Federally approved BI, CAC, CADI, DD and EW waiver plans, Minn. Stat. 256B.0913, Minn. Stat. §256B.49, Minn. Stat. Ch. 256S, Minn. Stat. §256B.092, Minn. R. 9525.0004 to 9525.0036, Minn. Stat. §256.012, Minn. Session Laws – 2021, 1st Special Session

This page applies to case management and care coordination provided under the following programs:

Waiver, AC and ECS case management: A service that provides people and their families with access to assessment, person-centered planning, referral, linkage, support plan monitoring, coordination and advocacy related to waiver/AC/ECS services, resources and informal supports that are not necessarily funded through the waiver/AC/ECS.

Care coordination: A service for people enrolled in Minnesota Senior Health Options (MSHO) and/or Minnesota Senior Care Plus (MSC+). It provides assessment and coordination of the delivery of all health and long-term care services among different health and social service professionals and across settings of care. Care coordination also includes the waiver case management responsibilities identified above. References to "case management" on this page also include care coordination, when applicable.

Case manager/care coordinator: The professional who assists with access to and navigation of social, health, educational, vocational and other community and natural supports and services based on the person’s values, strengths, goals and needs. This professional is responsible to provide the person with information necessary to make informed choices. References to "case manager" on this page also include care coordinator, when applicable.

Contracted case management: Case management services provided by a private agency who contracts with the person’s lead agency.

Courtesy case management: BI, CAC, CADI or DD case management services provided by a lead agency other than the lead agency responsible for managing the person’s waiver.

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

Waiver, AC and ECS case management includes the following activities:

1. Plan:

2. Refer and link:

3. Coordinate:

4. Monitor:

5. Advocate:

Waiver, AC and ECS case management cannot duplicate other Minnesota state plan or waiver services.

Administrative activities are not billable under any waiver, AC or ECS program. Administrative activities include:

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, tools such as those available on HB101.org.

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:

BI, CAC, CADI and DD case manager training

“Supporting A Person’s Move: A Case Manager’s Role” is an online, on-demand course for disability waiver case managers to guide them through their role and responsibilities in supporting a person to find a new home. All disability waiver case managers must complete this course and pass the required knowledge check.

This course is available through TrainLink. You must have a unique key to register and receive credit for training.

Steps to take the course

The case manager should:

Provision of case management

A person who receives waiver, AC or ECS services must be assigned an individual case manager. The case manager must provide their contact information so the person is able to contact them directly.

AC, ECS and EW

The county of residence (COR) or enrolled tribal nation provides access to and arranges the provision of AC, ECS and EW case management. For people enrolled in MSHO and MSC+, the MCO is responsible to provide EW case management services through care coordination.

BI, CAC, CADI and DD

The county of financial responsibility (CFR) or enrolled tribal nation arranges the provision of BI, CAC, CADI and DD waiver case management.

Choice of case management

The Minnesota Olmstead Plan and the Person-Centered and Informed Choice Transition Protocol, DHS-3825 (PDF) require that each person has choice, including choice of case management. A lead agency may support a person's choice of case management provider through available contracted case management providers or through BI, CAC, CADI and DD courtesy case management. A person’s case management options depend on the lead agency’s capacity, their contracted case management providers or other lead agencies. Minnesota's federally approved waiver plan gives lead agencies the authority to choose the providers with whom they contract.

Questions and grievances

Lead agencies must ensure that people receive contact information to file a grievance with the county about the quality of their contracted case management services (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). Lead agencies should provide grievance contact information to all people who receive waiver, AC or ECS case management.

When a person and/or their legal representative has questions about the case management services they receive, DHS recommends having a conversation that includes the person, the case manager, their supervisor and/or the CFR or COR, enrolled tribal nation or MCO. During this conversation, the participants should:

A person and/or their legal representative may request a new case manager and/or case management provider. In this situation, the lead agency must engage collaboratively with the person to discuss the available options and ensure they have explored all options to support the person's choice. The lead agency should clearly explain and document these conversations and any limitations to the person and/or their legal representative.

Financial interest

The case manager, care coordinator or case management aide cannot have a financial interest in any of the services the person receives.

Additionally, case management/case management aide services cannot be provided by a private agency that has a financial interest in any of the services the person receives.

Services under all waiver/AC programs must meet the requirements listed on the services section of CBSM – Waiver and AC programs overview.

AC, BI, CAC, CADI and EW

People on AC, BI, CAC, CADI and EW must receive another waiver service in addition to waiver/AC case management.

The lead agency may authorize waiver/AC case management without another waiver service for a maximum of 60 calendar days. During this timeframe, the case manager/care coordinator must check in with the person at least monthly (e.g., phone calls or in-person visits).

If the lead agency does not authorize an additional waiver service during the 60-day timeframe, the person must exit the waiver or AC until the person becomes eligible and the lead agency can authorize additional waiver services.

Exception

If the reason for not authorizing additional waiver/AC services is that the person is transitioning between providers, services or settings, DHS allows an additional 60 days to authorize an additional waiver/AC service. During this timeframe, the case manager/care coordinator must check in with the person at least monthly (e.g., phone calls or in-person visits).

If the lead agency does not authorize services during the additional 60 days (120 days total), the person must exit the waiver or AC until the person becomes eligible and the lead agency can authorize additional waiver services.

For people who receive AC and fee-for-service EW, refer to the instructions in section of 301.07 of the Instructions for Completing and Entering the LTCC Screening Document and Service Agreement Into MMIS, DHS-4625 (PDF).

