Home and Community-Based Services (HCBS) Programs Provider Enrollment Criteria and Forms

Revised: November 9, 2023

· Overview

· Heightened Scrutiny

· How to Enroll

· Enroll Using the Online MPSE Portal

· Submit Forms via Fax

· HCBS Waiver and AC Provider Training 101 Proof of Completion

· Background Study

· General Liability Insurance Certificate

· Providers Enrolling with a DBA

· Exceptions for Lead Agencies

· Remote Support

· Revalidation

· Adding Services to Current Enrollment Record

· Reporting Changes

· Additional Resources

Overview

Minnesota Health Care Programs (MHCP) requires providers to enroll for the services they provide to MHCP members for each location that is providing services and receiving reimbursement.

The steps and instructions in this section apply to services for any of the following programs:

· Alternative Care (AC)

· Elderly Waiver (EW)

· Essential Community Supports (ECS)

· Home and Community-Based Waivers, which include Brain Injury (BI), Community Alternative Care (CAC), Community Access for Disability Inclusion (CADI), Developmental Disabilities (DD)

To enroll or revalidate to provide customized living services, follow the enrollment process outlined on this page. Also, see License requirement changes for customized living services providers for information about the new license requirement for this service effective Aug. 1, 2021.

To enroll or revalidate for additional Moving Home Minnesota (MHM) services, see Moving Home Minnesota (MHM) Enrollment Criteria and Forms.

Newly enrolling day support services providers must obtain a needs determination authorization letter from the Department of Human Services - Disability Services Division (DHS-DSD) prior to completing the following enrollment steps. The needs determination letter approves the county or tribe lead agencies and the day support services provider’s needs determination application request. For more information, contact your local county agency or tribe. The needs determination authorization letter is not applicable for providers who were already enrolled in Adult Day Care, Day Training and Habilitation, or Structured Day prior to Jan. 1, 2021.

Heightened Scrutiny

The instructions in this Heightened Scrutiny section apply to adult day service, adult foster care and customized living for any of the following programs:

· Alternative Care (AC)

· Elderly Waiver (EW)

· Essential Community Supports (ECS)

Effective March 18, 2023, newly enrolling adult day service, adult foster care and customized living providers must comply with all home and community-based settings standards before they enroll with Minnesota Health Care Programs.

Important: DHS must assess providers who provide services in settings in or adjacent to an institution (hospital, nursing facility, intermediate care facility for persons with developmental disabilities [ICF/DD], institution for mental disease [IMD]) to determine compliance with all HCBS standards through the heightened-scrutiny process. To initiate a heightened-scrutiny review for a new setting, email the Aging and Adult Services HCBS unit and include “Heightened Scrutiny” in the subject line. Include the setting’s name, address, contact information and license number, if available. Refer to the Requirements for new HCBS settings webpage for more information.

How to Enroll

Pay the application fee if a federal employer identification number (FEIN) is used, or attach proof that the fee was paid to either Medicare or another state for the same location and for the same services. Use the MHCP Provider Screening Fee Collections System to pay the fee online. The fee must be paid before applying to MHCP.

Review the MHCP Service Combinations for HCBS (DHS-8371) (PDF) for a list of different HCBS enrollment record types.

Providers who wish to enroll or reenroll with MHCP, can do so in one of the following ways:

Enroll Using the Online MPSE Portal

· Use the Minnesota Provider Screening and Enrollment (MPSE) portal by following the Registration Instructions. Also, upload the following in the MPSE portal:

· A copy of the contract from the lead agency (for contracted case management services only).

· Copies of licenses, certification, assurance statements and registrations, if indicated in MPSE.

· Use the HCBS Programs Service Request (DHS-6638) (PDF) as a guide to identify specific credentials required based on services provided.

· Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (PDF) or the MCO Provider In-Network Agreement (DHS-8355) (PDF)

· Request for Licensing Agency ID Number (DHS-3891) (PDF), if applicable. See Background Study.

· Proof of completion of the HCBS Waiver and AC Provider Training 101. See HCBS Waiver and AC Provider Training 101 Proof of Completion for a list of acceptable forms of proof.

· A copy of your general liability insurance certificate, if indicated in MPSE.

· Waiver Services Remote Support Provider Assurance Statement (DHS-8059) (PDF) if you chose to deliver services remotely, see Remote Support to determine which services require the assurance statement.

or

Submit Forms via Fax

· Complete the following documents for each location providing services and fax the materials to MHCP at 651-431-7493.

