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Moving Home Minnesota (MHM)

Revised 01-04-2018

  • Overview
  • Eligible Providers
  • Covered Services
  • Noncovered Services
  • Authorization Requirements
  • Billing
  • Managed Care Recipients
  • Legal References
  • Overview

    Moving Home Minnesota (MHM) is a federal demonstration project. The goal of MHM is to create opportunities for Minnesotans to move from institutions to their own homes in the community. MHM promotes the development and implementation of transition plans that reflect the preferences of those receiving services and the opportunity to receive services in the most integrated setting.

    Lead agencies (counties, tribes or health plans) will assign a transition coordinator to each person receiving MHM services. The transition coordinator will help create a plan to transition the person back to the community.

    People who receive MHM services must transition from a qualified institution where they have resided for 90 days or more to a qualified community residence. They must also be eligible for Medical Assistance (MA) prior to discharge and maintain eligibility. The 90-day requirement may be fulfilled through sequential stays in multiple qualifying instituations. Medicare-paid days do not count toward the 90-day requirement. The days before and after a Medicare-paid stay both count as being a continuous stay, as long as both were in a qualified institution.

    Example: A person may start out in a MA-paid hospital, and then move to a facility providing rehabilitative services paid by Medicare, then to a nursing facility paid by MA. The stay is regarded as continuous, but only the MA-paid days count toward the 90 stay requirement.

    Qualified institution
    A qualified institution can be any of the following:

  • • Hospital
  • • Nursing facility
  • • Intermediate care facility for people with developmental disabilities (ICF/DD)
  • • Institution for mental disease (IMD) such as Anoka Metro Regional Treatment Center, to the extent that these services are covered by Medical Assistance for people under age 21 or age 65 or older.
  • • Child and Adolescent Behavioral Health Services facility in Willmar (CABHS)
  • • Community behavioral health hospitals
  • Qualified community residences
    People receiving MHM services must live in a qualified community residence. These include:

  • • A home owned or leased by the person or the person’s family
  • • An apartment leased by the person or the person’s family in which he or she has control with lockable access and egress, including living, sleeping, bathing and cooking areas
  • • A community-based residential setting, in which no more than four unrelated people live (for example, adult foster care)
  • Eligible Providers

    Refer to the MHM Provider Enrollment page for new Minnesota Health Care Programs (MHCP) enrollment.

    MHM transition coordination
    The transition coordinator can be any of the following:

  • • Case manager
  • • Managed care organization (MCO) care coordinator
  • • Relocation services coordinator (RSC)
  • • Other person who meets the qualifications
  • Transition coordinators must meet the minimum qualifications of a relocation services coordinator outlined in Minnesota Statutes 256B.0621; subd. 5.

    These services may be delivered by an organization or individual that is one of the following:

  • • A lead agency (county, tribal nation or managed care organization)
  • • Under contract with a lead agency
  • • Registered with the state as one of the qualified providers shown on the Moving Home Minnesota Demonstration and Supplemental Services table (PDF).
  • Transition coordination services are activities that help a person in a qualified institution access medical, social, educational, financial, housing and other services and supports needed so they can move to the community. The transition coordinator will meet with the person in the institution and does the following:

  • • Facilitates signing of enrollment and informed consent forms
  • • Conducts assessment or arranges assessment within 30 days of assignment
  • • Develops an individualized person-centered transition plan
  • • Leads the transition planning process
  • • Works with lead agency to arrange details of waiver services, if appropriate
  • • Works with the housing specialist to locate housing
  • • Works with the Disability Hub MN Line® to identify appropriate employment supports (if necessary)
  • • Sets up transportation to look for housing or employment
  • • Coordinates details to set up a home
  • • Coordinates meeting(s), medical follow up appointment, delivery of medical equipment, availability of medications, etc.
  • • Coordinates day of discharge and is present the day of the move to assure medications and required services are in place
  • • Coordinates an orderly hand-off to the case manager and community providers. If the person will have a different case manager after transition, the transition coordinator must facilitate an in-person meeting with the person and the community case manager.
  • The following forms are required for MHM enrollment and participation:

