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Minnesota Department of Human Services Provider Manual
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Elderly Waiver (EW) and Alternative Care (AC) Program

Revised: 10-20-2014

  • • 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
  • • Adult Foster Care Services
  • • Case Management
  • • Case Management Aide/Paraprofessional
  • • Chore Services
  • • Companion Services - Adult
  • • Consumer Directed Community Supports (CDCS)
  • • Customized Living Services
  • • Environmental Accessibility Adaptations
  • • Extended State Plan Home Health Services – EW Program Only
  • • Family Caregiver Coaching and Counseling – including assessment
  • • Family Caregiver Training & Education
  • • Home Delivered Meals
  • • Home Health Services – AC Program Only
  • • 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.

    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 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 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 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 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 MA.
  • Covered Services (By Program)

    Service

    EW

    AC

    Adult Day Services

    X

    X

    Adult Day Services Bath

    X

    X

    Adult Corporate Foster Care (Monthly)

    X

     

    Adult Family Foster Care (Monthly)

    X

     

    All MA covered services

    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

    Customized Living

    X

     

    Environmental Accessibility Adaptations

    X

    X

    Family Caregiver Coaching and Counseling (including assessment)

    X

    X

    Family Caregiver Training and Education

    X

    X

    Home Care – Extended Services HHA, Home Care Nursing, 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

     

    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.

    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 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:

  • • 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 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:

  • • 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, including:
  • • 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 (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 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/Certification

    EW and AC program providers must enroll with MHCP and meet specific standards 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. The Waiver and Alternative Care (AC) Programs Service Request Form (DHS-6638) 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/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 EVS or online via MN–ITS.

    Billing

    Bill EW and AC services 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 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 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.

    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, S5102, S5100 U7, S5102 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, S5130 TF), Home Management (S5131 TG, S5131 TF) and Homemaker Services or Cleaning (S5130, S5131)
  • • 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 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)

    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 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 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.
  • 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 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/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 (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 Day Services and Adult Day Services Bath

    Service and 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
  • Adult Day Service Bath

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

  • 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.

    Covered Services

    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 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 provided:

  • • 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 per 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, Family Adult Day Services (FADS) participants must be age 55 or older, and not have a serious or persistent mental illness or developmental disabilities.
  • • A FADS 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.

    Adult Foster Care Services

    Service and 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
  • Noncovered 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 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:

  • • 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 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)
  • Noncovered Services

    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 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 148.171 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
  • • 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, subd. 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/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:

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

    A case management aide must not:

  • • 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:

  • • 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
  • Chore Services

    Service and HCPCS

    EW

    AC

    Chore Services

  • • S5120 – 15 minutes
  • X
  • X
  • Definition

    Chore services support or assist a recipient (enrollee) or his or 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 and 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 for delivering 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 to get 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
  • Explore other sources of funding, including CSSA or Title XX, or in the case of rental property, the responsibility of the landlord under the lease agreement before the county authorizes an EW or AC payment

    MHCP covers chore services 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 or 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 case manager, lead agency or tribal human services agency must review the lease agreement will 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 that people who provide the chore services 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.

  • • Chore services must provide a cost-effective, appropriate means of meeting the needs defined in the participant’s community support plan.
  • • DHS Provider Enrollment verifies provider qualifications for enrolled providers every five years.
  • • Lead agencies are responsible to verify and monitor that non-enrolled providers meet the provider qualifications at least annually, as needed.
  • Companion Services – Adult

    Service and 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 that are not purely diversional.

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

    Socialization that is diversional is for 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 a person to maintain and enhance community integration and social relationships; 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.

    Noncovered Services

    Adult companion services do not include:

  • • Hands-on nursing care.
  • • Activities that are not directed at a goal.
  • • Payment to people related to the EW or AC enrollee by blood, marriage or adoption 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

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

    People 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:

  • • Is able to read and write
  • • Is able to follow written and oral instruction
  • • Has had experience or training in homemaking skills 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
  • • Is able to converse effectively on the telephone
  • • Is able to work under intermittent supervision
  • • Is able 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. A provider of Adult Companion Services who is a National Community Services Senior Companion Program grantee, is exempt from the background study requirements of Minnesota Statute 245C.

    A person may be required to pass a job-related physical examination before providing services.

    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
  • { 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)
  • Customized Living Services

    Service and HCPCS

    EW

    Customized Living Services

    • T2030 – monthly

    • T2030 with modifier TG for 24 HR CL

    X

    EW providers must not bill for full days in which the recipient is absent.

