Minnesota Minnesota

Community-Based Services Manual (CBSM)

Community-Based Services Manual (CBSM)


Elderly Waiver (EW) hospital high-needs budget exception and nursing facility conversion budget

Page posted: 9/25/19

Page reviewed: 12/30/25

Page updated: 12/30/25

Legal authority

Federally approved Elderly Waiver (EW) Plan, Minn. Stat. §256S.19, Minn. Stat. §256S.191

Definitions

Case mix classification: Classification used to establish a person’s individual community budgets under various programs. The classification is based on the assessment of the person’s:

  • · Ability to complete certain activities of daily living (ADLs).
  • · Need for behavioral interventions.
  • · Need for treatment and monitoring related to medical/health conditions.

    • Complex medical needs: Health conditions or situations that may require extensive and/or specialized medical care, management or interventions.

    Complex cognitive and/or behavioral health needs: Conditions or situations that cause a person to experience significant challenges related to their mental health or behavioral well-being that may require specialized and comprehensive interventions.

    EW hospital high-needs budget exception: Exception to the monthly case mix budget for a person on EW who is discharging from a hospital. The hospital high-needs exception is a budget amount requested by the lead agency that reflects the person’s individual needs to be supported in the community.

    EW nursing facility (NF) conversion budget: Exception to the monthly case mix budget for a person on EW who is leaving an NF. The NF conversion budget calculation process determines a new maximum set amount to be used for the person’s EW services.

    Hospitalized: Admission to a hospital as an inpatient after an official doctor’s order. The order must state that the person needs inpatient hospital care to treat the illness or injury.

    Lead agency: County, tribal nation or managed care organization (MCO).

    Monthly case mix budget: Total dollar amount available per month to support EW and Medical Assistance (MA) state plan home care services for a person based on their case mix classification.

    Overview

    The lead agency may submit a request for an EW hospital high-needs budget exception or EW NF conversion budget when the person meets the following criteria:

  • · Eligible for EW.
  • · In a hospital or NF.
  • · Has EW service needs that exceed the monthly EW case mix cap/budget.

    • The lead agency must submit the exception request before the person discharges from the applicable facility.

    Eligibility

    EW hospital high-needs budget exception

    A person may be eligible for the EW high-needs budget exception if they meet all the following criteria:

    1. Meets all eligibility criteria for EW, as described on CBSM – EW.

    2. Currently in a hospital, and hospitalization is no longer medically necessary. The person must be:

  • · Formally admitted as an inpatient in the hospital. Emergency room care or observation-only treatment does not meet the requirement for an exception request.
  • · In a hospital that is licensed by the Minnesota Department of Health or Forensic Mental Health Program (FMHP) with Direct Care and Treatment (DCT).

    • 3. Has complex medical, cognitive and/or behavioral health needs.

    4. Has service costs (as documented in the support plan) that exceed their assigned monthly case mix cap/budget.

    EW NF conversion budget

    A person may be eligible for the EW NF conversion budget if they meet all the following criteria:

  • · Meets all eligibility criteria for EW, as described on CBSM – EW.
  • · Is a resident of a certified NF for 30 or more consecutive days.
  • · Has service costs (as documented in the support plan) that exceed their assigned monthly case mix cap/budget.

    • Complex health need determination

    The assessor uses professional judgement when determining a complex health need. The person may present or report physical and/or cognitive/behavioral health symptoms that affect their ability to function each day and require support from another person. The assessor should do a comprehensive review of their needs, including medical and functional supports.

    To determine whether the person has complex health needs, it can be useful for the assessor to review and consider the following information:

  • · Current conditions and health stability.
  • · Need for complex health treatments and clinical monitoring.
  • · Chemical use or substance abuse issues that contribute to the person’s support needs because of impaired judgment, emotional instability and greater difficulty managing daily responsibilities.
  • · Dementia, significant cognitive decline or memory loss issues that require extensive or specialized intervention.
  • · How the person’s health needs affect their daily life.
  • · Supporting medical documentation from the person and/or their providers.

