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Elderly Waiver (EW) and Alternative Care (AC) Program

Provider Type Links
Review related webpages and the Minnesota Health Care Programs (MHCP) Provider Manual sections for the latest news and additions, forms and quick links.

· Home and Community-Based Services (HCBS) Waiver Services Provider Manual section

· Home and community-based services providers webpage

Overview

Elderly Waiver (EW) and Alternative Care (AC) programs fund home and community-based services (HCBS) for people 65 years old and older who require the level of care provided in a nursing home, but choose to live in the community. These programs provide services and supports for people to live in their homes or a community setting and may delay or prevent nursing facility (NF) care. The purpose of these programs is to promote community living and independence with services and supports designed to address each person’s individual needs and choices. In the case of EW, the additional services go beyond what is otherwise available through Medical Assistance (MA).

· The Elderly Waiver (EW) program is a federal Medicaid waiver program that funds home and community-based services for people 65 years old and older who are eligible for Medical Assistance (MA), require the level of care provided in a nursing home, and choose to live in the community. People enrolled in EW can receive waiver services and MA services funded through a managed care organization (MCO). This can be through Minnesota Senior Care Plus (MSC+) or Minnesota Senior Health Options (MSHO).

· The Alternative Care (AC) program is a state-funded program that supports limited home and community-based services for people 65 years old and older who are not financially eligible for MA, but who meet AC financial and service eligibility requirements, and require the level of care provided in a nursing home. People eligible for AC have low levels of income and assets but are not yet eligible for MA or choose not to have MA.

Eligible Members

All applicants must meet the service eligibility criteria for the specific HCBS program in which they anticipate receiving services. Refer to the MHCP Provider Manual, Programs and Services for more information about MA and eligibility.

· To be eligible for EW services, applicants must also be eligible for MA.

· To be eligible for AC, applicants would be financially eligible for MA within 135 days of entering a nursing facility.

Lead Agency Roles and Responsibilities

For EW, the lead agencies can be counties, Tribal Nations or MCOs (also known as health plans). For AC, lead agencies can be counties or Tribal Nations. A lead agency can be the local public health agency, human service agency or social service agency. Lead agencies are responsible for the following:

Financial Eligibility
County or Tribal Nation financial eligibility workers determine financial eligibility and complete asset evaluations for payment of Elderly Waiver services and conduct informational asset assessments as requested. Lead agency assessors determine AC financial eligibility and the member fee at assessment, and case managers make adjustments throughout the year as needed for changes.

Eligibility Determination
The lead agency staff, called certified assessors, provide long-term care consultation (LTCC) services through a MnCHOICES assessment. The MnCHOICES assessment determines eligibility for AC, EW, and other HCBS programs. It also determines eligibility for 24-hour customized living services and Community First Services and Supports (CFSS). The assessment provides the foundation for which the support plan will be based off. For more information see CBSM – MnCHOICES and CBSM - MnCHOICES certified assessors.

Anyone may request an assessment for themselves or another person by contacting the local lead agency.

Sending Notice of Action for Eligibility Determination
After conducting a MnCHOICES assessment, county and Tribal Nation certified assessors communicate any changes to eligibility using the “Assessment Summary: Action Taken by the Lead Agency and Your Right to Appeal” document in MnCHOICES. MCOs use their own forms and appeal rights to communicate any changes to eligibility.

Support Planning
A person who is eligible for and chooses to receive EW or AC will receive case management or care coordination services. The case manager or care coordinator assists with access to and navigation of social, health, educational and other community and natural support and services based on the person’s values, strengths, goals and needs. A summary of the person’s choice of support and services and the person’s preferences for the delivery of support and services are outlined in the support plan. MHCP requires a copy of the plan to be given to and signed by providers. For more information on support planning and support plan signature requirements, review the CBSM - Support planning for long-term services and supports (LTSS). For information on case manager and care coordinator qualifications and a complete description, go to CBSM - Waiver, AC and ECS case management and CBSM - Care coordination.

Notice of Action for Changes to Services and Supports
Counties and Tribal Nations must use the Notice of Action - Explanation of Changes to Your Support Plan in MnCHOICES to notify the person of a denial, termination, or reduction of services. MCO’s use their own forms and processes.

For timelines and a complete list of reasons a Notice of Action must be sent, see CBSM - Notice of action.