    Definition

    Customized living is an individualized package of regularly scheduled health-related and/or supportive services provided to a person residing in a qualified residential center that is a registered housing with services under Minnesota Statutes 144D.

    Covered Services

    Customized living services include individualized supports that are chosen and designed specifically for each person’s needs. The services include:

    • Arranging for or providing transportation

    • Helping the person with personal funds

    • Helping the person with setting up meetings or appointments

    • Home management tasks including cleaning, laundry and meal preparation and service

    • Socialization

    • Up to 24-hour supervision and oversight

    • Help with personal care or mobility

    • Dressing

    • Grooming

    • Bathing

    • Eating

    • Continence

    • Walking

    • Wheeling

    • Transferring

    • Positioning

    • Help with medication

    • Medication reminders

    • Medication administration, including insulin injections

    • Medication set-ups, including insulin draws

    • Delegated nursing tasks as ordered by a physician and described in the plan

    • Help with therapeutic or passive range of motion exercises

    • Performing other routine delegated medical or nursing or assigned therapy

    • Active behavior or cognitive support for behavioral or cognitive needs that have been assessed by an appropriate professional, and for which there is a plan to implement and monitor the support

    • Device to summon help and response to calls for help within timeframes established in the individual customized living plan, but not to exceed 10 minutes

    • Service delivery is directed by the recipient or provider, with oversight from the case manager.

    • The case manager is the primary party that is responsible to assure that the needs of the recipient are met through the community support plan and customized living plan that is created specifically for that recipient.

    • All homemaker and chore services needed by a recipient are included in the customized living services package. Homemaker, chore, respite and consumer directed community services may not be separately authorized or billed.

    • Customized living services may be provided in any number of living units within a housing with services establishment.

    • 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 develop individual customized living plans and rates using the DHS-issued customized living tools.

    • Management of the congregate living setting or providers under contract with the management or lead agency, must provide customized living services. People receiving customized living services are not eligible for homemaking in addition to customized living services.

    • Providers may not request supplemental payment for covered services. Minnesota Statutes 256B.0915, Subd 3e(g) and Subd 3g(h) state, “A provider may not bill or otherwise charge an elderly waiver participant or their family for additional units of any allowable component service beyond those available under the service rate limits described in paragraph (d), nor for additional units of any allowable component service beyond those approved in the service plan by the lead agency.”

    Noncovered Services

    • Room and board

    • Socialization when it is diversional or recreational

    • 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

    • Customized living services when the recipient is not in the setting

    Provider Standards and Qualifications

    The state agency requires that the 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 a Class A, Class F or Comprehensive home care license in a registered Housing with Services Establishment.

  • Customized Living service providers who are not licensed under Minnesota Rules, parts 9555.5105 to 9555.6265 (adult foster care), and who provide services in settings of one to five residents, must comply with Minnesota 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 Statutes 144A.043 and Minnesota Rules, Chapter 4668 and 4669.

  • • Staff providing health-related services must meet qualifications under Class A or Class F home care license or a comprehensive home care license
  • • 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 people 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

    • Recognize the need for and provide help required or be able to summon appropriate help

    Have on going awareness of the participant’s needs and activities

    24-Hour Customized Living Rate Limit

    To be eligible for 24-Hour Customized Living rate limit recipients must meet eligibility requirements and the provider must meet the applicable provider standards. Authorizations for the 24-hour CL rate limit should use T2030 with modifier TG- monthly.

    To be eligible for the 24-hour CL rate limit, the provider must:

  • • Remain aware of the recipient’s needs and the activities that an employee of the customized living services provider provides for the recipient. This employee may not be a recipient of services. His or her primary job responsibility is to provide supervision to people in the setting.
  • • Have a way for the recipients to call for help, and a 24 Hour Customized Living Services employee available to respond to the call in-person within a reasonable amount of time. See Comprehensive Policy on EW Customized Living
  • To be eligible for the 24-hour CL rate limit, the lead agency must document that one or more of the following criteria have been assessed as a need of the recipient:

    • Cognitive or behavioral intervention

    • Clinical monitoring with special treatment

    • Staff assistance in toileting, positioning or transferring (single dependency)

    • Help with medication management, plus at least 50 hours of customized living service per month and have a dependency in at least three of the following activities of daily living (ADL’s): bathing, dressing, grooming, walking or eating (when eating is scored as 3 or greater.) “Fifty hours of service” means 50 hours of direct component services per month approved to be part of the 24-hour customized living plan as the assessor, case manager or care coordinator, along with the waiver participant, determine.

