5300, Member Choice and Enrollment in the CDS Option

Revision 20-1; Effective March 16, 2020

A member or legally authorized representative (LAR) who decides to participate in the Consumer Directed Services (CDS) option must, with assistance from the managed care organization (MCO) service coordinator, complete the following forms:

  • Form 1582, Consumer Directed Services Responsibilities;
  • Form 1583, Employee Qualification Requirements;
  • Form 1584, Consumer Participation Choice;
  • 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 Licensure for Certain Services Delivered through Consumer Directed Services, if required by the policies of the member's program; and
  • Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option, if the service is available in the member's program.

A member or LAR who elects to participate in the CDS option must complete the self-assessment in Form 1582 and, if applicable, complete any assessment required by the member's program.

A member or LAR who is not able to complete the self-assessment must appoint a designated representative (DR) to participate in the CDS option.

The MCO service coordinator presents the information on Form 1582 and allows the member or LAR to choose the CDS option. The MCO service coordinator develops the member’s service plan according to policy and CDS option rules.

5310 Choosing the CDS Option and an FMSA

Revision 20-1; Effective March 16, 2020

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

  • provides Form 1583 information on the additional responsibilities of being a CDS 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;
  • signs and dates the forms; and
  • assists the member or LAR in choosing a financial management services agency (FMSA).

The MCO service coordinator presents a list of MCO-contracted FMSAs and home and community support services agencies (HCSSAs) providers. The member or LAR must select:

  • an FMSA to provide CDS financial management services (FMS); and
  • an HCSSA provider to deliver all other STAR Kids and Medically Dependent Children Program (MDCP) services that are not delivered under the CDS option.

The MCO service coordinator develops the individual service plan (ISP) according to STAR Kids and MDCP program policy and CDS option rules.

5311 Developing the Individual Service Plan in the CDS Option

Revision 20-1; Effective March 16, 2020

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

  • determining the member's needs;
  • determining service levels;
  • justifying changes to the service plan;
  • maintaining costs and cost limits;
  • reviewing services; and
  • obtaining approval for planned services.

The managed care organization (MCO) service coordinator must adhere to rules and requirements of the member's program if the member's services, or a request for services, is recommended for:

  • denial;
  • reduction;
  • suspension; or
  • termination.

The MCO service coordinator must provide a verbal explanation of an action recommended by a service planning team. The procedure for requesting a fair hearing must be provided verbally and in accordance with the member's program requirements.

All STAR Kids and Medically Dependent Children Program (MDCP) program financial and non-financial eligibility requirements apply. All existing Medicaid eligibility requirements apply in the CDS option. CDS is not a service; it is a service delivery option. The MCO service coordinator completes all forms currently required for STAR Kids and MDCP program services, including Form 2603, STAR Kids Individual Service Plan (ISP) Narrative, and Form 2604, STAR Kids Individual Service Plan – Service Tracking Tool.

The member using the CDS option must have a back-up plan to assure the provision of certain or critical authorized CDS services without a service break, even if there are unexpected changes in personnel. The CDS employer or designated representative (DR) must develop and receive approval from the MCO service coordinator for each required service back-up plan in order to participate in the CDS option. Refer to 5323, Service Back-Up Plans.

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

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

In the CDS option, an RN must develop the nursing plan of care that determines hours of nursing needed and how many, if any, of the nursing hours can be provided by a licensed vocational nurse (LVN) and the same RN responsibilities listed in the paragraphs above. The RN and LVN must acknowledge nursing rules, including that an LVN must practice under the supervision of an RN, by completing Form 1747, Acknowledgement of Nursing Requirements.

The RN may be employed through contract with a home health agency or private arrangement. The same expectation of collaboration exists between the MCO RN service coordinator and the RN who develops the plan of care in the CDS option.

5312 Initiation of and Transition to the CDS Option

Revision 20-1; Effective March 16, 2020

Within five business days after receipt of a completed Form 1584, Consumer Participation Choice, by an eligible member or legally authorized representative (LAR), or upon receipt of Form 1584 and within five business days after eligibility determination for an applicant applying for program services, a managed care organization (MCO) service coordinator must provide the following documentation to the financial management services agency (FMSA):

  • Form 1584;
  • the individual service plan (ISP);
  • date the CDS employer may begin incurring expenses to initiate start-up activities and to incur recruitment and hiring expenses;
  • date the CDS employer may begin delivery of program services through the employer's service providers;
  • the number of units, the approved rate or the amount authorized in the ISP for each service to be delivered through the CDS option;
  • total funds authorized for each program service to be delivered through the CDS option; and
  • 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.

