Minnesota Minnesota

Provider Manual

Provider Manual


Moving Home Minnesota (MHM)

Revised: July 8, 2025

  • · Overview
  • · Eligible Providers
  • · Eligible Members
  • · Qualified Institution
  • · Qualified Community Residence
  • · Lead Agency Responsibilities
  • · Member Enrollment
  • · Transition Coordinator Responsibilities
  • · Community-Based Participation
  • · Changes and Ending Enrollment with MHM
  • · Re-institutionalization During MHM Participation
  • · Covered Services
  • · Service Coverage Limitations
  • · Noncovered Services
  • · Authorizing Services
  • · Fee for Service
  • Ÿ  Managed Care
  • · Billing
  • · Billing for Fee for Service Claims
  • · Billing for Managed Care
  • · Legal References
  • Overview

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

    Eligible Providers

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

  • · A lead agency (county of financial responsibility (CFR), tribal nation or managed care organization)
  • · Under contract with a lead agency
  • · A Minnesota Health Care Programs (MHCP)-enrolled provider.
  • For instructions on how to enroll to become a new MHCP MHM provider or add MHM services to an existing MHCP-enrolled MHM provider enrollment record, refer to the MHM Provider Enrollment manual page.

    Eligible Members

    Eligibility for MHM services requires the member to currently reside in one or more qualified institutions for 60 or more consecutive days (refer to qualified institution section for details).

    Example: A member may start their institutional stay in a hospital and then move to another qualified institution without a stay in the community. This person’s stay is continuous and fulfills the 60-day institutional stay requirement if the member:

  • · Is enrolled in Medical Assistance (MA) before discharge from the qualified institution, with MA paying for at least one day of the institutional stay.
  • · Maintains enrollment in MA during the time they are eligible to receive MHM services.
  • · Desires to transition to a qualified community residence (refer to qualified community residence section for details).
  • Members age 65 and older
    All MHM-enrolled members age 65 or older must enroll in the Elderly Waiver (EW) program when they move to the community in order to access MHM services unless the member is eligible to enroll in a disability waiver program. For additional information on EW exceptions, refer to the “65 years of age” section of the Waiver, AC and ECS general processes and procedures page in the Community-Based Services Manual (CBSM).

    For members age 65 and older who are enrolled in either Minnesota Senior Health Options (MSHO) or Minnesota Senior Care Plus (MSC+), the Managed Care Organization (MCO) will serve as the lead agency for MHM and EW, and is responsible for transition service coordination. The MCO may arrange for another entity, such as, a private relocation services provider or a county agency, to serve in this capacity.

    For all other members, the county or tribe will serve as the lead agency. Please refer to the Lead Agency Responsibilities section and the MHM Program Manual for additional information.

    Qualified Institution

    A qualified institution can be any of the following:

  • 1. Hospital, including community behavioral health hospital (CBHH)
  • 2. Nursing facility
  • 3. Intermediate care facility for persons with developmental disabilities (ICF/DD)
  • 4. Child and adolescent behavioral health services (CABHS)
  • 5. Psychiatric residential treatment facility (PRTF)
  • 6. Institute for mental disease (IMD) for people younger than 21 and older than age 64 who reside in that IMD, as these people continue to be eligible for federally funded MA, as described in Eligibility Policy Manual – Program for people living in IMDs (section 2.5.4)
  • Note: For a person age 21 to 64, days spent in an IMD can count toward the 60-day requirement for MHM eligibility if the person spent at least one full day in a qualified institution immediately after IMD discharge and maintained their state-funded MA coverage while in the IMD.

  • 7. IMD/SUD, for people age 21 to 64, that meets the following requirements:
  • · Provider licensed under Minnesota Statutes, 245G as a residential substance use disorder (SUD) treatment program.
  • · Attested to provide a specified American Society of Addiction Medicine (ASAM) level of care and meet ASAM criteria standards under the 1115 Substance Use Disorder System Reform Demonstration, as required by Minnesota Statutes, 265B.0759, subd. 2b.
  • Note: For more information about the SUD refer to the Guide for MHM access and SUD in the MHM Program Manual.

