Health Plan Name:Centers Plan for Healthy Living (CPHL)

I. CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM (CDPAP)
AGREEMENT
The Consumer Directed Personal Assistance Program (the “Program”) is a program for
Medicaid recipients (“Consumers”) who need home care services, including help with
personal care and certain home health and skilled nursing services. The Program gives
Consumers more flexibility and freedom of choice by letting them direct their own care,
including choosing their own personal assistants in accordance with their Health Plan’s
authorization.
To participate in the Program, Consumers must be able to direct their own care and
understand and fulfill the Consumer’s responsibilities within the Program or have a
Designated Representative that will do this for them. The Consumer or Designated
Representative must also understand the roles and responsibilities of the Health Plan and
the Fiscal Intermediaries under the Program.
As used throughout this agreement the term “Consumer” also includes the Consumer’s
Designated Representative when applicable, unless otherwise specified. As used throughout
this agreement the terms “I” and “my” will refer to the Consumer or alternatively to the
Consumer’s Designated Representative when applicable and depending on context.
This agreement outlines the roles and responsibilities of the Consumer and the Health Plan
under the Program. The Consumer must enter into this agreement to acknowledge that they
understand the roles and responsibilities and to participate in the Program. The Consumer
must also enter into a separate agreement with their chosen Fiscal Intermediary (FI), which will outline the roles and responsibilities of the Consumer and FI.

II. RESPONSIBILITIES OF THE CONSUMER/DESIGNATED REPRESENTATIVE:

As a Consumer participating in the Program, I will:

1. Read and understand this agreement and the roles and responsibilities of the
Health Plan, FI, and Consumer under the Program.

2. Only work with one FI. I understand that I can change my FI at any time, but I will
work with only one at a time. If I am working with more than one FI, I must choose
just one FI to continue working with.

3. Manage my plan of care.
4. Be responsible for recruiting, hiring, training, supervising, and scheduling a
sufficient number of qualified individuals of my choosing to serve as my personal
assistant(s) in accordance with my Health Plan’s authorization.
5. Maintain a back-up plan for substitute coverage when a personal assistant is
temporarily unavailable for any reason.
6. Maintain an appropriate home environment.
7. Review the plan of care with each personal assistant outlining their responsibilities.
8. Ensure my personal assistant(s) safely and competently performs only the tasks
identified in the plan of care during authorized hours.
9. Comply with labor laws, providing equal employment opportunities as specified in
the Consumer’s agreement with the CDPAS FI.
10. Inform the Health Plan and FI within 5 business days of any change in status or
condition, including but not limited to hospitalizations, address and telephone
number changes, and vacations.
11. Terminate a personal assistant’s employment, if necessary.

12. Notify the FI of any changes in the employment status of a personal assistant.
13. Ensure my personal assistant’s required documents are submitted to the CDPAP
FI including annual worker health assessments and required employment
documents.
14. Ensure my personal assistant(s) adhere to EVV requirements, including those
outlined by the EVV Program Guidelines and Requirements.
15. Attest to the accuracy of the hours my personal assistant(s) worked either through
the EVV data system or by signing the personal assistant’s time sheet.
16. Distribute paychecks to each personal assistant, if applicable

17. Comply with Program eligibility requirements including participating, as needed, in
the required assessment and reassessment processes.
18. Report and return to the health plan any overpayment or inappropriate payments
from the Medicaid program made to my personal assistant(s).

III. ADDITIONAL RESPONSIBILITIES OF THE DESIGNATED REPRESENTATIVE
ONLY:

In addition to responsibilities listed above that I, as Designated Representative, must perform
on behalf of the Consumer, I will:
1. Make myself available to ensure the consumer responsibilities are carried out without
delay.
2. Be available and present for any scheduled assessment or visit by the independent
assessor, examining medical professional or health plan when the member is not selfdirecting.

IV. RESPONSIBILITIES OF THE HEALTH PLAN:

The health plan must provide the Consumer with written educational materials outlining the
roles and responsibilities of the Consumer to ensure they are making an educated, informed
choice to receive Program services and will:
1. Determine if the Consumer (not including the Designated Representative) is
eligible for the Program and whether home care or personal care services should
be authorized.
2. Determine if the Consumer is able and willing to assume all responsibilities
associated with participating in the CDPAP or has a Designated Representative
able and willing to act on the Consumer’s behalf.
3. Discuss and document that the Consumer’s or Designated Representative’s plan
to assure adequate supports are available to meet the Consumer’s needs.
4. Develop a patient centered plan of care with the Consumer or Designated
Representative, outlining the tasks to be completed by the personal assistant.
5. Maintain a copy of the plan of care in the Consumer’s file and give a copy to the
both the Consumer and Designated Representative.
6. Authorize the type/amount of services and number of hours required.

CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM AGREEMENT BETWEEN THE CONSUMER/DESIGNATED REPRESENTATIVE AND THE HEALTH PLAN

7. Only authorize Program services provided through one FI and work with the
Consumer or Designated Representative to select just one FI should the health
plan become aware that services are being provided by more than one FI.
8. Evaluate on an ongoing basis whether the Consumer requires personal care, home
health care, or some other level of service.

9. Notify the Consumer and Designated Representative that Program services are
being decreased or discontinued if the health plan determines such services are no
longer appropriate and, if applicable, refer the Consumer to other appropriate
programs.
10. Provide the Consumer and Designated Representative with the appropriate fair
hearing notice.
ALL PARTIES ACCEPT THE ROLES AND RESPONSIBILITIES TO PARTICIPATE IN THECDPAP AS EXPLAINED ABOVE. FULFILLING THE CONSUMER’S ROLES AND
RESPONSIBILITIES IS A REQUIREMENT OF PARTICIPATION IN THE PROGRAM.
FAILURE TO FULFILL THE CONSUMER’S ROLES AND RESPONSIBILITIES MAY
RESULT IN DISCONTINUANCE OF PROGRAM SERVICES.

                                                             Signatures