Skip to: Main content | Subnavigation |
Department of Human Services Department of Human Services  
 
Elderly Waiver (EW) and Alternative Care (AC) Program

Revised: 06-03-2014


• Overview
• Covered Services (By Program)
• Roles
• Providers
• Authorization of Services (Prior Authorizations)
• Billing
• Service Descriptions, Billing Codes, Provider Standards
• Adult Day Services/Adult Day Services Bath
• Family Caregiver Training & Education
• Family Caregiver Coaching and Counseling – including assessment
• Adult Foster Care Services
• Case Management
• Case Management Aide/Paraprofessional
• Chore Services
• Companion Services - Adult
• Consumer Directed Community Supports (CDCS)
• Customized Living Services
• 24-Hour Customized Living Services
• Environmental Accessibility Adaptations
• Extended State Plan Home Health Services – EW Program Only
• Home Health Services – AC Program Only
• Home Delivered Meals
• Homemaker Services
• Nutritional Services
• Residential Care Services
• Respite Care
• Specialized Supplies & Equipment
• Specialized Supplies & Equipment Authorization & Billing Responsibilities
• Transitional Services
• EW and AC Transportation
• Provider Quick Reference

Provider Type Home Page Links
Review related Web pages for the latest news and additions, forms, and quick links.

• HCBS Waiver and AC Home Page

Overview
Elderly Waiver (EW) and Alternative Care (AC) programs fund home and community-based services (HCBS) for people age 65 and older who require the level of care provided in a nursing home, but choose to reside in the community. These programs provide services and supports for people to live in their homes or a community setting, and may delay or prevent nursing facility (NF) care. The purpose of these programs is to promote community living and independence with services and supports designed to address each person’s individual needs and choices. In the case of EW, the additional services go beyond what is otherwise available through Medical Assistance (MA).

• The Elderly Waiver (EW) program is a federal Medicaid waiver program that funds home and community-based services for people age 65 and older who are eligible for Medical Assistance (MA) and require the level of care provided in a nursing home and choose to reside in the community. EW recipients can receive waiver services and/or MA services funded through a managed care organization (MCO). This can be through Minnesota Senior Care Plus (MSC+) or Minnesota Senior Health Options (MSHO).
• The Alternative Care (AC) program is a state-funded program that supports limited home and community-based services for people age 65 and older who are not financially eligible for MA, but who meet AC financial and service eligibility requirements and require the level of care provided in a nursing home. People eligible for Alternative Care have low levels of income and assets but are not yet eligible for Medical Assistance.

Covered Services (By Program)

Service EW AC
Adult Day Services X X
Adult Day Services Bath X X
All MA covered services X  
Customized Living X  
24-Hour Customized Living X  
Family Caregiver Training and Education X X
Family Caregiver Coaching and Counseling X X
Case Management X X
Case Management Aide (Paraprofessional) X X
Chore X X
Companion Services X X
Consumer Directed Community Supports X X
Conversion Case Management   X
Adult Corporate Foster Care (Monthly) X  
Adult Family Foster Care (Monthly) X  
Environmental Accessibility Adaptations X X
Home Care – Extended Services HHA, PDN, PCA X X
Home Delivered Meals X X
Homemaker X X
Non-Medical Transportation X X
Nutrition Services   X
Residential Care X  
Respite Care X X
RN Supervision of PCA   X
Specialized Supplies and Equipment X X
Tele-homecare X X
Transitional Supports X  

Recipient Assessments
Any recipient may request an assessment for themselves or another recipient by making a referral to the local lead agency. The lead agency will determine program eligibility. EW and AC have different application processes, financial eligibility requirements and covered services.

Recipient Eligibility
All applicants must meet the service eligibility criteria for the specific HCBS program in which they anticipate receiving services. Refer to the MHCP Provider Manual, Provider Basics for more information about MA and eligibility.

• To be eligible for EW services, applicants must also be eligible for MA.
• To be eligible for AC, applicants would be financially eligible for MA within 135 days of entering a nursing facility as determined by a case manager.

Roles
County Financial Worker
County financial workers determine financial eligibility for payment of Elderly Waiver services. Financial workers will also conduct asset assessments as needed for determination of AC and EW financial eligibility.

Lead Agency Case Managers
Lead agency case managers determine financial eligibility for payment of Alternative Care services.

Lead Agency
For EW the lead agencies can be tribes, counties or health plans. For AC, lead agencies can be counties or tribes. A lead agency can be the local public health agency, human service agency or social service agency. Lead agencies are responsible for the following:

Long Term Care Consultation
The lead agency provides Long-Term Care Consultation (LTCC), services including:

• A community assessment of the needs of the recipient
• Assistance with the application process
• Development of a community support plan

Case Management
A recipient approved for EW or AC will receive case management or care coordination from a public health nurse or social worker who:

• Helps develop the community support plan based on the person’s needs
• Implements and monitors the community support plan. The community support plan must ensure that the health and safety needs of the recipient are reasonable met
• Assures informed choice and consent
• Helps with referrals
• Arranges for and coordinates service delivery

Program Access and Administration
Lead agencies are responsible for providing program access and administration, which includes:

• Working in partnership with DHS and other organizations to provide information, services, and assistance to people who request and wish to gain HCBS access
• Providing recipient case management or care coordination services, which includes:
• Assessing program eligibility
• Developing a service plan
• Assisting recipients to access, coordinate and evaluate available services
• Generating additional copies of provider Service Agreement (SA) letters, if needed
• Inputting recipient enrollment data (e.g., screening document) and service authorization, as required, into the DHS Medicaid Management Information System (MMIS)
• Authorizing and monitoring services to reasonably assure health and safety
• Monitoring the ongoing provision of individual services for efficiency, consumer satisfaction, and continued eligibility, and adjusting these provisions as necessary
• Managing the contract(s) and systematic monitoring of provider performance
• Assuring that all providers meet state standards relevant to their area of service and have signed provider agreements
• Authorizing funds for all HCBS services provided to the eligible recipient

Notice of Action
By law, the lead agency/state is required to notify the recipient anytime services are denied, terminated, reduced or suspended. Notification must be in writing and sent at least 10 days before the action is taken. Lead agencies must use the Notice of Action (DHS-2828) to notify the recipient of impending changes to the waiver services.

Informed Choice
The lead agency will:

• Provide individuals seeking EW or AC services the necessary information to make informed choices among the services for which they are eligible
• Inform the recipient and legal representative when a recipient is likely to require the level of care provided in an institution, such as a hospital or nursing home, of home and community based supports as an alternative
• Document that the above information was given
• Take reasonable steps to provide the information in a format the recipient can understand and with a choice of service providers for all services
• Inform a recipient nearing age 65 of the other community support options so that the recipient can choose which alternative will best meet their needs. A recipient receiving waiver services before age 65 remains eligible for the respective waiver after their 65th birthday if all other eligibility criteria are met. Other options may include the EW, remaining on their current HCBS waiver or other alternatives that may meet the needs and preferences of the recipient. For information about HCBS waivers for persons under age 65 refer to the Community-Based Services Manual.

Providers
There are many advantages for both providers and lead agencies to coordinate efforts to ensure that a recipient receives necessary services, and that providers receive timely payments for services rendered. Providers who are contracting with health plans to provide services should receive instructions from the health plan on how to ensure payment.

Enrollment/Licensure/Certification
EW and AC program providers must enroll with MHCP and meet specific standards in order to bill and receive payment for waiver services. Providers must also determine which program services they are qualified to provide. Specific provider qualifications are found in this Manual within each service description. Qualifications are also listed on the Waiver and Alternative Care (AC) Programs Service Request Form (DHS-6638)

Some waiver services require one or more of the following:

• License(s) from DHS or the Minnesota Department of Health
• Medicare certification
• Other certification or registration

For more information, please refer to one or more of the following:

• The lead agency in which you will be providing services
• DHS Licensing at 651-431-6500
• Minnesota Department of Health at 651-201-5000 for general information

Authorization of Services (Prior Authorizations)
A completed screening document that opens the EW or AC eligibility span must be entered into MMIS.

EW and AC services require prior authorization from a lead agency in the form of a completed service agreement (SA).

Service Agreements/Service Agreement Letters
Fee-for-service (FFS) EW and AC services require prior authorization from a case manager in the form of a service agreement (SA) which county and tribal agencies initiate and enter into MMIS that ensures provider payment. If the rate, procedure code(s), or begin and end dates on the SA are incorrect, providers must contact the case manager. If an SA line item is changed and approved, DHS will automatically generate a revised SA letter to the provider. Letters are generated overnight and sent the following day.

The SA allows the provider to bill DHS and receive payment after services are provided. Only services on the SA can be paid; however, an approved SA is not a guarantee of payment. The case manager is ultimately responsible to ensure that the SA is accurate when it is entered in MMIS. When the provider receives the SA letter, they should review it for accuracy.

Each line item on the SA lists the following:

• MHCP-enrolled provider who is authorized to provide the needed services
• Rate of payment for the service
• Number of units approved or total amount
• Date or date span of service
• Approved procedure code(s)
• MA home care services of SNV, HHA, PDN, and PCA that must be utilized before EW extended services

The EW/AC service agreement displays units, duration and rates. All authorized services need to stay within the published case mix budget caps and published state maximum rates for services.

Verifying Recipient Eligibility Monthly
Providers must verify program eligibility for each recipient each month through the MHCP phone-based EVS or online via MN–ITS.


Billing
EW and AC services must be billed using the 837P Professional claim transaction. Submit claims for extended home care services approved on the waiver or AC authorization using the 837I Institutional Outpatient transaction, following home care billing guidelines. For additional billing information review the MHCP Billing Policy guidelines. The service must be completed before a provider may bill for it.

Health plans have their own service authorization systems. Service providers who are contracting with health plans need to contact the health plan for instructions on how to submit claims. South Country Alliance health plan contracts with MHCP to act as the Third Party Administrator (TPA) for submitting claims and receiving reimbursements for EW services. Contact the health plan for particular instructions when obtaining authorizations and billing for EW services.

Diagnosis Codes (ICD)
MHCP requires agencies to enter the most current, most specific, primary diagnosis code when submitting claims for most waiver and AC services. Use the most specific, most current primary diagnosis codes.

Service authorization/agreement letters to the provider display the diagnosis code of the recipient if the diagnosis is required for billing. The diagnosis is pulled from the primary diagnosis field on the last approved screening document. It is not necessary to use the diagnosis code listed on the service authorization/agreement letter if you have a more recent or correct diagnosis code.

Authorized Services vs. Non-Authorized Services
Services that require a SA cannot be billed on the same claim as services that do not require an SA. For example, for MA eligible recipients, home care therapy services (physical, occupational, respiratory and speech therapy) do not require an SA and cannot be billed on the same claim form as a waiver service, such as, Adult Day Services.

Payment Rates
Lead agencies authorize service and provider payment rates. DHS establishes upper rate limits for AC and EW services. Service rates authorized and claimed may not exceed the DHS published maximum allowable service rates, and, for some market rate services must be determined based on the lowest cost effective bid within the limits.

Information about service rate changes and limits for EW and AC services are first made available through publication of Bulletins. Review Continuing Care Provider Rate and Grant Changes web page for the most up to date information about the current rate limits.

Clients Leaving Nursing Facilities (Conversion Rates)
Persons receiving EW services may access a higher monthly budget if the person is a resident of a certified nursing facility and has lived there for 30 consecutive days. Refer to the Bulletin EW Conversion Rates and Maintenance Needs Allowance Changes (PDF).

Elderly Waiver Obligation
Eligibility for EW is based on two income limits:

• People with incomes equal to or less than the Special Income Standard (SIS) are eligible for EW without an MA spenddown. They must contribute any income over the maintenance needs allowance and other applicable deductions to the cost of services received under EW. This is known as the waiver obligation.
• People with incomes greater than the SIS may still be eligible for EW but they will have an MA spenddown. The lead agency’s financial assistance unit is responsible for determining the financial obligation of the EW client. The client is informed if they have a waiver obligation or will be responsible for a spenddown.

The waiver obligation is:

• Deducted from the cost of services received under the Elderly Waiver; the full amount of the waiver obligation does not have to be met each month
• The amount the client is responsible to pay towards the services that were utilized that month, which may be a portion of the waiver obligation or the entire waiver obligation

An MA spenddown may be met with any combination of MA services including HCBS services. MA spenddowns are to be met each month.

The county financial worker enters the waiver obligation into MMIS. DHS will report the amount the provider can bill the recipient on their remittance advice. Claims that are reduced due to the EW obligation will show claim adjustment reason code PR 142 on the remittance advice. Health plans also receive reports on their recipients who have waiver obligations. Each health plan has a process for informing providers on amounts of waiver obligations. See the Special Income Standards (SIS), section 22.10, of the Health Care Programs Manual.

A recipient can designate a provider to whom they will pay their obligation. The recipient must notify their financial worker if they wish to choose this option. Recipients who receive waiver services through a health plan cannot use the designated provider option that is available through the financial worker request.

