Fillable PARTICIPANT-SUPPORT BROKER EMPLOYMENT AGREEMENT

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PARTICIPANT-SUPPORT BROKER EMPLOYMENT AGREEMENT

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Revised 11/09/2015 Page 1 of 3
01248
PARTICIPANT-SUPPORT BROKER EMPLOYMENT AGREEMENT
This agreement is hereby made between a Participant of the
Participant’s Name
Family-Directed Community Supports (FDCS) Option, a Medicaid option administered by the Department of
Health and Welfare (department), and a Support Broker.
Support Broker’s Name
The participant wants to hire the support broker for services under the FDCS Option. In exchange, the
support broker wants to be paid for the services provided to the participant. Both parties understand and
agree that payment is made through a fiscal employer agent (FEA), using Medicaid monies and based on
time sheets submitted by the support broker and approved by the employer, who is the participant.
To these mutual purposes, the parties promise and agree as follows:
1. Support broker services are to be provided in accordance with “Participant-Support Broker Agreement,”
and the FDCS rules, according to the Idaho Administrative Procedures Act (IDAPA) 16.03.13,
“Consumer-Directed Services.”
2. The support broker is hired to help the participant, and assumes no responsibility for the Participant’s
conduct.
3. That the Support Broker is an employee of the Participant and not an employee of the FDCS Option or
the FEA, and agree that the Support Broker is not entitled to, nor will make claim for any employee
benefits from the FDCS Option or the FEA, including but not limited to, worker’s compensation,
disability, life insurance, or health insurance.
4. The Support Broker will take all actions necessary to become the Participant’s employee, and to maintain
the employment relationship by submitting necessary documents to the FEA, including:
A “Support Broker Letter of Approval” from the Department.
A Completed W-4, I-9, and other IRS required forms.
A completed criminal history check, including clearance in accordance with IDAPA 16.05.06,
"Criminal History and Background Checks”.
A copy of this agreement.
Participant approved time sheets that record the hours the support broker worked.
5. The Support Broker will provide all required support broker duties outlined in Subsection 136.02 of
IDAPA 16.03.13, “Consumer-Directed Services” and, as mutually agreed upon with the Participant, the
optional support broker duties outlined in Subsection 136.03 of IDAPA 16.03.13, “Consumer-Directed
Services.”
6. The Support Broker’s wage is not to exceed $18.72 per hour. It is mutually understood that any overtime
hours or services not described in the Participant’s “Family-Directed Community Supports Support and
Spending Plan,” or described elsewhere in this agreement, are not covered by or paid through this
agreement.
Revised 11/09/2015 Page 2 of 3
01249
7. Terms and conditions of work (job duties). Effective Date: .
☐ Please check this box if employer is requiring the support broker to specifically document
activities that support billable time in writing in a manner agreed upon between the employer and the
support broker and identified in the “other” section of the agreement.
Service or Task
Identify the activity that will be completed under each
service or task.
Service
Code
Number of
hours per
year needed
to perform
this task
Wage
per hour
Annual Cost
Person centered planning participation includes:
SBS
SB2
SB3
X
=
$
Sub Total
Developing the written Support and Spending Plan
includes:
SBS
SB2
SB3
X
=
$
Sub Total
Helping the employer to review and monitor the budget
includes:
SBS
SB2
SB3
X
=
$
Sub Total
Submitting the employer satisfaction documentation to
the department as requested includes:
SBS
SB2
SB3
X
=
$
Sub Total
Participating in the quality assurance process with the
department includes:
SBS
SB2
SB3
X
=
$
Sub Total
Helping the employer with the annual re-determination
process includes:
SBS
SB2
SB3
X
=
$
Sub Total
Helping the employer to meet participant
responsibilities includes:
SBS
SB2
SB3
X
=
$
Sub Total
Criminal History Check Waiver Process (example:
complete waiver form, education and counseling to
participant and circle of support, assist with detailing
rationale for waiver and identifying how health and
safety will be protected).
SBS
SB2
SB3
X
=
$
Sub Total
Other: Give details of job duties:
SBS
SB2
SB3
X
=
$
Sub Total
Total Cost of Annual Support:
$
Revised 11/09/2015 Page 3 of 3
01250
The support broker agrees not to provide or bill for services until:
An authorized “Support and Spending Plan” has been submitted to the FEA.
The signed “Employment Agreement” has been submitted to the FEA.
The signed “Medicaid-Support Broker Agreement” has been submitted to the FEA.
Medicaid funding can only pay for services that are provided. Under the provision of this
agreement, the employee cannot bill for holiday, vacation, or sick time taken. Overtime hours
are not allowed.
The provisions of this agreement represent the entirety of the agreement between the parties. It
may be amended only in writing with both parties consenting with their signatures. It is
mutually understood that this is employment at will. Either party can terminate the relationship
without cause with 30 days notice. This agreement can be terminated immediately at any time
by the participant due to unsatisfactory support broker performance.
Participant Signature
Date
Legal Guardian Signature (if applicable) Date
Support Broker Signature Date
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PARTICIPANT-SUPPORT BROKER EMPLOYMENT AGREEMENT

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Completed 27 August 2021

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