Texas Medicaid May Let You Choose Your Own Caregiver. Here’s How CDS Works

If you get certain Medicaid services at home in Texas, you may have more control over who provides your care than you realize.

Texas has an option called Consumer Directed Services (CDS) that allows eligible Medicaid participants to recruit, hire and manage the people who provide certain approved services.

That may include certain family members or friends, as long as the person you want to hire meets Texas and program-specific requirements.

Here’s how CDS works, who may be able to use it, and what you should know before becoming the employer.

What Is Consumer Directed Services?

Consumer Directed Services is a service-delivery option available through certain Texas Medicaid programs.

Instead of having an agency make all the decisions about who provides your authorized services, CDS gives you more control.

Depending on your program and services, you may be able to:

• Recruit and hire your own workers;
• Train and manage them;
• Set their schedules;
• Decide how certain approved services are provided;
• Set wages within your approved budget and applicable rules; and
• Dismiss workers who aren’t a good fit.

CDS doesn’t automatically give you additional Medicaid services or more care hours.

Instead, it changes how certain services you’ve already been authorized to receive are managed and delivered.

Which Texas Programs Offer CDS?

Texas HHSC currently lists CDS options involving several programs and services, including:

• Community Living Assistance and Support Services (CLASS);
• Consumer Managed Personal Attendant Services (CMPAS);
• Deaf-Blind with Multiple Disabilities (DBMD);
• Home and Community-based Services (HCS);
• Medically Dependent Children Program (MDCP);
• Primary Home Care (PHC);
• Family Care (FC);
• Personal Care Services (PCS);
• Community Attendant Services (CAS); and
• Texas Home Living (TxHmL).

CDS is also available for certain services delivered through Texas Medicaid managed-care programs, including STAR+PLUS and STAR Kids.

The exact services you can direct depend on the Medicaid program you’re enrolled in and what’s authorized in your individual service plan.

If you’re not sure what program you’re receiving services through, ask your service coordinator or case manager whether CDS is available to you.

What Kind of Care Can You Direct?

That depends on your Medicaid program.

For example, STAR+PLUS allows CDS for certain personal assistance services. Depending on the program and service package, other services that may be available through CDS can include respite, nursing, employment assistance, supported employment and certain therapies.

You don’t necessarily have to direct every service yourself.

In programs that allow it, you may be able to use CDS for some eligible services while continuing to receive other services through an agency or traditional provider.

Your service coordinator can explain exactly which of your authorized services are eligible for CDS.

Can You Hire a Family Member or Friend?

In some cases, yes.

One of the biggest reasons people choose CDS is the ability to recruit workers they already know and trust.

You may be able to hire certain family members, friends or other people you know.

However, not every relative or household member can automatically be paid through CDS.

Texas has rules governing who can work as a paid CDS employee, including requirements based on the worker’s relationship to the person receiving services or the CDS employer.

Prospective employees may also need to complete required background, registry and employment eligibility checks.

Your Financial Management Services Agency, or FMSA, will help determine whether the person you want to hire meets the applicable requirements.

Don’t allow someone to begin providing paid CDS services until they’ve completed the required hiring process and have been approved to work.

Who Can Use CDS?

You may be able to choose CDS if:

• You’re enrolled in a Texas Medicaid program that offers the CDS option;
• You receive at least one authorized service that can be delivered through CDS; and
• You’re willing and able to handle the responsibilities that come with directing your own services.

If you can’t independently handle those responsibilities, you may be able to appoint an eligible designated representative to help you.

A designated representative can assist with employer responsibilities, but Texas has specific rules about who can serve in that role.

There may also be restrictions based on where you live.

For example, some programs limit CDS based on whether you live in your own or a family home or receive certain residential services.

Because those rules aren’t identical across every Texas Medicaid program, ask your service coordinator whether CDS is available in your current living arrangement.

What Does Being the Employer Mean?

This is probably the most important thing to understand before choosing CDS.

With more control comes more responsibility.

As the CDS employer, you may be responsible for things such as:

• Finding and interviewing potential workers;
• Hiring eligible employees;
• Training your workers;
• Setting schedules;
• Managing and supervising employees;
• Approving timesheets;
• Setting wages within the available service budget and applicable wage rules;
• Handling problems with workers;
• Finding backup help when a regular worker isn’t available; and
• Dismissing workers when necessary.