    Qualified Community Residence

    Members participating in MHM must transition to a qualified community residence to maintain eligibility to receive MHM community-based services. These residences should honor personal choice and control of the member’s home, afford opportunities for independence and community integration, and include:

  • · A home owned or leased by the person or their family member.
  • · An apartment with an individual lease and living areas in which the person or their family has control.
  • · A Minnesota Department of Health (MDH)-licensed assisted living residence with an individual lease, lockable access and egress and living areas in which the person or the person’s family has access or control.
  • · A home in a community-based residential setting (for example, community residential settings, adult foster care or family foster care) in which no more than four unrelated people live.
  • Note: Sober living homes or environments, recovery residences and board and lodging with special services are not considered qualified community residences.

    Lead Agency Responsibilities

  • · To receive MHM services, the lead agency must complete a MnCHOICES assessment, long-term care consultation (LTCC) assessment, or a developmental disabilities (DD) screening to determine program eligibility and provide the member with informed choice. Applicants must meet the hospital or institutional level of care to be eligible to receive MHM services. Review the MHM – services page located in the MHM Program Manual for additional information on authorizing MHM.
  • · If the person has had a MnCHOICES or long-term care consultation (LTCC) assessment, the lead agency can authorize MHM within 365 days from the date of the assessment.
  • · If the person has had a developmental disabilities (DD) screening, the lead agency can authorize MHM within six months from the date of the assessment.
  • · If a member screens eligible for and chooses to receive MHM services, a MHM Intake Form (DHS-5032) must be submitted to DHS to confirm the member meets federal eligibility requirements.
  • · The lead agency is responsible for assigning a MHM transition provider if the lead agency will not be providing the transition coordination services. Review the MHM services section of the MHM Program Manual for information on using SSIS and BRASS codes when the lead agency is providing and billing for MHM services. The lead agency is also responsible for identifying if the member is eligible for waiver services and will assign a waiver case manager to assist the member when they transition into the community. Find more information on MHM community-based services in the Community-Based Participation and Transition to the Community - Service Authorization sections on this page.
  • Who acts as Lead Agency?

    Health Care Product

    Acting Lead Agency

    Enrolled in SNBC (under or over age 65)

    County of Financial Responsibility (CFR) or Tribal nation

    Enrolled in Families and Children

    CFR or Tribal nation

    Enrolled in Fee-for-Service MA (not enrolled in Managed Care)

    CFR or Tribal nation

    Enrolled in MSHO or MSC+ (age 65 and older)

    Managed Care Organization

    Enrolled in SNBC, Families and Children or fee-for-service MA (age 22-64), who are residing in an IMD which is:

  • · Licensed under Minnesota Statutes, chapter 245G as a residential SUD treatment program;
  • · Attested to provide a specified ASAM level of care and meet ASAM criteria standards under the 1115 Substance Use Disorder System Reform Demonstration, as required by Minnesota Statutes, 265B.0759, subd. 2b
  • Refer to MHM Program Manual – Guide for MHM access and SUD.

    Refer to the Lead agency responsibilities for MHM section of the MHM Program Manual for additional information.

    Member Enrollment

    Members may begin the enrollment process to receive MHM transition services at any point during their institutional stay by completing the online MHM Intake Form (DHS-5032). The intake form can also be faxed to 651-431-7745 or mailed to:

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

    The Senior LinkAge Line® (800-333-2433), Disability Hub MN™ (866-333-2466), the member’s county or tribal human services agency, or the member’s MCO care coordinator are also available to help provide information on assistance with enrollment in MHM.

    MHM Eligibility and Enrollment will provide notification of program eligibility and approval determinations to all pertinent parties via encrypted email to lead agencies and transition coordination providers. Paper copies will be delivered to the member’s most current address.

