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Elderly Waiver (EW) and Alternative Care (AC) Program

Revised: 12-06-2018

  • Overview
  • Roles
  • Providers
  • Authorization of Services and Service Authorization/Agreement Letters (SAL)
  • Billing
  • Billing for Waiver and Alternative Care (AC) Program
  • Specialized Equipment & Supplies Authorization & Billing Responsibilities
  • Covered Services
  • Adult Day Services and Adult Day Services Bath
  • Adult Foster Care Services
  • Case Management
  • Case Management Aide or Paraprofessional
  • Chore Services
  • Companion Services - Adult
  • Consumer Directed Community Supports (CDCS)
  • Customized Living Services
  • Environmental Accessibility Adaptations
  • Family Caregiver
  • Extended State Plan Home Health Services – EW Program Only
  • Home Health Services – AC Program Only
  • Homemaker Services
  • Individual Community Living Support (ICLS)
  • Nutrition Services – AC Program Only
  • Respite Care
  • Specialized Equipment and Supplies
  • Transitional Services
  • EW and AC Transportation
  • Service Descriptions, Billing Codes, Provider Standards
  • Provider Quick Reference
  • Legal References and Resources
  • Provider Type Links
    Review related webpages and MHCP Provider Manual sections for the latest news and additions, forms, and quick links.

    Overview

    Elderly Waiver (EW) and Alternative Care (AC) programs fund home and community-based services (HCBS) for people 65 years old and older who require the level of care provided in a nursing home, but choose to live 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 65 years old and older who are eligible for Medical Assistance (MA), require the level of care provided in a nursing home, and choose to live in the community. EW recipients can receive waiver services and 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 65 years old 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 AC have low levels of income and assets but are not yet eligible for MA.
  • Assessments

    Anyone may request an assessment for themselves or another person by contacting the local lead agency. The lead agency will determine program eligibility. EW and AC have different application processes, financial eligibility requirements and covered services.

    Eligible Recipients

    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, Programs and Services 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 Worker

    County financial or human services eligibility workers determine financial eligibility for payment of Elderly Waiver services. These county staff members 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 counties, tribes 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 the following:

  • • A community assessment of the needs of the recipient
  • • Assistance with the application process
  • • Development of a community support plan
  • Case Management
    A person approved for EW or AC will receive case management or care coordination from a public health nurse or social worker who does the following:

  • • 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 reasonably 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 the following:

  • • 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 case management or care coordination services, including the following:
  • • 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 (for example, 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 or state must 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 (Assessments and Reassessments) (DHS-2828A) (PDF) and Notice of Action (Service Plan) (DHS-2828B) (PDF) to notify the member of impending changes to the waiver services.

    Informed Choice
    The lead agency will do the following:

  • • 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 his or her needs. A recipient receiving waiver services before age 65 remains eligible for the respective waiver after turning 65 years old if he or she meets all other eligibility criteria. 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 people 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 and Certification

    EW and AC program providers must enroll with MHCP and meet specific standards to bill and receive payment for waiver services. To enroll in MHCP to provide waiver or AC program services, follow the instructions in the Home and Community Based Services (HCBS) Waiver and Alternative Care Provider Enrollment section.

    Providers must also determine which program services they are qualified to provide. Specific provider qualifications are found in this manual within each service description. The HCBS Programs Service Request Form (DHS-6638) (PDF) also lists qualifications.

    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, 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 and Service Authorization or Agreement Letters (SAL)

    A completed screening document that opens the EW or AC eligibility span must be entered into MMIS.

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

    County and tribal agencies initiate the service authorization and enter it into MMIS. This 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. MMIS generates a letter overnight that is sent the following day to the provider’s MN–ITS mailbox.

    The SA allows the provider to provide services and then bill DHS and receive payment. MHCP will pay only services on the SA; 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, Home Care Nursing , and PCA that must be utilized before EW extended services
  • The EW and 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.

    Providers must verify program eligibility for each recipient each month through the MHCP phone-based eligibility verification system (EVS) or online via MN–ITS.

    Billing

    To bill for EW and AC services, refer to the Billing for Waiver and Alternative Care (AC) Program section.

    For extended home care services approved on the waiver or AC authorization, submit claims using the 837I Institutional Outpatient transaction, following home care billing guidelines.

    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. Effective Jan 1, 2019, South Country Health Alliance (SCHA) will no longer contract with MHCP to act as the third party administrator (TPA) for submitting claims and receiving reimbursements for EW services. For dates of services on and after Jan. 1, 2019, contact SCHA to obtain authorization and bill for EW services. Contact all the health plans 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.

    Service authorization or agreement letters to the provider that display the diagnosis code of the recipient are 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 or agreement letter if you have a more recent or correct diagnosis code. Use the ICD-10 codes for services provided October 1, 2015, or later.