  • Moving Home Minnesota Intake Form (DHS-5032) (PDF) – complete and send to DHS for an eligibility determination
  • Moving Home Minnesota Housing Transitions Worksheet (DHS-6759G) (PDF) – complete with the person and transition coordinator
  • Moving Home Minnesota Communication Form (DHS-6759H) (PDF) – complete and send to DHS when the transition coordinator has an estimated date when the person will be moving. DHS needs this information to schedule a quality of life survey with Vital Research before the person moves. The communication form also needs to be completed a second time with the date the person moved, as well as the housing information.
  • Moving Home Minnesota Informed Consent (DHS-6759I) (PDF) – complete when the transition coordinator meets with the person, then send it to DHS. The 180 days of eligibility for transition coordination begins on the date the form is signed.
  • Moving Home Minnesota Transition Planning Tool (DHS-6759J) (PDF) –complete with the person and the transition coordinator
  • Provider Enrollment:
    Complete and submit the Moving Home Minnesota – Transition Planning, Transition Coordination and Demonstration Case Management Providers – Applicant Assurance Statement (DHS-3879) (PDF) to enroll with MHCP to provide transition planning and coordination. This form is required to be authorized to be paid for any of the following:

  • • Furnishing, supplies and costs for securing housing and environmental modifications
  • • Durable medical equipment
  • • Personal emergency response systems
  • • Tools, clothing and equipment necessary for employment
  • Currently Enrolled Providers
    MHCP allows any providers who are currently enrolled to provide services in the covered services section below to MHM recipients. To add any additional MHM services, you must complete the HCBS Programs Service Request Form (DHS-6638) (PDF).

    Providers wanting to provide overnight assistance must complete an Overnight Assistance Provider Applicant Assurance Statement (DHS-6808) (PDF).

    The following services require specific qualifications and may be delivered only with DHS approval. These services include:

  • • Certified peer specialist
  • • Youth Assertive Community Treatment Services
  • Supported employment
  • MHM Recipient Enrollment

    Individuals may enroll for MHM services by contacting the Disability Hub MN Line® 866-333-2466 or the Senior LinkAge Line® 800-333-2433. They may also complete the online MHM Intake Form (DHS-5032) (PDF). The intake form can also be faxed to 651-431-7745 or mailed to:

    Moving Home Minnesota
    P.O. Box 64250
    St. Paul, MN 55164-0250

    A MHM enrollment specialist at DHS will work with the transition coordinator to confirm if the person meets eligibility requirements for MHM services. If the person is determined eligible for MHM, the person must complete the Moving Home Minnesota Informed Consent (DHS-6759I) (PDF) and return it to DHS before the person can begin receiving MHM services.

    Changes and Disenrollment from MHM
    DHS must be notified with the Moving Home Minnesota Communication Form (DHS-6759H) (PDF) by either the lead agency, transition coordinator or case manager if a person approved to receive MHM services chooses not to utilize MHM services, or in any of the following situations during or after transition.

    During transition the person:

  • • Decides he or she wants to remain at the facility
  • • Is transferred to a hospital
  • • Passes away
  • • Leaves the facility against medical advice and does not return
  • Post-transition during case management the person:

  • • Decides he or she wants to return to the facility
  • • Is transferred to a hospital
  • • Passes away
  • • Is unwilling to complete paperwork to maintain Medical Assistance. The person must be on MA while receiving MHM services.
  • • Wants to dis-enroll from MHM case management
  • • Relocates or moves to another state
  • MHM Evaluation

    As part of the federal demonstration project, all people receiving MHM services will be part of a national Quality of Life (QoL) study. Each person receiving MHM services will receive a face-to-face Quality of Life Survey at three points:

  • • Prior to discharge from the institution
  • • At the 11th month using the program
  • • At 24 months from beginning the demonstration program
  • This survey is intended to capture the person’s satisfaction with services prior to discharge from the institution, just before the end of participation in the demonstration and one year following the end of the demonstration period. The person will be contacted directly by the research firm.

