Consumer/Designated Representative
Acknowledgement of the Roles and Responsibilities for Receiving
Consumer Directed Personal Assistance Services

I acknowledge that Consumer Directed Personal Assistance Services (CDPAS) allows chronically ill and/or physically disabled members receiving home care services greater flexibility and freedom of choice in obtaining such services.

In order to receive CDPAS I understand the respective roles and responsibilities of the consumer and the ________________________________________ Health Plan (Health Plan).


The Health Plan will:

  1. Determine whether the member is on the most current Plan Roster.
  2. Provide the member requesting personal care services with information about how to qualify for CDPAS and other community based long term care services.
  3. Provide the member with written educational materials outlining the roles and responsibilities for the member/designated representative if member expresses an interest in CDPAS.
  4. Assess whether the member is eligible to receive home care or personal care services.
  5. Determine if the member is able and willing to assume all responsibilities associated with receiving the service, or has a designated representative or other identified adult, able and willing to act on the member´s behalf.
  6. Determine whether member is eligible to receive CDPAS.
  7. Assess and document the member´s health patient centered care plan to assure adequate supports are available to meet the member´s needs.
  8. Authorize the type, amount and level of services required by the member.
  9. Develop a plan of care with the member, outlining the tasks to be completed by the personal assistant. The plan of care document will be maintained with Plan and a copy will be provided to the member.
  10. If it is determined that the member is no longer eligible to continue receiving CDPAS, or Plan terminates the member´s receipt of CDPAS the MCO will assess on an ongoing basis whether the member requires personal care, home health care or some other level of service.
  11. Provide the member with appropriate notices including a notice of fair hearing for reduction, termination of the level and amount of services or determining that the member is not eligible or no longer eligible to receive CDPAS.


The Member/Designated Representative (Member) will:

  1. 1. Review the information provided by the Plan about CDPAS and understand the roles and responsibilities of the Plan, the fiscal intermediary and the Member.
  2. 2. Be responsible for recruiting, hiring, and training, supervising, scheduling and terminating the personal assistant(s) of the member´s choosing in adequate numbers to meet the needs of the member.
  3. 3. Maintain an appropriate home environment for the safe delivery of care required by the member.
  4. 4. Train the personal assistant(s) to implement the plan of care.
  5. 5. Comply with labor laws, providing equal employment opportunities as specified in the agreement between Member and the Fiscal Intermediary (FI).
  6. 6. Inform the Plan and the FI of any change in status or condition including but not limited to: hospitalizations, address and telephone number changes, vacations within 5 business days.
  7. 7. Assure the accurate and timely submission of the personal assistant´s required paper work to the FI including time sheets, annual worker health assessments, and required employment documents.
  8. 8. Develop and maintain a contingency plan to assure adequate supports are available to meet the member´s needs.
  9. 9. Review and sign the personal assistant´s timecards assuring that the hours reflect the actual number of hours worked within the weekly authorized hours.
  10. 10. Cooperate with the Plan and agree to comply with Medicaid Managed Care Program requirements including but not limited to availability for required reassessments.
  11. 11. Report and return to MCO any overpayment or inappropriate payments from the Medicaid program made to Consumer Directed Personal Assistants.

I have read and understand the roles and responsibilities of the Plan and me in order to receive CDPAS.

______________________________________               __________________________
Member/ Designated Representative                                   Date

______________________________________               __________________________
Witness                                                                                Date

October 1, 2012