Within five business days after eligibility determination for the STAR Kids program or Medically Dependent Children Program (MDCP), new applicants who choose the CDS option are referred to the FMSA they select to begin the initiation process.

Within five business days of receipt of the completed Form 1584, ongoing STAR Kids program or MDCP members who choose the CDS option are referred to the FMSA they selected to begin the CDS initiation process.

The MCO service coordinator provides the FMSA the following documentation:

  • Form 1584;
  • Form 1582, Consumer Directed Services Responsibilities; and
  • the ISP.

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

Some applicants may have been anticipating the availability of the CDS option and may elect to go directly to the CDS option. The MCO service coordinator must emphasize that the applicant assumes all responsibility for arranging their self-directed services.

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.

MCO service coordinators must carefully coordinate transition activities when transitioning applicants or members to and from the CDS option.

5313 Initiation and Orientation of the Member as CDS Employer

Revision 20-1; Effective March 16, 2020

Upon choosing to participate in the Consumer Directed Services (CDS) option, a CDS employer, legally authorized representative (LAR) and the designated representative (DR), if applicable, must:  

  • complete the initial CDS employer orientation provided by the financial management services agency (FMSA) in the member's residence or setting of the member’s or legally authorized representative’s (LAR’s) choosing;
  • complete and maintain a copy of Form 1736, Documentation of Employer Orientation by Financial Management Services Agency, upon completion of the orientation;
  • complete Form 1735, Employer and Financial Management Services Agency Service Agreement, with the program addendums, if applicable;
  • complete Form 1726, Relationship Definitions for Consumer Directed Services;
  • as required by the member's program, complete Form 1733, Employer and Employee Acknowledgement of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services, or Form 1585, Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services;
  • complete Form 1728, Liability Acknowledgment;
  • submit completed original forms specified in this section to the FMSA within five business days after the date of the initial orientation; and
  • retain copies of completed documentation required by this section.

Upon receipt of the CDS referral from the managed care organization (MCO) service coordinator, the FMSA completes the initial CDS employer orientation with the member, LAR or DR, if applicable, in the member's residence. The FMSA provides an overview of the CDS option, including the rules and requirements of applicable government agencies, and the roles of the CDS employer and the FMSA.

During the initial face-to-face orientation, the FMSA must also:

  • explain the roles, rules and responsibilities that apply to a CDS employer, provider, FMSA, MCO and state agencies, including:
    • the employer budget based on the authorized service plan;
    • the hiring process, including documents and forms to be completed for new employees; and
    • managing paper and electronic timesheets, due dates, payday schedules and disbursing employee payroll checks;
  • review and leave with the CDS employer, LAR and DR, if applicable, a printed document that clearly states the FMSA's:
    • normal hours of operation;
    • key persons to contact with issues or questions and how to contact these persons; and
    • the complaint process, including how to file a complaint with the FMSA or about the FMSA;
  • review Form 1735 and required addendums, emphasizing rule and policy requirements of the member's program, including:
    • service definitions;
    • provider qualifications;
    • required documentation to be kept in the home;
    • training requirements for service providers;
    • program staff who will be reviewing the employer's records; and
    • if applicable, nursing requirements as described on Form 1747, Acknowledgement of Nursing Requirements; and
  • review and leave with the CDS employer, LAR and DR, if applicable, printed information on how to report allegations of abuse, neglect and exploitation.

The FMSA must provide to the CDS employer, LAR or DR a printed or electronic copy of the HHSC CDS Option Employer Manual.

Upon conclusion of the orientation, the FMSA and CDS employer must complete Form 1736, Documentation of Employer Orientation by Financial Management Services Agency.

The FMSA must receive a completed Form 1735 with required attachments signed and dated by the CDS employer before initiation of the CDS option.

The CDS employer or DR, if applicable, signs and submits all required forms for participation in the CDS option and returns the forms to the FMSA within five business days after the date of initial orientation.

The CDS employer and FMSA notify the MCO service coordinator when all initiation activities are complete. The MCO must ensure the FMSA performs all FMSA responsibilities, including providing orientation to CDS employers.