    Authorized Services vs. Non-Authorized Services

    Services that require an 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.

    Bill the following services provided on or after July 1, 2014, at the statewide maximum rate:

  • • AC Nutrition Services S9470
  • • Adult Day Service Bath S5100 TF
  • • Adult Day Service S5100, S5100 U7,
  • • Chore S5120
  • • Companion Services S5135
  • • County-provided case management T1016, T1016 UC, T1016 UC TF, and T2041
  • • Family Caregiver Coaching and Counseling S5115 TF
  • • Home Delivered Meals S5170
  • • Homemaker or Assistance with Personal cares (S5130 TG), Home Management (, S5131 TF) and Homemaker Services or Cleaning (S5130)
  • • Respite in Home S5150, S5151
  • • Respite out-of-home H0045
  • Information about service rate changes and limits for EW and AC services are available through publication of bulletins. Review the long-term services and supports rates changes web page for the most up-to-date information about current rate limits.

    Clients Leaving Nursing Facilities (Conversion Rates)

    A person 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 Elderly Waiver-Monthly Conversion Budget Limits 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 receives a notice 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 the client used that month, which may be a portion of the waiver obligation or the entire waiver obligation.
  • A MA spenddown may be met with any combination of MA services, including HCBS services. MA spenddowns must 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 the obligation. The recipient must notify the financial worker if he or she wishes 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 care nursing
  • • Home health aide (HHA) visits
  • • Occupational therapy (OT)
  • • RN PCA supervision
  • • Personal care assistant (PCA)
  • • Physical therapy (PT)
  • • 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).
  • • 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 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 or 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.

    Covered Services

    Select the link below to view the Community Based Services Manual (CBSM) policy page for each service that includes the legal reference, service description, covered and noncovered services when applicable and provider standards and qualifications. If a service is not linked to the CBSM, see service descriptions, billing codes, and provider standards below the table.

    Service

    EW

    AC

    Adult companion services

    X

    X

    Adult day services

    X

    X

    Adult day services bath

    X

    X

    Adult corporate foster care

    X

    Adult family foster care

    X

    All MA covered services

    X

    Case management

    X

    X

    Case management aide (Paraprofessional)

    X

    X

    Chore services

    X

    X

    Consumer Directed Community Supports (CDCS)

    X

    X

    Conversion case management

    X

    Customized living

    X

    Environmental accessibility adaptations

    X

    X

    Family adult day services

    X

    X

    Family caregiver services

    X

    X

    Home care – extended services HHA, home care nursing, PCA

    X

    X

    Home-delivered meals

    X

    X

    Homemaker

    X

    X

    Individual community living supports (ICLS)

    X

    X

    Non-medical transportation

    X

    X

    Nutrition services

    X

    Respite care

    X

    X

    RN supervision of PCA

    X

    Specialized equipment and supplies

    X

    X

    Tele-homecare

    X

    X

    Transitional services

    X

    Service Descriptions, Billing Codes and Provider Standards

    The following EW and AC service descriptions include:

  • • Definitions
  • • Covered services
  • • Noncovered services
  • • Provider qualifications and standards
  • • Procedures
  • • Secondary information (where appropriate)
  • 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 Foster Care Services

    Service and HCPCS

    EW

    Foster Care – Corporate

  • S5141 with modifier HQ – Monthly, Adult (cannot be used for dates of services on or after July 1, 2016)
  • S5140 with modifier U9 – Daily (effective for dates of services on or after July 1, 2016)
  • X

    Foster Care – Family

  • S5141 – Monthly, Adult (cannot be used for dates of services on or after July 1, 2016)
  • S5140 – Daily (effective for dates of services on or after July 1, 2016)
  • 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. Beginning July 1, 2015, lead agencies must use the EW Residential Services Tool (formerly known as the Customized Living Tool) to determine rates for foster care.

    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 the following:

  • • 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
  • Noncovered Services

    Payment for EW foster care service does not include the following:

  • • 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 Minnesota Rules, parts 9555.51059555.6265 and Minnesota Statutes, section 245A or Community Residential Setting (CRS) under Minnesota Statutes 245D.

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

    Case Management

    Service and HCPCS

    EW

    AC

    Case Management

  • T1016 with modifier UC – 15 minutes
  • X

    X

    Case Management Conversion

  • T1016 – 15 minutes
  •  

    X

    Definition

    This service will help people gain 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 or 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 lives 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 the following:

  • • Development and implementation of a relocation plan
  • • Coordination of referrals and helping a person to access services
  • • Coordination and monitoring of the overall implementation of a relocation plan
  • • 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 he or she 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 the following:

  • • 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)
  • Noncovered Services

    Case Management Administrative Activities

    Case management administrative activities are not billable under any HCBS program. Case management administrative activities include the following:

  • • 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 and assists 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
  • The lead agency may employ or contract with the following people to provide case management:

  • • Public health nurse or registered nurse licensed under Minnesota Statutes, sections 148.171148.285
  • • 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.
  • • Physicians, physician’s assistants and nurse practitioners – must meet all state standards and possess all professional licenses necessary to practice
  • Alternative credentialing

  • • Alternative credentialing standards may be applied to services provided by tribal governments under Minnesota Statutes, section 256B.02, subdivision 7
  • • For MSHO and MSC+ enrollees, the managed care organization may establish alternative credentialing standards consistent with their DHS contracts
  • Case Management Aide or Paraprofessional

    Service and HCPCS

    EW

    AC

    Case Management Aide/Paraprofessional

  • T1016 with modifiers TF & UC – 15 minutes
  • X

    X

    Definition

    Paraprofessional and case management aides help the case manager carry 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 include the following:

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

    A case management aide must not do the following:

  • • Assume responsibilities that require professional judgment
  • • Conduct assessments
  • • Conduct reassessments
  • • Develop service plans
  • 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 meet the following criteria:

  • • 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
  • Procedures

  • • All nonprofessional case management related tasks 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
  • Consumer Directed Community Supports (CDCS)

    Service and 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
  • • T2040 – each check for Background Checks
  • T2041–15 minutes for Required Case Management
  • X

    X

    Definition

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

    Covered Services

    CDCS covers four service categories:

  • • Personal assistance
  • • Treatment and training
  • • Environmental modifications and provisions
  • • Self-direction support activities
  • Individuals can hire, terminate, manage and direct their own 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.

    Noncovered Services

    Services provided to people living in licensed foster care settings, settings licensed by DHS or MDH, or registered as a housing with services establishment.

    For more information, refer to the DHS public web pages listed here:

  • CDCS Overview
  • CDCS Comparison (PDF)
  • Consumer Directed Community Support Lead Agency Operations Manual (DHS-4270) (PDF)
  • Extended State Plan Home Health Services – EW Program Only

    Service and 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

    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

    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

    RN Complex, Extended

  • T1002 with modifiers TG and UC – 15 minutes
  • X


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

    Home Health Services – AC Program Only

    Service and 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

    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

    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

    RN Complex

  • T1002 with modifier TG – 15 minutes
  • X

    Skilled Nurse Visit

  • • G0154—15 minutes (cannot be used for date of service after December 31, 2015)
  • • G0299 – Services of a skilled nurse (RN), Home Health 15 minutes (use for dates of service on or after January 1, 2016)
  • • G0300 – Services of a skilled nurse (LPN), Home Health 15 minutes (use for dates of service on or after January 1, 2016)
  • T1030— Visit
  • X

    Tele- Homecare

  • T1030 with modifier GT
  • X

    Residential Care Services

    Service and HCPCS

    EW

    AC

    Residential Care Services

  • T2032 – monthly
  • X

     

    This service has been discontinued as of June 30, 2018. Do not bill for dates of service on or after July 1, 2018. For additional details, see Discontinuation of the residential care waiver service in the Community-Based Services Manual (CBSM).

    Definition

    Supportive and health supervision services provided to people in a residential care home as documented in the community support plan. The person or provider directs the service delivery with oversight by the case manager.

    Covered Services

    Supportive services for the recipient include the following:

  • • 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 help with the following:

  • • Dressing, grooming and bathing
  • • Reminding a person to take medications that are self-administered
  • • Storing medications, if requested
  • • Medication reminders
  • Noncovered 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 Minnesota Statutes, sections 157.15157.17. The residential care home must meet the appropriate local building codes.Management of the residential care home must provide residential services.

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

  • • Dressing
  • • Grooming
  • • Bathing
  • • Medication reminders or storage of medications. If medications are to be distributed or stored, a registered nurse must supervise this process.
  • Staff providing supervision and supported services must meet the following criteria:

  • • Be able to read and write and follow written and oral instructions
  • • Have experience or training in caring for people with disabilities
  • • Have good physical and mental health
  • • Be able to 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
  • EW and AC Transportation

    Service and 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, use family, neighbors, friends or community agencies that provide this service without charge.

    Transportation and adult companion services may be authorized and billed when the services are provided by the same provider on the same day. The provider may not bill both companion as well as transportation for the same period of time.

    Transportation and individual community living support (ICLS) services may be authorized and billed when the services are provided by the same provider on the same day. The provider may not bill both ICLS as well as transportation for the same period of time.

    Adult day services and transportation are always separately covered, but in order and not provided at the same time.

    For EW the adjective “extended” is not applicable as a waiver service because waiver transportation services are not an extension of MA 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 or AC Noncovered Services

  • • Transportation reimbursement already included in the contracted rate for other services
  • • Noncovered 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 his or her own vehicle
  • Additional EW Noncovered Services

    Access transportation as defined in the Provider Requirements section.