You still have help with the administrative side.

That’s where the Financial Management Services Agency (FMSA) comes in.

What Does the FMSA Do?

The FMSA helps handle many of the financial and administrative responsibilities associated with CDS.

Depending on the program, that can include:

• Helping with required employer paperwork;
• Conducting required background and registry checks;
• Verifying employment eligibility;
• Processing payroll;
• Handling payroll taxes and required reports;
• Helping you develop and manage your service budget; and
• Providing required CDS training and support.

Texas STAR+PLUS guidance, for example, requires the FMSA to distribute payroll at least twice a month.

The FMSA doesn’t take over your role as the employer, though. You remain responsible for managing the people providing your services.

There Are Legal Responsibilities Too

CDS gives you more independence, but becoming the employer comes with legal responsibilities that shouldn’t be overlooked.

Texas STAR+PLUS guidance warns that the CDS employer assumes employment-related liability and can be responsible for negligent acts or omissions involving employees or the designated representative.

The FMSA generally handles payroll taxes and related administrative responsibilities on the employer’s behalf. However, Texas also warns that the employer may ultimately be responsible for required payroll taxes owed to the IRS or Texas Workforce Commission if those taxes aren’t properly paid.

That doesn’t necessarily mean CDS is a bad option.

It means you should understand the employer responsibilities before choosing it and use the training and assistance provided by your FMSA.

Can You Choose How Much Your Caregiver Gets Paid?

CDS can give you some flexibility in setting employee wages, but you don’t have unlimited control over the amount.

Wages must fit within the funds available for your authorized services and comply with applicable wage and overtime requirements.

You also can’t turn an authorized number of service hours into more or fewer Medicaid-approved hours simply by changing the employee’s hourly wage.

Your FMSA can help you understand the budget and wage rules that apply to your program.

How Do You Sign Up for CDS?

A good first step is to tell your service coordinator or case manager that you’re interested in Consumer Directed Services.

The enrollment process varies somewhat by program, but generally includes:

1. Learning about the CDS option and your responsibilities;
2. Choosing whether you want to act as the employer yourself or use an eligible designated representative;
3. Selecting an FMSA;
4. Completing required CDS forms and orientation;
5. Developing the required service budget and other plans;
6. Recruiting workers; and
7. Completing the required hiring and screening process before workers begin providing paid services.

Some programs also require a written backup plan describing what you’ll do if your regular employee can’t provide a scheduled service.

If you previously declined CDS, that doesn’t necessarily mean you’ve lost the option permanently. You can ask your service coordinator about choosing CDS later if you’re still eligible.

What Happens If CDS Isn’t Working for You?

You aren’t necessarily locked into CDS forever.

If managing your own workers becomes too difficult or CDS isn’t a good fit, you can request to return to an agency or provider-managed service option.

However, Texas programs can have different rules about changing service-delivery options.

Depending on your program, you may need to remain with another delivery option for at least 90 days before returning to CDS or changing options again.

Ask your service coordinator about the rule that applies to your specific Medicaid program before making the switch.

Keep Your Records

CDS employers also have recordkeeping responsibilities.

Texas requires certain CDS employment and service records to be retained for at least five years, and some records may need to be kept longer if they’re connected to an unresolved audit, claim or legal matter.

Your FMSA should explain which records you’re responsible for keeping and how long you need to retain them.

Relief Recap

If you receive eligible Texas Medicaid services, Consumer Directed Services may give you more control over who provides your care and how certain authorized services are delivered.

Depending on your program, you may even be able to hire an eligible family member or friend.

But CDS isn’t simply a program that pays anyone you choose to be your caregiver.

You’ll become an employer with responsibilities involving hiring, supervision, scheduling, paperwork, backup care and potentially legal liability. You’ll also work with an FMSA that handles many of the financial and administrative pieces.

Most importantly, CDS doesn’t automatically increase your Medicaid benefits or authorized care hours. It gives eligible participants another way to manage certain services they’re already approved to receive.

If you’re interested, ask your Texas Medicaid service coordinator or case manager whether Consumer Directed Services is available for your program and authorized services.

Want to learn more about paid family caregiving outside Texas? Read our guide on how to get paid to take care of a loved one next.