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National Academy for State Health Policy Reforming State Long-Term Services and Supports through Participant Direction. Texas: Self-determination with Consumer Directed Services. Marc S. Gold Texas Department of Aging and Disability Services October 5, 2010.

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National Academy for State Health Policy

Reforming State Long-Term Services and Supports through Participant Direction

Texas: Self-determination with Consumer Directed Services

Marc S. Gold

Texas Department of Aging and Disability Services

October 5, 2010

Consumer Directed Services (CDS) History

  • 1997: House Bill 2084: pilot model of

  • participant direction

  • 1999: Senate Bill 1586; expand CDS option

  • to Medicaid programs and established a

  • CDS stakeholder workgroup

  • 2001: CDS added to the Medicaid waivers

  • 2004: Consolidation of Human Services

  • 2010: CDS option in all waivers, state plan

  • and managed care programs

Long Term Services & Supports Program

  • Waivers:

    • Older and Physical Disabilities

      • Community-based Alternatives

      • Medically Dependent Children Program

      • STAR+ (managed care)

    • Intellectual and Developmental Disabilities

      • Home and Community-based Services

      • Deaf-Blind Multiple Disabilities

      • Community Living Assistance and Support

      • Services

      • Texas Home Living

  • State Plan Programs: Attendant Services

    • Primary Home Care

    • Community Attendant Services

    • (b) attendant services

What is Texas CDS?

  • Not “cash and counseling”

  • Mechanism to control hiring of selected

  • direct service workers and licensed staff

  • Service budget determined by agency staff

  • Limited budget flexibility: determine pay

  • rate within service rate set by state

  • Texas CDS is not:

  • Cash option

  • Service provision by legally liable adults

  • (spouse/parent)

  • “Individual goods and services”

Texas 2010

  • All individuals, across disabilities

  • and regardless of age have the option

  • to use CDS

  • Statutory Authority

    • 1915 (c) waivers

    • 1915 (b) waivers (managed care)

    • 1915 (j) state plan amendment (DRA

    • 2005) TX: attendant programs

    • No screening tool: self-determination

Available Services through CDS

  • All programs: Personal assistance

  • services; habilitation and respite

  • Selected waivers: Nursing and

  • physical/occupational/speech therapies

  • Texas Home Living: All services

Support Services to CDS Model

  • Financial Management Services (FMS)

    • payroll, deposit taxes and file tax

    • reports

    • $202/month in waiver program

    • $110/month in attendant programs

  • Support Consultation

    • Assistance and training: coaching the

    • individual how to interview/hire

    • $15.37/hour (from overall budget)

Getting the Word Out

  • Case managers or service coordinators

  • provide information about the CDS option

  • at program enrollment and annually upon

  • service review

  • Information includes an overview of the

  • CDS option, employer responsibilities, FMS

  • provider responsibilities as well as

  • benefits and risks of using the CDS option

Individual Responsibilities

  • Serve as employer

  • Recruit and hire services provider

  • Determine the work schedule

  • Determine the wage rates and benefits

  • Provide initial and ongoing training

  • Approve services provider timesheets

  • Handle conflicts

  • If necessary, terminate provider

Budget and Spending Flexibility

  • Budget based on approved service plan

  • Any budget change must be proceeded by a service plan change

  • Wages determined within the rate established by the state

  • Budget allows employers to purchase employer-related supports: advertising costs, fax machine for sending time sheets, background checks and training for attendants (not individual goods/services)

  • 90% of budget must be allocated to service provider pay and benefits

Factors in Increase Usage

  • Addition of CDS to waiver program (HCS;

  • MDCP)

  • Expansion of managed care to urban areas

  • within Texas

Population Differences

  • 49% of participants with related conditions

  • in CLASS waiver program

  • 3% of participants with intellectual or

  • developmental disabilities in HCS waiver

  • Less than 1% participants with physical

  • disabilities and those who are aging in CBA

  • 33% of parents of children with special

  • medical needs MDCP waiver program

Fee-for-Services vs. Managed Care

  • Less than 1 percent in fee-for-service programs

    for individuals who are older or with

    physical disabilities

  • Three percent for same population in

    managed care

Factors Impacting Usage

  • Elderly too ill to manage self-direction

  • Lack of informal support to help with self-

  • direction

  • Independent case managers versus agency

  • case managers

  • Conflict of interest when case management

  • provided by program provider

Quality Assurance/Improvement

  • Data collected from the:

    • Personal Experience Survey

    • National Core Indicators

  • Those who use CDS reported they:

    • required less medical attention

    • required less support to prevent

    • disruptive behavior

    • felt safer in their homes

    • were more satisfied with their lives

    • felt less lonely

Cost Effectiveness Studies

  • 4 studies, however mixed results with

  • inconclusive data

  • Trend data indicate:

    • Utilization of services increased with

    • CDS

    • Few hospitalizations and return to

    • nursing facility


  • Strengths

    • Available to all individuals served by

    • Texas’ long-term services system

    • Operates under a single set of

    • administrative rules; consistency

  • Considerations

    • Ties CDS to specific waiver and rule

    • requirements such as service plan

    • developments/provider requirements,

    • case management or service coordination

    • Limits budget flexibility

Workgroup Recommendations

  • Develop and implement outreach activities across TX to increase awareness and understanding of the benefits of the CDS

  • Establish a certification process for CDS Agencies (CDSAs) to improve quality of services and ensure cost-effective oversight

  • Make workers’ compensation insurance affordable for workers

  • Create a budget neutral, cross disability, self-determination pilot waiver in at least one rural and one urban site

Future Considerations

  • Service Responsibility Option

  • Self-determination Waiver

  • Addition of individual goods and services

  • Require certification

  • Regional “supra” contract role

  • Increase responsibilities of support advisors

Contact Information

Marc S. Gold

Director, Promoting Independence Initiative


[email protected]

Elizabeth Jones, Ph.D., CDS Specialist


[email protected]


  • CDS Option:


  • index.cfm

  • TX Administrative Code: Title 40, Part 1, Chapter 41:


  • Ch41CDSJan2009.pdf.