Maximizing Other Payors
EW and AC recipients are expected to maximize access to other federal or private program benefits for primary health care coverage through Medicare benefits, private insurance, Medicare supplemental policies, or long-term care insurance policies.

Home Care Services provided for an MA-eligible Recipient Receiving EW Services
All recipients receiving EW services must first access MA home care services to the highest extent before adding EW services to the community support plan.

MA covers the following home care services:

• Home Health Aide (HHA) visits
• Occupational Therapy (OT)
• RN PCA Supervision
• Personal Care Assistant (PCA)
• Physical Therapy (PT)
• Private Duty Nursing (PDN)
• Respiratory Therapy (RT)
• Skilled Nursing Visits (SNV)
• Speech Therapy (ST)

Home Care and EW Waiver
• Some recipients on EW receive their EW services fee-for-service (FFS) and their MA home care through managed care, formally called the Prepaid Medical Assistance Program (PMAP).
• The managed care products that serve Elderly Waiver recipients are Minnesota Senior Care Plus (MSC+) and Minnesota Senior Health Options (MSHO).
• With the exception of therapies, the FFS case manager of EW services determines the amount of home care services and approves the service agreement. When the recipient has MA services through managed care, the case manager uses a pseudo code (X5609), which authorizes the amount of home care services that are counted towards the recipient’s case mix budget.
• For managed care recipients of EW services, the designated care coordinator is responsible for approval and provision of all home care and EW services.

Home Care and AC
The FFS case manager determines and authorizes the amount of home care services that are counted towards the recipients case mix budget. AC does not have an MA benefit.

Extended Home Care Services – EW
Extended home care services include extended PCA, extended Home Health Aide, and extended Home Health Nursing (RN/LPN).
• A recipient must first access needed home care service benefits through MA home care, either FFS or managed care, before “extended home care” benefits may be approved
• Home care service needs that cannot be met within the MA home care limits may be approved and billed to the waiver as extended MA services within the budget limit available.

Refer to Home Care Services for more information about MA Home Care services.


Service Descriptions, Billing Codes, and Provider Standards
The following EW and AC service descriptions include:

• Definitions
• Covered services
• Non-covered services
• Provider qualifications and standards
• Procedures
• Secondary information

These services and requirements are the minimum guidelines. Lead agencies may negotiate with providers in their contracts for any additional specific performance standards or requirements needed to meet needs of specific individuals.


Adult Day Services and Adult Day Services Bath

Service/HCPCS EW AC
Adult Day Service
• S5100 – Center Based Services15 minutes
• S5100 with modifier U7 – Family Adult Day Services (FADS)– 15 minutes
• S5102 – Center Based Services Daily
• S5102 with modifier U7 – Family Adult Day Services Daily

X
X
X
X

X
X
X
X
Adult Day Service Bath
• S5100 with modifier TF – 15 minutes (limited to two units per day )
 

X

Definitions
Adult Day Service
Adult day services is a program operating less than 24 hours per day that provides an individualized and coordinated set of services (including health services, social services, and nutritional services) directed to maintaining or improving a recipient’s capabilities for self-care.

This includes:

• Supervision
• Care assistance
• Training
• Activities based on the recipient’s needs and directed toward the achievement of specific outcomes identified in the community support plan

Service goals include but are not limited to:

• Optimizing health and/or cognitive functioning
• Increasing socialization
• Improving community integration

Services must be designed to meet both the health and social needs of a recipient, and may not be used solely for recreational or diversional purposes.

Adult day is a licensed service that must be:

• On a regularly scheduled basis
• One or more days per week
• Two or more hours per day

Meals that are provided as part of these services will not constitute a “full” nutritional regimen (that is, 3 meals/day) according to 42 CFR 441.310(a)(2)(ii). Adult day services may not be authorized for more than 12 hours in a continuous 24 hour period. The cost of transportation is not included in the rate.

Provider Standards and Qualifications
• Adult day services are established under Minnesota statutes, section 245A.01 to 245A.16.
• Adult day services provided in the license holder’s primary residence, when the license holder is the primary provider of care, must be licensed under Minnesota Statutes, section 245A.143 (Family Adult Day Services). In addition, FADS participants must be age 55 or older, and not have a serious or persistent mental illness or developmental disabilities.
• A family adult day service license holder may not serve more than eight adults at one time. Adult day services provided in any other location must be licensed under Minnesota Rules, parts 9555.9600 to 9555.9730
• Nursing facilities, board and care facilities, and hospitals providing adult day care services to five or fewer non-residents/patients are exempt from adult day care licensure.
• Lead agencies must authorize services in 15 minute units or use the daily rate for recipients.

Adult Day Service Bath
A recipient receiving adult day services may also receive a bath provided by an adult day service provider. To receive an adult day bath, a recipient must be receiving adult day services. The adult day service bath and reason for not providing a bath in the recipient’s home must be documented in the community support plan. This service is limited to two 15 minute units of service per day.



Family Caregiver Training and Education

Service/HCPCS EW AC
Family Caregiver Training & Education
• S5115 – per 15 minutes – (up to 48 units (12 hours) over a 365 day period)

X

X
Family Caregiver Coaching and Counseling/Caregiver Assessment
• S5115 with modifier TF - Per 15 minutes (up to 48 units (12 hours) over a 365 day period)

X

X

Definition and Covered Services
This service provides training, education, coaching and counseling services for family and informal caregivers who provide direct and ongoing services for recipients enrolled in EW and AC programs.

Caregivers may include:

• Spouse
• Adult child
• Parent
• Other relative
• Foster family
• In-laws
• Other non-relative caregiver (such as, partners or friends)

The family caregiver is not paid and is not employed or a volunteer through the organization that cares for the recipient. Under EW and AC, the family caregiver does not need to be living in the same household as the care recipient to obtain caregiver support services. All services must be documented in the recipient’s community support plan.

Family Caregiver Training and Education:
Training and education is provided to improve the health and well-being of the family caregiver, and to improve or maintain the quality of care provided for the recipient. It includes individual or group sessions and updates as necessary.

Examples include:

• Instruction about treatment regimens
• Disease management
• Nutrition
• Direct care skills
• Use of equipment or technology to maintain the health and safety of the recipient.

It may also include education about:

• Caregiver roles
• Family dynamics
• Self-care skills
• Dealing with difficult behaviors
• Communicating with health care providers
• Other areas, as specified in the plan

Family Caregiver Coaching and Counseling/Caregiver Assessment:
Caregiver coaching is an individualized person-centered service. The goal is to equip the caregiver with knowledge, skills and tools to become a stronger caregiver capable of self-directed care.

Coaching or counseling includes:

• Assessment of the caregiver’s needs and strengths
• Development of a person-centered plan with goals
• Skills development (i.e., disease management, self-care skills such as managing stress, techniques for managing difficult behaviors)
• Problem solving (i.e., learning assertiveness and communications skills, dealing with family dynamics, and developing an informal support network)
• Coaching
• Ongoing support to reach established goals
• Conducting family meetings and memory care consultation

Caregiver counseling offers professional consultation to assist caregivers in making decisions and solving problems related to their caregiving role.

This includes:

• Assessment to identify needs and preferences
• Development of an individualized approach and plans
• Family counseling
• Conflict resolution
• Problem solving or guidance directly related to providing care to the older adult

Limits or Conditions:
Family caregiver training and education pays for the costs of training offered by enrolled providers, or conference registration fees for family caregivers.

Non-covered costs:

• Transportation
• Travel
• Meals
• Lodging

If any such costs are included in the registration fee, they must be deducted. The provider or individual requesting training must submit documentation of the need for training and an outline of the training (i.e., a course syllabus, training objectives, workshop description, etc.) to the lead agency for approval.

Family caregiver coaching and counseling/caregiver assessment is limited to enrolled providers and pays for staff time spent with family caregivers.

Non-covered costs:

• Preparation time
• Travel
• Materials

Providers must submit a service description and plan to the lead agency for approval. Based on the information provided and the individual’s needs, the care manager determines whether the service will be authorized. If the service is authorized, the lead agency maintains the submitted documentation in the recipient’s file. The lead agency, as an enrolled Medicaid provider, will submit claims for this service to MMIS as appropriate.

Provider Standards and Qualifications
Staff Qualifications
Acceptable providers for family caregiver training and education include these professionals:

• Public health nurses
• Registered nurses
• Licensed practical nurses
• Physicians
• Social workers
• Rehabilitation therapists
• Gerontologists
• Pharmacists
• Caregiver consultants
• Memory care consultants
• Health educators
• Nutritionists
• Vocational and technical colleges offering home health aide and certified nursing assistant training
• Independent living specialists
• Medical equipment suppliers

Acceptable providers for family caregiver coaching and counseling include these professionals:

• Public health nurses
• Registered nurses
• Licensed practical nurses
• Physicians
• Social workers
• Rehabilitation therapists
• Gerontologists
• Pharmacists
• Caregiver consultants
• Memory care consultants
• Health educators
• Nutritionists

Acceptable provider agencies for family caregiver coaching and counseling include home care agencies, and care or support related organizations (non-profit social service organizations, voluntary or faith-based agencies, and state and local chapters of chronic disease organizations, such as the Alzheimer’s Association)
In addition, enrolled providers will have one of the following:

• At least one year of experience in providing home care or long-term care service to older adults
• At least one year of experience providing training, education or counseling to caregivers of older adults

Physical cares requiring a specific technique for the safety of both the caregiver and older adult must be taught by a professional specializing in such techniques, such as:

• Public health nurse
• Registered nurse
• Licensed practical nurse

Training and education of caregivers may also be provided by vocational and technical schools offering courses such as:

• Home health aide and certified nursing assistant training
• Disease specific training provided by care or support related organizations (e.g., Alzheimer’s Association) when it is determined by the case manager that the content of the training or conference directly applies to the care and well-being of the EW or AC recipient needing care.

Caregiver consultants will have completed the Minnesota Board on Aging (MBA) caregiver coaching basic training curriculum and continuing education offered by the MBA or Area Agencies on Aging.

Documentation and Reimbursement
The following must be documented for this service to be reimbursed:

• Requested areas of training and education, or coaching or counseling
• Potential sources of training and education, or coaching or counseling
• Identified methods by which the family caregiver will receive information about training, educational or coaching or counseling opportunities

Documentation of the training, education, coaching or counseling (such as the course syllabus, workshop description, or training objectives) and receipts for any fees and expenses must be submitted to the lead agency prior to payment.

The lead agency, as an enrolled MA provider, may pay the family caregiver directly and then submit claims to MMIS for reimbursement of the service.

All family caregiver training, education, coaching or counseling must be included in the EW or AC recipient’s community support plan.


Adult Foster Care Services

Service/HCPCS EW
Foster Care – Corporate
• S5141 with modifier HQ – Monthly, Adult

X
Foster Care – Family
• S5141 – Monthly, Adult

X

Definition
Foster care services are ongoing residential care and supportive services provided to a recipient living in a home licensed as foster care.

Services include:

• Personal care assistant services
• Homemaker
• Chore services
• Companion services
• Medication oversight (to the extent permitted under state law) provided in a licensed home

Adult foster care is provided to recipients who receive these services in conjunction with residing in the home. Foster care services are based on the individual needs of the recipient, and service rates must be determined accordingly.

When placing an adult into a licensed foster care setting, all federal, state, county, and licensing agency rules and regulations must be followed. Requirements for services and supports are identified in the community support plan of the recipient.

Adult Foster Home Size
The total number of people (including waiver recipients) living in the home cannot exceed four when all residents are:

• Diagnosed with a serious and persistent mental illness or a developmental disability
• Not related to the principal care provider

The total number of people (including waiver recipients) living in the home cannot exceed five when all residents:

• Do not have a diagnosis of serious and persistent mental illness or developmental disability
• Are not related to the principal care provider

Covered Services
Adult foster care homes provide:

• Food preparation
• Protection
• Household services
• Homemaking
• Chore services
• Medication assistance (as permitted under state law)
• Assistance safeguarding cash resources
• Personal care assistance
• Homemaking
• Oversight and supervision
• Transportation

Non-Covered Services
Payment for EW Foster Care service does not include:

• Room and board
• Duplication of services paid by other sources
• Items of comfort or convenience
• Costs of facility maintenance, upkeep and improvement
• Payment for foster services when the recipient is not in the foster setting
• Separate payment for homemaker or chore services
• Payment for foster care services when a recipient is a resident of a different foster care setting

Provider Standards and Qualifications
Payments will be made only to those entities or recipients that meet current legal Foster Care licensure requirements found in MN Rules, part 9555.5050 – 9555.6265.and 2960.3000 to 2960.3230 and Minnesota Statutes §245A.03

Adult foster care providers may be licensed for up to five adults per home if all foster care recipients are age 55 or older, and have neither serious persistent mental illness nor any developmental disability.


