Federally approved BI, CAC, CADI, DD and EW waiver plans, Minn. Stat. §256B.0911, Minn. Stat. §256B.092, Minn. Stat §256B.0913, Minn. Stat. Ch. 256S

Support planning: A person-centered process that helps people identify and access social, health, educational, vocational and other supports and services based on each person’s values, strengths, goals, preferences and needs. The process encourages the use of technology, informal supports, formal supports and services. The support planning process is documented in the community support plan (CSP) and coordinated services and supports plan (CSSP).

Community support plan (CSP): A written summary completed for everyone who has an assessment, regardless of whether the person is eligible for Minnesota Health Care Programs (MHCP) or chooses to receive publicly funded home and community-based services or state plan services. This document provides a summary of what the assessor discovered through the assessment process and identifies next steps based on the person’s needs.

Coordinated services and supports plan (CSSP): A summary of the person’s choice of supports and/or services and the person’s preferences for the delivery of supports/services. A CSSP is only completed if the person is eligible for and chooses to receive publicly funded home and community-based services and/or state plan services.

Support planner: A professional who helps the person with the long-term services and supports (LTSS) support planning process. Professionals who can provide this support include certified assessors, case managers and care coordinators.

Informal supports: Any unpaid support provided by family, friends, coworkers, neighbors or other community members.

The person who receives services must be at the center of the support planning process. The support planning process must involve the person and their legal representative, if applicable. The certified assessor, case manager or care coordinator will lead the process with the person. The process may also involve providers and other people, as designated by the person (e.g., informal supports).

Summary of the process for counties and tribal nations

Throughout the initial/annual assessment and support planning process, the certified assessor and case manager are responsible to:

Counties and tribal nations summarize the decisions made during the person-centered planning process using the CSP and CSSP in the MnCHOICES Support Plan Application.

Summary of the process for MCOs

Managed care organization (MCO) care coordinators use the care plan tool(s) provided by the MCO, which include all required support planning components.

This page provides information about:

A person has the right to request a conciliation conference or appeal hearing at any time during the assessment and support planning process. The lead agency provides the person with a copy of Your Appeal Rights, DHS-1941 (PDF) at assessment and during the support planning process. For more information, refer to CBSM – Appeals.

Lead agencies must ensure support planners who help people develop support plans meets the qualifications for their role.

Certified assessors

For qualifications, refer to CBSM – MnCHOICES certified assessors.

Case managers

For qualifications, refer to CBSM – Waiver/AC case management and CBSM – Rule 185 case management.

Care coordinators

Qualifications for MCO care coordinators are outlined in the contracts between DHS and MCOs. For more information, refer to DHS – Managed care contracts.

People age 65 or older

When completing a support plan for people age 65 or older who are currently fee-for-service and will be transitioning to an MCO and the Elderly Waiver (EW), the county/tribal nation may choose to use either the MnCHOICES Support Plan Application or the MCO-specific care plan tool(s).

Information from providers

Providers can inform the support planning process by providing the certified assessor or case manager with written reports.

A 245D intensive support services provider must provide written reports about the person’s progress as requested by the person, legal representative, case manager or team. The CSSP support planner should note the expected frequency of these reports in the CSSP.

Record keeping

Lead agencies are responsible to maintain clear records in the event of a review. Lead agencies should:

Contact information for grievances

Lead agencies should provide grievance contact information to all people who receive waiver case management, Rule 185 case management and developmental disability targeted case management.

Counties must ensure that people receive contact information to file a grievance with the county about the quality of their contracted case management services. This requirement applies to people with developmental disabilities who receive contracted case management services and access an HCBS waiver, Rule 185 case management or developmental disability targeted case management.

The certified assessor and the case manager must work together so the person is provided the CSP and CSSP in a timely manner, no later than 60 calendar days from the in-person assessment.

Note: MCOs may have different timelines. Care coordinators must follow the MCO’s protocol.

Lead agencies must:

The certified assessor is responsible for the initial/annual assessment and does all of the following:

The case manager and certified assessor work together to share information and provide continuity of care throughout the assessment and support planning process. Case managers should use MnCHOICES Reassessment Communication Form, DHS 6791E (PDF) to communicate with the certified assessor about the person’s assessment.

Before the initial assessment/annual assessment

The case manager follows internal lead agency procedures or uses MnCHOICES Reassessment Communication Form, DHS 6791E (PDF) to share the following information with the certified assessor:

The case manager also:

After the assessment

Once the certified assessor completes and closes the assessment and CSP, the case manager and the person develop a CSSP that is person-centered and identifies the person’s goals, needs and preferences of how the person will receive services and supports.

The case manager:

If a person informs their case manager that they would like to move out of their current home, or would like information about service alternatives and living somewhere else, the case manager should discuss possible service and housing options with the person that could assist the person with moving to and living somewhere else, for example, Housing Stabilization Services and tools such as those available on HB101.org. If the person chooses Housing Stabilization Services, the case manager will assist the person with accessing Housing Stabilization Services.

Each person must be provided all available options and requirements must be met as identified in Minn. Stat. §256B.4905 and the Person-Centered, Informed Choice and Transition Protocol. The case manager/care coordinator must also:

For additional information, refer to:

If a person is enrolled in MSHO/MSC+ and not on BI, CAC, CADI or DD waivers, the MCO care coordinator is responsible to perform all assessment and case management activities for the person.

The care coordinator should follow the MCO’s protocols for assessment, support plans and authorization. For information about assessment responsibilities, refer to CBSM – Assessment applicability and timelines.

Care coordinators use the care plan tool(s) provided by the MCO instead of DHS’ CSP and CSSP. These tools include all required components.

For BI, CAC, CADI and DD, if a person’s county of financial responsibility (CFR) changes mid-year, the new CFR should update the CSSP with any significant changes using the CSSP created by the previous CFR.

In the MnCHOICES Support Plan, the new case manager should:

The lead agency monitors and makes necessary changes to a person’s support plan when the person is admitted to and discharged from certain settings (e.g., hospital, residential treatment, nursing facility).

When a person experiences stays in certain settings for 121 or fewer days, the person may restart their waiver without receiving a new assessment (refer to CBSM – Temporary waiver exits and restarts).

A person must receive a new reassessment to restart their waiver if they enter a setting and one or more of the following is true:

When a person needs a new assessment, the lead agency must notify the county where the person is located or tribal nation in a timely manner about the person’s need for an in-person assessment. If the person is enrolled in MSHO or MSC+ the MCO assigns a care coordinator to complete the assessment. For more information, refer to CBSM – Assessment applicability and timelines.

The certified assessor/care coordinator must monitor assessment timelines and use an eligibility update if the person experiences a delay in proposed discharge date from the institutional stay that will or is likely to exceed 60 days from the in-person assessment. For more information, refer to CBSM – Eligibility update for home and community-based services.

For instructions about temporary waiver exits and restarts specific to the waiver and type of institution, refer to CBSM – Temporary waiver exits and restarts.