Program Access and Administration
Lead agencies are responsible for providing program access and administration, which includes the following:

· Working in partnership with the Department of Human Services (DHS) and other organizations to provide information, services and assistance to people who request and wish to gain access to HCBS services

· Determining program eligibility

· Providing case management or care coordination services, including the following:

· Developing a support plan

· Assisting people to access, coordinate and evaluate available services

· Inform people of the option to self-direct their own services

· Generating additional copies of provider service authorization (SA) letters, if needed

· Inputting member enrollment data (for example, screening document) and service authorization, as required, into the DHS Medicaid Management Information System (MMIS)

· Authorizing and monitoring services to reasonably assure health and safety

· Monitoring the ongoing provision of individual services for efficiency, consumer satisfaction and continued eligibility, and adjusting these provisions as necessary

· Monitoring provider performance and quality

· Assuring all providers comply with DHS requirements if opting to review and approve non-enrolled providers as qualified to deliver EW and AC services (see CBSM – Lead agency oversight of waiver/AC approval-option service vendors). Authorizing funds for all HCBS services provided to those eligible for enrollment in MHCP.

Informed Choice
The lead agency will do the following:

· Provide people requesting EW or AC services the necessary information to make informed choices among the services for which they are eligible.

· Provide the person with informed choices about their options of receiving services in the community or in an institution, such as hospital or nursing facility.

· Take reasonable steps to provide the information in a format the person can understand and with a choice of service providers for all services.

Eligible Providers

Providers who wish to offer and receive MHCP payment for EW and AC waiver services must enroll with MHCP and meet specific standards. To enroll in MHCP to provide waiver or AC program services, follow the instructions in the Home and Community-Based Services (HCBS) Programs Provider Enrollment section.

Providers must also determine which program services they are qualified to provide. Providers can find specific provider qualifications in this manual within each service description. The HCBS Programs Service Request Form (DHS-6638) (PDF) also lists qualifications.

Some waiver services require one or more of the following:

· License(s) from DHS or the Minnesota Department of Health (MDH)

· Medicare certification

· Other certification or registration

For more information, refer to one or more of the following:

· The lead agency in which you will be providing services

· DHS Licensing at 651-431-6500

· Minnesota Department of Health at 651-201-5000 for general information

Covered Services

Select the link in the following Service table to view the Community-Based Services Manual (CBSM) policy page for each service that includes the legal reference, service description, covered and noncovered services when applicable and provider standards and qualifications. If a service does not link to the CBSM, see service descriptions, billing codes, and provider standards in the sections following the table.

Service	EW	AC
Adult Companion Services	X	X
Adult Day Services	X	X
Adult Day Services Bath	X	X
Adult Foster Care	X
Case Management	X	X
Conversion Case Management		X
Case Management Aide (Paraprofessional)	X	X
Chore Services	X	X
Consumer Directed Community Supports (CDCS)	X	X
Customized Living	X
Discretionary Services		X
Environmental Accessibility Adaptations	X	X
Family Adult Day Services	X	X
Family Caregiver Services · Caregiver Counseling · Caregiver Training	X	X
Home delivered meals	X	X
Homemaker	X	X
Individual Community Living Supports (ICLS)	X	X
Nutrition Services		X
Respite	X	X
Specialized Equipment and Supplies	X	X
Transitional Services	X	X
Transportation (non-medical)	X	X

These services and requirements are the minimum guidelines. Lead agencies may refer to the Community-Based Services Manual (CBSM) for more information.

Extended Home Care Services – EW Program Only

Service

EW

Extended Community First Services and Supports (CFSS)/ Extended Personal Care Assistance (PCA)

X

Extended home care services

· Home health aide (HHA)

· Home care nursing (HCN)

X

Additional information for EW extended home care services:

· An MHCP member must first access needed home care service benefits through MA home care, either fee for service (FFS) or managed care organization (MCO), before MHCP can approve extended home care benefits.

· Bill home care services not covered by MA home care to the waiver as extended MA services within the waiver budget limit available.