Case Management

Service/HCPCS EW AC
Case Management
• T1016 with modifier UC – 15 minutes

X

X
Case Management Conversion
• T1016 – 15 minutes
 

X

Definition
This service will assist individuals in gaining access to needed EW, AC, and MA services, as well as needed medical, social, educational and other services, regardless of the funding source.

Case management for MSHO and MSC+ enrollees receiving EW services that coordinate the provision of health and long-term care services to an enrollee among different health and social service professionals and across settings of care includes, but is not limited to, needs assessment, prior approval, care communication, coordination and risk assessments.

Covered Services

• Ongoing monitoring of the provision of services included in the plan of care/community support plan
• Development of a service plan
• Providing information to the recipient or the recipient’s legal guardian or conservator
• Assisting the recipient in the identification of potential providers and choice of providers
• Assisting the recipient to access services and choice of services including referrals
• Coordination of services
• Assessment and reassessment of the individuals level of care and the review of the plan at least annually

Conversion Case Management Access (AC)
AC conversion case management service is available when the client has been admitted to a nursing facility including certified boarding care facilities and Hospitals and it is anticipated that the client will return to the community with AC as the payer of services to address the client’s long-term needs. The activities of AC Conversion Case Management are designed to help a person who resides in an institution to gain access to services and supports that are necessary to move from the institution to the community.

Activities include, but are not limited to:

1. Development and implementation of a relocation plan
2. Coordination of referrals and assisting a person to access services
3. Coordination and monitoring of the overall implementation of a relocation plan
4. Coordination of efforts with the discharge planner at the institution and others

Access to this service is limited to 180 consecutive days. The 180 day limit is a “per admission” limit meaning that a person may receive another 180 days of Conversion Case Management if they are readmitted to an eligible institution.

Additional Information
All case management services billed to the EW or AC programs must be based on a service actually provided to the recipient. Services must be planned and delivered based on individual need and may not be billed based on averages of the number of billable units provided to a recipient, nor across program populations.

Some recipients receiving case management services may also be determined to be eligible for other forms of case management (such as hospice or mental health). In these situations, DHS recommends:

• One of the case managers is designated as the primary contact
• Active coordination among the case managers so services are not duplicated
• Roles and responsibilities of each case manager are clearly defined so efforts are not duplicated

Recipients eligible for and receiving case management under EW are not concurrently eligible for the following forms of case management services:

• Targeted Case Management for Vulnerable Adults and Adults with Developmental Disabilities (VA/DD-TCM)
• Relocation Service Coordination (RSC)

Case Management Administrative Activities
Case management administrative activities are not billable under any HCBS program. Case management administrative activities include:

• Diagnosis
• Intake
• Responding to requests for conciliation conferences and appeals
• Review of eligibility for services
• Screening activity
• Service authorization
• Transportation
• Determines financial eligibility, assesses fees/assist with the collection of overdue fees (AC clients)

Provider Standards and Qualifications
Recipients receiving services under the EW and AC programs may choose to receive case management services from qualified and approved vendors that have provider agreements and contracts with the lead agency or State. The lead agency is responsible for monitoring the terms of the contract. If the provider is a federally recognized tribal government, the case management contract may be between the tribal government and the department. For contracts between a tribal government and DHS, DHS is responsible for monitoring the terms of the contracts. Managed care organizations can also contract for case management services or provide case management services.

The recipient may choose to receive case management services from another county or lead agency. This applies to case management service activities only. Administrative activities are not directly billable under any individual program. The provider of case management services must not have a financial interest in other services provided to a recipient.

• Case managers, with the exception of county or tribal agency employees, must not have a financial interest in the provision of services
• If the case manager is not a county or tribal employee, then the provider of services will be required to execute a contract with the agency in order to provide case management

Case management may be provided by the following individuals who are employed by, or contracted with, the lead agency:

• Public Health Nurse or Registered Nurse licensed under Minnesota Statutes, sections 148.171 to 148.285
• Social Worker graduate of an accredited four year college with a major in social work, psychology, sociology, or a closely related field; or be a graduate of an accredited four year college with a major in any field and one year experience as a social worker in a public or private social service agency. Social workers must also pass a written exam through the Minnesota Merit System or a county civil service system in Minnesota. Standards are authorized under Minnesota Rules 9575.0010 to 9575.1580. Authority to set personal standards is granted under Minnesota statutes, section 256.012
• Alternative credentialing standards may be applied to services provided by Tribal Governments under Minnesota statutes, section 256B.02, subd. 7
• For MSHO and MSC+ enrollees, the managed care organization may establish alternative credentialing standards consistent with their DHS contracts
• Physicians, Physician’s Assistants and Nurse Practitioners must meet all state standards and possess all professional licenses necessary to practice

Case Management Aide/Paraprofessional

Service/HCPCS EW AC
Case Management Aide/Paraprofessional
• T1016 with modifiers TF & UC – 15 minutes

X

X

Definition
Paraprofessional and case management aides provide assistance to the case manager in carrying out administrative activities of the case management function.

Covered Services
Case management aides must perform only those tasks delegated and supervised by the case manager, which do not involve professional expertise or judgment, per Minnesota Statutes, section 256B.49, subdivision 13 Examples of duties case aides may perform:

• Filing
• Contacts to vendors to schedule services
• Phone contacts

Non-covered Services
A case management aide must not:

• Assume responsibilities that require professional judgment
• Conduct assessments
• Conduct reassessments
• Develop service plans

Billing
• All case management related tasks that are not professional in nature must be billed as case aide services and not as case management services
• Duplicate payments will not be made for case aide management services by more than one provider

Provider Standards and Qualifications
The case management aide must understand, respect and maintain confidentiality concerning all details of each case. The case aide cannot have a financial interest in the services provided to the individual. The case manager is responsible for providing oversight to the case aide.

The case management aide must:

• Be a high school graduate
• Have one year of experience as a case aide or in a closely related field or one year of education beyond high school (for example, business school or college)
• Be employed by the agency providing case management
• Receive oversight by the case manager of delegated tasks

Chore Services

Service/HCPCS EW AC
Chore Services
• S5120 – 15 minutes

X

X

Definition
Chore services support or assist a recipient/enrollee or his/her primary caregiver to maintain the home of a recipient as a clean, sanitary, and safe environment.

Covered Services

• Heavy household chores such as washing floors, windows and walls, and indoor/outdoor general home maintenance
• Moving or removal of large household furnishings and heavy items to provide safe access inside the home and egress or to prevent falls
• Shoveling snow and lawn maintenance to provide access and egress to and from the home
• May include customary service charges made for the delivery of grocery store products when these products represent the majority of the consumers’ needs for a minimum of a 7-day period and it is the most cost efficient way of procurement of groceries in the community. The amount and service charge should be reasonable and customary in the recipient’s community
• Extermination and pest control limited to the reasonable number of treatments required to alleviate the pest problem
• Dumpster rental and refuse disposal
• Other sources of funding, including CSSA/Title XX, or in the case of rental property, the responsibility of the landlord pursuant to the lease agreement should be explored before the county authorizes an EW or AC payment

Chore services will be covered only if both of the following conditions are met:

• Neither the recipient nor anyone else in the household is capable of performing or financially providing for the chore services
• No relative, caretaker, landlord, local county or tribal agency, community volunteer/agency or third party payer is capable of or responsible for the provision of the chore services

Services cannot be duplicated with other MA covered services. In the case of rental property, the lease agreement shall be reviewed to determine if the service may be the responsibility of the landlord. If the care plan also includes homemaker services, the care plan must be specific enough to assure that there is no duplication.

Provider Standards and Qualifications
The lead agency approves the provider of chore services and assures the chore services are provided by individuals who meet the unique needs and preferences of the recipient who will receive the chore services as identified in the care plan. Structural pest control applicators must meet the standards and requirements under Minnesota Statute, Chapter 18B.


Companion Services – Adult

Service/HCPCS EW AC
Adult Companion Service
• S5135 – 15 minutes

X

X

Definition
Non-medical care, assistance, or supervision and socialization provided to an adult according to a therapeutic goal in the community support plan and are not purely diversional.

Socialization that is therapeutic is directly tied to the individual’s goals in the care plan such as a game or activity that enhances fine one’s fine motor skills to help them recover from a stroke.

Socialization that is diversional is for purposes of recreation and pleasure such as attending a community event or playing any game, but the activity does not necessarily address specific goals in the care plan.

However, waiver services are also specifically intended to support an individual to maintain and enhance community integration, social relationships, and are not limited to remediation of a medical condition and can be used to support community integration goals. Activities that support “therapeutic” socialization could be associated with a care plan goal to reduce social isolation, or help the individual maintain the most inclusive community life, for example.

Covered Services
The goals of adult companion services are directed at companionship, assistance or supervision of the recipient in the home or community. Adult companion services may include the assistance or supervision of the recipient with such tasks as:

• Meal Preparation
• Laundry
• Shopping
• Light housekeeping tasks incidental to care and supervision

Companions do not perform the above tasks as discrete services.

Non-covered Services
Adult companion services do not include:

• Hands-on nursing care
• Activities that are not directed at a goal
• People related to the EW/AC enrollee by blood, marriage or adoption cannot be paid for providing this service.

Provider Standards and Qualifications
Providers must be licensed under Minnesota Statutes, Chapters 245D or 144A, unless they are excluded under Minnesota Statutes, section 245A.03, subd. 2.

Providers who meet the standards established by the Corporation for National and Community Service do not have to meet the licensing requirements of Minnesota Statute chapter 245D

Individuals licensed under Minnesota Statutes, Chapter 144A as a home care provider must meet the provider standards in Minnesota Statutes, Chapter 245D.

Individuals meeting the licensing exclusions of Minnesota Statutes, section 245A.03, subd. 2 (1) and (2) must meet the requirements of: section 245D.04, subd. 1(4), subd 2 (1), (2) (3) (6) and subd. 3 regarding service recipient rights; sections 245D.05 and 245D.051 regarding health services and medication monitoring; section 245D.06 regarding incident reporting and prohibited and restricted procedures; section 245D.061 regarding the emergency use of manual restraint; and section 245D.09 subds. 1, 2, 3, 4a, 5a, 6 and 7 regarding staffing standards as applicable.

The local lead agency is responsible to assure that whoever provides services (individual or agency) meets the following minimum standards and:

• Is able to read and write
• Is able to follow written and oral instruction
• Has had experience or training in homemaking skills and/or in care of people with cognitive or physical limitations or other functional impairments
• The ability to perform essential job functions as identified in the person’s care plan.
• Is in good physical and mental health
• Has the ability to converse effectively on the telephone
• Has the ability to work under intermittent supervision
• Has the ability to manage emergency and/or crisis situations and report them to the lead agency
• Is able to understand, respect and maintain confidentiality in regard to the details of any circumstances surrounding the recipient

Apply the standards in Minnesota Statutes, chapter 245C concerning criminal background checks. If the provider of Adult Companion Services is a National Community Services Senior Companion Program grantee, they are exempt from the background study requirements of MN Statute 245C.

An individual may be required to pass a job-related physical examination before providing services.


Consumer Directed Community Supports (CDCS)

Service/HCPCS EW AC
Consumer Directed Community Supports
• T2028 with modifier U1 for Personal Assistance
• T2028 with modifier U2 for Medical Treatment and Training
• T2028 with modifier U3 for Environmental Modifications and Provisions
• T2028 with modifier U4 for Self-Direction Support Activities
• T2028 with modifier U8 for Flexible Case Management
• Background Checks; T2040 – each check
• Required Case Management; T2041–15 minutes

X
X
X
X
X
X
X

X
X
X
X
X
X
X

Definition
A person who wishes to receive CDCS must meet all eligibility criteria for one of the programs and be determined eligible or already be receiving EW or AC services. CDCS may include traditional goods and services provided by EW/AC including alternatives that support individuals and which are a part of the community support plan.

Limitations
Persons residing in a Customized Living, 24-Hour Customized Living Services, Foster Care, or Residential Care Setting are not eligible to choose this option.

Covered Services
Four service categories are covered in CDCS:

• Personal Assistance
• Treatment and Training
• Environmental Modifications and Provisions
• Self-Direction Support Activities

Individuals:

• Hire
• Terminate
• Manage
• Direct their support workers

The individual may purchase these functions through a Fiscal Support Entity (FSE). People or entities providing goods or services covered by CDCS must have a written agreement with and bill through the FSE.

For more information refer to the DHS Public Web Pages listed here:


Customized Living Services

Service/HCPCS EW
Customized Living Services
• T2030 – monthly

X

Definition
Customized living services are up to 24 hours of supervision, individualized home care aide tasks, home health aide tasks, and home management tasks provided to residents of a congregate living setting licensed as a home care provider and registered as Housing with Services Establishment.

Covered Services
Individualized means that services are designed specifically for each resident’s needs.

