Missouri Consumer Directed Services Is Approved. How Do You Start the First Shift?

You have a Missouri Consumer Directed Services approval and someone willing to help. That does not mean the person can start billing hours.

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The service has to be assembled in order. Missouri must authorize the tasks and units. You must select an enrolled Consumer Directed Services vendor. The vendor must establish the attendant's employment and payroll records, complete required screening and teach both of you how visits are recorded. The first payable shift comes after those pieces are connected.

Who pays

Consumer Directed Services, usually called CDS, is a MO HealthNet personal care service administered through the Missouri Department of Health and Senior Services, Division of Senior and Disability Services. The state authorizes a person-centered care plan. An enrolled CDS vendor files the Medicaid claims and processes payroll for the attendant on your behalf. You supervise the attendant and verify the work. The attendant is not an employee of the vendor or the state. These roles come from the Missouri DHSS Home and Community Based Services Manual, section 3.25, and Missouri law, section 208.909.

Before arranging a start date, ask the vendor to confirm four items in writing: the authorization is visible in its system, the authorized service and tasks match the plan, the effective date has arrived, and the attendant is cleared to work. If any answer is no, ask who owns the missing step and when you should call again. Do not assume an approval letter by itself permits payment for a shift.

If the participant has Medicaid spend down, ask the vendor whether MO HealthNet shows active coverage for the service period. Missouri's section 3.25 policy says a participant may be authorized for CDS while qualifying through spend down, but the participant can become responsible for services delivered during a period when the spend down liability has not been met. Send the rate question to the vendor before accepting any private-pay arrangement.

The papers

Keep the authorization and the employment packet in separate folders. The authorization folder should contain the person-centered care plan, commonly shortened to PCCP, and the Participant Choice Statement. The state may use the Consumer-Directed Services Worksheet, form HCBS-3c, to support care-plan development, but that worksheet is not your permission to add tasks or hours. The authorized PCCP controls what the program may pay for. Missouri DHSS describes this sequence in its Home and Community Based Services Process Overview and Manual section 4.20.

Read the plan task by task. Mark what the attendant may do, how often it is authorized and which needs remain uncovered. If bathing is authorized but meal preparation is not, do not treat the two as interchangeable hours. Ask DSDS for a care-plan review when the written plan does not match the person's actual unmet needs. The vendor cannot rewrite the state authorization.

The employment folder begins with the vendor's intake packet. Ask for a checklist before the attendant fills anything out. A typical employee file may require federal Form I-9, Employment Eligibility Verification, federal Form W-4, Employee's Withholding Certificate, and Missouri Form MO W-4, Employee's Withholding Certificate. Ask the vendor which originals it must inspect, where the forms go and whether the attendant needs to complete any direct-deposit or payment election form. Do not email identity documents until the vendor gives you its secure delivery method.

The vendor also needs information to establish the participant's employer records. Missouri law, section 208.909, makes the participant responsible for supplying information needed to establish an employer identification number, while the vendor performs payroll and tax functions. Ask, "Will you obtain or use the employer identification number, and what document will show that the payroll account is ready?" If the vendor asks you to sign a tax document you do not understand, stop and ask the vendor to identify the form, the capacity in which you are signing and where its instructions appear. A tax professional takes over if you need advice about the participant's tax liability.

The runway to the first shift

First, choose the vendor. A state provider list shows enrollment, not whether a vendor can start this case. Call more than one and ask the same operational questions: Can you accept this authorization? Who handles attendant screening? Who is the payroll contact? Which visit verification system do you use? What must be complete before the first shift? How are rejected visits corrected? On what schedule are approved visits paid? Send any wage or rate question to the vendor because the approved amount, payroll deductions and available worker wage are not safely inferred from a public program description.

Second, name the attendant and wait for clearance. Missouri regulation 19 CSR 15-8.400 requires the vendor to confirm that an attendant is registered, screened and employable through the Family Care Safety Registry, the Employee Disqualification List and other applicable requirements before service delivery begins. Ask for a plain confirmation that the worker is "cleared to begin CDS service." Do not accept "the background check was submitted" as the same answer.

Third, complete orientation. The vendor must train the participant to recruit, employ, instruct and supervise attendants. The orientation must cover visit records, allowable and non-allowable tasks, fraud, attendant rights and responsibilities, and recognition of abuse, neglect and exploitation. Those vendor duties appear in 19 CSR 15-8.400 and the Missouri Medicaid Audit and Compliance page titled Consumer-Directed Services Vendor Responsibilities.

Use the orientation to build a one-page first-shift sheet. Write the authorized tasks, the planned arrival and departure, the vendor's call-off number, the electronic visit verification steps and the name of the person who corrects a missed clock-in. Leave medical instructions to the physician or nurse. CDS authorization does not turn a personal care attendant into a clinician.

Fourth, test electronic visit verification, commonly called EVV. Have the vendor show the attendant how to record arrival and departure from the participant's actual service location. Ask what happens when the phone fails, the system rejects the location or a visit must be edited. Missouri regulation assigns the vendor responsibility for collecting EVV records and verifying their accuracy, but you still need to verify that the recorded time and work are correct.

Fifth, confirm the launch. Before the attendant begins, get the vendor's answer to this sentence: "The participant is authorized, the attendant is cleared, payroll is open, EVV works and a shift beginning now can be submitted." Save the name of the person who confirmed it.

After the first shift, compare three records: the schedule you agreed to, the EVV entry and the vendor's payroll record. Check the participant name, attendant name, service date, start and stop entries, and authorized task. Report an error promptly. Never approve time that was not worked or a task the care plan does not authorize.

If the service stalls

Use one question per call. If the authorization is missing, call DSDS. If worker screening, orientation, EVV or payroll is missing, call the vendor. If the plan omits a needed personal care task, request a care-plan change from DSDS. Missouri DHSS says a participant may request a care-plan change when needs change.

Keep a call log with the office, telephone number, person reached, missing item and promised next action. Do not record medical details you do not need. If you are helping but the participant has not authorized the agency to speak with you, ask DSDS about its Authorization for Disclosure of Consumer Medical/Health Information. That authorization permits information sharing. It does not make you a guardian or give you authority to sign employment papers.

Free help

The Missouri Division of Senior and Disability Services handles HCBS referrals, assessments, authorizations and care-plan changes. Aging Ahead, the Area Agency on Aging serving much of the St. Louis region, can help you identify local options and the correct public office. Start with Local Help With Paying for Care for the public contact list.

If the dispute is about whether a worker was paid, whether employment taxes were handled or what a contract makes the participant responsible for, ask the vendor for its written policy and the governing form. If you need an interpretation of employment, tax or contract law, stop there and take the documents to a lawyer or tax professional.

Source trail: Missouri DHSS, Home and Community Based Services Process Overview; Missouri DHSS Home and Community Based Services Manual, sections 3.25 and 4.20 and form HCBS-3c; Missouri regulation 19 CSR 15-8.400; Missouri Revised Statutes sections 208.909 and 208.918; Missouri Medicaid Audit and Compliance, Consumer-Directed Services Vendor Responsibilities; IRS Form I-9 and Form W-4 instructions; Missouri Department of Revenue Form MO W-4 instructions. The desk's public source index is on the Sources page.