Home Care Services - AC Program Only

Service	AC
Community First Service and Supports (CFSS)	X
Home Health Services · Home Health Aide (15 min) · Home Health Aide (Visit) · Skilled Nursing LPN (15 min) · Skilled Nursing LPN (visit) · Skilled Nursing LPN, tele-homecare (visit) · Skilled Nursing RN (15 min) · Skilled Nursing RN (visit) · Skilled Nursing Visit RN, tele-homecare (visit)	X
Home Care Nursing · LPN (15 min) · LPN Complex (15 min) · LPN Shared, 1:2 (15 min) · RN (15 min) · RN Complex (15 min) · RN Shared, 1:2 (15 min)	X

Service Authorization

AC and EW services require a lead agency case manager/care coordinator to complete a service authorization (SA).

County and Tribal Nations initiate the FFS service authorization in MMIS.

MCOs have their own service authorization systems. Contact the MCOs for instructions when obtaining authorizations and billing for EW services.

The SA allows the provider to provide services and then bill DHS to receive payment. MHCP will only pay for services on the SA; however, an approved SA is not a guarantee of payment. For claim payment:

· Providers must be actively enrolled and have their credentials up to date to provide the approved service(s).

· The person must maintain their MHCP eligibility for the authorization to be valid.

· Providers are responsible for ensuring the SA is accurate upon receipt of their service authorization letters (SAL) in their MN–ITS mailbox.

Each line item on the SA lists the following:

· MHCP-enrolled provider who is authorized to provide the needed service(s)

· Rate of payment for the service

· Number of units approved or total amount

· Date or date span of service

· Approved procedure code(s)

· MA home care services of skilled nursing visits (SNV), home health aide (HHA), home care nursing and personal care assistance (PCA)/Community First Services and Supports (CFSS) that must be utilized before EW extended services

The EW and AC service authorization displays units, duration and rates. All authorized services need to stay within the published case mix budget caps (maximum monthly rate limit) and published state rate limits for services. For current long-term services and supports rate limits, please see Long-Term Services and Supports Rate Limits (DHS-3945) (PDF).

Providers must verify program eligibility for each member each month through the MHCP phone-based eligibility verification system (EVS) or online via MN–ITS.

Provider Quick Reference

Service Authorization Letters

· The lead agency can generate additional copies of the provider service authorization letter (SAL) as needed.

· The lead agency may suppress the DHS-generated SAL and send his or her own letter to the member.

Providers registered with MN–ITS receive their service authorization letters in their MN–ITS mailboxes. Providers can view letters, print them out or save them to their computer as letters are automatically purged after 90 days.

The Service Authorization Letters (SAL) file contains:

· Waiver

· Alternative Care

· Medical Assistance home care

Prior Authorization Letters (PAL) file contains:

· MA authorization letters

Service Authorization Changes

The county or Tribal Nation case manager is responsible for any changes made to the SA of any member.

· If the rate, procedure code(s) or begin and end dates on the SA are incorrect, contact the case manager to initiate corrections.

· If additional services are necessary, the provider must communicate with the lead agency before providing any additional services.

· If an SA line item is changed and approved, MMIS will automatically generate a revised SAL to the provider. MMIS generates the letters overnight and sends them out the following day.

The MCO care coordinator is responsible to change the SA of any member receiving EW services following the process for the system used by the MCO.

Changes in the Status of a Member

· The case manager or care coordinator informs providers and the lead agency financial worker of any status changes of the member, such as the living arrangement, address, phone number or incorrect birth date.

· The lead agency financial worker notifies the case manager or care coordinator of any changes in the person’s eligibility for MA or enrollment in an MCO.

· Providers and lead agencies notify one another when a member is hospitalized. Providers cannot bill when a person is out of the community, unless explicitly stated for specific services (e.g. AC conversion case management).

· Lead agency financial worker and case manager or care coordinator notify one another when a member is admitted to a long-term care facility. Then financial worker can update the living arrangement and make the appropriate changes to the SA line items.

Change in a Member’s Need

Providers need to contact the lead agency when a member’s needs change or when the way the services need to be delivered has changed. The case manager or care coordinator is responsible for revising the support plan and determining if a reassessment is needed.

Transitioning from MA Home Care to Waiver Services OR Waiver Services to MA Home Care Services

Refer to the Home Care Services section for more information.

Home Care Nursing Payment for Spouses

Refer to the Home Care Services section for more information.

People Enrolled in Waiver Services Who Elect Hospice

Refer to the Hospice Services section for more information regarding covered services.