    Assessment for MHM Services

    All MHM services require an evaluation to determine the person’s needs and eligibility for MHM services. The assessment will be completed by the appropriate lead agency using the MnCHOICES assessment.

    People under age 65
    People under age 65 may enroll in and choose to use MHM services, along with state plan services. However, they must be eligible for MA and the services must be medically necessary.

    If services under both MHM and state plan do not meet the needs, the transition coordinator may conduct an assessment or refer the person to request a Long-Term Care Consultation, Developmental Disabilities Screening or MnCHOICES Assessment to determine eligibility for a Home and Community-Based Services (HCBS) waiver program.

    Applicants must meet the hospital or institutional level of care to qualify for one of the HCBS waiver programs or MHM program.

    People age 65 and older
    All people age 65 or older will enroll in the Elderly Waiver program in addition to receiving MHM services.

    If a person receiving MHM services returns to an institution for less than 30 days, the person continues enrollment in MHM while the person is in the institution.

    If a person receiving MHM services returns to an institution for more than 30 days, MHCP will suspend the person from the MHM program. However, people may:

  • • Use any time left of their 12 month MHM program limit after they return to their qualified community residence
  • • Re-enroll in MHM if they continue to reside in a qualified institution for another 90 days
  • Covered Services

    MHM covers services approved in the person’s transition care plan. Refer to the Moving Home Minnesota Demonstration and Supplemental Services Table (PDF) for a complete list of MHM services.

    MHM Services

    DHS requires that people enrolled in the MHM program are provided MHM transition planning and transition coordination services, rather than some other form of case management or relocation coordination services. Only one type of case management can be billed at any one time. Transition coordination costs such as furnishing, supplies and expenses associated with securing housing may be paid under MHM as long as they are not available to the person under a waiver program.

    It is common for a person to have exhausted his or her 180-day benefit relocation coordination services without being discharged. It is allowable to use MHM transition planning and transition coordination services for an additional 180 days.

    The MHM program includes a range of services (see the Moving Home Minnesota Demonstration and Supplemental Services Table (PDF)). All the services listed here are available in addition to the state plan and waiver services a person is eligible to receive and can be provided without affecting the person’s waiver budget (see example below). In effect, these services are allowed and can be delivered to supplement other state plan and waiver services. They include:

  • • Pre and post discharge case consultation (see example below)
  • • Comprehensive community supports
  • • Certified peer specialist for people with mental illness
  • • Psychoeducational services for children with mental illness
  • • Youth Assertive Community Treatment
  • • Family memory care (less than 65 yers of age)
  • • Costs associated with finding housing or employment
  • • Membership fees for health clubs or fitness centers
  • Overnight assistance
  • Example for pre-discharge case consultation:
    The client has an eating disorder and is going into an adult foster care home. The caregivers don’t know anything about eating disorders. The transition coordinator would find a professional in that area of expertise to train the caregivers.

    Example for waiver budget:
    If belonging to a fitness center is identified in the person-centered transition plan as being important, the individual may receive the service without it being counted against the individual’s waiver budget.

    MHM services are not intended to duplicate, replace or extend services that are already covered by a person’s state plan or waiver benefit set. If the service is already available under the person’s waiver, it is not available under MHM.

    The following services are available only to people who are not on a waiver:

  • • MHM Demonstration case management
  • • Respite services for children with mental illness
  • • Environmental modifications
  • • Durable medical equipment
  • • Personal emergency response systems
  • • Tools, clothing and equipment necessary for employment (less than 65 years of age)
  • • Supported employment (less than 65 years of age)
  • MHM State Plan Services

    People receiving MHM services may also be eligible to receive state plan services, based on medical necessity and the eligibility requirements for the services. These services include, but are not limited to:

  • Home care
  • Skilled nurse visits
  • Home health aide visits
  • Home care nurse
  • Homecare therapies
  • PCA
  • Adult mental health rehab services:

  • Assertive community treatment (ACT)
  • Adult rehabilitative mental health services (ARMHS)
  • Adult crisis response services
  • Children’s mental health rehab services:

  • Day treatment
  • Individual, family and group psychotherapy
  • Residential treatment
  • Children’s therapeutic services and supports (CTSS)
  • Crisis response services
  • Noncovered Services

    Noncovered services are those services not authorized or listed in the covered services section of the Moving Home Minnesota Demonstration and Supplemental Services Table (PDF).


