CDS Missouri Eligibility: How to Apply for Consumer Directed Services

Missouri's Consumer Directed Services (CDS) program lets Medicaid-eligible adults hire, train, and manage their own personal care attendants instead of relying on agency-assigned aides. For families who want a trusted caregiver — a neighbor, a friend, an adult child — delivering the care, CDS is the mechanism that makes it possible with state funding.

But the application process involves two separate state agencies, a clinical assessment, and a fiscal intermediary. Here's how each step works.

Eligibility Requirements

To qualify for CDS, the participant must meet all four criteria:

1. Medicaid eligibility. The participant must be enrolled in MO HealthNet (Missouri Medicaid). For non-MAGI Medicaid, countable assets must be below $6,068.80 (single) or $12,137.55 (married couple). Income exceeding the Medically Needy Income Limit ($1,131/month single, $1,533/month married) requires a monthly spend-down — submitting medical expenses to offset the excess before coverage activates.

2. Nursing facility level of care. The participant must score at least 18 points on the Division of Senior and Disability Services (DSDS) InterRAI HC clinical assessment. This means demonstrating a need for direct, hands-on human assistance with activities of daily living — not just supervision or reminders.

3. Age 18 or older with a physical disability. CDS is open to adults of any age who have physical disabilities requiring personal care assistance. It's not limited to seniors.

4. Cognitive ability to direct care. The participant must be cognitively capable of acting as the employer — hiring, scheduling, training, and supervising their attendant. If cognitive impairment prevents this, the participant can designate an authorized representative (typically a family member with power of attorney) to manage the employer responsibilities on their behalf.

How to Apply: The Two-Track Process

CDS eligibility requires approval from two separate state agencies, and both tracks run simultaneously:

Track 1: Financial eligibility (DSS Family Support Division) Submit a MO HealthNet application through the myDSS portal or at a local FSD office. You'll need income verification (Social Security award letter, pension statements), bank statements, and asset declarations. FSD determines whether the participant meets the financial criteria for Medicaid.

Track 2: Clinical eligibility (DHSS Division of Senior and Disability Services) Submit an HCBS referral to DSDS — either through the online HCBS intake form or by emailing [email protected]. DSDS schedules an in-home InterRAI HC assessment. The assessor evaluates the participant's functional limitations across 12 domains and assigns a score.

Both tracks must result in approval before CDS services can begin. Financial approval without clinical approval (or vice versa) doesn't activate services. Expect 30-60 days for the full process, though timelines vary by caseload and region.

Choosing a Fiscal Management Provider

Once approved, the participant selects a fiscal management provider (also called a fiscal intermediary). This is a state-contracted company that handles the administrative and legal requirements of the employer-employee relationship between the participant and their attendant.

The fiscal intermediary:

• Processes payroll and issues the attendant's paychecks
• Withholds and remits federal and state employment taxes
• Handles workers' compensation insurance
• Manages the Family Care Safety Registry background screening for the attendant
• Submits claims to MO HealthNet for reimbursement

The participant doesn't pay the fiscal intermediary directly — their fees are covered through the CDS budget authorized by DSDS.

Missouri maintains a list of approved CDS fiscal intermediaries. Your DSDS case manager can provide the current list, or you can request it through the HCBS call center.

Attendant Rules: Who You Can (and Can't) Hire

CDS gives the participant broad discretion in choosing their attendant, but Missouri imposes specific restrictions:

You can hire: A friend, neighbor, adult child, other family member, or someone found through word of mouth or an online caregiving platform.

You cannot hire:

• Your spouse. Missouri law strictly prohibits an individual's spouse from serving as a paid CDS attendant.
• Your legal guardian. If the participant is under guardianship, the guardian cannot also be the paid attendant.

If your family situation requires a spouse to provide paid care — particularly for a parent with dementia — the Structured Family Caregiving Waiver (SFCW) is the appropriate alternative. The SFCW explicitly allows spouse caregivers for individuals with a diagnosed Alzheimer's or related dementia disorder.

Before the attendant can start working:

• A Family Care Safety Registry (FCSR) background screening must be completed. The attendant registers with the FCSR, and the participant (or their representative) requests the screening results. The fiscal intermediary typically initiates this process.
• If the screening reveals a substantiated finding of abuse, neglect, or misappropriation on the Employee Disqualification List, the attendant cannot work in the CDS program.

Budget and Service Limits

CDS authorization includes a monthly budget based on the participant's assessed care needs:

Basic personal care: The budget for standard CDS personal care services is capped at 60% of the average monthly cost of nursing home care. Based on current Missouri nursing home rates, this translates to approximately $4,000-$5,000 per month in authorized attendant hours.

Advanced Personal Care (APC): If the participant's needs require more intensive assistance — complex personal care tasks that go beyond basic ADL support — DSDS can authorize Advanced Personal Care, which raises the budget cap to 100% of the nursing facility equivalent cost.

RN visits: If the participant requires skilled nursing oversight (medication management, wound assessment, vital sign monitoring), DSDS can authorize periodic Registered Nurse visits as part of the care plan.

The participant controls how authorized hours are scheduled throughout the week. If the budget authorizes 30 hours per week, the participant decides whether that's 6 hours per day for 5 days, 4.3 hours per day for 7 days, or concentrated blocks around morning and evening ADL needs.

Timesheets and Payroll

The attendant submits timesheets to the fiscal intermediary, typically on a biweekly cycle. The timesheet records:

• Dates and hours worked
• Tasks performed
• Participant's signature (or authorized representative's signature) verifying the hours

The fiscal intermediary processes payroll, issues the attendant's paycheck, and submits claims to MO HealthNet for reimbursement. The participant doesn't handle tax withholdings or employment paperwork — that's the fiscal intermediary's role.

Common timesheet issues:

• Late submissions delay the attendant's paycheck. Establish a routine submission schedule.
• Hours exceeding the authorized budget will be rejected. If care needs increase, request a care plan review and budget adjustment through DSDS before the attendant works additional hours.
• The fiscal intermediary may have specific timesheet formats or submission methods (paper, fax, electronic portal). Confirm the process during enrollment.

Annual Reassessment

CDS authorization is not permanent. DSDS conducts annual reassessments to confirm the participant still meets the clinical level of care threshold and that the authorized service plan remains appropriate. If the participant's condition changes significantly between annual reviews, the participant or their representative can request an interim reassessment to adjust the care plan and budget.

For a complete CDS employer guide, attendant screening checklist, and Missouri care program comparison, see the Missouri Care Decision Toolkit.

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