5314 Employer and Employee Acknowledgment of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services

Revision 20-1; Effective March 16, 2020

If the Consumer Directed Services (CDS) employer will assume responsibility for training and supervising an unlicensed service provider to perform certain health related tasks, the financial management service agency (FMSA) assists the employer or designated representative (DR) in completing the CDS employer and employee acknowledgment of exemption from nursing licensure requirements for certain services delivered through CDS. Tasks prohibited from delegation are described in Texas Administrative Code §225.13, Tasks Prohibited from Delegation. The employee acknowledges that, as the person who delivers the service, they have not been:

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

The FMSA verifies potential service providers selected by the CDS employer or DR meet provider qualifications and other requirements of the STAR Kids program or Medically Dependent Children Program (MDCP) before the CDS employer or DR hires the service provider.

5315 Authorizing CDS

Revision 20-1; Effective March 16, 2020

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

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

5320 Ongoing CDS Requirements and Process

Revision 20-1; Effective March 16, 2020

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

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

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

The FMSA may also participate in the member's service planning, if requested by the member, LAR or designated representative (DR), and if agreed to by the FMSA. The MCO and service planning team members, as appropriate, participate in approving back-up plans, developing corrective action plans, if necessary, and recommending suspension or termination of the CDS option. Refer to 5323, Service Back-Up Plans.

5321 Budgets

Revision 20-1; Effective March 16, 2020

The CDS employer or designated representative (DR), with assistance obtained from the financial management services agency (FMSA) or others, must:

  • develop an initial and annual budget for each STAR Kids and Medically Dependent Children Program (MDCP) waiver program service to be delivered through the CDS option;
  • pay employees in accordance with minimum wage laws and any other applicable base wage requirements;
  • project expenditures of funds allocated in the individual service plan (ISP) for the effective period of the ISP;
  • use a workbook approved by the managed care organization (MCO) or applicable budget workbooks available through Texas Health and Human Services Commission (HHSC) at https://hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/consumer-directed-services-cds/cds-forms-handbooks;
  • request assistance from the FMSA, as needed;
  • submit each budget to the FMSA for review of the member's budgeted payroll spending decisions and verification that the applicable budget workbooks are within the approved budget. The FMSA must work with the CDS employer or DR to resolve issues that prevent the approval of budget plans; and
  • obtain written approval for each budget from the FMSA before implementation of the budget and initiation of service delivery through the CDS option.

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

Budget Revisions and Approval

A CDS employer or DR must make budget revisions if:

  • a change to the individual service plan (ISP) affects funding for a program service delivered through the CDS option;
  • a budget has been, or will be, exceeded before the end date of the ISP;
  • authorized units, unit rate or amount of funds allocated have changed;
  • an amount paid for one or more services, goods or items affects the approved budget;
  • revisions are made to a service back-up plan;
  • funds budgeted for a service back-up plan are not used or needed; or
  • the FMSA, the MCO service coordinator, the person-centered service planning team or an HHSC representative requires a revision.

The CDS employer or DR must submit budget revisions to the FMSA for approval. Revised budgets cannot be implemented until written approval is received from the FMSA.

The FMSA must provide assistance to the CDS employer or DR with budget revisions, as requested or needed by the member, validate the budget, and provide written approval to the CDS employer or DR. The FMSA must assist the CDS employer or DR to resolve issues that prevent the approval of budget plans.

The MCO service coordinator evaluates ISP changes requested by the CDS employer and participates in the interdisciplinary team meetings to resolve issues when the CDS employer or DR does not follow the budget or comply with CDS option budget requirements.

5322 Employer Support Services in the CDS Option

Revision 20-1; Effective March 16, 2020

A Consumer Directed Services (CDS) employer or designated representative (DR) may budget employer support services and start-up expenses through the services that are delivered by one or more employees in the CDS option. Employer support services include employment-related expenses, employer-related expenses and support consultation services. Employer support services exclude non-allowable expenditures listed in Appendix XI, Allowable and Non-Allowable Expenditures, in the Consumer Directed Services Handbook.

Start-up expenses must be:

  • budgeted for purchases projected before the delivery of services through the CDS option; and
  • accrued from the budgeted unit rate for services scheduled for delivery through the CDS option within the first three months of initiation of the CDS option.

A CDS employer or DR may budget allowable, necessary and reasonable employment-related services, goods or items, including:

  • recruiting expenses;
  • obtaining a criminal history report from the Texas Department of Public Safety;
  • purchasing employee job-specific training;
  • cardiopulmonary resuscitation training;
  • first aid training;
  • supplies required for an employee or provider of the service to perform a task, if not available through the member's program or other source and the purchase is allowable through the member's program;
  • non-taxable employee benefits; and
  • services, goods, and items specifically approved by the member's program as an employer support service or included as allowable expenditures in Appendix XI.