    Contact MHM Eligibility and Enrollment at movinghomemn.mfp@state.mn.us or 651-431-3951 for questions. Visit the MHM Eligibility and MHM Enrollment pages of the MHM Program Manual for additional information.

    For eligibility and enrollment information for MHM access and SUD, refer to the Guide for MHM access and SUD page.

    Transition Coordinator Responsibilities

    Find a list of enrolled and active MHM transition coordinators in the MHM Program Manual.

    The transition coordinator must complete and keep on record the following forms:

  • · MHM Informed Consent Form (DHS-6759I) (PDF) to review the member’s rights and responsibilities
  • · MHM Transition Planning Tool (DHS-6759J) (PDF) to assist in identifying what’s important to and for the member as part of the planning for the member’s transition to a qualified residence in the community.
  • · MHM Transition Planning Tool Part 2: Risk Mitigation and Emergency Backup Planning, DHS-6759K (PDF) to assist transition coordinators in addressing risks when no other risk mitigation tool exists.
  • · MHM Housing Transitions Worksheet (DHS-6759G) (PDF) to assist the member in choosing a qualified residence.
  • When a residence in the community has been selected, the transition coordinator must submit the online MHM Communication Form (DHS-6759H) and select the option “Assurance of Qualified Community Residence” for the “Reason for Communication.” The transition coordinator must provide the information requested and submit the form to MHM for review to ensure that the location is a qualified community residence. If the transition coordinator is certain that the location the participant will be moving to is not considered to be a qualified community residence, select the option “other” for the “Reason for Communication” and notify MHM of the planned move to an unqualified community residence. The member will be disenrolled at that time.

    Questions about how to complete the MHM Communication Form (DHS-6759H), please contact MHM Eligibility and Enrollment at movinghomemn.mfp@state.mn.us or 651-431-3951.

    Community-Based Participation

    Once the member has successfully transitioned to the community, the transition coordinator must notify MHM Eligibility and Enrollment by submitting the online MHM Communication Form (DHS-6759H). Select the option “Participant has transitioned to the community” for the reason for communication and provide the information requested and submit the form. When the member moves into a qualified community residence, the move-in date will serve as the start date for the member’s 365 days (366 days in a leap year) of MHM community-based service eligibility.

    When a MHM member is not receiving waiver case management, they will choose an MHM Demonstration Case Management (DCM) provider. The MHM DCM provider will complete the MHM service authorization (SA) using the MHM Service Authorization Plan (DHS-6759P) and submit this via:

  • · MHM Communication Form (DHS-6759H). Select option “Supporting Documents” for the reason for communication, or
  • · Secure email to MHM Eligibility and Enrollment at movinghomemn.mfp@state.mn.us.
  • If a member chooses MHM Comprehensive Community Support Services (CCSS) in addition to MHM DCM or waiver case magement, the CCSS provider must be a different provider than the DCM or waiver case management provider. The CCSS provider must communicate and collaborate with the assigned DCM or waiver case management provider to incorporate the CCSS services into the MHM service authorization.

    Changes and Ending Enrollment with MHM

    If a member receiving MHM services has a change in provider or case manager, or chooses not to utilize MHM services at any point in time after they have been approved and enrolled in MHM, the lead agency, transition coordinator, or case manager must notify MHM Eligibility and Enrollment of the change using the MHM Communication Form (DHS-6759H). For specific examples of when this notification must occur, please refer to the Reporting enrollment changes, reinstitutionalization and disenrollment for MHM page in the MHM Program Manual.