Customized Living Services may also include:

• Meal preparation
• Socialization
• Assisting clients in setting up meetings and appointments
• Assisting clients in setting up medical and social services
• Arranging for, or providing, socialization (If socialization is provided, it must be related to established goals and outcomes and not diversionary or recreational in nature and must be part of the care plan)
• Central storage of medication, individualized home health aide-like tasks, and incidental nursing services may be provided as allowed by home care licensure

Establishment or Housing with Services Establishment
An establishment providing sleeping accommodations to one or more adult residents, at least 80 percent of which are age 55 years or older, and offering or providing for a fee, one or more regularly scheduled health-related services or two or more regularly scheduled supportive services, whether offered or provided directly by the establishment or by another entity arranged for by the establishment; or an establishment that registers under section 144D.025.

Customized living services must be provided by the management of the congregate living setting or by providers under contract with the management or lead agency. Individuals receiving customized living services are not eligible for homemaking in addition to customized living services.

Additional Information
• Service delivery is directed by the recipient, or provider, with oversight from the case manager
• The case manager is the primary party responsible for negotiations with the provider to assure that the needs of the recipient are fully met through the package that is created specifically for that recipient
• All homemaker and chore services needed by a recipient are included in the Customized Living services package that is initially negotiated with the provider. These services are not separately authorized or billed
• Customized Living services may be provided in any number of apartments in a residential center for recipients who rent or own distinct units
• Customized Living services are covered under the EW program costs. Room and board, or raw food (groceries), and rent, while a recipient receives customized living services, are paid by the recipient’s income, which may include Supplemental Security Income. RSDI and other retirement. If the recipient has inadequate income for room and board or rent charges, he or she may be eligible for a Group Residential Housing (GRH) payment to the provider
• Lead agencies must negotiate rates based on the level of service needed and provided
• Customized living service monthly rates must be negotiated up to the individual limit described in Bulletin 14-69-01 and as the Legislature permits

Non-Covered Services
• Room and board
• EW funded homemaker, chore, and respite are not billable services during the period that the person is receiving Customized Living services
• EW providers cannot bill for full days on which the recipient is absent
• Payment for Customized Living services when the recipient is not in the setting

Provider Standards and Qualifications
Customized living service providers must meet the standards of licensure, certification or registration where they exist in state law and administrative rule.

Services must be provided by a provider who holds one of the following:

• Class “A” Home Care license
• Class “F” Home Care Living license
• Customized Living service providers who are not licensed under MN Rules, parts 9555.5105 to 9555.6265 (adult foster care), and who provide services in settings of one to five residents, must comply with MN Rules, parts 9555.6205, subparts 1 to 3, parts 9555.6215, subparts 1 and 3,and parts 9555.6225, subparts 1, 2, 6 and 10.

Home care licenses are issued under Minnesota Rules, Chapter 4668 and 4669. Providers must be registered with the State under Minnesota Statutes section 144D “Housing with Services Registration Act.”

Staff Qualifications
• Home Care Aides qualifications are listed in MN rules parts 4668.0100, subp. 2
• Home Health Aide qualifications are listed in MN Rules parts 4688.0100, subp 5
• Staff providing supervision, oversight and supportive services must:
• Be able to read, write and follow written or oral instructions
• Have had experience or training in caring for individuals with functional limitations
• Have good physical and mental health, and maturity of attitudes toward work assignments
• Have the ability to converse on the telephone, to work under intermittent supervision, to deal with minor emergencies arising in connection with the assignment, and work under stress in a crisis situation
• Understand, respect and maintain confidentiality
• Have a valid state driver’s license and insurance coverage in accordance with state requirements if they provide transportation to waiver clients

24-Hour Customized Living Services

Service/HCPCS EW
24-Hour Customized Living Services
• T2030 with modifier TG – monthly

X

Definition and Covered Services
24-Hour Customized Living services must meet the service definitions according to an individualized community support plan for “Customized Living.” In addition, 24-hour Customized Living service providers provide 24-hour on site supervision and only bill the 24-Hour Customized Living service rate to recipients whose community support plans include a 24-hour plan of care which includes an individual supervision plan.

24-hour On-site Supervision

• Ongoing awareness of recipient’s needs and activities provided by an employee of the customized living services provider, who is not a recipient of services and whose primary job responsibility is to provide supervision to individuals in the setting
• The provider must have a means for the recipient to summon assistance, and a 24-Hour Customized Living Services employee available to respond in person to the request within a reasonable amount of time. See Comprehensive Policy on Elderly Waiver (EW) Customized (Formerly Assisted) Living (PDF)

Additional Information
• Service delivery is directed by the recipient, or the provider, with oversight from the case manager/service coordinator
• The case manager is the primary party responsible for negotiations with the provider to assure that the needs of the recipient are fully met through the package that is created specifically for that recipient
• Lead agencies can negotiate individualized monthly rates up to the recipient’s budget cap based on the level of service needed and provided
• All homemaker tasks and chore services are a part of the 24-Hour Customized Living Services package initially negotiated with the provider, and meets all of the home management task service needs for the recipient

Non-covered Services
• Room and board
• EW funded homemaker, chore, and respite services are not billable services during the period that the person is receiving 24-Hour Customized Living Services
• EW providers cannot bill for days on which the client is absent

Provider Standards and Qualification
The state agency requires that the 24-hour customized living service providers meet the standards of licensure, certification or registration where they exist in state law and administrative rule.

Services must be furnished by a provider who holds one of the following:

• Class “A” Home Care license
• Class “F” Home Care license under MN Rules, parts 4668 to 4669 is available only to a setting registered as a Housing with Services establishment
• 24-Hour customized living services can be provided only in settings registered as “Housing with Services” establishments under MN Statutes, Chapter 144D.
• Customized living service providers who are not licensed under MN Rules, parts 9555.5105 to 9555.6265 (adult foster care), and who provide services in settings of one to four residents, must comply with MN Rules, parts 9555.6205, subparts 1 to 3, parts 9555.6215, subparts 1 to 3, and parts 9555.6225, subparts 1, 2, 6 and 10

Home care licenses are issued under Minnesota Rules, Chapters 4668 and 4669.

Providers must be registered with the State under Minnesota statutes Section 144D “Housing with Services Registration Act.”

Class “E” customized living program licensed providers may not provide 24-Hour Customized Living Services.

Staff Qualifications
• Home Care Aides qualifications are listed in MN rules parts 4668.0100, subp. 2
• Home Health Aide qualifications are listed in MN Rules parts 4688.0100, subp 5
• Staff providing supervision, oversight and supportive services must:
• Be able to read, write and follow written or oral instructions
• Have had experience or training in caring for individuals with functional limitations
• Have good physical and mental health, and maturity of attitudes toward work assignments
• Have the ability to converse on the telephone, to work under intermittent supervision, to deal with minor emergencies arising in connection with the assignment, and work under stress in a crisis situation
• Understand, respect and maintain confidentiality
• Have a valid state driver’s license and insurance coverage in accordance with state requirements if they provide transportation to waiver clients

Environmental Accessibility Adaptations

Service/HCPCS EW AC
Environmental Accessibility Adaptations – Home Install
• S5165

X

X
Assessment of Environmental Accessibility Adaptations for Home
Authorization of assessments to determine the most appropriate adaptation or equipment
• T1028



X



X
Environmental Accessibility Adaptation –Vehicle Install
Authorization of vehicle installations that may include but are not limited to: adapted seat devices, door handle replacements, lifting devices, roof extensions, and wheelchair securing devices
• T2039



X



X
Assessment of Environmental Accessibility Adaptations for Vehicle
Authorization of assessments to determine the most appropriate vehicle modifications
• T2039 with modifier UD



X



X

Definition
Physical adaptations to the home or vehicle required by the recipient’s community support plan, which are necessary to ensure the health and safety of the recipient with mobility problems, sensory deficit or behavior problems, or which enable the recipient to function with greater independence in the home, and without which he or she would require institutionalization. The adaptations are made to the recipient’s primary place of residence and are of direct and specific benefit to the individual. Environmental Accessibility Adaptations also includes modifications to vehicles that allow the individual to function with greater independence in the community. Adaptations must be documented in the community support plan and are the most cost effective solution.

This service also covers the necessary assessments to determine the most appropriate adaptation or equipment and the most appropriate vehicle modification

Covered Services

Adaptations may include, but are not limited to:

• Installation and maintenance of ramps and grab-bars, widening of doorways
• Modification of bathrooms and kitchens
• Installation of specialized electric and plumbing systems that are necessary to accommodate the medical equipment and supplies
• Floor coverings (i.e. allergy flooring, accessibility flooring)
• Modifications to meet egress
• Alarm systems and other requirements of the applicable life safety and fire codes, if any

Equipment purchase for personal emergency response systems (PERS) as defined in Bulletin #13-25-04 when the system entails changes to the physical structure and becomes a permanent part of the participant’s home and is not easily removed should be authorized as an environmental accessibility adaptation. (PERS equipment that is easily removable should be authorized as Specialized Supplies and Equipment.) PERS equipment purchase is subject to a $1,500 annual limit.

Non-covered PERS items and services include:
• Participants receiving 24-hour customized living, except for use outside of their residence
• Telehealth and biometric monitoring devices
• Supervision or monitoring of activities of daily living which are provided to meet the requirements of another service
• Equipment used in the delivery of MA or other waivered service
• Video equipment (Use of video equipment authorized under other services must meet criteria negotiated with CMS described in Bulletin #13-25-04, Appendix A.)

Vehicle modifications to the person’s primary means of transportation (one operating vehicle) may include, but are not limited to:

• Door handle replacements
• Door widening
• Roof extensions
• Wheelchair lifts
• Wheelchair securing devices
• Adapted seat devices
• Handrails and grab bars
• Acceleration and breaking controls

Vehicle modifications must be provided according to applicable state and federal safety and motor vehicle standards.

Environmental modifications and adaptations include modifications to adaptive equipment as required by the recipient, such as:

• Adaptive furniture,
• Positioning devices
• Utensils

The service will reimburse environmental modifications and equipment:

• Purchase
• Installation
• Maintenance
• Repairs of (repairs must be cost efficient compared to replacement of the items)

Limitations
Adaptations and modifications are limited to a combined total of $10,000.00 per recipient waiver year for recipients of EW or AC services
. This limit is subject to changes authorized by the CMS.

Non-Covered Services
Excluded are adaptations or improvements to the home that are of a general utility and not of direct medical or remedial benefit to the individual, including:

• Carpeting
• Roof repair
• Central air conditioning
• Adaptations that add to the square footage of the home with the exception of wheelchair accessible bathrooms

Authorization Criteria
The item is:

• Not able to be funded through any other source
• Necessary to avoid institutionalization of the person
• For the sole utility of the person
• Used in the person’s primary place of residence

All services must be provided according to applicable state or local building codes

When appropriate and cost-effective, EW or AC funding is available for:

• Purchase or rental
• Installation
• Maintenance and repairs

Provider Standards and Qualifications
Home modification installation
Individuals or agencies that provide home modification installations must meet one of the following:
• Be licensed as a residential building contractor by the commissioner of Commerce if they meet the definition of residential building contractor as defined in Minnesota Chapter 326B.802 subd. 11. Construction workers are exempt from licensure when the skills they perform meet the definition of “special skill” as defined in MN Statutes Chapter 326B.82,subd.15
• Hold a current license or certificate to perform the service if required by Minnesota Statutes or administrative rules
• Meet all professional standards and training requirements that may be required by state law or rule for the service(s) they provide
• Provide all services according to applicable local, state and city building codes

Home modification or assessment
Individuals or agencies that provide home modification assessments must meet one of the following:
• Occupational therapist that is currently registered by the American Occupational Therapy Association to perform assessment or evaluation functions and have at least one-year of experience with home modification assessments
• Certified aging-in-place specialist with at least one-year of experience with home modification assessments
• Certified accessibility specialist, certified through the Minnesota Department of Labor and Industry with at least one-year of experience with home modification assessments

Vehicle modification or install
Agencies that provide vehicle installation services must be accredited through the National Equipment Dealer Association’s Quality Assurance Program.

Vehicle modification or assessment
Individuals or agencies that provide vehicle modification assessments must meet one of the following:

• Certified driver rehabilitation specialist
• Occupational therapist with a specialty certification in driving and community mobility
• Five years of full time experience in the field of driver rehabilitation
• Four year undergraduate degree in a health related field with:
• One year full-time experience in the degree area of study

• Supervision by a certified driver rehabilitation specialist or an occupational therapist with a specialty certification in driving and community mobility or a person with two years of full time experience in the field of driver rehabilitation

• Continued education in the area of driving mobility and rehabilitation through the Association for Driver Rehab Specialists, Rehabilitation Engineering and Assistive Technology Society or the American Occupational Therapy Association or any programs that have been approved by these entities


Authorization Procedures
Review and authorization must occur before purchase. The description of the minor environmental adaptation or modification must be included in the recipient’s community support plan.

