Legal authority

Federally approved BI, CAC, CADI, DD and EW waiver plans, federally approved AC 1115 demonstration, Minn. Stat. §256B.0911, Minn. Stat. §256B.092, Minn. Stat §256B.0913, Minn. Stat. Ch. 256S, 42 C.F.R. §441.725(b)(9), Minn. Stat. §256B.0922

Definitions

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 lead agency documents the support planning process in the MnCHOICES support plan.

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

Support plan: A summary of the person’s choice of supports and/or services and the person’s preferences for the delivery of supports/services. A person only receives a support plan if they are eligible for and choose to receive publicly funded HCBS and/or state plan services.

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

Overview

The person who receives services (and their legal representative, if applicable) must be at the center of the support planning process. The certified assessor and case manager/care coordinator 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

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

The lead agency summarizes the decisions made during the person-centered planning process using the MnCHOICES support plan.

Information on this page

This page provides information about:

For instructions to complete the assessment summary and support plan in MnCHOICES, refer to the guidance documents in the MnCHOICES Help Center.

Appeals

A person has the right to request an appeal (all people) or a conciliation conference (people on the DD Waiver) at any time during the assessment and support planning process. Counties and Tribal Nations provide people with copies of their appeal rights at assessment and during the support planning process. MCOs provide an MCO-specific appeal information form.

For more information, refer to CBSM – Appeals.

Provider standards and qualifications

Lead agencies must ensure staff meet the qualifications for their role when they work with people to develop their support plans.

Case managers

For qualifications, refer to CBSM – Waiver, AC and ECS 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.

Secondary information

Information from providers

Providers can inform the support planning process by providing the certified assessor or case manager/care coordinator with written reports. Providers should submit this information at least 60 days before the end of the person’s service agreement span.

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

Record keeping

The lead agency must:

Contact information for grievances

Lead agencies should provide grievance contact information to all people who receive waiver/AC/ECS case management/care coordination as part of the support planning process.

Grievance process for contracted development disability case management

Counties and Tribal Nations must ensure 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 receive contact information to file a grievance with the county/Tribal Nation about the quality of their case management services.

Support plan signatures and timeline

The following people develop the support plan:

Within 60 calendar days of the assessment or initial assessment review (IAR), the case manager/care coordinator must provide the full support plan to and get signatures from:

Lead agencies must:

Person’s signature requirements

The person’s (or legal representative’s, if applicable) signature indicates they received and acknowledge the information outlined on the support plan signature sheet.

If the person has a legal representative, the legal representative must sign the support plan. The person’s signature is not required if the legal representative signs on the person’s behalf.

Providers’ signature requirements

All enrolled providers of waiver/AC/ECS-funded services must sign the support plan and keep a copy that includes the person’s signature. If using the lead agency approval option, the lead agency must sign the support plan. For more information about approval-option services, refer to CBSM – Lead agency oversight of waiver/AC approval-option service vendors.

The provider’s signature indicates they:

Instructions for signatures

For instructions to collect a signature using the MnCHOICES application, refer to the support plan practice guide located in the MnCHOICES Help Center.

Exceptions to provider signatures

The case manager/care coordinator does not need to obtain a provider signature in the following situations:

Signatures for initial and annual/reassessment support plans

The case manager/care coordinator must obtain a signature from each enrolled HCBS provider (i.e., waiver/AC/ECS) for all initial and annual/reassessment support plans.

Signatures for plan revision changes to support plans

When revising a support plan using the plan revision reason, updated signatures are required when changes affect how a service is provided. Examples include:

When updated signatures are required, the case manager/care coordinator must:

The signatures document both the person’s and the provider’s agreement to the support plan changes. The case manager/care coordinator must upload the provider’s signature to the signature section in the person’s support plan.

Signatures for personal care assistance (PCA)/Community First Services and Supports (CFSS) and home care services

Waiver/AC and PCA or home care

If a person is on a waiver/AC and receiving PCA and/or home care services, the case manager/care coordinator must send the support plan to the PCA/home care provider for a signature.

Waiver/AC and CFSS

If a person is on a waiver/AC and receiving CFSS services, the case manager/care coordinator must send the support plan to the following CFSS providers for signatures, as applicable:

PCA/CFSS or home care not on a waiver/AC

If a person is receiving PCA/CFSS or home care services and not on a waiver/AC, the case manager/care coordinator is not required to obtain the PCA/CFSS/home care provider’s signature on the support plan.

Additional information

For people receiving PCA/CFSS, providers should sign the CFSS Service Delivery Plan. For more information, refer to CFSS Manual – PCA/CFSS service delivery plan.

Consumer directed community supports (CDCS)

MnCHOICES support plan

The lead agency must obtain a signature from the FMS provider included in the MnCHOICES support plan.

CDCS community support plan

The CDCS Policy Manual and CDCS Community Support Plan, DHS-5788A will include information about CDCS participant requirements for signature collection.

Note: DHS is working to update DHS-5788A to reflect signature requirements.

Case manager/care coordinator responsibilities

The case manager/care coordinator and certified assessor (if not the same person) work together to share information and provide continuity of care throughout the assessment and support planning process. The case manager uses MnCHOICES Communication Form, DHS 6791E (PDF) to communicate with the certified assessor about the person’s need for an assessment.

Before the assessment

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

The certified assessor:

After the assessment

Once the assessment is complete, the case manager/care coordinator and the person develop a support plan 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/care coordinator:

Supporting a person’s move

If the person expresses a desire to move or wants more information about options or processes before deciding to move, the certified assessor and case manager/care coordinator must:

For additional resources, refer to:

Mid-year lead agency change

If a person’s lead agency changes mid-year, the transferring lead agency must review and update the support plan before the transfer, as needed. After the transfer, the new lead agency updates the support plan, as needed, including updating services and providers.

For more information about case transfers, refer to:

For MnCHOICES guidance, refer to the smart guide: assignments transfers and discharges document in the MnCHOICES Help Center. For MCO information, refer to the smart guide: transfer guidance for MSHO/MSC+ care coordinators in the MnCHOICES Help Center.

Temporary waiver exits and restarts

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 a stay 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: MMIS actions and CBSM – MnCHOICES assessment process.

The case manager/care coordinator still must monitor the situation to ensure the person receives a new assessment/reassessment if needed.