Minnesota Minnesota

Community-Based Services Manual (CBSM)

Community-Based Services Manual (CBSM)


Relocation service coordination targeted case management (RSC-TCM)

Page posted: 10/1/03

Page reviewed: 8/1/22

Page updated: 8/1/22

Legal authority

Minn. Stat. §256B.0621, subd. 2-4 and 6-10

Definitions

Relocation service coordination targeted case management (RSC-TCM): A form of TCM that provides coordination of activities to help a person who resides in an eligible institution gain access to medical, social, educational, financial, housing and other services and supports that are necessary to move to the community.

Institution: For the purposes of this page, "institution" is defined as any of the following:

  • · Hospital
  • · Nursing facility (NF), including certified boarding care facility
  • · Intermediate care facility for persons with developmental disabilities (ICF/DD)
  • · Regional treatment center (RTC) that provides inpatient services to people who currently receive Medical Assistance (MA).
  • Eligibility

    To receive RSC-TCM, a person must meet all of the following criteria:

  • · Be eligible for and receiving MA
  • · Reside in an eligible institution (per the definition section) at the time the person receives RSC-TCM
  • · Be closed to any home and community-based services (HCBS) waivers due to a stay in an eligible institution
  • · Choose to live in the community
  • · Choose to receive RSC-TCM
  • · Not receive duplicative services as part of the institution’s discharge plan
  • · Have an assessment to determine and document eligibility for RSC-TCM.
  • Upon admission to or at any time during a stay in an eligible institution, a person (or someone acting on their behalf) can request RSC-TCM:

  • · During the MnCHOICES assessment, which must occur before the 80th day of admission for people younger than age 65 (For information about MnCHOICES and long-term care consultation [LTCC] assessment timelines, refer to CBSM – Assessment applicability and timelines.)
  • · By contacting the county in which the person resides
  • · By contacting the managed care organization (MCO) care coordinator if the person is enrolled in Minnesota Senior Health Options (MSHO) or Minnesota Senior Care Plus (MSC+).
  • Note: 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.

    Before authorizing RSC-TCM, the lead agency must review the person’s eligibility in the Medicaid Management Information System (MMIS) or the DHS Eligibility Verification System (EVS) (refer to MN-ITS User Manual – Eligibility verification).

    Timeline

    A person needs an assessment to determine and document their eligibility for RSC-TCM. The timeline for authorization is different depending on the type of assessment:

  • · If the person had a MnCHOICES or LTCC assessment, the lead agency can authorize RSC-TCM within 365 days from the date of the assessment
  • · If the person had a developmental disabilities (DD) screening, the lead agency can authorize RSC-TCM within six months from the date of the assessment, as long as RSC-TCM is listed as a current service.
  • A person eligible for RSC-TCM must be assigned an RSC targeted case manager who begins working with the person within 20 days of their request for services.

    A person receiving RSC-TCM is limited to 180 consecutive days of service per eligible institutional admission. For more information, refer to the limitations section below.

    To access RSC-TCM again, a person must have one full day in the community between discharge from the institution and eligible readmission. The financial worker must document this information in MMIS.

    Roles and responsibilities

    Counties of financial responsibility (CFRs) and enrolled tribal nations are responsible to ensure all eligible people receive RSC-TCM, except for people enrolled in the following programs:

  • · MSHO
  • · MSC+.
  • MCOs are responsible to ensure people enrolled in the following programs receive RSC-TCM:

  • · MSHO
  • · MSC+.
  • If a person is on MSHO or MSC+, the assigned MCO care coordinator provides or arranges for RSC-TCM. If a person has been receiving RSC-TCM before enrolling in the MCO, the person can choose to continue to work with their current RSC targeted case manager or receive RSC-TCM from the care coordinator.

    The RSC targeted case manager must take the necessary steps to coordinate all relocation efforts with the CFR, tribal nation or MCO to ensure continuity of care and non-duplication of effort. This includes documenting the role and responsibilities of the RSC targeted case manager, as well as other professionals providing support to the person.

    If the CFR, tribal nation or MCO is unable to provide RSC-TCM, it can:

  • · Contact the county where the person resides and request that it provide RSC-TCM
  • · Contact a private RSC-TCM agency certified by DHS.
  • Private RSC-TCM providers must coordinate efforts with the person’s CFR, tribal nation or MCO.