• MHCP recommends that lead agencies consider bids from a minimum of two contractors or vendors
• All services must be provided according to applicable state and local building codes and if the lead agency determines that all criteria are met and the bid for the work is reasonable, the local agency enters a line item and amount on the recipient’s service agreement using procedure code S5165
• If the item does not meet authorization criteria, documentation regarding the determination and rationale is to be kept on file and the recipient notified and given information regarding appeal process
• Providers of modifications must have a current license or certificate if required by Minnesota Statutes or Administrative rules, to perform their services
• Providers of modification services must meet all the professional standards or training requirements which may be required by Minnesota Statutes or administrative rules for the services that they provide
• Lead agencies are responsible for assuring that providers of modification services are qualified to provide the necessary modifications

Costs may be averaged over the span of a service agreement (up to 12 months) provided the person is expected to remain on the program for the full span of the service agreement. However, should the cost of an item be spanned beyond the month the cost was authorized and incurred and the person exits the program, the program cannot pay for any service or time billed after the individual’s exit date (e.g., the date the person is no longer EW or AC eligible).

Services and items purchased prior to the LTCC screening and eligibility begin date of the program or without case manager approval are not covered.


Extended State Plan Home Health Services – EW Program Only

Service/HCPCS EW
Home Health Aide Extended
• T1004 – 15 minutes

X
LPN Regular Extended
• T1003 with modifier UC – 15 minutes (LPN Regular)
• T1003 with modifiers TT and UC – 15 minutes (LPN Shared 1:2)

X
X
LPN Complex Extended
• T1003 with modifiers TG & UC – 15 minutes

X
PCA – Extended
• 1:1 – T1019 with modifier UC – 15 minutes
• 1:2 – T1019 with modifier UC & TT with a “Y” in the Shared Care field of the SA – 15 minutes
• 1:3 – T1019 with modifier UC & HQ with a “Y” in the Shared Care field of the SA – 15 minutes

X
X
X
RN, Regular, Extended
• T1002 with modifier UC – 15 minutes
• T1002 with modifiers TT and UC and a “Y” in the Shared Care field of the SA – 15 minutes (RN Regular Shared 1:2)

X
X
RN Complex, Extended
• T1002 with modifiers TG and UC – 15 minutes

X

See Home Care Services section for more detailed information about MA State Plan services.


Home Health Services – AC Program Only

Service/HCPCS AC
Home Health Aide
• T1004 – 15 minutes

X
Home Health Aide Visit
• T1021

X
LPN Regular
• T1003 – 15 minutes (LPN Regular)
• T1003 with modifier TT – 15 minutes (LPN Shared 1:2)

X
X
LPN Complex
• T1003 with modifiers TG – 15 minutes

X
PCA
• 1:1 – T1019 – 15 minutes
• 1:2 – T1019 with modifier TT with a “Y” in the Shared Care field of the SA – 15 minutes
• 1:3 – T1019 with modifier HQ with a “Y” in the Shared Care field of the SA – 15 minutes
• RN Supervision – T1019 UA – 15 minutes

X
X
X
RN Regular
• T1002 – 15 minutes
• T1002 with modifier TT and a “Y” in the Shared Care field of the SA – 15 minutes (RN Regular Shared 1:2)

X
X
RN Complex
• T1002 with modifier TG – 15 minutes

X
Skilled Nurse Visit
• G0154—15 minutes
• T1030— Visit

X
X
Tele- Homecare
• T1030 with modifier GT

X

Home Delivered Meals

Service/HCPCS EW AC
Home Delivered Meal (HDM)
• S5170 – one meal/day

X

X

Definition
An appropriate and nutritionally balanced meal, delivered to the residence of the EW/AC recipient. All home delivered meals must contain at least one-third of the current Dietary Reference Intake (DRI) established by the Food and Nutrition Board of the Institute for Medicine of the National Academy of Sciences. Modified diets, when appropriate, will be provided to meet the individual requirements of a person.

Home delivered meals are provided to a person who is unable to prepare his or her meals and has no other person(s) available to do so or when the home delivered meal is the most cost effective method to provide a person with a nutritionally adequate meal. Menu plans must be reviewed and approved by a licensed dietician or licensed nutritionist. One meal per day is covered by EW or AC

Participants 60 years and over and their spouses may also access congregate meals funded through Title III. Home delivered meals may be funded through the Older Americans Act only when the service/amount of service needed cannot be authorized within the participant’s EW or AC community budget cap.

Home delivered meals are not covered for EW recipients who live in settings licensed for foster care or board and lodge.

Title IIIC Funding: Home delivered meal providers who contract with Area Agencies on Aging (AAA’s) for funding to support their program may be receiving funds available from Title IIIC of the Older Americans Act, USDA funding, or state grants. These funds are all distributed by AAA’s through a contractual agreement with the provider. Specific revenue sources may be defined, including all other grants and anticipated client contributions in these contracts. County agencies may find these contracts helpful in identifying provider revenue resources in determining the portion of the meal cost met by other revenue sources.

No Receipt of Title IIIC Funding: Although some HDM providers do not receive any Title IIIC funding, USDA funding, or state grants funding, they may receive funding from other sources such as grants from organizations (such as United Way) and grants from local government or revenue from client contributions. Information about providers’ other funding sources is essential to assure waiver and AC funds are not supplanting other funds and negotiated rates do not exceed the cost of the home delivered meal.

Neither AC nor EW clients may be required to make a contribution to their meal cost or be asked to pay for a portion of their meal cost unless, under EW, the meal is provided as an EW service and a waiver obligation is charged. Title IIIC funding may not be available and meals may be funded by EW/AC due to geographic inaccessibility, special dietary needs, the time of day or day of the week, or there are existing waiting lists or demands exceed the funding available.

Provider Standards and Qualifications
The following providers may offer home delivered meals:

• Hospitals
• Schools
• Restaurants
• Any entity that provides home delivered meals

Any entity that provides home delivered meals must comply with all state and local health laws and ordinances that regulate preparation, handling and serving of food as defined under Minnesota Rules, Chapter 4626. Insulated hot and cold containers must be used to assure that food is delivered at appropriate temperatures. Licensed dietician or nutritionist must meet the requirements as specified in Minnesota Statutes 148.621 and Minnesota Rules Chapter 3250.


Homemaker Services

Service/HCPCS EW AC
Homemaker Service
• S5130 Homemaker/Cleaning – 15 minutes
• S5130 with modifier TF, Homemaker/Home Management – 15 minutes
• S5130 with modifier TG, Homemaker/ Assistance with Personal Cares – 15 minutes
• S5131 Homemaker/ Cleaning – per diem
• S5131 with modifier TF, Homemaker/Home Management – per diem
• S5131 with modifier TG, Homemaker/ Assistance with Personal Cares – per diem

X
X
X
X
X
X

X
X
X
X
X
X

Definition
Homemaker services are provided when a recipient is unable to manage general cleaning and household activities or when the person regularly responsible for these activities is temporarily absent or unable to manage the household activities. Homemaker services range from light household cleaning to household cleaning with incidental assistance with home management and activities of daily living. Homemakers may monitor the recipient’s well-being while in the home, including home safety.

Homemaker/cleaning services include light housekeeping tasks. Homemaker and cleaning providers deliver home cleaning services exclusively.

Homemaker/Home Management activities may include assistance with the following:

• Laundry
• Meal prep
• Shopping for food
• Clothing and supplies
• Simple household repairs
• Arranging for transportation

Homemaker/home management providers deliver home cleaning services in addition to home management activities.

Homemaker/assistance with activities of daily living (ADL) includes assistance with the following:

• Bathing
• Toileting
• Grooming
• Eating
• Ambulating

Homemaker /assistance with ADL providers deliver home cleaning services in addition to providing assistance with ADL Activity

Homemaker services must be listed in the community support plan

Provider Standards and Qualifications
Criminal background studies apply to individuals and organizations providing these services:

Homemaker /Cleaning Service

• Must comply with the standards outlined in Minnesota Statutes Chapter 245C concerning criminal background studies.
• Providers must be able to perform the cleaning duties expected and provide a cost-effective means of meeting the client’s home cleaning needs.

Homemaker Service/Assistance with ADL’s

• Providers must be licensed under Minnesota Statutes, Chapter 245D or Class B,C, or F licensure unless excluded from DHS licensure under Minnesota Statutes 245A.03, subd 2 (1) and (2) .
• Providers licensed as a class A, B, C or F home care provider must meet the requirements of Minnesota statutes chapter 144A.
• As a home care provider must meet the requirements of Minnesota Statutes 144a.43 to 144A.46

Homemaker Service/Home Management

• Providers must be licensed under Minnesota Statutes, Chapter 24D or Class A, B, C or F licensure unless excluded from DHS licensure under Minnesota Statutes 245a.03 subd 2 (1) and (2)
• Providers licensed as a Class B, C or F home care provider must meet the requirements of Minnesota Statute chapter 144A
• As a home care provider must meet the requirements of Minnesota Statute 144A.43 to 144A.46

Nutrition Services – AC Program Only

Service/HCPCS EW AC
Nutrition Services
• S9470 – visit
 

X

Definition
Nutrition services include nutrition education and nutrition counseling to address a recipient’s nutritional needs. The goal of this service is to improve or maintain a recipient’s nutritional status, and to improve management of the older adult’s chronic diseases or conditions.

Covered Services
Nutrition education is one or more individual or group sessions which provide formal and informal opportunities for recipients to acquire knowledge and skills in managing their diet and nutritional needs.

Examples include:

• Shopping
• Food selection
• Meal preparation
• Menu planning
• Preparing normal and therapeutic diets
• Cooking for one or two
• Tips for eating well on a limited budget

Nutrition counseling is one or more individual sessions to advise and assist individuals on appropriate nutritional intake.

Nutrition counseling includes:

• Assessment of a recipient’s nutritional needs that results in an individualized plan with goals, and
• Follow-up on established nutritional goals

Nutrition counseling can assist recipients with:

• Managing therapeutic diets (e.g., diabetic, low sodium, low cholesterol, renal, or gluten free)
• Providing weight management strategies for recipients who are chronically underweight or overweight
• Severe weight loss gain
• Difficulty chewing or swallowing
• Other nutritional care issues

Nutrition services are tied to a specific goal and authorized in the older adult’s community support plan. All services are consistent with the recipients’ cultural background.

Provider Standards and Qualifications
Includes:

• Licensed dietitians
• Licensed nutritionists
• Registered dietitians who meet education and practice requirements specified in Minnesota Statutes 148.621 and Minnesota Rules Chapter 3250.
• Other professionals who are exempt from licensure, as per MN Statutes 148.623, and perform service incidental to their practice, such as a diabetic educator or registered nurse

Residential Care Services

Service/HCPCS EW AC
Residential Care Services
• T2032 – monthly

X
 

Definition
Supportive and health supervision services provided to individuals in a residential care home as documented in the community support plan. Service delivery is directed by the person or the provider with oversight by the case manager.

Covered Services
Supportive services for the recipient include:

• Up to 24-hour supervision
• Meal preparation
• Individualized home management tasks
• Socialization
• Assistance in setting up meetings and appointments
• Assistance in arranging medical and social services
• Assistance with management of personal funds
• Arranging for or providing transportation

Health Supervision services are limited to minimal assistance with:

• Dressing, grooming and bathing
• Reminding a person to take medications that are self-administered
• Storing medications, if requested
• Medication reminders

The lead agency assures the needs of the person are fully met through the package created specifically for that person.

Non-Covered Services
• Homemaking billed separately
• Chore service billed separately
• Services duplicated by other MA covered services or EW services
• Respite billed separately
• Items of comfort or convenience
• Costs of facility maintenance, upkeep and improvement
• Costs for room and board (items paid for under room and board cannot be duplicated in residential care costs)

Provider Standards and Qualifications
Residential care services are provided to recipients in residential care homes licensed as board and lodging establishments that are registered with the Minnesota Department of Health as board and lodge with special services. The standards for residential care services are defined in MN Statutes 157.15 to 157.17. The residential care home must meet the appropriate local building codes.

Residential services must be provided by the management of the residential care home.

Staff is required to have eight hours of training and orientation by a registered nurse in providing assistance with:

• Dressing
• Grooming
• Bathing
• Medication reminders or storage of medications. If medications are to be distributed or stored, a Registered Nurse must provide supervision of this process.

Staff providing supervision and supported services must:

• Be able to read and write and follow written and oral instructions
• Have experience and/or training in caring for persons with disabilities
• Have good physical and mental health
• Converse on the phone
• Work with only intermittent supervision
• Deal with emergencies
• Work under stress in a crisis situation
• Understand, respect, and maintain confidentiality
• Have a valid Minnesota state driver’s license if providing transportation for a person receiving waiver services

Respite Care

Service/HCPCS EW AC
In-Home Respite
• S5150 –15minutes
• S5151 – per diem

X
X

X
X
Out-of-home Respite
• S5150 with modifier UB – 15 minutes
• H0045 – per diem (Includes hospital and other certified facilities providing 24-hour overnight service)

X
X

X
X

Definition
Services provided to recipients unable to care for themselves, provided on a short-term basis because of the absence or need for relief of the person who normally provides the care and who is not paid or is only paid for a portion of the total time of care or supervision provided. The unpaid caregiver does not need to reside in the same house as the recipient.