Billing

There are many advantages for both providers and lead agencies to coordinate efforts to ensure that an MHCP member receives necessary services, and that providers receive timely payments for services rendered. If a provider has a contract with an MCO to provide services, the provider should receive instructions from the MCO on how to ensure payment.

The support plan and service agreement work together as complementary documents. Before submitting claims for payment, it is beneficial for the provider to have a copy of the signed support plan, as well as the service agreement. In addition to supporting billing, the support plan is used during audits to verify that services were authorized, delivered in accordance with the individual's assessed needs, and compliant with program requirements. To bill for FFS elderly waiver and alternative care services, refer to the Billing for Waiver and Alternative Care (AC) Program section.

For extended home care services approved on the waiver authorization, submit claims using the 837I Institutional Outpatient transaction (via MN–ITS), following home care billing guidelines.

MCOs have their own service authorization systems. Contact the MCOs for particular instructions when obtaining authorizations and billing for EW services.

Authorized Services vs. Non-Authorized Services

Do not bill for services that require an SA on the same claim as services that do not require an SA.

For example, for people eligible for MA, home care therapy services (physical, occupational, respiratory and speech therapy) do not require an SA and cannot be billed on the same claim as a waiver service, such as adult day services.

Payment Rates

Lead agencies authorize service and provider payment rates. DHS establishes rate limits for AC and EW services and publishes the limits in Long-Term Services and Supports Service Rate Limits (DHS-3945-ENG) (PDF). Service rates authorized and claimed may not exceed these limits.

Most AC and EW services are authorized and paid a state-established rate. The dollar value for state-established rates is the rate limit for the service published in Long-Term Services and Supports Service Rate Limits (DHS-3945-ENG) (PDF). Some services are authorized and paid a market rate, up to the state-established limit, based on the typical price charged for the service in the community market. EW residential services, which include customized living and adult foster care, are authorized and paid a daily rate determined by the Elderly Waiver Residential Services Tool (EWRS Tool) completed by lead agencies within the MnCHOICES support plan.

More information about payment rates is available on the Rate methodologies for AC, ECS and EW service authorization web page in the CBSM. Review the long-term services and supports rates changes web page for the most up-to-date information about changes to rate limits.

Elderly Waiver Customized Living Services Rate Adjustment

The 2026 Minnesota Legislature approved changes to the rate floor adjustment (or minimum daily rate) for customized living services providers that are designated as disproportionate share facilities.

Eligible facilities
To be eligible to apply for customized living services minimum daily rate adjustment payments in 2027, the facility must meet all the following requirements as of Sept. 1, 2026:

· The facility was determined eligible for the disproportionate share rate adjustment in application year 2023 and received payments in 2024.

· At least 83.5 percent of the facility’s residents are customized living residents who use EW, BI or CADI waivers.

· At least 70 percent of those customized living residents use EW.

Effective Oct. 1, 2023, the commissioner must not process any new initial applications for disproportionate share facilities.

Statutory requirements

1. Coercion prohibited: A facility must not pressure, coerce, entice or otherwise unduly influence a resident to use EW, as described in Minnesota Statutes, 256S.205, subd. 8, added by Laws 2025, First Special Session, chapter 9, article 1, section 29.

2. Compensation requirements: A provider designated as a disproportionate share facility must use a minimum of 66% of the increase in revenue generated by the minimum daily rate for direct care staff compensation, as described in Minnesota Statutes, 256S.205, subd. 9, added by Laws 2025, First Special Session, chapter 9, article 1, section 30.

Providers must acknowledge they understand these requirements when they apply.

Language changes

The 2026 Minnesota Legislature made the following language changes about residency in disproportionate share facilities:

· Effective Aug. 31, 2026, a resident who experiences an interruption to waiver benefits because of a temporary absence from the facility is considered a customized living resident during the temporary absence, as described in Minnesota Statutes, 256S.205, subd. 1(c), added by Laws 2026, chapter 95, section 33, subdivision 1.

· “Residing in the facility” means the facility is the resident’s fixed permanent home and the place to which the resident intends to return following a temporary absence, as described in Minnesota Statutes, 256S.205, subd. 1(g), added by Laws 2026, chapter 95, section 33, subdivision 1.