    All MHM services require an assessment to determine the person’s needs. Individuals apply for MHM by completing an application and informed consent form. The lead agency and person will receive either an approval or denial notice confirming enrollment or denial into the program. After program approval, the transition coordinator will work with the person to develop a transition plan. The transition plan is to be developed with person-centered principles, which means the person’s preferences and choices are identified and reflected in the plan.

    After the 12-month transition period, people continue to receive the same services through state plan or a waiver program. If MHM services are needed for a limited time beyond the 12 months, DHS may cover the costs using state-only funds. The MHM enrollment specialist must authorize use of demonstration services beyond the 12-month enrollment period. The person receiving the services, or anyone acting on the person’s behalf, such as a transition coordinator or case manager, may request that services continue.

    Most of MHM services require a service agreement, with the exception of those that occur prior to discharge, including the following:

  • • Transition planning and coordination
  • • Pre-discharge case consultation
  • • Costs associated with finding housing or employment
  • Service Authorization Letters (SAL)

    Once services are approved, MHCP will provide the person, the provider of service(s) and the case manager a copy of an authorization letter. The provider and the case manager will each receive the letter in their MN–ITS SAL mailbox. The letter shows the services authorized through MHM. Providers must enter the authorization number on their claims.

    The person receiving MHM services and the provider are responsible for reviewing the authorization letter for accuracy before receiving and billing for services.


    To submit claims for homecare and mental health services, follow the billing guidelines in the home care services and mental health services sections of the MHCP Provider Manual.

    MHM services approved through the HCBS waiver programs, follow the waiver billing guidelines in the HCBS waiver program services section of the MHCP Provider Manual.

  • Use the Professional (837P) claim transaction and:
  • • Enter the service authorization (SA) number on the claim
  • • Enter the diagnosis code on the claim
  • • Submit claims only after the services have been provided
  • • Submit claims for the following MHM services according to the additional instruction in the Moving Home Minnesota Demonstration and Supplemental Services Table (PDF)
  • Submit claims for T2029 U6 Specialized Equipment and Supplies following the billing instructions above and add the appropriate modifiers as listed below even though the modifiers are not listed on the SA.

    NU= New when purchasing new equipment or supplies
    UE= Used when purchasing used equipment or supplies
    RR= Rental of equipment or supplies
    RB= Repair of an item or part

    Managed Care Recipients

    For people age 65 and older who are enrolled in MSHO or MSC+, the managed care organization (MCO) is responsible for Elderly Waiver services and for relocation services coordination. In this case, the MCO will serve as the lead agency for transitions. The MCO may arrange for another entity, such as a private relocation services provider or a county agency, to serve in this capacity.

    For all other people, the county or tribe will serve as the lead agency, regardless whether the person is enrolled in a MCO. This includes those over the age of 65 enrolled in SNBC, as well as people over the age of 65 who are excluded from managed care.


    Case manager or community provider: Helps with issues that come up during the year of transition and arranges support for the person in the community.

    Person-centered transition care plan: A person receives the right services and supports at the right time, and according to his or her wishes and needs.

    Legal References

    Deficit Reduction Act, 2005 (PL 109), sec. 6071
    Patient Protection and Affordable Care Act, 2010 Sec. 2403

    2011 Minnesota Statutes 256B.04 Subd. 20

    Minnesota Statutes 256B.0621
    ; subd. 5 (Covered Services: Targeted Case Management Services)

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