    Re-institutionalization During MHM Participation

    A member receiving MHM community-based services may need to return to an institution for short or long-term care, such as hospital or nursing facility rehabilitation. In these situations the lead agency, transition coordinator or case manager must notify MHM Eligibility and Enrollment of the change using the MHM Communication Form (DHS-6759H). Select the option “Moving Home Minnesota participant has been re-institutionalized”. Ongoing MHM participation will be affected depending on the length of stay:

  • · 30 days or less: MHM participation and eligibility spans will conitinue.
  • · More than 30 days: MHM participation will be suspended; however, people may:
  • · use any time left on their 365/366-day eligibility span after they return to the qualified community residence; or
  • · re-apply for MHM services, if they have continuously resided in a qualified institution for 60 or more days.
  • Covered Services

    Pre-transition services
    The following demonstration services are available through MHM before a person transitions to the community:

  • · 180 days of transition coordinationwith extensions available on a case-by-case basis
  • · Costs for finding housing and employment (including transportation, meals and lodging)
  • · Environmental modifications deposit
  • · Pantry stocking
  • · Pre-discharge case consultation and collaboration
  • · Pre-transition clean-up services
  • · Pre-transition non-medical transportation
  • · Records and fees
  • · Transition integration fund
  • · Transition plan development
  • · Transitional services(including furnishings, supplies and expenses associated with securing housing)
  • For details about specific services, refer to the pages linked in the bulleted list in this section.

    Post-transition services
    The following demonstration and supplemental services are available through MHM after a person transitions to the community for a 365-day enrollment period or 366-day enrollment period in a leap year:

  • · Community education and integration costs
  • · Comprehensive community support services
  • · Costs for finding employment
  • · Environmental modifications
  • · Home care training (family and non-family)
  • · Membership fees
  • · MHM demonstration case management services
  • · Overnight assistance
  • · Pantry stocking
  • · Personal emergency response systems (PERS)
  • · Records and fees
  • · Respite services
  • · Specialized supplies and equipment
  • · Transition integration fund.
  • · Tools, clothing and equipment necessary for employment
  • Service Coverage Limitations

    MHM services coverage is time-limited. Members are eligible for MHM services during the following time spans and circumstances:

  • · 180 days of eligibility for transition planning and transition coordination services while in a qualified institution
  • · MHM enrolled individuals may begin utilizing select transition services at any point during their stay in a qualified institution. Please refer to the MHM services page in the MHM Program Manual for additional information on services allowable prior to the 60 day institutional stay requirement.
  • · The 180-day limit starts with the start date on the approval letter from DHS.
  • · MHM start dates cannot be back dated. Retroactive enrollments will not be approved.
  • · DHS may grant extensions to the 180-day transition planning and transition coordination eligibility span on a case-by-case basis. The transition coordinator may request an extension using the MHM Communication Form (DHS-6759H). Select the option “Transition Coordinator Extension Request” communication reason.
  • · The transition coordinator must:
  • · Identify and describe the reason for the extension request.
  • · Identify the estimated number of additional days of transition planning and transition coordination services needed to transition the person to a qualified residence.
  • · 365 days (366 in a leap year) of eligibility for community-based demonstration and supplemental services while in a qualified community residence.
  • Transition providers and lead agencies must work closely to avoid claim denials due to ended eligibility, exceeded service limits or duplication of services.

    Refer to the MHM services page in the MHM Program Manual for a complete list of MHM services, including identification of whether or not the service(s) can be provided in addition to HCBS waiver program services.

    Find additional information on how MHM services interact with other waiver and state plan covered services on the MHM program interactions page of the MHM Program Manual.

    Noncovered Services

    This section of noncovered services is not all-inclusive. Receiving MHM services does not make the member ineligible to receive any state plan services, as long as the services do not duplicate or replace any other state plan or waiver services.

    A member cannot receive MHM transition planning and transition coordination services at the same time as they are receiving any of the following services:

  • · Relocation Service Coordination (RSC)
  • · Housing Stabilization Services (HSS) Transition Services
  • Denied or Suspended Claims

    MHM processes the denied claims for the following reasons:

  • · Beyond 180 days of Transition Coordination
  • · RSC and MHM in the same month
  • To request to reprocess a claim, use the MHM Communication Form (DHS-6759H). Select the option “Denied Claim(s).” The provider may enter up to four denied claims for the same person.

