Description.
| Participants with an adult or child in the household who have one of the following conditions:
1. Meet the criteria for home care services.
2. Meet the criteria for a home or community-based waiver services program.
3. Serious mental illness in a child – an organic disorder of the brain or disordered though, mood, perception, orientation, memory or behavior that has led to inpatient or residential treatment, the need for such treatment, significant impaired functioning or a diagnosis of psychosis, depression, risk to self or others or symptoms of trauma.
4. Serious and persistent mental illness in an adult – mental illness that has led to two or more episodes of inpatient care; hospitalization or residential treatment of more than 6 months; treatment by a crisis team 2 or more times; or a combination of specific diagnosis of serious mental illness with significant impairment in functioning and the likelihood of needing inpatient treatment in the future.
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1. Home Care Services.
| · Medically necessary health services ordered by a physician.· Provided in the participant’s home, not a hospital or long-term care facility.· Documented in a service plan.· Whose need is reviewed by the physician:· At least once every 60 days for home health or private duty nursing services.· At least once every 365 days for personal care. |
2. Home or Community-Based Program Medical Care Programs.
| Most are special programs run under Medical Assistance waivers and are available to people eligible for Medical Assistance. All of the services are designed to be an alternative to more costly nursing facility or hospital care. They include: · Alternative Care Program: For people 65 or older who need nursing level care but choose to stay in the community. This is the only program in this category for people NOT eligible for Medical Assistance.· Community Access for Disability Inclusion (CADI): For children and adults younger than 65 with disabilities who otherwise would need to be in a nursing facility.· Community Alternative Care: For children and adults who are chronically ill and would otherwise need hospital care.· Brain Injury Waiver: For children and adults with a disabling traumatic brain injury who are younger than 65 years old and would otherwise need nursing facility or hospital care.· Developmental Disabilities Waiver: For children and adults with a developmental disability and otherwise needing care in an Intermediate Care Facility.· Elderly Waiver: For people 65 and older who need nursing home level care but want to live in the community. |
3. Serious Mental Illness.
| · A child with an organic disorder of the brain or disordered thought, mood, perception, orientation, memory or behavior that has led to one of the following:· Inpatient or residential treatment· The need for such treatment· Significant impaired functioning · A diagnosis of psychosis, depression, risk to self or others or symptoms of trauma.
For more information and information about state funded mental health services, see the Minnesota Provider Manual.
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4. Serious and Persistent Mental Illness.
| Mental illness in an adult that has led to one of the following: · Two or more episodes of inpatient care.· Hospitalization or residential treatment of more than 6 months.· Treatment by a crisis team 2 or more times.· A combination of specific diagnosis of serious mental illness with significant impairment in functioning and the likelihood of needing inpatient treatment in the future.
For more information and information about state funded mental health services, see the Minnesota Provider Manual.
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Documentation Required.
| If the family member’s condition is serious and persistent mental illness or serious mental illness: The documentation should confirm a diagnosis by a qualified professional. See 17.45 (Qualified Professionals).
If the family member is receiving home care or home or community based services: The person receiving the services or the disability case manager (if there is a signed release) could provide a copy of either of the following for the individual’s: · Community Support Plan.· Coordinated Services and Support Plan.
If the family member is not receiving those services but is claiming eligibility: Participants can learn whether a household member meets any of these criteria by having a MNChoices Assessment done by the county. For more information about these assessments, participants may contact:
· The county or reservation where they live.· The Disability Linkage Line at 1-866-333-2466.· Senior LinkAge Line at 1-800-333-2433.
Do not require these participants to verify their ability to get or keep a job.
If the participant cannot get the necessary information from the health care provider:
1. Get a release of information allowing you to contact the family member’s health care provider.
2. Explain that you need the information in order to provide the appropriate services to the caregiver.
3. If that is not successful, contact the consumer representative at the family member’s health plan.
4. If that is not successful, contact the DHS Health Care Purchasing Division at 651-296-3386 or 1-800-657-3756.
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How Often to Review Documentation.
| Request updated verification at least annually – but sooner if the medical opinion includes a shorter time frame.
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When Does the Extension End?
| The Special Medical Criteria earns a household additional months to receive MFIP benefits through a process called “banked months”. · Participants eligible for special medical criteria receive “banked months”: Each month a participant is eligible for Special Medical Criteria before reaching the 60-month limit is “banked”.· MAXIS uses these banked months once the household member no longer meets the Special Medical Criteria or that person has left the household.· Only after the banked months are all used is the participant assessed for an extension.· Eligibility for banked months is not based on employment.· In a 2-parent family, only 1 parent can qualify for the Special Medical Criteria category. If the health care provider documents that both parents are needed in the home to care for the family member meeting Special Medical Criteria, extend the 2nd parent as needed in the home.· Banked months can be tracked retroactively if the county or tribe was not aware of the household’s eligibility at the time.
Notify the eligibility worker.
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For More Information Related to This Category.
| See 17.15 (Special Medical Criteria). |
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