    Environmental Accessibility Adaptations

    Service and 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 (such as, allergy flooring, accessibility flooring)
  • • Modifications to meet egress
  • • Alarm systems and other requirements of the applicable life safety and fire codes, if any
  • Equipment purchased for personal emergency response systems (PERS) as defined in bulletin Authorization for Personal Emergency Response Services (PERS) for Home and Community-Based Services Waivers, Alternative Care (AC) and Moving Home Minnesota (MHM) (#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.

    Items and services not covered under PERS include:

    • Participants receiving 24 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 State Plan 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
  • Provide vehicle modifications 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.

    Noncovered 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
  • Provide all services 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
  • 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 person’s exit date (for example, the date the person is no longer EW or AC eligible).

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

    Provider Standards and Qualifications

    Home modification installation
    As otherwise required by state law related to the trade area or item being furnished, for example, the plumbing required for a bathroom, an appropriately licensed person or company must provide the modification.

    Limited Install Providers: Providers who do exclusively small install projects, such as grab bars or ramps, are exempt from licensure when the skills they perform meet the definition of “special skill” as defined in Minnesota Statutes Chapter 326B.082, subd. 15

    The provider must be qualified by professional certification or references, to install, repair, or maintain the home modification defined in the participant’s community support plan. All installations must be done according to applicable state and local 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
  • • 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
  • • Continued education in the area of driving mobility and rehabilitation through the Association for Driver Rehabilitation Specialists, Rehabilitation Engineering and Assistive Technology Society or the American Occupational Therapy Association or any programs that have been approved by these entities
  • • 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
  • Family Caregiver

    Service and 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; Counseling and Caregiver Assessment

  • • S5115 with modifier TF - Per 15 minutes (up to 48 units (12 hours) over a 365 day period)
  • X

    X

    Definition

    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)
  • A family caregiver is not paid and is not employed or a volunteer through the organization that cares for the recipient. Under EW and AC, a family caregiver does not need to be living in the same household as the care recipient to obtain caregiver support services. Document all services 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 a 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.

    Covered Services

    Training and Education includes:

  • • 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 or 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.

    Covered Services – Caregiver Coaching includes:

  • • Assessment of the caregiver’s needs and strengths
  • • Development of a person-centered plan with goals
  • • Skills development (disease management, self-care skills such as managing stress, techniques for managing difficult behaviors)
  • • Problem solving (learning assertiveness and communications skills, dealing with family dynamics, and developing an informal support network)
  • • Coaching skills, such as active listening, championing and reframing
  • • Ongoing support to reach established goals
  • • Conducting family meetings and memory care consultation
  • Caregiver counseling is professional consultation to help caregivers make decisions and solve 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

    <br>

    Noncovered Services

    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.

    Noncovered costs:

  • • Transportation
  • • Travel
  • • Meals
  • • Lodging
  • Deduct any such costs that are included in the registration fee. The provider or individual requesting training must submit documentation of the need for training and an outline of the training (that is, a course syllabus, training objectives, workshop description, etc.) to the lead agency for approval.

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

    Noncovered 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 to authorize the service. 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

    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
  • • Care or support related organizations (nonprofit 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 the techniques, such as:

  • • Public health nurse
  • • Registered nurse
  • • Licensed practical nurse
  • Caregivers may also receive training and education by attending courses at vocational and technical schools, such as:

  • • Home health aide and certified nursing assistant training
  • • Disease-specific training provided by care or support related organizations (for example, Alzheimer’s Association) when the case manager determines 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.

    The DHS Provider Enrollment Division verifies all provider qualifications every five years.

    Lead agencies may review and verify provider qualifications for providers that meet Family Caregiver Training and Education services standards. This may be necessary when using vouchers, purchase orders or other similar methods to purchase goods or services from vendors that are not enrolled as Medicaid providers when the vendor maintains all required licenses, permits and/or registrations.

    Procedures

    Document the following 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
  • Submit 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 to the lead agency before 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.

    Include all family caregiver training, education, coaching or counseling in the EW or AC recipient’s community support plan.

    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 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
  • 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
  • • T1030— Visit
  • 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 or 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. EW or AC provides for modified diets, when appropriate, to meet a person’s individual requirements.