· The number of customized living residents [add] residing [end] in the facility on Sept. 1 of the application year, broken out by specific waiver program, as described in Minnesota Statutes, 256S.205, subd. 2(1), added by Laws 2026, chapter 95, section 33, subdivision 2.

Adjustment amounts
The Legislature-approved minimum daily rate adjustment is $141 for calendar year 2027. Qualified facilities will get adjustments up to the minimum daily rate on claims for people who use EW and receive 24-hour customized living services from Jan. 1, 2027, to Dec. 31, 2027. The payment does not apply to claims for residents who use Brain Injury (BI) and Community Access for Disability Inclusion (CADI) waivers.

Individual disproportionate share facilities began receiving minimum daily rate payments in calendar year 2022, when the rate adjustment first took effect. DHS adjusts the value of the minimum daily rate annually on January 1 as directed by law. The minimum daily rate amounts are reported in the following table.

Effective dates	Minimum Rate
July 1, 2022, to December 31, 2022	$119
January 1, 2023, to December 31, 2023	$131
January 1, 2024, to December 31, 2024	$190
January 1, 2025, to December 31, 2025	$141
January 1, 2026, to December 31, 2026	$141
January 1, 2027, to December 31, 2027	$141

How to apply
Currently approved facilities can apply using Disproportionate Share Facility Application (DHS-8157) (PDF). Submit your application by Sept. 1 to Sept. 30, 2026. Review the Billing section for more information.

Facilities must submit one application for each licensed assisted living facility. A facility that holds a single license for a setting that meets the definition of an assisted living facility campus under Minnesota Statutes,144G.08, subd. 4a must submit one application for the licensed campus. Providers who are exempt from assisted living licensure must submit one application for each building that has a unique street address. As a part of reviewing completed application forms, DHS will request applicants submit a census list of members on a waiver program in a secure and encrypted format to verify the resident numbers submitted on the application form.

DHS will designate eligible facilities by Oct. 15, and qualified facilities receive the minimum daily rate adjustment from Jan. 1 through Dec. 31, in the year immediately following the application period.

Lead agency information
For lead agency information, see the Customized living (including 24-hour customized living) section of the Community-Based Services Manual (CBSM) or contact dhs.aasd.hcbs@state.mn.us.

Elderly Waiver Obligation and MA Spenddown

Eligibility for EW is based on two income limits:

· People with incomes equal to or less than the Special Income Standard (SIS) are eligible for EW without an MA spenddown. They must contribute any income over the maintenance needs allowance and other applicable deductions to the cost of services received under EW. This is known as the waiver obligation.

· People with incomes greater than the SIS may still be eligible for EW but they will have an MA spenddown. The lead agency’s financial assistance unit is responsible for determining the financial obligation of the EW member. The member receives a notice if they have a waiver obligation or will be responsible for a spenddown.

The waiver obligation is:

· Deducted from the cost of services received under the Elderly Waiver; the full amount of the waiver obligation does not have to be met each month.

· The amount the member is responsible to pay towards the services the member used that month, which may be a portion of the waiver obligation or the entire waiver obligation.

An MA spenddown may be met with any combination of MA services, including HCBS services. MA spenddowns must be met each month.

The lead agency financial worker enters the waiver obligation or MA spenddown into MMIS. DHS will report the amount the provider can bill the member on their remittance advice. Claims that are reduced due to the EW obligation or spenddown will show claim adjustment reason code PR 142 on the remittance advice. MCOs also receive reports on their enrollees who have waiver obligations and spenddowns. Each MCO has a process for informing providers on amounts of waiver obligations and spenddowns. See the Special Income Standards (SIS), in Appendix F, of the MHCP Eligibility Policy Manual.

A person enrolled in MHCP can designate a provider to whom they will pay the obligation. The member must notify the financial worker if he or she wishes to choose this option. Members who receive waiver services through an MCO cannot use the designated provider option that is available through the financial worker request.

Home Care Services Provided for an MA-eligible Member Receiving EW Services

All people receiving EW services must first access MA home care services to the highest extent before adding EW services to the support plan.

MA covers the following home care services:

· Home care nursing

· Home health aide (HHA) visits

· Occupational therapy (OT)

· RN PCA supervision

· Community First Services and Supports (CFSS)/ Personal care assistance (PCA)

· Physical therapy (PT)

· Respiratory therapy (RT)

· Skilled nursing visits (SNV)

· Speech therapy (ST)

Coordination of Home Care and EW

· If a member is on the EW and served by an MCO, the MCO manages the state plan home care and waiver services.

