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Community-Based Services Manual (CBSM)

Community-Based Services Manual (CBSM)


Transitional services – Alternative Care (AC) and Elderly Waiver (EW)

Page posted: 1/27/17

Page reviewed:

Page updated: 2/4/25

Legal authority

Federally approved AC 1115 demonstration, federally approved EW Plan, Minn. Stat. §256B.0915, Minn. Stat. §256B.0911, Minn. Stat. §256B.0913

Definition

Transitional services: Items and supports necessary for a person to move from a licensed setting to independent or semi-independent community-based housing.

Eligibility

A person is eligible to receive transitional services under the Alternative Care (AC) program or Elderly Waiver (EW) if they are:

  • · Moving from an eligible licensed setting to independent or semi-independent community-based housing.
  • · Moving from a setting where the items were provided to a setting where these items are not normally furnished.
  • · Not able to access the items or support from other funding sources.

    • A person also must be either:

  • · Enrolled on AC or EW.
  • · Reasonably expected to enroll within 180 days.

    • Licensed settings

    Eligible licensed settings include:

  • · Hospitals licensed under Minn. Stat. §144.50 to 144.591.
  • · Adult foster settings licensed under Minn. R. 9555.5105 to 9555.6265 and Minn. Stat. Ch. 245A or under Minn. Stat. Ch. 245D.
  • · Certified nursing facilities and intermediate care facilities as defined under Minn. R. 9505.0175, subd. 23 and licensed under Minn. Stat. Ch. 144.

    • Covered services

    Transitional services/items

    Transitional services cover items such as:

  • · Basic household items.
  • · Essential furniture.
  • · Lease and rental deposits.
  • · One-time pest and allergen treatment of the setting.
  • · Personal items.
  • · Utility set-up fees and deposits.
  • · Window coverings.

    • Transitional services cover reconditioned items if the lead agency determines they are appropriate and safe by reasonable standards.

    Transitional services/supports

    Transitional services also cover personal supports to help the person:

  • · Locate and transition to community-based housing.
  • · Move personal items from the licensed setting to the home.
  • · Arrange for utilities to be connected.
  • · Purchase household items and essential furniture.

    • Non-covered services

    Transitional services do not cover:

  • · Clothing.
  • · Food.
  • · Ongoing rent and housing costs.
  • · Recreational or diversional items or expenses (e.g., computers, DVD players, televisions, cable access).
  • · Supports or items that are covered under other state plan or waiver services the person already receives, such as chore, homemaker, environmental accessibility and adaptations and specialized equipment and supplies.

    • Remote support

    Transitional services can be delivered through remote support. Services delivered through remote support must meet all the requirements listed on CBSM – Remote support.

    Secondary information

    The lead agency is responsible to:

  • · Identify the person’s assessed need for transitional services in the support plan.
  • · Ensure the transitional items and supports are necessary and reasonable.
  • · Maintain receipts and documentation for all items in the person’s file for auditing purposes.

    • Provider standards and qualifications

    Transitional services/items

    Transitional services / items are approval-option: purchased-item services. For more information, refer to CBSM – Waiver/AC service provider overview.

    Transitional services/supports

    Transitional services / supports are approval-option: direct-delivery services. For more information, refer to CBSM – Waiver/AC service provider overview.

    A provider of transitional supports must, as determined by the lead agency, have all of the following:

  • · A cost effective, appropriate means of meeting the needs defined in the person’s support plan.
  • · Functional knowledge of housing options in the community.
  • · General knowledge of disabilities and chronic illnesses and their effect on a person’s ability to live independently in the community.
  • · Sufficient understanding of housing procurement procedures and funding mechanisms to advise the person regarding these matters.
  • · The ability to assess the person’s community-based housing needs.
  • · The ability to assist the person in attaining the services and supports that are covered by transitional services.

    • Background study

    To provide transitional services involving direct contact with the person, providers must have a background study. For more information, refer to CBSM – Waiver/AC service provider overview – Required DHS background studies for direct-contact services.

    Authorization, rates and billing

    The lead agency authorizes transitional services at the market rate. For more information, refer to:

  • · CBSM – Rate methodologies for AC, ECS and EW service authorization.
  • · Long-Term Services and Supports Service Rate Limits, DHS-3945 (PDF).

    • Timeline

    The lead agency may:

  • · Authorize transitional services before a person’s discharge from a licensed setting if the person is expected to be discharged and enrolled on the waiver.
  • · Only bill the waiver after the person enrolls.

    • The items must be purchased or supports provided within 90 days of the date the person enrolls on the waiver.

    Unforeseen circumstances

    If the person does not enroll on the waiver for an unforeseen reason (i.e., death or a significant change in condition) and meets certain criteria, the lead agency may request reimbursement for expense(s) it incurred in anticipation of the person enrolling.

    For more information, refer to CBSM – Waiver/AC reimbursement for unforeseen circumstances.

    Managed care organization (MCO) – EW only

    If a person on EW receives or was receiving services through an MCO, the lead agency contacts the specific MCO about procedures it needs to follow for reimbursement. An MCO may not request reimbursement from DHS under unforeseen circumstances.

    Additional resources

    CBSM – AC
    CBSM – EW
    CBSM – EW conversion rates
    CBSM – Remote support
    CBSM – Transitional services – BI, CAC, CADI, DD
    CBSM – Waiver/AC reimbursement for unforeseen circumstances
    MHCP Provider Manual – EW and AC

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