    All people eligible for RSC-TCM must have free choice of the available providers of RSC-TCM. The CFR, tribal nation or MCO must provide service coordination provider options at the first contact and upon request. For a list of private providers, refer to CBSM – Transition services provider contact list.

    Covered services

    RSC-TCM includes, but is not limited to:

  • · Development and implementation of a relocation plan with the person
  • · Coordination and monitoring of the implementation of the plan
  • · Communication with the person, legal representative (if applicable), informal supports, service providers and others as necessary to implement the relocation plan
  • · Coordination of referrals and assistance to access services and housing
  • · Coordination of efforts with the discharge planner at the institution
  • · Travel to conduct a visit with the person and others identified as necessary to develop and implement the goals of the relocation plan
  • · Updates to the relocation plan when necessary
  • · Completion and maintenance of documentation in case notes that supports and verifies RSC-TCM activities.
  • RSC targeted case managers will contact and communicate with the person based on the person’s preferences and needs.

    Non-covered services

    RSC-TCM does not include:

    1. Services for a person who lives in the community or an ineligible institution
    (Note: Intensive residential treatment services facilities licensed as board and lodging or supervised living facilities are not eligible RSC-TCM facilities.)

    2. Services for a person who receives:

  • · Mental health (MH) TCM
  • · Vulnerable adult/developmental disability (VA/DD) TCM
  • · Behavioral health home services
  • 3. Services for a person currently on an HCBS waiver program

    4. Transition assistance when a person moves from one institution to another, unless the person’s relocation plan indicates a move to another institution is a necessary step toward their eventual move to the community.

    Limitations

    If the person receives RSC-TCM, they are limited to 180 consecutive days of RSC-TCM per eligible institutional admission, starting on the date they first receive any of the following services:

  • · RSC-TCM
  • · MH-TCM
  • · VA/DD-TCM.
  • The 180-day limit starts on the date of service listed on the first TCM claim. MMIS will create a 180-day window based on that date, which prevents providers from billing past the 180-day limit.

    The person cannot receive RSC-TCM, MH-TCM and VA/DD-TCM at the same time. This is considered a duplication of services.

    Relocation plan

    The MnCHOICES/LTCC assessment results and the person’s preferences provide a foundation for the start of a relocation plan.

    A relocation plan is a written document that includes steps to help the person successfully discharge from the institution to the community, and it identifies who is responsible to complete each step. The RSC targeted case manager works with the person to develop the relocation plan. It must include all of the following information:

  • · The person and legal representative (if applicable)
  • · All case managers responsible for coordinating and planning for care
  • · The person’s goals
  • · The person’s needs, and how those needs will be met
  • · The amount, duration and frequency of RSC-TCM services
  • · The anticipated service outcomes, including anticipated discharge
  • · The method and frequency of monitoring the relocation plan.
  • Authorization, rates and billing

    The RSC targeted case manager may bill regardless of whether:

  • · The person’s community reintegration happens through an HCBS waiver or by other means
  • · The relocation plan was successful (i.e., the person returned to the community or remains in the institution).
  • For more information, refer to:

  • · MHCP Provider Manual – RSC-TCM
  • · Section 201.08 about RSC-TCM in Instructions for Completing and Entering the LTC Screening Document and Service Agreement into MMIS, DHS-4625 (PDF).
  • Additional resources

    Training

    “RSC: Learning the basics” is a self-paced online training. This module is located in TrainLink. You must have a unique key to register. If you do not have a unique key, refer to TrainLink – Unique key request form.

    In TrainLink, follow these steps:

    1. Under learning center, click Disability Services

    2. Under courses and classes, click find a course

    3. In the search by class name field, search for RSC101

    4. Click select next to the course name

    6. Enter your unique key and click OK.

    This course is also available on YouTube: RSC: Learning the basics (video). If you choose this option, you will not receive credit in TrainLink.

    Other resources

    CBSM – Appeals
    CBSM – Transition services provider contact list
    Disability Hub MN – Housing toolkit
    MHCP Provider Manual – RSC-TCM
    MN-ITS User Manual – Eligibility verification

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