Defining the Players

Medicaid Waiver programs, as well as the Community First Choice program, start with 3 “parties” involved:

  • the participant,
  • the case manager, and
  • the provider

They also have an option for 2 additional “parties:

  • Consumer-Directed Services employers
  • the payroll agency for the Consumer-Directed option

Let’s discuss these roles for each program:

HCS/TxHmL CLASS MDCP/Star+Plus Waiver
Participant: person enrolled in the program Individual with an intellectual disability Individual with a physical or intellectual disability Individual with a nursing need
Case Manager: person who assists with service planning and accessing resources “Service Coordinator” who from the Local Intellectual and Developmental Disability Authority (LIDDA) for your county Case Manager from a contracted Case Management Agency “Service Coordinator” from a Medicaid Managed Care Organization (MCO)
Provider Agency: agency that hires staff, keeps documentation of background, training, & CPR, and bills HHSC for services the provider agency is a business that:

  • contracts with day programs or has one of their own,
  • monitors and pays providers of Foster/Companion Care,
  • hires staff for CFC PAS/Hab, keeps documentation of background, training, & CPR, and bills HHSC for services.
 the provider agency is a licensed Home Health Agency (referred to as a Direct Service Agency (DSA)). a licensed Home Health Agency who staffs respite hours with nurses or attendants, keeps documentation of background, training, & CPR, and bills HHSC for services.
Consumer Directed Service employer: A participant or parent that does employer tasks INSTEAD OF A PROVIDER AGENCY, except providing the funding and billing HHSC.
The employer is a parent if the individual is under 18 years old, or if the parent is the guardian of the individual over 18 years old.
The employer is the individual over 18 years old without a guardian.
The payroll agency: for CDS The payroll agency – the agency (referred to as a Financial Management Service Agency (FMSA)) that provides the funding and billing of HHSC on behalf of a Consumer Directed Service (CDS) employer, but does not have all the licensing-liability of a DSA.

Now let’s look at the Service Delivery Options…

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