Covered Services

• Respite care can be provided in settings that have appropriate licensure and qualifications including a private home that is identified by the recipient.
• Respite care is limited to 30 consecutive days per respite stay in an out-of-home placement in accordance with the care plan

Non-Covered Services
• Respite care is not provided separately to recipients residing in corporate or family foster care settings or receiving 24-Hour Customized Living Services
• Room and board payments cannot be made for respite care provided in the recipient’s home or other private residence

Provider Standards and Qualifications
Out-of-home Respite Care
Facilities providing respite care must meet all licensing and certification requirements. Respite care must be provided in one of the following facilities approved by the lead agency:

• Hospital
• Nursing Facility
• Licensed adult foster home
• Non-MA certified facility if the facility meets applicable state licensure standards

Respite care may be provided in a private unlicensed home when the lead agency determines that the service and setting can safely meet the recipient’s needs. The lead agency must take into account the accessibility and condition of the physical plant, ability and skill level of the caregiver, and the recipient’s needs and preferences. The unlicensed home and caregiver cannot otherwise be in the business or routine practice of providing respite services.

In the event of a community emergency or disaster that requires an emergency need to relocate a participant, out of-home respite services may be provided whether or not the primary caregiver resides at the same address as the participant, and whether the primary caregiver is paid or unpaid, provided the commissioner approves the request as a necessary expenditure related to the emergency or disaster. This does not allow the primary caregiver to provide respite services. The commissioner may waive other limitations on this service in order to ensure that necessary expenditures related to protecting the health and safety of participants are reimbursed. In the event of an emergency involving the relocation of waiver participants, the Commissioner may approve the provision of respite services by unlicensed providers on a short-term, temporary basis.

In-home Respite Care Providers
Must be provided by:

• Registered or licensed practical nurses
• Home health aides
• Personal care assistants specifically trained to provide care to the recipient
• A home health aide or PCA must be under the supervision of an RN who assures the respite care worker is able to read, write, follow instructions, and has the skill level to meet the person’s needs.
• A currently registered housing with services establishment when services are delivered by a licensed home care agency

Respite care providers must meet the licensing and certification standards specific to the level of care they are providing and receive supervision as required by their respective license or service standard.

Billing
Lead agencies must define the unit of service to be billed in the contract. Daily rates must be used when respite care is provided for 12 or more hours or for overnight respite.

Respite Care Services: Provider Standards and Qualifications EW AC
I: Indicates an in-home provider/location
O: Indicates an out-of-home provider/location
1. Certified Hospitals – Hospitals are acute care institutions defined in Minnesota Statute 144.696, subdivision 3, licensed under Minnesota Statutes 144.50 to 144.56. and Providers must be licensed under Minnesota Statutes, Chapters 245D or 144A, unless they are excluded under Minnesota Statutes, section 245A.03, subd. 2(a)(7). Agencies licensed under Minnesota Statutes, Chapter 144A as a home care provider must meet the HCBS provider standards in Minnesota Statute 245D.

Agencies meeting the licensing exclusions of Minnesota Statutes, 245A.03, subd. 2
(1) and (2) must meet the requirements of: sections 245D.04, subd. 1(4), subds. 2 (1), (2) (3) (6) and subdivision 3 regarding service recipient rights; sections 245D.05 and 245D.051 regarding health services and medication monitoring; section 245D.06 regarding incident reporting and prohibited and restricted procedures; section 245D.061 regarding the emergency use of manual restraint; and section 245D.09 subds. 1, 2, 3, 4a, 5a, 6 and 7 regarding staffing standards.
O O
2. Licensed Practical Nurses and Registered Nurses must be licensed under MN Statutes 148.171 to 142.284 4 and Providers must be licensed under Minnesota Statutes, Chapters 245D or 144A, unless they are excluded under Minnesota Statutes, section 245A.03, subd. 2 (1) and (2) Individuals licensed under Minnesota Statutes, Chapter 144A as a home care provider must meet the provider standards in Minnesota Statute 245D.

Individuals meeting the licensing exclusions of Minnesota Statutes, 245A.03, subd. 2 (1) and (2) must meet the requirements of: sections 245D.04, subd. 1(4), subds. 2 (1), (2) (3) (6) and subdivision 3 regarding service recipient rights; sections 245D.05 and 245D.051 regarding health services and medication monitoring; section 245D.06 regarding incident reporting and prohibited and restricted procedures; section 245D.061 regarding the emergency use of manual restraint; and section 245D.09 subds. 1, 2, 3, 4a, 5a, 6 and 7 regarding staffing standards if applicable.
I I
3. Adult Foster Care is licensed under MN Rules 9555.5105 to 9555.6265 and and 2960.3000 to 2960.3230 and Minnesota Statute 245a.03 AND Providers must be licensed under Minnesota Statutes, Chapters 245D or 144A, unless they are excluded under Minnesota statutes, section 245A.03, sub 2 (1) and (2) to provide respite service.

Agencies licensed under Minnesota Statutes, Chapter 144A as a home care provider must meet the HCBS provider standards in Minnesota Statute 245D.

Providers meeting the licensing exclusions of Minnesota Statutes, 245A.03, subd. 2 (1) and (2) must meet the requirements of: sections 245D.04, subd. 1(4), subds. 2 (1), (2) (3) (6) and subdivision 3 regarding service recipient rights; sections 245D.05 and 245D.051 regarding health services and medication monitoring; section 245D.06 regarding incident reporting and prohibited and restricted procedures; section 245D.061 regarding the emergency use of manual restraint; and section 245D.09 subds. 1, 2, 3, 4a, 5a, 6 and 7 regarding staffing standards
O O
4. Personal care provider organizations and personal care assistants employed by the agencies must meet the standards under MN Statute 256B.06 59 and MN Rule 9505.0335. Providers must be licensed under Minnesota Statutes, Chapters 245D or 144A, unless they are excluded under Minnesota Statutes, section 245A.03, subd. 2 (1) and (2) Agencies licensed under Minnesota Statutes, Chapter 144A as a home care provider must meet the HCBS provider standards in Minnesota Statute 245D. Agencies meeting the licensing exclusions of Minnesota Statutes, 245A.03, subd. 2 (1) and (2) must meet the requirements of: sections 245D.04, subd. 1(4), subds. 2 (1), (2) (3) (6) and subdivision 3 regarding service recipient rights; sections 245D.05 and 245D.051 regarding health services and medication monitoring; section 245D.06 regarding incident reporting and prohibited and restricted procedures; section 245D.061 regarding the emergency use of manual restraint; and section 245D.09 subds. 1, 2, 3, 4a, 5a, 6 and 7 regarding staffing standards. I I
5. Home Health Aides must meet the standards under MN Rules 9505.0290, subpart 3, B
• Home Health Agencies In-home respite care providers, including nurses employed by home health agencies, must be licensed under Minnesota Statutes, sections 148.171 to 148.284. and
• Providers must be licensed under Minnesota Statutes, Chapters 245D or 144A, unless they are excluded under Minnesota Statutes, section 245A.03, subd. 2 (1) and (2)

Home health agencies must have a class A license and must meet the standards under Minnesota Rules, part 9505.0290, subpart 3, B and Minnesota Rules Chapter 4668 and Minnesota Statutes, chapters: 144A.45, 144a.46, 144.461, and 144.465.

Agencies licensed under Minnesota Statutes, Chapter 144A as a home care provider must meet the HCBS provider standards in Minnesota Statute 245D.

Agencies meeting the licensing exclusions of Minnesota Statutes, 245A.03, subd. 2 (1) and (2) must meet the requirements of: sections 245D.04, subd. 1(4), subds. 2 (1), (2) (3) (6) and subdivision 3 regarding service recipient rights; sections 245D.05 and 245D.051 regarding health services and medication monitoring; section 245D.06 regarding incident reporting and prohibited and restricted procedures; section 245D.061 regarding the emergency use of manual restraint; and section 245D.09 subds. 1, 2, 3, 4a, 5a, 6 and 7 regarding staffing standards.
I I
6. Certified Nursing facilities–Nursing facilities must meet the standards under MN Rule 9505.0175, subpart 23 Facilities providing respite care outside of the enrollee's home must be licensed in accordance with Minnesota Statutes, Chapter 144A. and Providers must be licensed under Minnesota Statutes, Chapters 245D or 144A, unless they are excluded under Minnesota Statutes, section 245A.03, subd. 2 (1) and (2) Providers licensed under Minnesota Statutes, Chapter 144A as a home care provider must meet the HCBS provider standards in Minnesota Statute 245D.

Providers meeting the licensing exclusions of Minnesota Statutes, 245A.03, subd. 2 (1) and (2) must meet the requirements of: sections 245D.04, subd. 1(4), subds. 2 (1), (2) (3) (6) and subdivision 3 regarding service recipient rights; sections 245D.05 and 245D.051 regarding health services and medication monitoring; section 245D.06 regarding incident reporting and prohibited and restricted procedures; section 245D.061 regarding the emergency use of manual restraint; and section 245D.09 subds. 1, 2, 3, 4a, 5a, 6 and 7 regarding staffing standards
O O
7. Customized Living Services/24-Hour Customized Living Service Providers must be licensed as a home care provider and the standards as delineated in Customized Living and 24 Hour Customized Living Services waiver service descriptions Out-of-home providers must meet the standards Minnesota Statutes, chapter §144D and be licensed as a Class A or F home care provider under Minnesota Rules, parts 4668.0002 to 4668.0870. and Providers must be licensed under Minnesota Statutes, Chapters 245D or 144A, unless they are excluded under Minnesota Statutes, section 245A.03, subd. 2 (1) and (2) Agencies licensed under Minnesota Statutes, Chapter 144A as a home care provider must meet the HCBS provider standards in Minnesota Statute 245D.

Agencies meeting the licensing exclusions of Minnesota Statutes, 245A.03, subd. 2 (1) and (2) must meet the requirements of: sections 245D.04, subd. 1(4), subds. 2 (1), (2) (3) (6) and subdivision 3 regarding service recipient rights; sections 245D.05 and 245D.051 regarding health services and medication monitoring; section 245D.06 regarding incident reporting and prohibited and restricted procedures; section 245D.061 regarding the emergency use of manual restraint; and section 245D.09 subds. 1, 2, 3, 4a, 5a, 6 and 7 regarding staffing standards.
O O
8. Residential Care Facilities – Residential Care Providers must meet all applicable licensing standards and the standards delineated in Residential Care waiver service description Providers must be licensed under Minnesota Statutes, Chapters 245D or 144A, unless they are excluded under Minnesota Statutes, section 245A.03, subd. 2 (1) and (2).

Agencies licensed under Minnesota Statutes, Chapter 144A as a home care provider must meet the HCBS provider standards in Minnesota Statute 245D.

Agencies meeting the licensing exclusions of Minnesota Statutes, 245A.03, subd. 2 (1) and (2) must meet the requirements of: sections 245D.04, subd. 1(4), subds. 2 (1), (2) (3) (6) and subdivision 3 regarding service recipient rights; sections 245D.05 and 245D.051 regarding health services and medication monitoring; section 245D.06 regarding incident reporting and prohibited and restricted procedures; section 245D.061 regarding the emergency use of manual restraint; and section 245D.09 subds. 1, 2, 3, 4a, 5a, 6 and 7 regarding staffing standards.
O O
9. The home of an unlicensed caregiver when the lead agency and family agree that the caregiver has met criteria to assure the health and safety of the recipient. In these situations, room and board payment will not be made as part of the respite rate. Providers must be licensed under Minnesota Statutes, Chapter 245D or 144A unless they are excluded under Minnesota statutes, section 245A.03, sub 2(1) and (2) Individuals providing in-home respite services must demonstrate to the case manager that they are able to provide, on a temporary, short term basis, the care and services needed by the enrollee.

The case manager must evaluate and document whether the provider meets the standards to provide respite services.
In addition, in-home respite providers who are excluded from licensing requirements must meet the following qualifications to ensure the health and safety of the enrollee:
• The provider is physically able to care for the enrollee
• The provider has completed training identified as necessary in the care plan
• The provider complies with monitoring procedures as described in the care plan.
O O

Specialized Supplies and Equipment

Service/HCPCS EW AC
Specialized Supplies and Equipment
• T2029 – Per Item negotiated based on the needs of the person and county or lead agency contract

X
 
Specialized Supplies and Equipment
• E1399 – Per Item negotiated based on the needs of the person and agency contract
 

X

Definition
Devices, controls or appliances mobility aids, and assistive technology devices including augmentative communication devices and personal emergency response systems (PERS), sensing equipment, controls or medical appliances as specified in the plan of care that enable the person to increase their ability to:

• Perform activities of daily living
• To perceive, control or interact with their environment or communicate with others

Supplies and equipment include durable medical supplies and equipment provided as a necessary adjunct to direct treatment or remediation of the recipient’s condition. These may include grab bars, handrails and stair lifts.

