Minn. Stat. §256B.0911, subd. 3a and 5

This page provides information about the applicability of and timelines for long-term services and supports (LTSS) assessments. For more information about assessments, including who does them and how, refer to CBSM – MnCHOICES.

This page includes information about:

Lead agencies must provide MnCHOICES assessments to all people, regardless of their eligibility for Minnesota Health Care Programs (MHCP).

People accessing a disability waiver or Rule 185, or people younger than age 65

This section applies to:

For the people listed above, the county where the person is located at the time of the request for assessment is responsible to complete the assessment activities. If eligible, the person may choose to have a tribal nation complete their assessment. For more information, refer to CBSM – Tribal administration and management of home and community-based services (HCBS) programs.

In most situations, the person’s county of residence completes the assessment activities. However, there are situations when the person may temporarily be located in another county. When the person is in a county other than their county of residence, the county where the person is located is responsible to complete the assessment activities.

The county/tribal nation must follow timelines and procedures detailed on:

People age 65 or older

For people age 65 or older who are not accessing the BI, CAC, CADI or DD waivers, assessment responsibility depends on whether the person is enrolled in Minnesota Senior Health Options (MSHO) or Minnesota Senior Care Plus (MSC+).

Not enrolled in MSHO or MSC+

When the person is not enrolled in MSHO or MSC+, the county where the person is located at the time of the request for assessment is responsible to complete the assessment activities. If eligible, the person may choose to have a tribal nation complete their assessment. For more information, refer to CBSM – Tribal administration and management of HCBS programs.

In most situations, the person’s county of residence completes the assessment activities. However, there are situations when the person may temporarily be located in another county. When the person is located in a county other than their county of residence, the county where the person is located is responsible to complete the assessment activities.

Enrolled in MSHO or MSC+

When the person is enrolled in MSHO or MSC+, the managed care organization (MCO) is responsible to complete the assessment activities, regardless of the person’s location. If eligible, the person may choose to have a tribal nation complete their assessment. For more information, refer to CBSM – Tribal administration and management of HCBS programs.

However, the MCO should refer the person to the county/tribal nation in which the person is located for an assessment if the person requests to:

The assessment interview always involves the following people:

The assessment is always conducted in person with the person exploring options or receiving services. The people who participate in the assessment must not have a financial interest in the provision of services (except for family members).

Legal representatives

A person’s legal representative should be present for the in-person assessment. The lead agency must make every effort to accommodate both the person’s and the legal representative’s schedules so both can attend the assessment in person.

If the legal representative cannot participate in person, the lead agency can engage with them using remote technology or telephone to ensure timely access to and continuity in service provision.

When entering information into MMIS about the people who participated in the assessment, the lead agency must use the comment section to indicate if the legal representative’s participation was via remote technology or telephone.

Case managers

In general, the person’s case manager should not attend the assessment. Both the case manager and the assessor have a responsibility to update each other and work cooperatively on the person’s behalf.

If a person specifically requests that their case manager attend the assessment, the assessor should honor the person’s request. However, the assessor must organize the interview to ensure the person has the opportunity to share information privately.

Billing

Attending an assessment is not a billable waiver case management activity. However, the case manager may bill for time engaged in allowable activities, including time engaged with the person in support-planning discussions. For more information, refer to CBSM – Waiver/AC case management.

Care coordinators

MSHO and MSC+

The care coordinator conducts the assessment for a person enrolled in MSHO and MSC+ who is not on the BI, CAC, CADI or DD waiver.

If a person age 65 or older is accessing the BI, CAC, CADI or DD waiver, the county/tribal nation is responsible to conduct the person’s assessment. The person may choose to have their MSHO or MSC+ care coordinator present for the assessment. DHS encourages lead agencies to coordinate the assessment so the certified assessor and care coordinator can conduct the meeting jointly.

SNBC

A person enrolled in SNBC might choose to have their care coordinator present for the assessment. DHS encourages lead agencies to coordinate the assessment so the certified assessor and care coordinator can conduct the meeting jointly.

Service providers

The input of providers is an important part of the assessment process. Service providers are encouraged to participate in the assessment process and submit supporting documentation, but they should not attend the in-person assessment. The person needs the opportunity to share information privately.

A person needs an in-person assessment when they:

Examples of when the lead agency must consider an in-person assessment include:

Remote reassessments conducted by interactive video or telephone may substitute for in-person reassessments in certain circumstances. For more information, refer to the remote reassessments section lower on this page.

Who needs it

An initial assessment is completed for a person who is not currently receiving waiver services.

In some situations, a person needs an annual initial assessment. This includes a person who:

A person or their legal representative may request an initial assessment at any time, whether they live in an institution or in the community.

Third party requests

When a third party requests an assessment on behalf of a person, the lead agency must contact the person to confirm it is the person’s choice to have an assessment. If the person does not agree to an assessment, the lead agency does not complete one. If the person is not able to communicate actively about their agreement to have an assessment, the lead agency should use professional judgment in honoring the third party’s request.