For people who receive EW through an MCO, refer to the MCO's instructions.

DD

People on the DD Waiver must receive waiver case management and habilitation (refer to CBSM – Habilitation).

Starting DD Waiver

When a person starts the DD Waiver, the lead agency may authorize a support plan that does not include habilitation for a maximum of 90 calendar days. The case manager must:

If the lead agency does not authorize habilitation during the 90-day timeframe, the person must exit the waiver until the person becomes eligible and the lead agency can authorize additional waiver services.

Loss of habilitation while currently on DD Waiver

People currently on the DD Waiver must receive waiver case management and habilitation.

The lead agency may authorize waiver case management without habilitation for a maximum of 60 calendar days. During this timeframe, the case manager must check in with the person at least monthly (e.g., phone calls or in-person visits).

If the lead agency does not authorize habilitation during the 60-day timeframe, the person must exit the waiver until the person becomes eligible and the lead agency can authorize habilitation.

Exception

If the reason for not authorizing habilitation within 60 days is that the person is transitioning between providers, services or settings, DHS allows an additional 60 days to authorize habilitation. During this timeframe, the case manager must check in with the person at least monthly (e.g., phone calls or in-person visits).

If the lead agency does not authorize habilitation during the additional 60 days (120 days total), the person must exit the waiver until the person becomes eligible and the lead agency can authorize habilitation.

Additional types of case management

Some people who receive waiver, AC and ECS case management may be eligible for other types of case management (e.g., mental health case management). In these situations, DHS recommends the waiver, AC and ECS case manager/care coordinator:

If the person has more than one type of case manager/care coordinator (e.g., person also has a mental health case manager), the waiver, AC and ECS case manager/care coordinator is responsible for all covered waiver, AC and ECS case management services (refer to the covered services section on this page).

Excluded types of case management

People who receive waiver, AC and ECS case management are not eligible for the following types of case management:

For more information about types of case management, refer to CBSM – Case management/care coordination.

Case managers are responsible for ongoing monitoring of the provision of services included in the person’s support plan. Case managers must document each person’s plan for monitoring in their support plan.

The timelines below represent the minimum required frequencies for face-to-face visits. The frequency of face-to-face visits should increase based on the person's needs.

AC, ECS and EW

The waiver, AC and ECS case manager/care coordinator must conduct at least one face-to-face visit per 12-month period. This visit can be included as part of the person's annual reassessment if the assessor is also the case manager/care coordinator.

BI, CAC, CADI and DD

The waiver case manager must have a minimum of two face-to-face visits with the person within the 12-month period. The person’s annual reassessment may count as one face-to-face visit when case management activities are performed at the time of the visit.

Supporting the person’s meeting preferences

The case manager must coordinate all meetings based on the person's preferences and needs and in a way that supports the person’s choice and control. This includes decisions about meeting frequency, location, participants, time, scope and other factors.

To help the person and their family feel comfortable with in-person visits, the case manager should encourage them to decide the following information:

If a person prefers phone visits, the case manager should:

When exiting a person for not meeting the face-to-face requirements, the case manager should consult their supervisor and any applicable lead agency practices.

AC, BI, CAC, CADI, ECS and EW

The lead agency may employ or contract with the following people to provide case management:

Public health nurse and registered nurse

A public health or registered nurse providing case management must be licensed under Minn. Stat. §148.171-§148.285.

Social worker

A social worker providing case management must either:

For lead agencies that use the Minnesota Merit System or a county civil service system, social workers must:

For more information, refer to DHS – Minnesota Merit System.

Care coordinator

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

DD

A case manager must have:

Registered nurse requirement

A registered nurse must be designated as either the case manager or the qualified developmental disability professional (QDDP) for people who are both:

Tribal nations

For services provided by tribal governments, alternative credentialing standards can be applied under Minn. Stat. §256B.02, subd. 7. For more information, refer to CBSM – Tribal administration and management of HCBS programs.

Training requirements (BI, CAC, CADI and DD only)

If a case manager works with a person on the BI, CAC, CADI or DD waiver, they must complete 20 hours of case management education and disability-related training each year.

Case managers can complete the 20 hours of training annually by calendar year or annually by hire date according to their county or tribal nation.

Required topics

The 20 hours of education and training must include:

DHS – Training opportunities for case managers and care coordinators includes a list of recommended trainings to help disability waiver case managers meet these requirements. This resource is part of DHS – Case manager and care coordinator toolkit.

With the exception of the required courses listed in the next sections, case managers can be flexible in the trainings they use to meet the 20-hour requirement. They may receive training from DHS, a county/tribal nation or training providers approved by a county/tribal nation. The county/tribal nation must monitor and record timely completion of case manager training.

Required one-time courses

Getting to Work: A Case Manager’s Guide to Supporting Employment

All case managers must complete this course by Aug. 1, 2024. Case managers hired after Aug. 1, 2024, must complete this training within the first six months of providing case management services. For instructions to complete the course, refer to TrainLink – Self-paced online course: Getting to Work: A Case Manager’s Guide to Supporting Employment.

This course satisfies the “employment planning” training category.

Supporting A Person’s Move: A Case Manager’s Role

Disability waiver case managers must complete this course, which is an online, on-demand course for disability waiver case managers to guide them through their role and responsibilities in supporting a person to find a new home. All disability waiver case managers must complete the course and pass the required knowledge check. For instructions and additional information, refer to TrainLink – Self-paced online course: Supporting My Move and the section on this page about supporting a person’s move.

This course satisfies the “community living” training category.