· HCBS Programs Service Request (DHS-6638) (PDF) to report the service(s) requested to provide and to determine the qualifications needed to provide those service(s). Submit a copy of specific credentials, certification, assurance statements and registrations that are required.

· HCBS – Provider Enrollment Application (DHS-4015) (PDF)

· Fee-for-Service (FFS) only or FFS and Managed Care Organization In-Network Provider Agreement (DHS-4138) (PDF) or the MCO Provider In-Network Agreement (DHS-8355) (PDF)

· Disclosure of Ownership and Control Interest of an Entity (DHS-5259) (PDF)

· Designation of Billing Person for HCBS Waiver or Alternative Care (DHS-6855) (PDF), if required. See HCBS Waiver and AC Training Requirements for requirements and exemptions.

· Proof of completion of the HCBS Waiver and AC Provider Training 101.

· Request for Licensing Agency ID Number (DHS-3891) (PDF), if applicable. See Background Study to determine if applicable.

· A copy of the contract from the lead agency (for contracted case management services only).

· A copy of the general liability insurance certificate, if applicable. See General Liability Insurance Certificate to determine if applicable.

· EFT Supplier ID Notification (DHS-3725) (PDF), to be paid through electronic funds transfer (EFT) (optional), see number 4 in Enrollment with Minnesota Health Care Programs (MHCP) in the MHCP Provider Manual.

· Waiver Services Remote Support Provider Assurance Statement (DHS-8059) (PDF) if requesting to deliver services remotely, see Remote Support to determine which services require the assurance statement.

Review and retain a copy of the MHCP Data Privacy Notice (DHS-6287) (PDF) for your records.

MHCP Provider Eligibility and Compliance will process documents in order of date received. Whether enrolling using the MPSE portal or by fax, allow 30 days for processing. If more information is needed to complete the enrollment, a request for more information letter will be sent via U.S. mail (or in the provider’s MN–ITS mailbox, if one has been created) listing what needs to be done to complete the enrollment.

HCBS Waiver and AC Provider Training 101 Proof of Completion

The owner or managerial official for the organization must complete the required HCBS Waiver and AC Provider Training 101 and competency test. Print proof of completion to submit with the application request. Proof of completion must show the name of the owner or managerial official who completed the training and date of completion.

Proof of completion may be any of the following:

1. Email confirmation that the Waiver Provider 101 Training has been successfully completed.

2. Screenshot of the transcript showing the Waiver Provider 101 Exam was mastered.

See HCBS Waiver and AC Training Requirements for requirements and exemptions. Upload proof of completion via the MPSE portal or fax to MHCP at 651-431-7493.

Background Study

If the provider is requesting to provide one of the following unlicensed services, the Request for Licensing Agency ID Number (DHS-3891) (PDF) form must be completed and a background study needs to be submitted for all owners and managers identified on the Disclosure of Ownership and Control Interest of an Entity (DHS-5259) (PDF) form or in the Owners/Authorized Persons section of the MPSE portal. The provider must wait until receiving notice from the Department of Human Services (DHS) licensing before allowing the person to provide direct care services to an MHCP member.

· 24-Hour Emergency Assistance (for face-to-face contact and assistance)

· Adult Companion

· Family Training (if direct contact in the home)

· Homemaker Services

· Individual Community Living Supports

· Night Supervision

· Individualized Home Supports (without training) formally known as Personal Support

· Respite In-Home

· Respite Out of Home

· Transitional Services (if direct contact with the person – EW only)

General Liability Insurance Certificate

If any of the following services are provided, a copy of the general liability insurance certificate naming “DHS Provider Eligibility and Compliance” as a certificate holder on the document, with the following address listed: PO Box 64987, St. Paul, MN 55164-0987 needs to be submitted:

· Any service that requires you to have a 245D program license.

· Exception: General liability insurance is not required if providing only:

· Family Foster Care or Family Residential services, or

· Respite services in a Family Foster Care or Family Residential services setting covered by Minnesota Statutes, 245.814.

· Foster Care funded by the EW or AC programs.

· Exception: General liability insurance is not required if providing Family Foster Care covered by Minnesota Statutes, 245.814.