    Additional AC Noncovered Services

    Access transportation as defined in the Provider Requirements section.

    Provider Standards

    EW or 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 or AC Special Transportation Standards

    Minnesota Department of Transportation under Minnesota Statutes, sections 174.29174.30, must certify providers of special transportation services not excluded in Minnesota Statutes, section 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 and 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, sections 174.29174.30.

    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 or Care Coordinator

    The EW or AC case manager or service coordinator is responsible for assessing and planning access to services as follows:

  • • Help recipients understand available transportation services through MA and the EW and AC programs
  • • Help recipients select transportation services through EW or 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

    DHS recommends that the case manager review the Transportation section of the MHCP Provider Manual for 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 and 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 or 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 his or her 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
  • 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 the Home Care Services section for more information.

    Home Care Nursing Payment for Spouses

    Refer to the Home Care Services section for more information.

    Waiver Recipient Who Elects Hospice

    Refer to the Hospice Services section for more information regarding covered services.

    Legal References and Resources

    Minnesota Statutes, sections 245A.01 – 245A.16 (Human Services Licensing)
    Minnesota Statutes, section 245A.143
    (Family Adult Day Services)
    Minnesota Rules, parts 9555.9600
    9555.9730 (Social Services for Adults)
    Minnesota Rules, parts 9555.5050
    9555.6265 (Social Services for Adults)
    Minnesota Statutes, section 245A.03
    (Who Must Be Licensed)
    Minnesota Statutes, sections 148.171
    148.285 (Public Health Occupations)
    Minnesota Rules, parts 9575.0010
    9575.1580 (Merit System)
    Minnesota Statutes, section 256.012
    (Minnesota Merit System)
    Minnesota Statutes, section 256B.02, subdivision 7
    (Definitions - Vendor of Medical Care)
    Minnesota Statutes, section 256B.0913
    (Alternative Care Program)
    Minnesota Statutes, section 256B. 0915
    (Medicaid Waiver for Elderly Services)
    Minnesota Statutes, section 144D.025
    (Optional Registration)
    Minnesota Rules, parts 9555.5105
    9555.6265 (Social Services for Adults)
    Minnesota Rules, part 9555.6205
    , subparts 1 – 3, part 9555.6215, subparts 1 and 3, and part 9555.6225, subparts 1, 2, 6 and 10 (Social Services for Adults)
    Minnesota Rules, chapters 4668
    (Home Care Licensure) – 4669 (Home Care Licensure Fees)
    Minnesota Statutes, chapter 144D
    (Housing with Services Establishment)
    Minnesota Rules, part 4668.0100, subpart 2
    and subpart 5 (Home Health Aide Tasks)
    Minnesota Statutes, section 326B.802, subdivision 11
    (Definitions - Residential Building Contractor)
    Minnesota Rules, chapter 4626
    (Food Code; Food Managers)
    Minnesota Statutes, chapter 245C
    (Human Services Background Studies)
    Minnesota Statutes, chapter 245D
    (Home and Community-Based Services Standards)
    Minnesota Statutes, section 245A.03, subdivision 2
    , paragraph (a), clauses (1) – (2) (Exclusion from licensure)
    Minnesota Statutes, chapter 144A
    (Nursing Homes and Home Care)
    Minnesota Statutes, sections 144A.43
    144A.46 (Nursing Homes and Home Care)
    Minnesota Statutes, section 148.621
    (Definitions) and Minnesota Rules, chapter 3250 (Licensure and Practice)
    Minnesota Statutes, section 148.623
    (Duties of the Board)
    Minnesota Statutes, section 157.17
    (Additional Registration Required for Boarding and Lodging Establishments or Lodging Establishments)
    Minnesota Statutes, section 144.696, subdivision 3
    (Definitions) licensed under Minnesota Statutes, sections 144.50 (Hospitals, Licenses; Definitions) – 144.58 (Interpreter Services Quality Initiative)
    Minnesota Statutes, section 256B.0659
    (Personal Care Assistance Program) and Minnesota Rules, part 9505.0335 (Personal Care Services)
    Minnesota Rules, part 9505.0290, subpart 3
    , item B (Home Health Agency Services)
    Minnesota Rules. part 9505.0175, subpart 23
    (Definitions – Long-term Care Facility)
    Minnesota Rules, part 9505.0310
    (Medical Equipment and Supplies)
    Minnesota Rules, part 9505.0195
    (Provider Participation)
    Minnesota Statutes, chapter 65B
    (Automobile Insurance)
    Minnesota Statutes, section 174.30
    (Operating Standards for Special Transportation Service)
    Minnesota Statutes, sections 174.29
    174.30 (Department of Transportation)
    Code of Federal Regulations, title 42, chapter IV, subchapter C, part 441, subpart G, section 441.310, paragraph (a)(2)(ii)
    (Limits on Federal financial participation (FFP)

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