    Covered Services

    EW or AC provides home delivered meals 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. A licensed dietician or licensed nutritionist must review and approve menu plans . EW or AC covers one meal per day.

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

    Noncovered Services

    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. AAA’s distribute these funds through a contractual agreement with the provider. These contracts may define specific revenue sources , including all other grants and anticipated client contributions. County agencies may find these contracts helpful for identifying provider revenue resources when 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 replacing other funds and negotiated rates do not exceed the cost of the home delivered meal.

    Neither AC nor EW clients may be required to contribute 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 or AC when other programs are not available where the person lives or due to special dietary needs, the time of day or day of the week, or existing waiting lists or demands that 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. Providers must use insulated hot and cold containers to assure that food is delivered at appropriate temperatures. A licensed dietician or nutritionist must meet the requirements as specified in Minnesota Statutes 148.621 and Minnesota Rules Chapter 3250.

    Procedures

    Neither AC nor EW clients may be required to contribute 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.

    The state EW or AC rate for home delivered meals must be approved on a SA.

    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
  • Definition

    EW and AC provide homemaker services 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 minor help with home management and activities of daily living. All homemakers may help monitor the client’s well-being in the home, including home safety.

    Homemaker cleaning services includes light housekeeping tasks. Homemaker cleaning services must meet the needs defined in the client’s community support plan and not duplicate other homemaker or cleaning services. Homemaker or cleaning providers exclusively deliver home cleaning services.

    Homemaker or home Management activities may include help with the following:

  • • Laundry
  • • Meal prep
  • • Shopping for food
  • • Clothing and supplies
  • • Simple household repairs
  • • Arranging for transportation
  • Homemaker or assistance with activities of daily living (ADL) includes help with the following:

  • • Bathing
  • • Toileting
  • • Grooming
  • • Eating
  • • Ambulating
  • Homemaker or assistance with activities of daily living providers deliver cleaning and services and while onsite, provide help as needed with activities of daily living.

    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 and Cleaning Service

  • • Providers must comply with the standards outlined in Minnesota Statutes Chapter 245C on 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 and 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.
  • • Home care providers must meet the requirements of Minnesota Statutes 144a.43 to 144A.46.
  • Homemaker Service and 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.
  • • Home care providers 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 help individuals on appropriate nutritional intake.

    Nutrition counseling includes:

  • • Assessment of a recipient’s nutritional needs that results in an individualized plan with goals
  • • Follow-up on established nutritional goals
  • Nutrition counseling can assist recipients with:

  • • Managing therapeutic diets (for example, diabetic, low sodium, low cholesterol, renal, or gluten free)
  • • Providing weight management strategies for recipients who are chronically underweight or overweight
  • • Severe weight loss or 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 recipient’s 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, according to Minnesota Statutes 148.623, and perform service incidental to their practice, such as a diabetic educator or registered nurse
  • Residential Care Services

    Service and HCPCS

    EW

    AC

    Residential Care Services

  • • T2032 – monthly
  • X
  •  

    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:

  • • 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:

  • • 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.

    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 MN Statutes 157.15 to 157.17. 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:

  • • 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:

  • • 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
  • Respite Care

    Service and HCPCS

    EW

    AC

    In-Home Respite

  • • S5150 –15minutes
  • • S5151 – per diem
  • 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
  • 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. This person is not paid or is paid only for a portion of the total time of care or supervision he or she provides. The unpaid caregiver does not need to live in the same house as the recipient.

    Covered Services

  • • A recipient can receive respite care 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 according to the care plan.
  • Noncovered Services

  • • Recipients living in corporate or family foster care settings or receiving 24-Hour Customized Living Services cannot receive respite care separately.
  • • 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. One of the following facilities approved by the lead agency must provide respite care:

  • • 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 site; 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 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 lives 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 to ensure that necessary expenditures related to protecting the health and safety of participants are reimbursed. In an emergency involving 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 in the contract the unit of service to be billed. Use daily rates 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. 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.

    People 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 Minnesota Rules 9555.5105 to 9555.6265 and 2960.3000 to 2960.3230 and Minnesota Statute 245a.03. 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 Minnesota 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 Minnesota Rule 9505.0175, subpart 23. Facilities providing respite care outside of the enrollee's home must be licensed according to Minnesota Statutes, Chapter 144A. 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 Providers must be licensed as a home care provider and meet the standards as delineated in Customized Living waiver service descriptions. Out-of-home providers must meet the standards in 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. 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.

