Consumer Directed Care Plus - Family Network On Disabilities

Consumer Directed Care Plus Module: CDC Application Packet 1

Introduction This module addresses the CDC Application Packet: CDC Program Application Form IRS Form SS-4 EIN Third Party Designee Authorization CDC Consumer/Consultant Agreement CDC Consent Form CDC Representative Agreement/Registration Form (optional) Check each form to ensure it has been completed in its entirety and that appropriate signatures have been obtained. 2

CDC Program Application The CDC Application Packet can be downloaded from the CDC website at: www.cdcplus.org. The CDC program application requires the following Medicaid waiver client information: Medicaid ID number; Social Security number; Date of birth; and Contact information. 3

CDC Program Application, continued The application must include the annual care plan amount, after case management fees are deducted. The application is signed by the consumer/representative and the consultant. Signatures from the appropriate agency: Agency for Health Care Administration, Area Agency on Aging, Department of Children and Families, or Department of Health must be obtained to authorize the Medicaid waiver client’s participation. 4

CDC Program Application Divide the annual care plan amount, after case management fees, by 12 months to determine the consumer’s monthly budget amount. All signatures are required. 5

Employer Identification Number (EIN) Third Party Designee Authorization The EIN Third Party Designee Authorization is a statement from the consumer/representative authorizing the DOEA, as Fiscal/Employer Agent (F/EA), to apply for an EIN with the IRS.

EIN Third Party Designee Authorization 7

IRS Form SS-4 The SS-4 Application for Employer Identification Number (EIN) authorizes the Department of Elder Affairs (DOEA), as Fiscal/Employer Agent (F/EA), to obtain an EIN for the consumer. For IRS purposes, a CDC consumer is a household employer, and an EIN is needed to file the correct employer taxes. 8

IRS Form SS-4 This section is for the CDC applicant’s Information. Complete lines 1-7b; EXCEPT lines 2 -3 IRS requires one of the following: a.Consumer’s signature. b.“X” along with witness’ signature. c.The consumer’s Power of Attorney (POA) is authorized to sign for the consumer (a copy must be provided with the application packet). 9

CDC Consumer/Consultant Agreement The CDC Consumer/Consultant Agreement outlines the consumer/representative’s responsibilities. The form also outlines the consultant’s responsibilities. 10

CDC Consumer/Consultant Agreement 11

CDC Consent Form The CDC Consent Form states: The consumer consents that he/she will use the monthly budget in accordance with his/her longterm care needs. Other consumer benefits may or may not be affected because of their participation in CDC . The consumer may decide, at any time, to disenroll from CDC and may return to his/her original home and community-based service program. 12

CDC Consent Form 13

CDC Personal Goal Setting Consumers will set goals for themselves for participation in CDC as it relates to receiving home and community-based services. Goals must relate to items listed in the savings section of the CDC Budget Plan. 14

Personal Goal Setting (PGS) 15

CDC Consumer Representative Agreement/Registration Form If the consumer wishes to appoint a representative, this form must be included in the Application Packet. This form outlines the representatives' responsibilities, such as agreeing to work on the consumers’ behalf, ensuring that consumers are getting the services they need and that their health and well being are not at risk. The appointed representative must pass a Level II Background Screening. Please review the module entitled: Background Screening for CDC Employees and Representatives. 16

Representative Agreement / Registration Form 17

How to submit the CDC Program Application 18

Technical Assistance All questions regarding this training module should be directed to: Customer Service: 1-866-232-3733 Email address: cdcplus@elderaffairs.org 19

Thank you. 20

CDC Program Application 3 The CDC Application Packet can be downloaded from the CDC website at: www.cdcplus.org . The CDC program application requires the following