CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM AGREEMENT BETWEEN THE CONSUMER/DESIGNATED REPRESENTATIVE AND HAMASPIK CHOICE

Consumer Name:   First Name*   Last Name*   
Designated Representative Name (if applicable):   First Name   Last Name   
Health Plan Name: Hamaspik Choice

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 State’s 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 self-directing.

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.
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
THE CDPAP 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.