    Home of an unlicensed caregiver – an unlicensed caregiver may provide services in their home 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, MHCP will not pay room and board payment 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:

  • • Is physically able to care for the enrollee
  • • Has completed training identified as necessary in the care plan
  • • Complies with monitoring procedures as described in the care plan
  • O

    O

    Specialized Supplies and Equipment

    Service and 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, specified in the plan of care, that enable the person to increase their ability to:

  • • Perform activities of daily living
  • • 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 if these items are essential to keep the recipient in the community.

    EW Covered Services

    See Equipment and Supplies section for clarification about covered and noncovered items and regulations. Recipients must first access MA benefits, as appropriate. 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 State plan that provides direct medical or remedial benefit to the individual
  • Items reimbursed with waiver funds are in addition to any medical equipment and supplies furnished under MA Supplies and equipment that exceed the limits set for MA covered services may be covered through the waiver.

    Equipment purchase (S5162) for personal emergency response systems (PERS) as defined in Bulletin #13-25-04 when the system does not entail changes to the physical structure and does not become a permanent part of the participant’s home which is not easily removed should be authorized as specialized supplies and equipment. (PERS equipment which is not easily removable should be authorized as environmental accessibility adaptation.) PERS equipment purchase is subject to a $1,500 annual limit. PERS monthly services fees (S5161) are limited to $110 per month. PERS installation (S5160) is limited to $500. The total annual authorization for PERA is $3,000 during a participant’s “waiver” year. For EW and AC participants, the waiver year begins each time an opening, reopening, or reassessment screening document is approved.

    Items and services not covered under PERS 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:

  • • Cannot 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
  • • Meant for the sole use of the recipient
  • • Determined by prevailing community standards or customary practice and usage to be:
  • • Either 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 or community)

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

    • Of an acceptable quality

    • Timely (that is, 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 MA covers an item, bill MA first to the extent of the limitations. If MA never covers an item, the case manager may decide to cover this item under the EW or 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 noncovered service that the provider adds to an MA-covered service. In this case, bill the MA-covered item 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 noncovered 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 EW program will cover the basket. 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 noncovered MA service (and often a more desirable service) that may 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 person may choose an upgraded service instead of an MA-covered service, even though MA will not pay for this item. The person 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 person sign a waiver acknowledging that MA does not cover the item, and agreeing to pay the entire cost for the upgraded item before the service is provided.
  • • The case manager may authorize EW to cover the entire cost of the upgraded item if it is determined to be medically necessary.
  • 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 is responsible for the entire charge for the bed as long as the provider informs 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 between the semi-electric bed and the total electric bed 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 extended supplies and equipment must be included in the client’s cost effectiveness monthly cap amount. Costs of supply and equipment items may be averaged over the span of an SA if the person maintains program eligibility for the available span of the SA. For example, if the cost of an item is averaged for months beyond the month the cost was incurred, and the person subsequently exits the program, then payments for the item will not continue after the exit date.

    Determining Appropriate Payer

    Elderly Waiver

    1. All other private and public payers (private insurance, Medicare, Medical Assistance) are exhausted before using EW funds for coverage.

    2. The local lead agency is responsible to authorize covered services according to the appropriate payer.

    3. The provider is responsible to bill only the appropriate payer for the client and the item(s).

    4. The provider submits copies of the denials from those payment sources to the lead agency.

    5. If inappropriate billing shows up in an audit, the provider is responsible and risks payment recovery.

    Alternative Care

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

    2. The AC program does not provide payment for medical supplies and equipment that are considered to be medically necessary.It does not 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 person to support their transition home from the nursing facility. Providers cannot bill through EW or AC programs for extended supplies and equipment until the local lead agency opens the program span for home and community-based services in MMIS. A provider can bill for extended supplies and equipment on the date of discharge, as long as the items are provided after the time of the person’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 only be approved when it is determined, for items that meet authorization criteria, as cost-effective, for example, when the item is needed for a defined amount of time and rental is less expensive than purchase.

  • • All rental contracts must 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 also 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
  • When the rental fee equals the purchase price, the item is considered to be the property of the person (normally after 10-12 months’ rental).

    Repair and Maintenance

    The HCBS program can pay for repair of equipment when the equipment meets the authorization criteria and the repair is a cost-effective alternative (that is, is expected to last, and without repair, the equipment would have to be purchased new at a higher cost). The HCBS program may purchase a maintenance agreement 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. Also 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

    An HCBS program may pay shipping and handling costs if the price of the item includes shipping cost , and the waiver is purchasing the item.

