Most MCOs are given broad discretion in developing and managing PD-MLTSS service delivery options. This discretion means that the features and flexibility of the PD-MLTSS program and what is meant by "participant direction" can vary (see discussion of budget authority models in Tennessee and Texas above). Respondents in Tennessee and Texas remarked that the adoption of PD-MLTSS programs largely depends on the emphasis the state gives to participant direction. Only Tennessee indicated having an incentive from the state (e.g., enrollment targets--see above) to promote PD-LTSS among their members. The following describes some of the common program features of the PD-MLTSS programs in the five states (see Appendix B, Table B1: State PD-MLTSS Program Overview).
In most states the MCO provides the information and assistance function in PD-MLTSS: Providing information and ongoing assistance to participant-directing individuals is a key supportive function of PD-MLTSS. In Arizona, Massachusetts, and New Mexico, this function is provided by the MCO service coordinator. Because Arizona sees PD-MLTSS as "just a different way to provide services," the MCO service coordinators typically have mixed caseloads of nursing home, assisted living, home and community-based agency-delivered, and PD-MLTSS members. Tennessee MCOs split the counseling function between the MCO service coordinator (who has initial responsibility to describe the program in general terms) and the support broker at the FMS (who has ongoing responsibility for assisting the member with selecting, training, and monitoring workers, and the development of the back-up plan). In Texas, the information and assistance function is performed by the FMS agencies (i.e., Consumer-Directed Service Agencies perform both financial management and information and assistance roles).
The most common model of PD-MLTSS offered was employer authority (but the MCOs provide little support in finding workers): All of the MCOs interviewed in Arizona, Massachusetts, Tennessee, and Texas offered the employer authority model. None of the MCOs appeared to know of registries where members could find a worker. In Massachusetts and Texas, it was noted that such a registry would be beneficial in the more rural areas of the state. Massachusetts indicated the state maintained a general information website on hiring personal care attendants. In Tennessee, the FMS provider has initiated the development of a worker registry for assisting the member with worker recruitment. This is on a regional basis (East, West, and Middle Tennessee). Texas noted that the state's Consumer-Directed Service Agencies would assist members in placing newspaper ads and/or provide general guidance on where to obtain a worker.
All the states allow family members to be paid workers, but some set restrictions or special conditions on legally-responsible family members or representatives: The most common worker restriction cited by the states was inability of the spouse or other legally-responsible representative to be hired as the participant's direct service worker. In some states, if the participant used a program representative, this person could not be hired as the member's direct service worker. Tennessee has an additional hiring limitation for non-spouse relatives/friends where the participant cannot hire a person who has lived with them within the past five years. While Arizona allows spouses to be hired as direct services workers, there are some restrictions that are typical in other participant-directed Medicaid programs. For instance, the paid services provided by a family member or spouse cannot be an activity that would ordinarily be performed by a family member; payment of spouses is limited to 40 hours per week; and spouses require additional monitoring, including a quarterly review of expenditures.