· If a member is on fee-for-service (FFS) EW, then the state plan home care is also FFS.

· For members receiving EW services and enrolled in managed care, the designated care coordinator is responsible for authorizing all home care (except home care therapies) and EW services.

· For members receiving FFS EW services, the county or Tribal Nation case manager is responsible for authorizing all home care and EW services.

Home Care and AC

The lead agency case manager determines and authorizes the amount of home care services that are counted towards the member’s case mix budget. AC does not have an MA benefit.

Legal References

Minnesota Statutes, 245A (Human Services Licensing)
Minnesota Statutes, 245A.143 (Family Adult Day Services)
Minnesota Rules, 9555.9600 – 9555.9730 (Adult Day Services Center Licensure)
Minnesota Rules, 9555.5050 – 9555.6265 (Adult Foster Care Services and Licensure)
Minnesota Statutes, 245A.03 (Who Must Be Licensed)
Minnesota Statutes, 148.171 – 148.285 (Public Health Occupations)
Minnesota Rules, 9575.0010 – 9575.1580 (Merit System)
Minnesota Statutes, 256.012 (Minnesota Merit System)
Minnesota Statutes, 256B.02, subdivision 7 (Definitions – Vendor of Medical Care)
Minnesota Statutes, 256B.0913 (Alternative Care Program)
Minnesota Statutes, 256S (Medical Assistance Elderly Waiver)
Minnesota Statutes, 144D.025 (Optional Registration)
Minnesota Rules, 9555.5105 – 9555.6265 (Social Services for Adults)
Minnesota Rules, 9555.6205, subparts 1 – 3, 9555.6215, subparts 1 and 3, and 9555.6225, subparts 1, 2, 6 and 10 (Social Services for Adults)
Minnesota Rules, 4668 (Home Care Licensure)
Minnesota Rules, 4669 (Home Care Licensure Fees)
Minnesota Statutes, 144D (Housing with Services Establishment)
Minnesota Statutes, 256B.0653 (Home Health Agency Services)
Minnesota Statutes, 326B.802, subdivision 11 (Definitions – Residential Building Contractor)
Minnesota Rules, 4626 (Food Code; Food Managers)
Minnesota Statutes, 245C (Human Services Background Studies)
Minnesota Statutes, 245D (Home and Community-Based Services Standards)
Minnesota Statutes, 245A.03, subdivision 2, (a)(1) – (2) (Exclusion from licensure)
Minnesota Statutes, 144A (Nursing Homes and Home Care)
Minnesota Statutes, 144A.43 – 144A.45 (Nursing Homes and Home Care)
Minnesota Statutes, 148.621 (Definitions)
Minnesota Rules, 3250 (Licensure and Practice)
Minnesota Statutes, 148.623 (Duties of the Board)
Minnesota Statutes, 157.17 (Additional Registration Required for Boarding and Lodging Establishments or Lodging Establishments)
Minnesota Statutes, 144.696, subdivision 3 Definitions -– Minnesota Statutes, 144.50 (Hospitals, Licenses; Definitions) Minnesota Statutes, 144.058 (Interpreter Services Quality Initiative)
Minnesota Statutes, 256B.0659 (Personal Care Assistance Program)
Minnesota Rules, 9505.0335 (Personal Care Services)
Minnesota Rules, 9505.0290, subpart 3B (Home Health Agency Services)
Minnesota Rules. 9505.0175, subpart 23 (Definitions – Long-term Care Facility)
Minnesota Rules, 9505.0310 (Medical Equipment and Supplies)
Minnesota Rules, 9505.0195 (Provider Participation)
Minnesota Statutes, 65B (Automobile Insurance)
Minnesota Statutes, 174.30 (Operating Standards for Special Transportation Service)
Minnesota Statutes, 174.29 – 174.30 (Department of Transportation)
Code of Federal Regulations, title 42, part 441, subpart G, 441.310(a)(2)(ii) (Limits on Federal Financial Participation [FFP])
Laws of Minnesota, 2022 Regular Session, Chapter 98, Article 7, Section 31 or 2022 Minnesota Statutes, 256S.205 (Customized Living Services; Disproportionate Share Rate Adjustments)

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