· Adult Day Care

· Customized Living Services

Providers Enrolling with a DBA

For providers opting to use a DBA (Doing Business As) name on their application, please note that MHCP pays the license holder. Therefore, if a DBA is used with licensing and the application lists that name, payment will be addressed to the DBA name. This may mean that the provider will be unable to cash or deposit the check to any other named account. Be sure to register the correct name with the Office of the Minnesota Secretary. Failure to do so will result in a rejection of the application and MHCP will send the provider a request for more information.

Exceptions for Lead Agencies

Lead agencies (county and tribal human services) must do the following when completing the enrollment documentation:

· Use code number “5 – Public” for the ownership code on the HCBS Provider Enrollment Application (DHS-4015) (PDF) form or in the Organization Information section of the MPSE portal.

· Use code number “5 – Public” for the entity code on the Disclosure of Ownership and Control Interest of an Entity (DHS-5259) (PDF) form or in the Organization Information section of the MPSE portal.

· Counties and tribes do not need to list the county board members, but do need to list the managing employees involved when completing the review for the human services offices. Managing employees are limited to the services for which the county is enrolling.

Remote Support

If a provider chooses to provide services remotely, a completed Waiver Services Remote Support Provider Assurance Statement (DHS-8059) (PDF) must be submitted for the following remote support waiver services:

· 24-Hour Emergency Assistance (non-equipment)

· Adult Companion Services (AC, EW)

· Adult Day Services (ECS, Waiver, AC)

· Assistive Technology – Assessments (DD)

· Community Residential Services

· Crisis Respite

· Day Support Services

· Employment Services – Exploration, Development and Support

· Family Residential Services

· Family Training and Counseling

· Family Caregiver Services – Caregiver Training (EW, AC, ECS)

· Family Caregiver Services – Family Caregiver Counseling (EW, AC, ECS)

· Homemaker – Home Management

· Individual Community Living Supports (EW, AC)

· Independent Living Skills Therapies

· Individual Home Supports (without training, with training and with family training)

· Integrated Community Supports

· Positive Support Services (Analyst, Professional, and Specialist)

· Prevocational Services

· Respite In-Home (15-min units)

· Specialist Services

· Transitional Services (EW)

Revalidation

MHCP is required to follow the Centers for Medicare & Medicaid Services final federal provider screening regulations.

MHCP will notify you when you are due for revalidation. When you are notified, you must submit a revalidation request through the MPSE portal or fax all required forms and documents listed in the How to Enroll section to DHS.

We recommend using the MPSE portal and following the Revalidation Instructions in the MPSE user manual to revalidate your record. Log in to your MN–ITS account on the MN–ITS: Home webpage and choose the Minnesota Provider Screening and Enrollment (MPSE) portal link. If you have not registered your MN–ITS account, your login information is on your original Welcome Letter. Call the MHCP Provider Resource Center at 651-431-2700 or 800-366-5411 if you do not have your Welcome Letter.

Refer to Revalidation in Provider Screening Requirements under Provider Basics in the MHCP Provider Manual for important information, including timelines, about the revalidation process and impacts to your enrollment. Providers who do not meet the revalidation timelines will have their enrollment terminated.

Review the Frequently Asked Questions for HCBS revalidation available for providers.

Adding Services to Current Enrollment Record

Because there are multiple service options for HCBS programs, providers may add additional services after they have enrolled. To add additional waiver or AC programs services to a current waiver enrollment record:

1. Use the MPSE portal or fax the HCBS Programs Service Request (DHS-6638) (PDF) form to add the requested services and to submit qualifications to provide the services.

Include the appropriate assurance statements (see the HCBS Programs Service Request (DHS-6638) (PDF) to determine which services require an assurance statement and for a link to the appropriate assurance statement for that service.

2. Communicate with the lead agency to ensure your contracts include the new service.

Reporting Changes

The provider must notify MHCP any time a change occurs. Refer to Changes to Enrollment in the Enrollment with Minnesota Health Care Programs (MHCP) section of the MHCP Provider Manual for details.

MHCP will process the change information in date order received and will notify the agency if any more documentation is necessary to continue or maintain enrollment with MHCP in relation to the changes.

Additional Resources

Minnesota Statutes, 245C Human Services Background Studies
Minnesota Statutes, 245.814 Liability Insurance for Licensed Providers
Minnesota Statutes 256B.4912 Home and Community-Based Waivers; Providers and Payment