Covered Services
See Equipment and Supplies section for clarification about covered and non-covered items and regulations. MA benefits must be accessed first, as appropriate. MA medical equipment and supplies are defined under Minnesota Rules 9505.0310.

The service covers:

• Items necessary for life support
• Supplies and equipment necessary for the proper functioning of such life support items
• Durable medical equipment not available or denied under MA that provides direct medical or remedial benefit to the individual
• May include evaluation of the need for equipment and/or device
• Can include equipment rental during a trial period or when device is being repaired
• Customization
• Training and technical assistance to recipient
• Maintenance and repair unless covered by warranty

Items reimbursed with waiver funds are in addition to any medical equipment and supplies provided under MA. Supplies and equipment that exceed the limits set for MA covered services may be covered through the waiver.

All prescription and over the counter medications, compounds, and related fees including premiums and copayments are not covered

Equipment purchase (S5162) for personal emergency response systems (PERS) as defined in Bulletin #13-25-04 when the PERS does not entail changes to the physical structure and does not become a permanent part of the participant’s home and is easily removed should be authorized as specialized supplies and equipment. (PERS equipment that is not easily removable should be authorized as environmental accessibility adaptation.)

Personal Emergency Response Systems (PERS) Limits

• PERS equipment purchase (S5162) is subject to a $1,500 annual limit
• PERS monthly services fees (S5161) are limited to $110/month
• PERS installation and testing (S5160) is limited to $500
• The total annual authorization for PERS is $3,000 during a participant’s “waiver” year, for EW and AC participants, which begins each time an opening, reopening, or reassessment screening document is approved

Non-covered PERS items and services include:

• Participants receiving 24-hour Customized Living except for use outside of their residence
• Telehealth and biometric monitoring devices
• Supervision or monitoring of activities of daily living which are provided to meet the requirements of another service
• Equipment used in the delivery of MA or other waivered service
• Video equipment (Use of video equipment authorized under other services must meet criteria negotiated with CMS described in Bulletin #13-25-04, Appendix A.)

Authorization Criteria
Case managers must ensure and document in the community support plan before purchase of the supply or equipment that the item meets all of the following criteria:

• Not able to be funded through any other source. If an item is never covered by MA, it is not necessary to seek a written denial from MA. If an item may be covered by MA, the medical supplier must seek authorization from MA before seeking authorization of coverage under the EW program
• Specified in a community support plan as necessary to avoid institutionalization
• For the sole utility of the recipient
• Determined by prevailing community standards or customary practice and usage to be:
• Medically necessary: appropriate and effective for the medical needs and health and safety of the recipient; or

• Remedially necessary: appropriate to assist a recipient in increased independence and integration in their environment/community

• Appropriate and effective for the medical needs, diagnosis, and condition of the recipient

• Of an acceptable quality

• Timely (e.g., the accommodation is provided at the time it is needed)

• The most cost-effective health service available to meet the medical needs of the recipient

• An effective and appropriate use of MA waiver funds


When cost effective, funding is available for the following with extended supplies and equipment:

• Individual evaluation or assessment
• Purchase or rental
• Installation
• Maintenance and repairs

Medical supplies and equipment are available through MA but with limitations. When an item is covered by MA, bill MA first to the extent of the limitations. If an item is never covered by MA, the case manager may decide to cover this item under the EW/AC if it meets criteria. After an item is purchased, it becomes the property of the recipient it is purchased for.

Add-ons vs. Upgrades
An add-on is an MA non-covered service that the provider adds to an MA-covered service. In this case, the MA-covered item is billed to MA. The add-on may be billed to the waiver, or the recipient may choose to pay for the add-on out of other funding sources they have available to them.

Example: A recipient wants an MA non-covered basket added to an MA-covered walker. The supplier can bill MA for the walker and bill the recipient for the basket; or the lead agency may determine that the basket is covered by EW program but the supplier still must bill MA for the MA-covered service.

For both fee-for-service and managed care recipients, the provider may receive payment for the covered service under MA and charge the recipient or EW program for the add-on.

An upgrade is a non-covered MA service (and often a more desirable service) that substitute for a covered service:

• The provider may choose to provide the upgrade and receive payment for the basic service as payment in full for the upgrade
• The recipient may choose an upgraded service instead of an MA-covered service, even though MA will not pay for this item. The recipient is responsible for the entire cost of the upgraded item as long as the provider informed them that they are responsible before providing the service. In this case DHS recommends that the provider have the recipient sign the Advance Recipient Notice of Non-covered Service/Item form (DHS-3640), and agrees to pay the entire cost for the upgraded item before the service is provided
• The case manager may authorize an upgraded item to be covered under EW, if determined to be medically necessary, and cover the entire cost of the item under EW

Example: A recipient wants a total electric bed, but does not meet the medical necessity criteria for MA to cover the bed. MA will only cover a semi-electric bed.

A case manager may elect to cover the entire cost of a total electric bed under the EW program.

If the supplier will not accept MA payment for a semi-electric bed and the service coordinator does not approve the upgrade for payment under the EW program, the recipient may still get the total electric bed. The recipient would be responsible for the entire charge for the bed as long as the provider informed them that they are responsible for payment before providing the item or service.

The supplier may not provide a total electric bed to the recipient, bill MA and charge the difference related to the upgrade to the recipient, or to the EW program.

The case manager may need prior approval from DHS for some specialized supplies and equipment depending on the cost of the item. The item must be entered on the SA.

Add-ons and upgrades do not apply to the AC program.

Cost of Providing Supplies and Equipment under a Recipient’s EW or AC Cap
The cost of specialized supplies and equipment must be included in the recipient’s monthly budget cap amount. Costs of supply and equipment items may be averaged over the span of an SA provided the recipient maintains program eligibility for the available span of the SA.

For example: If the cost of an item is averaged for a number of months beyond the month the cost was incurred, and the recipient subsequently exits the program before the item is fully paid, then MHCP cannot continue to make payment for the item after the exit date.

Determining Appropriate Payer
The local lead agency is responsible to authorize covered services according to the appropriate payer. The provider is responsible to bill only the appropriate payer for the recipient and the item(s).

For EW, all other private and public payers (private insurance, long term care insurance, Medicare, Medical Assistance) must be exhausted before using EW funds for coverage. The provider submits copies of the denials from those payment sources to the lead agency. If inappropriate billing shows up in an audit, the provider is responsible and risks payment recovery.

For AC, all other private and public payers (private insurance, Long term care insurance. Medicare, client's cost-sharing obligations, long-term care insurance) must be exhausted before using AC funds for coverage.

Limitations
The AC program does not provide payment for medical supplies and equipment that are considered to be medically necessary, or provide items that address a client's acute, sub-acute, or rehabilitative status that would otherwise be addressed through a client's primary or secondary payer coverage. In the absence of other payers to address those needs, the AC program does not provide any form of payment.

Long-Term Care Facility Providing Supplies and Equipment during Discharge Process to Home or Community Setting
The nursing facility is required to provide certain types of supplies and equipment to a recipient to support their transition home from the nursing facility.

• Providers cannot bill through EW or AC programs for specialized supplies and equipment until the program span for home and community-based services has been opened in MMIS by the local lead agency.
• Providers can bill for specialized supplies and equipment on the date of discharge, as long as the item(s) is/are provided after the time of the recipient’s discharge and the item is not a requirement within the NF payment rate for that person or the community setting to which the person is entering.

Rental
Rental contracts for supplies and equipment may be approved only for items that meet authorization criteria when it is determined as cost-effective.

For example:

• Item is needed for a defined amount of time and rental is less expensive than purchase
• All rental contracts should include a “rent to purchase” clause
• The cost of renting a supply or equipment must not exceed the cost of purchase
• The written contract must be clear that the vendor is responsible for repairs over the duration of the rental agreement
• The equipment item cannot be rented for an indefinite period of time
• New and upgraded equipment must be made available to replace the older currently rented item during the rental period

After the rental fee equals the purchase price, the item is considered to be the property of the recipient (normally after 10-12 months’ rental).

Coverage of Repair and Maintenance
• Repair of equipment when the equipment meets the authorization criteria and the repair is a cost effective alternative (e.g., is expected to last and without repair the equipment would have to be purchased new at a great cost)
• A maintenance agreement may be purchased for items that meet authorization criteria when the maintenance agreement is expected to be cost-effective

For example, a maintenance agreement that covers evaluating an item but not actual repair may not be cost effective. The recipient with the case manager should consider other payment sources for repairs. MA covers the repair costs of certain items such as communication devices, wheelchairs, etc.

Shipping, Handling, Installation, Repair Maintenance
Shipping and handling costs may be paid by an HCBS program if the shipping cost is included in the price of the item, and the waiver is purchasing the item.

Installation can be covered regardless of who purchased the item, if the item meets HCBS program authorization criteria. If installation involves attaching an item to, or altering the existing physical structure of a home or vehicle, the costs are billed under minor environmental adaptations and modifications.

Reconditioned Equipment
Reconditioned equipment may be purchased if the county determines that all authorization criteria are met and the item is considered of adequate quality, expected to be durable, and the cost is commensurate with the age and condition of the item (e.g., if a new item could be purchased at the similar cost, it may be worthwhile to purchase the new item).

Non-Covered Services
• Items that are covered by MA, Medicare, private insurance and/or other funding resources and items that do not provide direct medical or remedial benefit to the person.
• Items and services purchased prior to the LTCC screening and program begin-date or without case manager approval are not covered.

Provider Standards and Qualifications
Medicaid enrolled home health agencies, pharmacies, and medical suppliers (including wheelchair and oxygen vendors) and other providers approved by lead agencies and Managed Care Organizations (MCO). State plan medical equipment and supplies are defined under Minnesota Rule 9505.0310.Pharmacies are licensed by the Minnesota Board of Pharmacy in accordance with Minnesota Rules, parts, 6800.0100 to 6800.9954.

Provider participation is defined under Minnesota Rule 9505.0195.

The following agencies have signed a Medical Supply Performance Agreement:

• Home Health Agencies
• Pharmacies
• Medical suppliers (including wheelchair and oxygen vendors)

Billing
Before billing for specialized supplies and equipment, the lead agency and the provider must fulfill their Authorization and Billing Responsibilities when authorizing and requesting reimbursement.


Transitional Services

Service/HCPCS EW AC
• T2038 – per service
X
 

Definition
Community transitional support services include expenses related to establishing community based housing for individuals transitioning to independent or semi-independent community residence from a certified nursing facility or other setting.

Covered Services Examples

• Lease and rental deposits
• Essential furniture
• Utility set up fees and deposits
• Personal supports to assist in locating and transitioning to the community based housing
• Basic household items
• Personal items
• One-time pest and allergen treatment of the setting

Expenses must be reasonable and do not include services or items that are covered under other waiver services:
Examples:

• Chore
• Homemaker
• Home modifications and adaptations
• Supplies and equipment

If there is an unforeseen reason the person does not open to the waiver (due to death, or significant change in condition) the local agency may bill for the service and be reimbursed through Medicaid administrative funds. Managed care organizations may not bill for administrative funds under these circumstances.

Authorization Criteria
The person:

• Must not have another source to fund or attain the items or support
• Must be moving from a living arrangement where the items were provided to a residence where these items are not normally furnished
• The service will be considered to be provided and may be billed after the waiver is opened
• When not presently using EW, the local agency must evaluate and reasonably expect that the person will be eligible to open to the waiver within 180 days
• Incur the expense within 90 days of the waiver opening date
• Services must be identified on the individual’s plan of care

Non Covered Services
• Recreational or diversional items
• Expenses related to ongoing expenses such as rent, housing costs, food, or clothing

Provider Qualifications
Providers of personal supports must, as determined by the lead agency, have:

• General knowledge of disabilities and chronic illnesses and their effect on an recipient’s ability to live independently in the community
• The ability to assess the individual’s community-based housing needs
• Functional knowledge of housing options in the community
• Sufficient understanding of housing procurement procedures and funding mechanisms to advise the person regarding these matters
• The ability to assist the person in attaining the services and supports that are covered by transitional services
• A contract with the lead agency or MCO that outlines their service responsibilities including maintaining client confidentiality

The case manager must:

• Assure that the transitional support items are necessary and reasonable
• Prior authorize the items and include the items in the individual’s care plan
• Contract or obtain purchase agreements for vendors of personal support
• Receipts and documentation for all transitional support items must be maintained in the recipients’ file for auditing purposes
• Make sure providers obtain and maintain other applicable licenses, permits, registration or other governmental approvals required to provide the transition service
• Consider reconditioned items if they are safe by reasonable standard and determined appropriate by the case manager

EW and AC Transportation

Service/HCPCS EW AC
• T2003 with modifier UC – Per one-way trip
X
 
• S0215 with modifier UC – Per mile
X
 
• T2003 – Per one-way trip
 
X
• S0215 with modifier UC – Per mile
 
X


Definition and Covered Services
The case manager may approve transportation services to enable recipients to gain access to EW and AC services, along with other community services, activities, and resources. The case manager must specify the goals and needs for the service in the plan of care. Whenever possible, family, neighbors, friends, or community agencies that provide this service without charge must be utilized.

