Recuperative Care

Revised: January 1, 2025

· Overview

· Eligible Providers

· Eligible Members

· Covered Services

· Noncovered Services

· Authorization

· Billing

· Recuperative Care Health Services Claim

· Recuperative Care Facility Claim

· Legal References

Overview

Recuperative care services are available to eligible Minnesota Health Care Programs (MHCP) members experiencing homelessness to help prevent hospitalizations; or provide medical care and support services when they are unable to recover from a physical illness when living in a shelter or they are otherwise unhoused. MHCP members receive recuperative care services when they don’t need to be hospitalized or remain hospitalized, or don’t meet severity of illness for other levels of care.

An MHCP member must have a referral for recuperative care services from a hospital or clinic.

Eligible Providers – Facility

Eligible recuperative care facilities must enroll as a recuperative care provider with MHCP. Refer to the Recuperative Care Enrollment Criteria and Forms section under Provider Basics in the MHCP Provider Manual for complete enrollment information. Each setting needs to be enrolled as a recuperative care facility.

Recuperative Care Facility Services Requirements
Recuperative care may be provided in any setting, including, but not limited to, homeless shelters, congregate care settings, single-room occupancy settings, or supportive housing, if the recuperative care or housing provider can provide the following to the MHCP member within the designated setting:

· 24-hour access to a bathroom with a shower, sink and toilet. The bathroom may be shared.

· 24-hour access to a bed.

· We recommend one member per room.

· We do not recommend room sharing because privacy, security, and infection control purposes.

· Access to three meals per day that are based on the member’s needs (included in per diem).

· Availability to environmental services (cleaning sanitation services).

· Access to a telephone.

· Secure place to store the MHCP member’s belongings.

· Staff available on site at the facility to provide an in-person wellness check as needed, or at the minimum of once every 24 hours.

· We require that one staff member is available at the facility at all times (24 hours a day).

· The member needs to be checked on (for example, visited in-person) at least once every 24 hours.

· The staff available to conduct the wellness check must be listed on the Recuperative Care Provider Assurance Statement (DHS-8486) (PDF).

· Providers do not get reimbursed for the wellness check because this is included in the room and board charge.

Eligible Providers – Health Services

Supervising Recuperative Care Health Services
Recuperative care health services must be supervised by an advanced practice provider that is enrolled with MHCP. The following providers may supervise recuperative care health services:

· Advanced practice registered nurse (nurse practitioner and clinical nurse specialist)

· Physician (MD, DO)

· Physician Assistant

Providing Recuperative Care Health Services
The following professional health care providers may provide recuperative care health services at a facility that meets the recuperative care facility requirements:

· Registered nurse (RN)

· Licensed practical nurse (LPN)

· Social worker (SW)

· Case manager (RN or SW)

· Mental health counselor

· Community health worker

· Community health workers must enroll as individual providers with MHCP. Refer to the Recuperative Care Enrollment Criteria and Forms section under Provider Basics in the MHCP Provider manual for complete enrollment information.

· Community health worker as defined under section Minnesota Statutes, 256B.0625, subdivision 49.

Or

· If the recuperative care facility partners with a licensed, MHCP-enrolled health services group provider, the health services should be provided by the group of caregivers listed on the Recuperative Care Provider Assurance Statement (DHS-8486) (PDF).

· These providers may be from a home care or public health services group that the recuperative care facility is partnering with to provide the health services. The affiliated health services group provider will have an established medical director.

RNs, LPNs, social workers and case managers do not need to enroll with MHCP to provide recuperative care services.

Eligible Members

To be eligible for recuperative care services, an MHCP member must meet all the following criteria.

· 21 years or older if they have Medical Assistance, or 19 years or older if they have MinnesotaCare.

· Experiencing homelessness or are unhoused.

· In need of short-term medical care for fewer than 60 days.

· In need of assistance with the following covered services.

Covered Services

Facilities and providers must ensure they are providing services only within their scope of practice. Providers can start offering recuperative care services only after their MHCP enrollment has been approved.

MHCP covers the following recuperative care services:

· Basic nursing care including monitoring physical health and pain level

· Wound care

· Medication support

· Patient education

· Immunization review and update

· Clinical goals development for the recuperative care period and discharge plan

· Care coordination including initial assessment of medical, behavioral and social needs

· Care plan development

· Support and referral assistance for legal, housing, transportation, case management and community social services

· Support and referral assistance for health care benefits, health and other eligible benefits

· Care plan implementation follow-up and monitoring

· Medical, social and behavioral (counseling and peer support) services that can be provided in the recuperative care setting

· Community health worker services (Minnesota Statutes, 256B.0625, 43.25 subdivision 49. 43.26)

Note: The member must receive care for the physical medical condition needing recuperative care services otherwise we will deny the daily room and board claim. Recuperative care is focused on the member’s physical medical condition and the recuperative facility cannot be centered on one covered service (for example, mental health only).

