Legal authority

Federally approved EW Plan, Minn. Stat. §256B.0913, Minn. Stat. Ch. 256S

Definitions

Monthly case mix budget: The total dollar amount available per month to support Alternative Care (AC), Elderly Waiver (EW) and Medical Assistance (MA) state plan home care services for a person based on their case mix classification.

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

Institution: For this policy, an institution is defined as a:

Overview

This page provides information about:

Note

Essential Community Supports (ECS) does not use case mix classification to determine budgets. Instead, it has a specified budget. For more information, refer to CBSM – ECS.

Case mix classifications

Case mix classification for a person on AC or EW is determined by one of the following assessment methods:

Each case mix classification has a monthly budget amount determined by DHS. A person uses this budget to pay for services they choose that support their health and safety in their home and community. AC, BI, CADI, EW Case Mix Classification Worksheet, DHS-3428B (PDF) describes the steps used in case mix classification determination.

For current long-term services and supports rate limits, refer to Long-Term Services and Supports Rate Limits, DHS-3945 (PDF).

Budgets

AC or EW only

For people who only use AC or EW, the case manager or care coordinator arranges for and authorizes services based on the person’s:

AC and EW use a case mix budget amount over the span of the service agreement year. To calculate a person’s annual budget amount, the case manager or care coordinator multiplies the monthly case mix budget cap amount times the months in the waiver or AC span.

For example, a person classified as case mix B has a monthly budget amount of $3,931 x 12 = $47,172. The total is used as the person’s annual budget.

The AC or EW service agreement displays the budget amount, as well as the units, duration and rates for each authorized service. The authorized amount for all combined services must stay within the total annual budget amount. The case manager or care coordinator authorizes services using published rates and rate limits. For current long-term services and supports rate limits, refer to Long-Term Services and Supports Rate Limits, DHS-3945 (PDF).

AC or EW with state plan home care services

State plan home care services (including personal care assistance [PCA]) and EW extended home care (including extended PCA) are authorized on the person’s AC or EW service agreement. State plan home care services are included in the person’s case mix budget cap.

To authorize home care services for people on EW who are enrolled in an MCO, the care coordinator follows the MCO’s procedure, unless the person receives case management through a tribal nation. Contact the case manager at the tribal nation for more information and refer to CBSM – Tribal administration and management of HCBS programs.

AC or EW with CDCS

The monthly budget amount for consumer directed community supports (CDCS) under AC and EW is not the same as the case mix budget for traditional AC and EW services. This amount appears on the MMIS long-term care (LTC) screening document when the CDCS field is “Y”. These budget amounts are also included in Long-Term Services and Supports Rate Limits, DHS-3945 (PDF). For more information, refer to CDCS Policy Manual – Budgets.

Case mix budget exceptions

Premature exit

If a person exits AC or EW prematurely due to death or enters an institution for more than 30 days, AC or EW can exceed the individual budget cap to pay for all services authorized and provided before the date of the person’s death or institutional stay. The lead agency completes the exception process if the cost of AC or EW services to be reimbursed exceeds the budget amount available when the EW or AC span is shortened.

The lead agency can allow services that were previously authorized to be paid, even if those services exceed the person’s budget cap, if all of the following are true:

Instructions for fee-for-service

For people who are not enrolled in an MCO, refer to section 301.03 of Instructions for Completing and Entering the LTCC Screening Document and Service Agreement into MMIS, DHS-4625 (PDF).

Instructions for MCOs

For people on EW enrolled in an MCO, contact the MCO for exception process instructions and refer to section 201.05 of Instructions for Completing and Entering the LTCC Screening Document and HRA into MMIS for the MSC+ and MSHO Programs, DHS-4669 (PDF).

Instructions for CDCS

People who use CDCS can use their AC or EW case mix budget flexibly. If a person exits CDCS AC or EW prematurely, all services authorized and provided before the date of closure will be reimbursed. The case manager or care coordinator will be able to approve a closure of the AC or EW CDCS service agreement when the span is shortened. Refer to section 301.03 of Instructions for Completing and Entering the LTCC Screening Document and Service Agreement into MMIS, DHS-4625 (PDF).

EW conversion rates (traditional and CDCS)

When the monthly EW case mix budget caps (for both traditional and CDCS) are insufficient to support the services a person needs to transition to community living from a nursing facility, the case manager or care coordinator may request approval from DHS for a monthly conversion budget limit. For more information, refer to CBSM – EW conversion rates.

Monthly conversion budget limits are not available on the AC program.

CDCS

Budgets

All CDCS services must be provided within the person’s budget amount, with the exception of criminal background study costs.

CDCS required case management services have an annual maximum budget that cannot be exceeded. The required case management budget is added to the CDCS monthly budget. This total is the AC/EW CDCS monthly budget amount.

Prorated budgets

When a service plan will cover less than one year, the lead agency must prorate the person’s CDCS budget. For information on how and when to prorate for people who use AC and EW, refer to CDCS – Prorating budgets for AC and EW.

Enhanced rate/budget

An enhanced rate/budget helps people with high needs attract and retain qualified workers by adding a 7.5% enhanced reimbursement rate or budget for work that is both:

For information on the budget enhancement process, refer to:

Functional needs update

A functional needs update is a remote assessment that allows AC and EW case managers and care coordinators to make changes to the screening document fields when the person has changed needs that:

For policy guidance, refer to the functional needs update for AC/EW section on CBSM – Assessment applicability and timelines.