    HCBS can cover installation 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, bill the costs 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 (for example, if a new item could be purchased at the similar cost, it may be worthwhile to purchase the new item).

    Noncovered Services

  • • Items that are covered by MA, Medicare, private insurance or other funding resources and items that do not provide direct medical or remedial benefit to the person.
  • • Items and services purchased before the LTCC screening and program begin date or without case manager approval are not covered.
  • Provider Standards and Qualifications

    The following MA enrolled providers meet the standards and qualifications:

  • • Health agencies
  • • Pharmacies, and
  • • Medical suppliers (including wheelchair and oxygen vendors)
  • Lead Agencies, Tribal Human Services and managed care organizations (MCOs) may approve non-enrolled vendors who meet state service standards to deliver specialized supply and equipment services. Non-enrolled vendors approved by the local lead agencies must sign a service purchase agreement.

    Provider participation is defined under Minnesota Rule 9505.0195.

    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 people transitioning to independent or semi-independent community living from the following licensed settings: hospitals licensed under Minnesota statutes, sections 144.50 to 144.58; adult foster homes licensed under Minnesota Rules, parts 9555.5105 to 9555.6265; and certified nursing facilities and intermediate care facilities under Minnesota Rules, part 9505.0175, subpart 23.

    Covered Services

  • • Lease and rental deposits
  • • Essential furniture
  • • Utility set up fees and deposits
  • • Personal supports to help locate and transition to the community based housing
  • • Basic household items
  • • Personal items
  • • One-time pest and allergen treatment of the setting
  • • Window coverings
  • 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
  • • The person 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 the waiver within 180 days and incur the expense within 90 days of the waiver opening date

  • • Services must be identified on the individual’s plan of care
  • • Transitional services may be authorized and provided before a person’s discharge from a licensed setting if the person is expected to be discharged and enrolled on the waiver. Lead agencies may only bill the waiver for transitional services after the date the person is discharged from the licensed setting and enrolled on the waiver.
  • Unforeseen Circumstances

    If for any unforeseen reasons, such as death or a significant change in condition, the person is not discharged and enrolled on the waiver, the lead agency may request reimbursement of the incurred expense(s) by submitting the Requesting Reimbursement for CAC, CADI, DD, BI, Elderly waiver or Alternative Care (AC) Program (DHS-5504) to DHS along with original receipts or invoices for the work completed. This form may be submitted to DHS for reimbursement up to twelve months after the date of service.

    Managed care organizations may not request reimbursement from DHS under unforeseen circumstances. Lead agencies will need to contact the specific health plan about the procedures they need to follow for reimbursement.

    Noncovered 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
  • The case manager must:

  • • Assure that the transitional support items are necessary and reasonable
  • • Authorize the items and include the items in the individual’s care plan
  • • Obtain purchase agreements for vendors of personal support
  • • Maintain receipts and documentation for all transitional support items 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 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 companion services may be authorized and billed using the mileage rate when the services are provided at the same 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 their own vehicle

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

    Additional EW Noncovered Services

    Access transportation as defined in Provider Requirements.

    Additional AC Noncovered Services

    Access transportation as defined in Provider Requirements.

    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, Section 174.29 - 174.30 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, 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 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/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 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 must 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)

    Bill all regular MA-covered services through the health plan. Contact the health plan for coverage information. List all other EW and extended services on the SA and bill them to DHS under the waiver.

    Recipients Enrolled in MSHO and MSC+

    Bill all EW services 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.

    Home Care Nursing 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 they provided services before the time of admission or after the time of discharge.

    Exceptions:

  • • EW and AC allows payment for respite care services provided in a hospital or long-term care facility using 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
  • • Residential care
  • • Foster care
  • Waivers do not pay for room and board. Other sources may cover room and board 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
  • • Foster Care
  • • Residential Care
  • The Centers for Medicare and Medicaid Services (CMS) policy states Medicaid will pay for services actually provided to an eligible recipient.

    Process and Procedure

    Consider a variety of overhead expenses when the rate is established using the approved rate tools. 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

  • • 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”.

    Claims must include only one line item that represents the adjusted authorized monthly service rate as identified in the rate tool

  • • 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 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 9555.9730

    MN Rules, part 9555.5050 – 9555.6265
    .and 2960.3000 to 2960.3230
    MS 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 Rules 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).

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    Updated: 10/20/14 3:33 PM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 10/20/14 3:33 PM