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Community-Based Services Manual (CBSM)

Community-Based Services Manual (CBSM)


Transitional services – BI, CAC, CADI and DD

Page posted: 11/4/05

Page reviewed: 12/28/20

Page updated: 10/28/25

Legal authority

Federally approved BI, CAC, CADI and DD waiver plans, Minn. Stat. §256B.0916, Minn. Stat. §256B.49, Minn. Stat. §256B.092

Definitions

Transitional services: Items and expenses necessary and reasonable for a person to transition from an eligible setting to their own home or an integrated community supports setting.

Person’s own home: For the purposes of this page, a person’s own home is a setting they own, rent or lease that is not operated, owned or leased by a provider of services or supports. The person has full control of their housing and choice of service provider.

Integrated community supports setting: Refer to CBSM – Integrated community supports.

Eligibility

A person is eligible to receive transitional services if they meet all the following criteria:

  • · Age 18 or older.
  • · Enrolled on the Brain Injury (BI), Community Access for Disability Inclusion (CADI), Community Alternative Care (CAC) or Developmental Disabilities (DD) waiver, or reasonably expected to enroll within 180 days.
  • · Moving from an eligible setting to their own home or an integrated community supports setting.
  • · Moving to a setting where these items and expenses are not normally furnished.
  • · Not able to access transitional services from other funding sources (e.g., community nonprofit organizations).

    • Eligible settings

    A person can use transitional services to move to their own home or an integrated community supports setting from any of the following eligible settings:

  • · Adult foster care home (corporate and family).
  • · Assisted living facility that provides customized living services.
  • · Hospital.
  • · Institution for mental diseases (IMD).
  • · Intensive rehabilitation treatment or rule 36 setting.
  • · Intermediate care facility for persons with developmental disabilities (ICF/DD).
  • · Nursing facility.
  • · Unlicensed setting (e.g., person’s own home, family home or integrated community supports [ICS] setting).

    • Assisted living facility that provides customized living services

    Assisted living facilities generally are considered provider-controlled and not the person’s own home.

    In some circumstances, settings that deliver customized living services might meet the transitional services definition of own home in the definition section of this page. If a person is moving to a home where customized living services are available, the person can only receive transitional services if they will reside in a self-contained living unit (e.g., apartment) with a bathroom, kitchen/kitchenette and sleeping area.

    ICS setting

    If a person is moving to a home where ICS services are available, the person must receive transitional services from a provider who does not have direct or indirect financial interest in the property (i.e., cannot receive transitional services from the ICS provider).

    Covered services

    Transitional services cover:

  • · Essential furniture (e.g., bed frame, box spring, mattress, dining table and chairs, dressers, lamps, sofas).
  • · Household supplies (e.g., cleaning supplies, dishes, drinking glasses, flatware, pots and pans, sheets, towels).
  • · Lease or rental deposits.
  • · Moving expenses (e.g., moving vehicle rental, packing, unpacking).
  • · Pest and allergen treatment of the home.
  • · Utility set-up fees and deposits.
  • · Window coverings.

    • Non-covered services

    Transitional services do not cover:

  • · Clothing.
  • · Food.
  • · Items, expenses or supports that duplicate other waiver services (e.g., chore services, homemaker, environmental accessibility adaptations, specialized equipment and supplies).
  • · Recreational and diversionary items (e.g., computers, DVD players, televisions, cable access).
  • · Rent or mortgage payments.
  • · Services for a person moving into a home that does not meet the definition of a person’s own home.
  • · Supports to move (e.g., assistance from people to arrange for utilities or locate and secure a home; refer to DHS – Housing Stabilization Services).

    • Service amount

    Per person, transitional services cover a maximum of one transition every three years from when the person last moved/used transitional services.

    Line items with start dates on or after Jan. 1, 2025

    Transitional services cannot exceed a total of $5,000, including the following limits for each service:

  • · Moving expenses (T2038): Maximum total of $5,000.
  • · Essential furniture (T2038 U1): Maximum total of $1,500.
  • · Household supplies (T2038 U2): Maximum total of $500.

    • There are no exceptions to these limitations.

    Line items with start dates before Jan. 1, 2025

    Transitional services cannot exceed a total of $3,000, including the following limits for each service:

  • · Moving expenses (T2038): Maximum total of $3,000.
  • · Essential furniture (T2038 U1): Maximum total of $1,000.
  • · Household supplies (T2038 U2): Maximum total of $300.

    • There are no exceptions to these limitations.

    Secondary information

    The lead agency must:

  • · Determine this service is reasonable and necessary.
  • · Document the items and expenses this service will cover in the person’s support plan.

    • Provider standards and qualifications

    Transitional services are approval-option: purchased-item services. For more information, refer to CBSM – Waiver/AC service provider overview.

    Providers must:

  • · Maintain all applicable licenses, permits and registrations as required for their business.
  • · Provide services in a cost-effective and appropriate way to meet the person’s needs, as identified in their support plan.

    • Authorization, rates and billing

    The lead agency authorizes transitional services at the market rate. For more information, refer to CBSM – Market rate services and Long-Term Services and Supports Service Rate Limits, DHS-3945 (PDF).

    Timeline

    The lead agency must authorize transitional services to be provided prior to or within 45 days of the person’s move from the eligible setting.

    Authorization when the person is in an institution

    A person may begin receiving transitional services before they are discharged from an eligible institution if they are expected to be discharged and enrolled on a waiver. The lead agency makes a referral to a provider and documents it in the person’s support plan.

    However, the lead agency can only authorize the service agreement and the provider can only bill for transitional services after the date the person is discharged from the eligible institution and enrolled on the waiver.

    Unforeseen circumstances

    If the person does not enroll on the waiver for an unforeseen reason (i.e., death or a significant change in condition) and meets certain criteria, the lead agency may request reimbursement for expense(s) it incurred in anticipation of the person enrolling. For more information, refer to CBSM – Waiver/AC reimbursement for unforeseen circumstances.

    MCOs

    If the person receives or was receiving services through a managed care organization (MCO), the lead agency must contact the specific MCO about procedures it needs to follow for reimbursement. An MCO may not request reimbursement from DHS for unforeseen circumstances.

    Additional resources

    CBSM – Housing resources
    CBSM – Integrated community supports
    CBSM – Market rate services
    CBSM – My Move Plan Summary
    CBSM – Waiver, AC and ECS process and procedures
    CBSM – Waiver/AC reimbursement for unforeseen circumstances
    CBSM – Waiver/AC service provider overview
    DHS – Housing Stabilization Services
    Long-Term Services and Supports Service Rate Limits, DHS-3945 (PDF)
    Moving Home Minnesota Program Manual
    Minnesota Department of Health – Health care provider directory
    MinnesotaHelp.info

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