A CDS employer or DR may budget employer-related services, goods or items required to meet employer responsibilities, including:

  • basic office equipment, which may include a basic fax machine for the purpose of submitting documents to the financial management services agency (FMSA);
  • mailing costs;
  • expenses related to making copies;
  • file folders and envelopes; and
  • services, goods and items specifically approved by the member's program as an employer support service or included as allowable expenditures in Appendix XI.

A CDS employer or DR may budget up to 10 percent of the amount available, after the FMSA portion is calculated, in those services delivered by one or more employees. A CDS employer or DR must not budget more than $600 annually or more than $50 per month if less than 12 months remain in the service plan for employer support services.

Support consultation, if available through the member's program, is an optional service available to a member participating in the CDS option. Support consultation is delivered to a CDS employer, DR or a member receiving services through the CDS option if that member will be the CDS employer within six months of the initiation of support consultation services to the member.

Support consultation is provided by a person who meets the qualifications of a support advisor. A support advisor may be a contractor of the CDS employer or an employee or contractor of an FMSA.

Support consultation must provide a level of training, assistance and support that does not duplicate or replace the services delivered by the FMSA, managed care organization (MCO) service coordinator, or other available program or non-program services or resources.

Support consultation provides practical skills training and assistance to successfully manage service providers for authorized program services delivered through the CDS option. This includes skills training and assistance for:

  • recruiting, screening and hiring workers;
  • developing and documenting job descriptions;
  • verifying employment eligibility and qualifications;
  • completing documents required to:
    • employ an individual;
    • retain a contractor or vendor; and
    • manage service providers;
  • communicating effectively, solving problems and documenting CDS employer responsibilities in the CDS option;
  • developing, revising and implementing service back-up plans;
  • performing CDS employer responsibilities;
  • complying with the member's program and this section; and
  • developing ongoing decision-making skills for employer-related and employment-related situations.

A CDS employer or DR may budget and initiate support consultation services while the member is participating in the CDS option. Before initiation of the service, the CDS employer or DR must:

  • identify the person or persons (the CDS employer, the DR or the member within six months after becoming the CDS employer) to receive the service and establish goals specific to the service;
  • obtain approval of the goals established for the service from the member's service planning team;
  • develop a budget for support consultation; and
  • obtain approval of the budget from the FMSA.

If the member's service planning team authorizes support consultation, the team must:

  • approve the funds, the duration and the frequency of the service;
  • assist with development of goals and ensure that the activities required to meet the goals through support consultation comply with this section;
  • approve the goals for support consultation and the person or persons who will receive the service (the member, CDS employer or DR); and
  • terminate the service when goals are met.

5323 Service Back-Up Plans

Revision 20-1; Effective March 16, 2020

The managed care organization (MCO) service coordinator must discuss with the Consumer Directed Services (CDS) employer or designated representative (DR) the services delivered through CDS that are critical to the member's health and welfare. The MCO service coordinator must require the CDS employer 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 CDS employer or DR must develop a back-up plan, and document the plan on Form 1740, Service Backup Plan, to assure the provision of all authorized personal assistance services without a service break.

The CDS employer or DR, with the assistance of the MCO service coordinator (if needed), completes Form 1740. The service back-up plan must list the steps the CDS employer or DR will implement in the absence of the regular 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 CDS employer 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 service coordinator. The MCO service coordinator and service planning team, as appropriate, approve the plans as being viable in the event a service provider is absent. The MCO or service planning team must approve each service back-up plan and any revision before implementation by the member, LAR or DR. The MCO service coordinator approves the service back-up plan by signing, dating and returning a copy of the plan to the CDS employer or DR.

The CDS employer or DR is required to:

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

The FMSA must:

  • assist a CDS employer or DR as requested to revise budget to meet service back-up plan strategies approved by the member's service planning team;
  • review, validate, and approve revised budgets in accordance with §41.511, Texas Administrative Code relating to Budget Revisions and Approval;
  • 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 CDS employer or DR.

