers, are followed. The gaining case manager will identify potential STAR+PLUS cases. Once identified, these cases must be checked weekly for managed care enrollment. Confirmation of STAR+PLUS enrollment is obtained by checking the Texas Integrated Eligibility Redesign System (TIERS). Once a plan code is registered in TIERS, the individual is enrolled in managed care.

When the enrollment date is posted, the case manager will close non-managed care services effective the day before managed care organization (MCO) enrollment. The case manager will fax to the STAR+PLUS Support Unit (SPSU) Form 2101, Authorization for Community Care Services, for the current provider agency.

The SPSU posts Form 2101 on TexMed Central and notifies the MCO via email that information is posted in a specific folder without identifying the individual in any way.

During the transition period:

• Individuals receiving Primary Home Care (PHC) or Title XIX Day Activity and Health Services (DAHS) will continue receiving these services through traditional (non-managed care) DADS contractors and are assigned to a DADS case manager until the individual is enrolled with a MCO.

The enrollment could take from one to four months with the MCO, depending on when the individual selects an MCO or if the individual fails to make a choice and is assigned to an MCO. At the time the individual is enrolled with an MCO, the DADS case manager will close the PHC or DAHS case in the Service Authorization System (SAS), effective the day before MCO enrollment. The case manager must flag the case and check TIERS once a week. The SPSU will send a copy of the individual's current service authorization to the MCO using the TexMed system. Other non-CBA community care services can remain open and be managed by DADS until MCO enrollment is established.

• The MCO is required to continue delivery of DADS authorized services once the individual is enrolled in STAR+PLUS. The MCO must pay the individual's current provider, even if the provider is not in the MCO's network, until the MCO has made an assessment visit and developed a new plan of care. At the time of the MCO's assessment, the individual may have to switch providers if the provider currently being used is not within the MCO's network.

Under certain conditions, Supplemental Security Income recipients receiving non-Medicaid services can continue receiving services through DADS even after enrollment with a STAR+PLUS MCO. See Section 6420, STAR+PLUS Members Requesting Non-Medicaid Services, for additional information. These cases are managed by DADS case managers.

6430.2  Individuals Moving Out of a STAR+PLUS Area

When an individual moves out of a STAR+PLUS area, the managed care organization (MCO) must continue to pay for services (in accordance with the MCO's out-of-network payment procedures) through the end of the month of the move.

The following transfer processes must be followed to avoid gaps in service delivery:

• The MCO notifies the STAR+PLUS Support Unit (SPSU) of the move.
• The SPSU will contact the program manager in the gaining Department of Aging and Disability Services (DADS) service area, either verbally or by email, within two business days of notification of the move to obtain a case manager assignment.
• The SPSU will contact the individual to inform him of the case manager assignment, including complete contact information.
• The SPSU will obtain a copy of the individual's service plan from the MCO and forward to the gaining case manager.
• The SPSU and DADS case manager follow the usual policies regarding individual transfers, as described in Section 2722, Individual Moves and Case Transfers, and Section 2722.5, Adult Day Care and Personal Attendant Services Individuals Transferring Out of a STAR+PLUS Area.

In situations where the individual moves out of a STAR+PLUS area and then calls the local DADS office requesting services, DADS staff will inform the SPSU of the move within two business days. After receiving the notification, SPSU staff will follow applicable procedures outlined above.

The SPSU is the main contact point for transfers in and out of a STAR+PLUS service area. MCOs are instructed to contact the SPSU to assist with transfers of PHC, Title XIX DAHS or other community care services. SPSU will check the Service Authorization System (SAS) to see if the individual is receiving any non-managed care long term services and supports and will coordinate with the appropriate DADS case manager or Medicaid for the Elderly and People with Disabilities (MEPD) unit regarding the transfer of non-managed care cases.

The individual will be disenrolled from managed care the last day of the month of the move. For the individual to be disenrolled, a change of address must be made in the Texas Integrated Eligibility Redesign System (TIERS). TIERS entries trigger enrollment and disenrollment from STAR+PLUS. Once the change of address is reflected in TIERS, the individual is automatically disenrolled on the last day of the month. The MEPD specialist in the STAR+PLUS area can enter the address change for Medical Assistance Only cases when it is reported. The Supplemental Security Income (SSI) individual is responsible for reporting the address change to the Social Security Administration (SSA). If the address change is not reported to SSA, the TIERS change will revert to the former address when the systems interface, the Medicaid card will be delivered to the wrong address and the SSI case will be placed on hold because it cannot be forwarded.

The DADS case manager must follow the procedures in Section 2722.5 to ensure the individual continues to receive services under the MCO service plan until services can be authorized in the non-managed care area.