    For claims other than the above, please contact the MHCP Provider Resource Center at 651-431-2700 or 800-366-5411.

    Authorizing Services

    Fee for Service

    MHM services requires a Service Authorization with the exception of the following:

  • · Transition coordination
  • · Transition planning
  • · Transitional services (furnishing, supplies and expenses associated with securing housing)
  • · Pre-discharge case consultation
  • · Costs for finding housing and employment
  • If a member is on fee-for-service BI, CAC, CADI, DD or EW, their waiver case manager or case management aide authorizes MHM post-transition community services on their waiver service agreement in MMIS.

    Providers must not incur expenses until the provider receives a service authorization letter (SAL) in their MN–ITS SAL mailbox.

    If a member is not on a waiver, the MHM demonstration care management provider is responsible to authorize the person’s MHM post-transition community services. MHM staff enter service authorization information into MMIS for non-waiver participants only.

    The member’s living arrangement in MMIS must be updated to show the member has moved to the community for community-based claims to pay. Refer to the MHM services page in the MHM Program Manual for additional MHM service guidelines for MHM service authorizations.

    After post-transition services are approved, MHCP will provide the member, the provider of service(s), and the case manager a copy of the service authorization letter (SAL). The provider and the case manager will each receive the SAL in their MN–ITS SAL mailbox.

    The letter shows the services authorized through MHM. Providers must enter the service authorization number when submitting claims.

    The lead agency and the MHM provider are responsible for reviewing the SAL for accuracy before rendering and billing for services.

    Managed Care

    Minnesota Senior Health Options (MSHO) and Minnesota Senior Care Plus (MSC+):

  • · Providers should contact the MCOs directly for information on their authorization processes.
  • · For contact information, refer to DHS – MCO contacts for MHCP providers
  • For people enrolled in Special Needs BasicCare (SNBC) or Families and Children (PMAP), follow fee-for-service billing instructions.

    Follow the Billing for Waiver and Alternative Care (AC) Program guidelines for MHM services approved through the HCBS waiver programs. Refer to the MHM services page in the MHM Program Manual for additional MHM service guidelines for MHM service authorizations.

    Billing

    Billing Fee for Service Claims

    Bill only for services already provided to the member and approved on the SA, when required.

    Bill claims for MHM services according to the instructions of each service under the MHM services page in the MHM Program Manual. All submitted claims must be based on actual services or items purchased.

    Submitting Fee for Service Claims
    To submit claims for MHM services in MN–ITS, follow the MN–ITS Direct Data Entry (DDE) Professional (837P) User Guide.

    Billing for Managed Care

    Minnesota Senior Health Options (MSHO) and Minnesota Senior Care Plus (MSC+):

  • · Providers should contact the MCOs directly for information on their billing processes.
  • · For contact information, refer to DHS – MCO contacts for MHCP providers
  • For people enrolled in Special Needs BasicCare (SNBC) or Families and Children (PMAP), follow fee-for-service billing instructions.

    Legal References

    Deficit Reduction Act of 2005 (P.L. 109-171), section 6071 (Money Follows the Person Rebalancing Demonstration)
    Patient Protection and Affordable Care Act, 2010 (P.L. 111-148). section 2403 (Money Follows the Person Rebalancing Demonstration)
    Consolidated Appropriations Act, 2021 (P.L. 116-260), Division CC, Title II, Section 204, pages 1799-1802 (Extension of Money Follows the Person Rebalancing Demonstration)
    Minnesota Statutes, 256B.04, subdivision 20 (Money Follows the Person Rebalancing demonstration project)
    Minnesota Statutes, 256B.0621, subdivision 5 (Covered Services: Targeted Case Management Services)
    Minnesota Statutes, 256B.0911 (Long-Term Care Consultation Services)

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