    • Service cost determination

    To determine if the cost of EW services (either traditional services or consumer directed community supports [CDCS]) would exceed the monthly case mix cap/budget, the lead agency must:

    1. Complete a MnCHOICES assessment with an activity date during the person’s hospital or NF stay.

    2. Develop a support plan that includes the services the person will receive.

    3. Determine the cost of the services included in the support plan.

    4. Compare the service costs to the person’s EW monthly case mix cap/budget in the support plan and take the appropriate action:

  • · If the cost of services in the support plan is equal to or less than the assigned case mix cap/budget, the person does not need a high-needs budget exception or conversion budget.
  • · If the cost of services in the support plan exceeds the assigned case mix cap/budget, the lead agency can request a high-needs budget exception or conversion budget.

    • Customized living considerations

    When a person is eligible for a high-needs budget exception or conversion budget, the lead agency can approve the customized living daily rate at a higher amount than the assigned case mix daily rate maximum. For an NF conversion budget request, the total amount of the person’s service costs must still fit under the EW conversion rate budget maximum.

    Request submission

    For all budget exception requests, the lead agency must complete the EW budget exception request form in MnCHOICES. The MnCHOICES Help Center includes a practice guide with details to complete the form.

    Instructions for people not enrolled in an MCO (i.e., fee for service [FFS])

    For instructions to submit the form to DHS, refer to the MnCHOICES practice guide – EW budget exception request in the MnCHOICES Help Center.

    Instructions for people enrolled in an MCO

    The lead agency must submit all required documentation to the MCO for approval. Contact the MCO for instructions.

    Approval

    DHS or the MCO will review the request and documentation and either:

  • · Approve the higher amount.
  • · Request more information from the case manager/care coordinator.

    • Budget authorization

    Instructions for people not enrolled in an MCO (i.e., FFS)

    After DHS approves the request in MnCHOICES, DHS will send instructions to the county or tribal nation to authorize the budget in MMIS.

    Instructions for people enrolled in an MCO

    After the MCO reviews and approves the request in MnCHOICES, the MCO follows their own process to authorize the high-needs budget exception or conversion budget amount. The MCO must approve the high-needs budget exception or conversion budget before they approve the support plan.

    Increase requests/rate adjustments

    Increase to NF conversion budget

    If the person’s approved conversion budget amount is less than the calculated maximum conversion budget, the lead agency may request an increase within the first service span, up to the calculated maximum conversion budget. DHS or the MCO must approve this change.

    To submit the request, the lead agency must complete a functional needs update (FNU) assessment to reflect the person’s change in needs and submit a new request form. The lead agency can only submit an increase request during the first service span.

    Rate adjustment to NF conversion budget

    If EW rates increase through a legislative rate adjustment, the lead agency may request an increase that equals that percentage increase.

    To submit the request, the lead agency must complete an assessment (i.e., reassessment or FNU) to reflect the person’s change in needs and submit a new request form. The request must include detailed documentation of the person’s continued need for service costs in excess of their current conversion budget and greater than the published case mix budget.

    Approval of high-needs budget exception or NF conversion budget after a reassessment or FNU

    DHS or the MCO must review and approve all high-needs budget exceptions and conversion budgets after a reassessment or FNU to continue or modify the previously approved cap/budget. A person no longer needs a high-needs budget exception or conversion budget when their needs can be met within the published monthly case mix cap/budget.

    The lead agency must submit a new request form after a reassessment or FNU.

    Note: EW high-needs exceptions address ongoing/long-term needs for the person that cannot be met by available EW case mix cap/budget. The person must receive an assessment (i.e., reassessment or FNU) to continue or modify the exception.

    Coordination with other resources

    In addition to the high-needs exception, the following programs and services can help support the person’s transition to community from an institution:

  • · Community resources.
  • · Informal supports.
  • · Moving Home Minnesota (MHM).
  • · Complex transitions team.
  • · Relocation service coordination targeted case management (RSC-TCM).
  • · EW transitional services.

    • The lead agency must ensure services are not duplicated. For more information, refer to CBSM – Waiver, AC and ECS case management.

    Additional resources

    CBSM – Assessment and support planning
    CBSM – EW
    CBSM – Rate methodologies for AC, ECS and EW service authorization
    CBSM – Resource: Customized living component service definitions and guide for computing time for rate-setting tools
    CBSM – Support planning for long term services and supports (LTSS)CBSM – Waiver, AC and ECS general processes and procedures
    CBSM – Waiver/AC service provider overview
    CDCS Manual – Budgets
    DHS – EW residential services
    Long-Term Services and Supports Service Rate Limits, DHS-3945 (PDF)

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