Timeline

The lead agency must complete an in-person assessment no later than 20 business days after the date on which an assessment was requested or recommended.

The lead agency must conduct assessments in a timely manner and expedite urgent referrals and requests. The lead agency should evaluate urgent requests based on the person’s needs and potential risks if the assessment is delayed.

The following sections include timelines for specific situations.

Admission to ICF/DD

The lead agency must complete an in-person assessment and evaluate the person’s need within five business days of an emergency admission to an ICF/DD.

Admission to NF

For people admitted to an NF, the following timelines apply:

If the person leaves the NF for another institutional setting (e.g., hospital) for any amount of time after admission, the 80-day timeline resets when the person reenters the NF.

45-day temporary start of service

When a provider requests a 45-day temporary start of service for PCA/CFSS services, the lead agency must complete a telephone assessment with the person to determine the person’s needs before services start. Then, the lead agency must complete an in-person assessment within the 45-day authorization period. For more information, refer to CFSS Manual – 45-day temporary start of PCA/CFSS services.

Note

Each time a person opens or reopens to a waiver program, the lead agency must apply the conversion or diversion definitions to determine the waiver type. If a person opens to a conversion waiver but then exits, the person cannot reopen to a conversion waiver.

For more information, refer to:

Starting services within 60 calendar days of the initial assessment

A person can start need-based services (e.g., CFSS) and move to waiver services within 60 days without receiving a new assessment. In this situation, the person does not need a new assessment. The lead agency can reopen the person’s MnCHOICES assessment if the person needs updates to their assessment summary within 60 days of the in-person assessment. The waiver span cannot overlap with the CFSS service agreement. The lead agency must close the type B service agreement before opening a waiver.

Initial assessments are valid for 365 days after the date of the in-person assessment interview to:

LTSS reassessments are valid for 60 days from the date of the reassessment interview to continue a person on a program.

An IAR is a remote activity that follows an initial assessment. The assessor can use it to document new changes and open a person to a program. For more information, refer to CBSM – IAR for HCBS.

Who needs it

A person needs an annual reassessment if they are on:

Note

In some situations, a person needs an annual initial assessment.

This means the assessment type is an initial assessment, rather than a reassessment. An annual initial assessment is required for a person who:

Choice to waive

Although DHS strongly encourages an annual reassessment for everyone, the person or their legal representative may waive it in certain situations. For more information, refer to CBSM – Choice to waive annual reassessment.

Timeline

AC, ECS and EW

A person must receive an annual reassessment within 60 days before the end of their current service agreement or program eligibility span, but no later than 365 days from the last in-person assessment, if the person uses:

BI, CAC, CADI, DD and CFSS

A person must receive an annual reassessment within 60 days prior to the end of their current service agreement if the person uses:

When a person does not have a service agreement, the annual reassessment must occur no later than the anniversary month of their last in-person assessment.

Waiver waiting list

A person who wishes to remain on the waiver waiting list must receive an annual reassessment no later than the anniversary month of their last assessment.

Changes in need after an assessment

The lead agency may address some short-term changes after an assessment if a person already has an assessed need for supports by:

If a person only uses state plan services (i.e., not waiver services), the lead agency must complete an in-person reassessment to address needs that require more than 45 days of increased CFSS services.

If a person experiences a change in need that cannot be addressed using the above strategies, the lead agency may conduct an early reassessment or, for a person on AC/EW, complete a functional needs update (refer to the section below about functional needs updates).

The person, case manager or others (on behalf of the person) may request an early reassessment.

Timeline

The lead agency must:

Remote reassessments conducted by interactive video or telephone may substitute for in-person reassessments in certain circumstances:

When available, DHS recommends using interactive video to allow for observation (including observation of the person’s environment) and completion of screening tools (e.g., the mini-cog).

Note: For all programs, IARs do not count as a remote reassessment. The remote assessment policy only applies to reassessments.

Informed choice

If a person is eligible for a remote reassessment, the lead agency must provide information for the person to make an informed choice between a remote and in-person reassessment.

A person may only receive a remote reassessment if the lead agency provides informed choice and the person or their legal representative provides informed consent for a remote reassessment. When selecting a remote reassessment in MnCHOICES, the lead agency must document in the corresponding text box that they offered informed choice.

Considerations

Informed choice means a person understands all options available to them, including the benefits and risks of their decision. When providing information about remote and in-person reassessments, the lead agency must consider what information is important for the person to make an informed choice.

Some examples of considerations include:

For additional information about informed choice, refer to CBSM – Guide to encouraging informed choice and discussing risk.

What it is

A functional needs update is a remote assessment used by lead agencies to document a change to a person’s assessed need(s) any time during the service agreement year.

The certified assessor conducts the functional needs update. DHS recommends the certified assessor who completed the assessment for the service plan also completes the functional needs update.