Noncovered Services

· The member’s behavioral health needs are greater than what the​ provider within the setting can manage.

· The member is not independent with activities of daily living. For example, the member would not be covered for recuperative care services if they are unable to stand or independently use the bathroom.

Authorization

Recuperative Care Extended Stay
Providers may request an extension if a member requires recuperative care services for more than 21 days. Providers must complete and submit Recuperative Care: Extended Stay Request (DHS-8513) (PDF) along with required medical information to the medical reviewer. Refer to Authorization under Provider Basics in the MHCP Provider Manual to submit a prior authorization request. Extended stays are not expected to go past 60 days.

Readmissions
Any consecutive readmission to recuperative care services for the same diagnosis will continue the same 21-day limit. If the member is close to the 21-day limit, providers must submit the Recuperative Care: Extended Stay Request (DHS-8513) (PDF) along with the required medical information to ensure continued payment. Any readmission to recuperative care services for a new diagnosis starts a new 21-day coverage limit.

Discharge From Recuperative Care Services
Providers must ensure either one of the following before discharging a member from recuperative care services:

· The member’s medical condition has improved.

· The member is being discharged to another setting that can meet their needs.

Note: The member can choose to be discharged with no housing option if that is their choice.

Billing

Recuperative care providers may get reimbursed for the recuperative care health services rate and the recuperative care facility rate. Providers can bill for services only after their MHCP enrollment has been approved.

Refer to the following information for definitions and payment rates.

Recuperative Care Health Services Rate
The recuperative care health services rate is a bundled per diem payment of​ $300.00 per day for the services provided to the member. Services provided within the bundled payment may include, but are not limited to, the covered services.

Recuperative Care Health Services Claim (Professional Claim)

· Bill on 837P claim format. Refer to the MN–ITS 837P Professional User Guides.

· Bill CPT code T2033 for the recuperative care bundled payment.

· Bill all CPT or HCPCS codes on the same DOS and same claim that describes the services rendered with a $0.00 charge (these will be zero pay).

· Report the enrolled MHCP MD, PA or APRN NPI as the rendering provider who is supervising health services. This provider must be reported on the Recuperative Care – Health Services Provider Acknowledgment (DHS-8562)

· The recuperative care facility can bill for the recuperative care health services claim and be on the professional claim as the pay-to provider when the recuperative care facility is providing the health services with a medical director as rendering provider.

· Or if, the recuperative care facility affiliates with health services group provider the health services group providers will submit the professional claim for their health services separately which is the recuperative care health services bundled rate of $300.00 per day. The recuperative care facility will not be able to bill for the professional services bundle rate.

· One of the ICD-10 diagnosis codes for homelessness will also need to be on the claim. It is the provider’s responsibility to determine the appropriate diagnosis code for the service that was provided.

Recuperative Care Facility Rate
The recuperative care facility rate is approximately $34.00 per day. This includes the room and board daily rate.

Recuperative Care Facility Claim

· 86X Residential Facility claim format. Refer to the MN–ITS 837I Institutional User Guides.

· One of the ICD-10 diagnosis codes for homelessness also needs to be on the claim and condition code 17. It is the provider’s responsibility to determine the appropriate diagnosis code for the service that was provided.

Note: The recuperative care services professional claim must be submitted and paid through MHCP before submitting the recuperative care facility claim. We reimburse the recuperative care facility rate only when the recuperative care health services rate is reimbursed to a provider. Providers may opt to only receive the recuperative care health services rate. The eligibility standards in chapter 256I do not apply to the recuperative care facility rate.

Managed Care Members

If a member is enrolled with a Managed Care Organization (MCO), the recuperative care health services claim must be submitted to the member’s MCO. Recuperative care providers must contact the MCO for enrollment requirements, billing and coverage policies when providing services to MCO enrollees. Contact the MCO with provider questions about coverage or contract issues.

The recuperative care facility (room and board) rate is a carve-out service. The recuperative care facility claims are covered through MHCP fee-for-service and should be billed directly to MHCP. It will be paid from state funds in an amount that equals the medical assistance room and board rate at the time the recuperative care services were provided.

Legal References

Minnesota Statutes, 256B.0701 (Recuperative Care Services)