Transportation services may be authorized and billed using the mileage rate when simultaneously provided by an individual or organization providing companion services.

Adult day services and transportation are always separately covered, but are sequentially, not simultaneously provided.

For EW the adjective “extended” is not applicable as a waiver service because waiver transportation services are not an extension of the MA state plan access (i.e., medical) transportation service but rather a separate and distinct service.

Special transportation services (STS) for transporting a recipient with physical or mental impairment who is unable to safely use a common carrier and does not require ambulance service may be provided.

Physical or mental impairment means:

• A physiological disorder
• Physical condition
• Mental disorder that prohibits access to, or safe use of common carrier transportation

An example includes a wheelchair accessible van for a person with mobility limitations.

EW/AC Non-Covered Services
• Transportation reimbursement already included in the contracted rate for other services
• Non-covered services for a personal vehicle include:
• Any payment beyond negotiated mileage or trip reimbursement
• Reimbursement to a person for the purpose of transporting themselves or the use of their own vehicle

Do not separately bill transportation when other EW/AC services are provided by the same person. Companion services are an exception to this rule.

Additional EW Non-Covered Services
Access transportation as defined in Provider Requirements.

Additional AC Non-Covered Services
Access transportation as defined in Provider Requirements.

Provider Standards
EW/AC common carrier transportation standards:

• Bus, Taxicab, or other commercial carriers, private automobile, or a lead agency owned or leased vehicle
• Private individuals may be designated to provide transportation when they meet the recipient’s needs and preferences in a cost-effective manner. Examples may include supports such as family, neighbors, friends, community agencies, volunteer driver programs or companion service providers
• Drivers must have a valid driver’s license and adequate insurance coverage as required by Minnesota Statutes, chapter 65B

EW/AC Special Transportation Standards
Providers of special transportation services not excluded in Minnesota Statutes, section 174.30 must be certified by Minnesota Department of Transportation under Minnesota Statutes, Section 174.29 - 174.30. The driver must provide driver-assisted services. Driver-assisted services include passenger pickup at and return to the individual’s residence or place of business, assistance in securing passengers/wheelchairs/stretchers in the vehicle.

With EW Special transportation provider standards, providers not excluded in Minnesota Statutes, section 174.30, must be certified by the Minnesota Department of Transportation under Minnesota Statutes, section 174.29 -174.30.

AC Special Transportation Standards (Exceptions)
• AC providers are not required to participate in the Minnesota Non-Emergency Transportation (MNET) program
• AC recipients are not required to have an additional level of need (LON) assessment
• The AC case manager determines if the recipient requires special transportation and if the provider meets the recipient’s individual needs

Responsibilities of the EW/AC Case Manager/Care Coordinator
The EW/AC case manager or service coordinator is responsible for assessing and planning access to services as follows:

• Help recipients understand available transportation services through Medicaid State Plan and the EW and AC programs
• Help recipients select transportation services through EW/AC that support their community participation and access to resources and social networks
• Determine if the contracted rate for the other needed and authorized services does or does not include transportation
• Clearly and accurately describe in the care plan transportation provided by different entities
• Determine and document in the care plan if recipient will use a family member, friend, neighbor, common carrier, special transportation, and if a non-driver attendant is required
• Determine if the need for transportation meets MA State Plan criteria
• Confirm recipient eligibility for special transportation using MHCP

Other Resources
It is recommended the case manager review the Transportation section of the MHCP Provider Manual to review the MA state plan transportation services and the certification for use of special transportation.

Authorization Billing
• The intent of the transportation service mileage rate is to pay for the vehicle, not the associated staff time
• The negotiated trip rate may or may not include staff time
• The mileage rate and the trip rate cannot be authorized/billed for the same trip

Limitations:

• The mileage rate cannot be used when payment for transportation is received for more than one rider for any portion of the trip regardless of payer
• The mileage rate cannot be authorized or billed for miles when the recipient is not in the vehicle

The trip rate may be used when transporting and receiving payment for more than one person on any portion of a trip.
Factors to consider when negotiating one-way trip rates:

• Distance
• Time
• Number of individuals transportation payment is received for
• Special vehicle
• Driver requirements

Use transportation services funded through the Older Americans Act only when the service or amount of service needed cannot be authorized within their community budget cap.

The case manager or care coordinator completes the Service Agreement by adding the vendor’s name, the provider’s NPI/UMPI, appropriate HCPCS code, and number of units and locally negotiated rate authorized.


Provider Quick Reference
Service Agreement Changes
The case manager is responsible for any changes made to the SA of any recipient.

• If the rate, procedure code(s), or begin and end dates on the SA are incorrect, contact the case manager to initiate corrections
• If additional services are necessary, the provider must communicate with the lead agency before providing any additional services
• If an SA line item is changed and approved, MMIS will automatically generate a revised SA letter to the provider. Letters are generated overnight and sent the following day

Service Agreement Letters
• The case manager has the ability to generate additional copies of the provider SA letters as needed
• The case manager may suppress the DHS-generated service agreement letter and send their own letter to the recipient

Providers registered with MN–ITS receive their service agreement letters (SAL) in their electronic mailboxes. Letters may be viewed, printed, or saved to a disc or computer hard drive and are automatically purged after 30 days.

SAL file contains:

• Waiver
• Alternative Care
• MA Home Care

PAL file contains:

• MA authorization letters

Multiple Providers Providing the Same Service at the Same Time
More than one provider may be authorized to provide the same service for the same recipient. Each provider has a separate line item on the recipient’s SA.

Some services may also be provided by more than one provider, on the same date of service, except if the service has a daily or monthly procedure code.

If two providers are providing the same service to one recipient, services must be coordinated.

• Each provider bills for the actual dates of service
• Use date spans on claims when services are provided on consecutive days

In addition, the case manager should contact all providers who will bill for the same daily or monthly procedure over the same period to coordinate services.

Changes in the Status of a Recipient
• The case manager informs providers and the county financial worker of any status changes of the recipient, such as the living arrangement, address, phone number, or incorrect birth date
• The county financial worker notifies the case manager of any changes in the person’s eligibility for MA or enrollment in managed care
• Providers and lead agency notify one another when a recipient is hospitalized, so that a provider can bill around the dates of hospitalization
• County financial worker and lead agency notify one another when a recipient is admitted to a long-term care facility, so the financial worker can update the living arrangement and appropriate changes can be made to the SA line items.

Change in Recipient Need
Providers need to contact the lead agency when a recipient’s needs change. The case manager is responsible for reassessing the recipient and amending the Community Support Plan.

Changes may include:

• Change of provider
• Increasing or decreasing services
• Addition of a new service
• Other appropriate assessed needs

Transitioning from MA Home Care to Waiver Services OR Waiver Services to MA Home Care Services
Refer to Home Care Services for more information.

Waiver Recipients Enrolled in Prepaid Health Plans (PMAP)
All regular MA-covered services must be billed through the health plan. Contact the health plan for coverage information. All other EW and extended services should be listed on the SA and billed to DHS under the waiver.

Recipients Enrolled in MSHO and MSC+
All EW services are billed through the health plan except for those recipients enrolled with South Country Alliance. Recipients enrolled with this health plan will have an EW service agreement entered in MMIS for payment processing. No service agreement will be entered for recipients enrolled in MSHO or MSC+ under any other health plan organization.

Private Duty Nurse (PDN) Payment for Spouses
Refer to Home Care Services for more information.

Waiver Recipient Who Elects Hospice
Refer to Hospice Services for more information regarding covered services.

Waiver Services in an Institutional Setting
Waiver services are not covered during a hospital, nursing facility, or ICF/DD stay. Providers may bill DHS for waiver services provided on the date of the admission and the date of discharge, if services were provided prior to the time of admission or after the time of discharge.

Exceptions:
• EW & AC allows payment for respite care services provided in a hospital or long-term care facility utilizing respite care procedure codes. See respite service description
• Up to 180 days AC case management conversion may be provided during the nursing facility stay and billed against the AC service agreement for AC recipients

It is important to bill for the dates on which services were provided:

• If the recipient was hospitalized from 1/15 through 1/25, bill 1/1 through 1/14 or 1/15 on line one of the claim, and 1/25 or 1/26 through 1/31 on line two. In this case if the entire month is billed, the claim will be denied.
• If the service is a monthly service, bill for one date span during the month, enter one in the unit field and put the prorated amount for the month in the amount field.
• In addition, if the waiver or AC claim is paid before the hospital or long-term care facility claim is submitted, DHS will automatically take back the waiver or AC payment when the hospital or long-term care facility claim is processed. The provider will need to resubmit their claim.

Waiver Services in a Residential Setting
Waiver services covered in a residential setting:

• Customized living
• 24-hour customized living
• Residential care
• Foster care

Waivers do not pay for room and board. Room and board may be covered by other sources such as:

• The income of the recipient
• Social Security Disability Insurance (SSDI)
• General Assistance (GA)
• Supplemental Security Income (SSI)

When the above sources do not cover the total cost of room and board, Group Residential Housing (GRH) funding may be accessed up to the base rate. The county financial worker must determine all appropriate payment sources for room and board.


Reimbursement for Overhead Expenses due to Residential Absence
Definition
Days when recipient is not receiving residential services are days a recipient is not in the residential setting.

Examples of residential absence include days for:

• Hospitalization
• Therapeutic leaves
• Crisis services
• Any days away such as home visits and vacation days

This policy affects the following HCBS services:

• Customized Living
• 24-Hour Customized Living
• Foster Care
• Residential Care

The Centers for Medicare and Medicaid Services (CMS) policy states Medicaid payment is made for services actually provided to an eligible recipient.

Process and Procedure
When negotiating individual rates with providers, lead agencies are allowed to take a variety of overhead expenses into consideration. A portion of the cost of absences may be considered an overhead expense. The authorized individual monthly limits and case mix caps for the individual still apply.

Monthly Rates
• In the contract, include a description of the package of services being purchased and the process that the county will use to adjust the monthly service rate for residential absences.
• The EW Customized Living Took Kit has predictable absent days built into the tool formula
• Using the monthly procedure code, enter the authorized service rate per month (unit) on the line item of the service agreement. If applicable, adjust the rate at the end according to the process outlined in the contract.

Claims for the above mentioned community services cannot include periods that overlap with a period of hospital admission, nursing facility stay, or other periods defined as “residential absence days”.

For a provider to be paid for days in which the person was not receiving services, the lead agency contract must include a provision allowing for payments in a month that includes residential absence days.

• Claims must include only one line item that represents the adjusted authorized monthly service rate as identified in the county contract
• The unit field must be one (1)
• The period is a time span that does not overlap with any residential absence days
• The total amount field is the total number of days in the setting for that month multiplied by the adjusted negotiated monthly rate
• A notation on the claim form must identify the period of time, minus the residential absence days, that the claim represents

Legal References and Resources
MS Section 245A.01 to 245A.16
MS Section 245A.143

MN Rules, parts 9555.9600 to 9555.97
30

MN Rules, part 9555.5050 – 9555.6265
.and 2960.3000 to 2960.3230
M
S 245A.03

MS Sections 148.171 to 148.285

MN Rules 9575.0010 to 9575.1580

MS Section 256.012

MS Section 256B.02
, subd. 7
MS Section 256B.49
, subd. 8
MS Chapter 18BMS Section 144D.025

MN Rules, parts 9555.5105 to 9555.6265

MN Rules, parts 9555.6205
, subparts 1 to 3, parts 9555.6215, subparts 1 and 3,and parts 9555.6225, subparts 1, 2, 6 and 10
MN Rules Chapter 4668
and 4669
MS section 144D

MN R
ules parts 4668.0100
, subp. 2
MN Rules parts 4688.0100
, subp 5
MS Chapter 144D

MN Chapter 326B.802
subd. 11
MN Rules, Chapter 4626

MS Chapter 245C

MS Chapter 245D

MS 245A.03
, subd 2 (1) and (2)
MS chapter 144A

MS
144a.43 to 144A.46

MS 148.621
and MN Rules Chapter 3250
MS 148.623

MS 157.17

MS 144.696
, subd 3, licensed under MS 144.50 to 144.58
MS 148.171 to 148.285

MS 148.171 to 142.285

MN Rules 9555.5105 to 9555.
6265

MS 256B.0627
and MN Rule 9505.0335
MN Rules 9505.0290
, subp. 3, B
MN Rule 9505.0175
, subp, 23
MN Rule 9505.0310

MN Rule
9505.0195

MS chapter 65B

MS section 174.30

MS Section 174.29 - 174.30

42 CFR 441.310(a)(2)(ii).


© 2014 Minnesota Department of Human Services Online
North Star is led by the Office of Enterprise Technology
Updated: 6/17/14 1:24 PM | Accessibility | Terms/Policy | Contact DHS | Top of Page |