The certified assessor uses professional judgment to determine when a person needs an in-person reassessment. A functional needs update does not replace an annual reassessment, and it does not reset or extend a program eligibility span or service agreement span. A person may choose to receive a reassessment instead of a functional needs update.

The certified assessor can only use a functional needs update when the person uses:

Note

The certified assessor cannot use a functional needs update when the person uses a disability waiver or CFSS services.

Who needs it

Situations in which the certified assessor can use a functional needs update include the need to make a change based on:

Process

After receiving a request for an assessment, the certified assessor contacts the person to determine the type of assessment needed. If the certified assessor determines a functional needs update is appropriate, the assessor must:

Timeline

The lead agency must:

Addressing changes without a functional needs update

A case manager/care coordinator can take the following actions without a functional needs update or a reassessment:

For more information, refer to CBSM – Support planning for LTSS.

The county/tribal nation must conduct reassessments for all people when they turn 65 years old if they are on one of the following waivers:

The person may be eligible for a remote reassessment on or after Nov. 1, 2023. For more information, refer to the remote reassessments section on this page.

Counties and tribal nations receive a quarterly report from DHS that identifies people who are turning 65 years old. DHS emails this report to the specific workers who subscribe to it.

During the person’s 64th year, the county/tribal nation must have a discussion with the person about service options and the implications of the person’s choice. During this discussion, the assessor and/or case manager should review the person’s need for services not offered by EW (e.g., employment services, independent living skills [ILS]).

Both the assessor and the case manager have a role in helping the person make an informed choice from all the available options.

At the 65th birthday reassessment, a person who receives disability waiver services may choose to:

Timeline

The county/tribal nation has a four-month window to conduct the 65th birthday reassessment. The four-month window includes the two months before the birthday month, the birthday month and one month after. For example, if the person turns 65 years old in January, the county/tribal nation can conduct the reassessment in November, December, January or February.

Recommendation

For people who are likely to transition to EW, it is best to conduct the assessment within 60 days of the person’s birthday. The county/tribal nation should:

How to document

To document the reassessment, the county/tribal nation enters a new screening document into MMIS using activity type 08.

The county/tribal nation should consult with the person about how this reassessment might affect the service authorization. After entering the in-person reassessment, the county/tribal nation can leave the current service authorization in place. This requires the lead agency to complete another assessment at the person’s typical annual reassessment time.

The lead agency can use the in-person 65th birthday reassessment to renew a service authorization in the following circumstances:

Additional information

People who turn 65 years old (including people enrolled in an MCO) can remain on, return to or move to another disability waiver if they are eligible to do so. For more information, refer to CBSM – Waiver, AC and ECS general processes and procedures.

There is no 65th birthday assessment for the DD Waiver. People age 65 or older who exit the DD Waiver may return to it because people of any age can access it if they meet eligibility requirements. For more information, refer to CBSM – DD Waiver.

If a person age 65 or older was previously on a BI, CAC, CADI or DD waiver (including people enrolled in an MCO or on EW), the person might be eligible to move to another disability waiver or return to a disability waiver if the person meets certain eligibility requirements.

Process

The assessor is responsible to:

Eligible to return to a disability waiver

For instructions, refer to CBSM – Waiver, AC and ECS general process and procedures.

Not eligible to return to a disability waiver

If the person is not eligible to return to the BI, CAC or CADI waiver, the assessor should determine the person’s eligibility for EW or other non-waiver services.

If the person is enrolled in an MCO, the MCO must use the assessment completed by the assessing lead agency. If the person chooses to receive EW, the MCO authorizes the renewal or return to EW.

Policy

CBSM – Activity timelines for reassessments when the COR and CFR are different
CBSM – Choice to waive annual reassessment
CBSM – DD screening
CBSM – IAR for home and community-based services
CBSM – FAQs about provider-signature requirements for HCBS support plans
CBSM – Long-term care consultation
CBSM – MnCHOICES
CBSM – Provider signature requirements for HCBS support plans
CBSM – Reassessments when the COR and CFR are different
CBSM – Rule 185 case management
CBSM – Support planning for LTSS
CBSM – Tribal administration and management of HCBS programs
CBSM – Waiver, AC and ECS general processes and procedures
CBSM – Waiver/AC case management
CFSS Manual – 45-day temporary increase of CFSS services
CFSS Manual – 45-day temporary start of CFSS services

Forms

CBSM – Forms for LTSS assessment, eligibility and support plans
Assessment Summary Worksheet, DHS-6791A (PDF)
HCBS Waiver, AC and ECS Case Management Transfer and Communication Form: Scenarios for People on AC, EW or ECS, DHS-6037A (PDF)
HCBS Waiver, AC and ECS Case Management Transfer and Communication Form: Scenarios for People on a Disability Waiver: BI, CAC, CADI and DD, DHS-6037B (PDF)
Instructions for Completing and Entering the LTCC Screening Document and Service Agreement into MMIS, DHS-4625 (PDF)