5324 Corrective Action Plans

Revision 20-1; Effective March 16, 2020

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

A written CAP may be required from an employer or designated representative (DR) if the employer or DR:

  • hires an ineligible service provider;
  • submits incomplete, inaccurate or late documentation of service delivery;
  • does not comply with program requirements related to the CDS option; or
  • does not meet other employer responsibilities.
  •  

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 CDS employer or DR may request assistance in the development or implementation of a CAP from the:

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

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

5330 Terminating the CDS Option

Revision 20-1; Effective March 16, 2020

A Consumer Directed Services (CDS) employer may request voluntary termination of participation in the CDS option and receive services through a program agency provider at any time. A member may also be involuntarily terminated from participation in the CDS option in accordance with the requirements of the member's program and Texas Administrative Code §41.407, Termination of Participation in the CDS Option. Termination from the CDS option must last at least 90 days.

A member’s managed care organization (MCO) service coordinator convenes the member's service planning team concerning issues that may warrant immediate termination of the member'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:

  • the member's health or welfare is immediately jeopardized by the member's participation in the CDS option;
  • the designated representative (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
  • HHSC or another government agency with applicable regulatory authority recommends that participation in the CDS option be immediately terminated.

If a CDS employer or designated representative (DR) does not implement and successfully complete the following steps and interventions, a member's service planning team may recommend termination of participation in the CDS option in accordance with the member's program requirements:

  • eliminate jeopardy to the member's health or welfare;
  • successfully direct the delivery of program services through CDS;
  • meet employer responsibilities;
  • successfully implement corrective action plans; or
  • appoint a DR or access other available supports to assist the employer in meeting employer responsibilities.

Before a financial management services agency (FMSA) recommends involuntary termination of participation in the CDS option to a member's MCO service coordinator, the FMSA must:

  • provide documentation to the member's MCO service coordinator of additional and ongoing training and supports provided by the FMSA when a CDS employer or DR demonstrates noncompliance with employer responsibilities;
  • provide assistance requested by the CDS employer or DR to develop and implement a corrective action plan;
  • provide documentation of any corrective action plan required of the CDS employer or DR by the FMSA in accordance with this section; and
  • notify the MCO service coordinator in writing, in accordance with the requirements of the member's program when recommending termination of a member's participation in the CDS option.

On receipt of a recommendation for involuntary termination from the FMSA or other party, the member's MCO service coordinator must:

  • provide assistance with accessing supports and developing and implementing a corrective action plan related to noncompliance with program and CDS requirements;
  • document interventions utilized by the CDS employer or DR to eliminate noncompliance with program requirements for delivery of program services through the CDS option; and
  • convene the service planning team to:
    • consider recommendations related to the member's participation in the CDS option;
    • recommend additional interventions to be implemented to protect the member's health and welfare for continued participation in the CDS option; and
    • make revisions to the member's service plan, if needed.

If the service planning team recommends terminating participation in the CDS option, the member's MCO service coordinator must document:

  • the reasons for the recommendation;
  • the conditions and time frame established by the member's service planning team that the member must meet prior to re-enrollment in the CDS option;
  • justification for any time period for a termination in excess of the minimum 90-day requirement; and
  • if applicable, the conditions and time frame specified by a hearing officer as the result of a fair hearing that upholds the termination.

When a member's participation in the CDS option is terminated, the MCO service coordinator must take steps and interventions in accordance with the requirements of the member's program to:

  • ensure continuity of delivery of program services that were being delivered through the CDS option; and
  • document arrangements made for delivery of program services that were being delivered through the CDS option to be delivered by the member's program provider or other resources.

5331 Re-enrollment in the CDS Option

Revision 20-1; Effective March 16, 2020

Following termination of participation in the Consumer Directed Services (CDS) option, a member or legally authorized representative (LAR) must request re-enrollment in the CDS option by notifying the member's managed care organization (MCO) service coordinator. If a member or LAR wishes to re-enroll in the CDS option, the MCO service coordinator must:

  • review the reason that the member was suspended or terminated from the CDS option;
  • verify that the member has fulfilled the minimum 90-day period and any conditions specified by the member's service planning team or a hearing officer, if applicable;
  • verify how each issue that contributed to the suspension or termination has been resolved; and
  • refer the request for re-enrollment in the CDS option to the member's service planning team and follow requirements of the member's program, including:
    • revising the member's service plan and re-enrolling the member in the CDS option upon approval; and
    • issuing a denial and providing information related to requesting a fair hearing if the request is not approved.

If approved for re-enrollment, the FMSA must:

  • provide an initial orientation in accordance with this section, following the member's re-enrollment in the CDS option if the current CDS employer or DR has not received initial orientation; and
  • notify the CDS employer, DR and the member's MCO service coordinator in writing within two business days after any repeat of prior noncompliance or additional noncompliance with requirements of the member's program or this section during the member's participation in the CDS option.