Federally approved BI, CAC, CADI, DD and EW waiver plans, Minn. Stat. 256B.0913, Minn. Stat. §256B.49, Minn. Stat. Chapter 256S, Minn. Stat. §256B.092, Minn. R. 9525.0004 to 9525.0036, Minn. Stat. §256.012

This page applies to case management and care coordination provided under the following programs:

Waiver, AC and ECS case management: A service that provides people and their families with access to assessment, person-centered planning, referral, linkage, support plan monitoring, coordination and advocacy related to waiver services, resources and informal supports that are not necessarily funded through the waiver.

Care coordination: A service for people enrolled in Minnesota Senior Health Options (MSHO) and/or Minnesota Senior Care Plus (MSC+). It provides assessment and coordination of the delivery of all health and long-term care services among different health and social service professionals and across settings of care. Care coordination also includes the waiver case management responsibilities identified above. References to "case management" on this page also include care coordination, when applicable.

Case manager/care coordinator: The professional who assists with access to and navigation of social, health, educational, vocational and other community and natural supports and services based on the person’s values, strengths, goals and needs. This professional is responsible to provide the person with information necessary to make informed choices.

Waiver, AC and ECS case management includes the following activities:

1. Plan:

2. Refer and link:

3. Coordinate:

4. Monitor:

5. Advocate:

Waiver, AC and ECS case management cannot duplicate other Minnesota state plan or waiver services.

Administrative activities are not billable under any waiver, AC or ECS program. Administrative activities include:

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

For additional information, see:

BI, CAC, CADI and DD case manager training

“Supporting my move: A case manager’s role” is an online, on-demand course for disability waiver case managers to guide them through their role and responsibilities in supporting a person to find a new home. DHS strongly recommends all disability waiver case managers complete this course and pass the required knowledge check.

This course is available through TrainLink. You must have a unique key to register and receive credit for training.

Steps to take course

The case manager should:

AC, BI, CAC, CADI and EW

People on AC, BI, CAC, CADI and EW must receive another waiver service in addition to waiver/AC case management.

The lead agency may authorize waiver/AC case management without another waiver service for a maximum of 60 calendar days. During this timeframe, the case manager/care coordinator must check in with the person at least monthly (e.g., phone calls or in-person visits).

If the lead agency does not authorize an additional waiver service during the 60-day timeframe, the person must exit the waiver or AC until the person becomes eligible and the lead agency can authorize additional waiver services.

Exception

If the reason for not authorizing additional waiver/AC services is that the person is transitioning between providers, services or settings, DHS allows an additional 60 days to authorize an additional waiver/AC service. During this timeframe, the case manager/care coordinator must check in with the person at least monthly (e.g., phone calls or in-person visits).

If the lead agency does not authorize services during the additional 60 days (120 days total), the person must exit the waiver or AC until the person becomes eligible and the lead agency can authorize additional waiver services.

For people who receive AC and fee-for-service EW, see the instructions in section of 301.07 of the Instructions for Completing and Entering the LTCC Screening Document and Service Agreement Into MMIS, DHS-4625 (PDF).

For people who receive EW through a managed care organization (MCO), refer to the MCO's instructions.

DD

People on the DD Waiver must receive waiver case management and habilitation (see CBSM – Habilitation).

Starting DD Waiver

When a person starts the DD Waiver, the lead agency may authorize a support plan that does not include habilitation for a maximum of 90 calendar days. The case manager must:

If the lead agency does not authorize habilitation during the 90-day timeframe, the person must exit the waiver until the person becomes eligible and the lead agency can authorize additional waiver services.

Loss of habilitation while currently on DD Waiver

People currently on the DD Waiver must receive waiver case management and habilitation.

The lead agency may authorize waiver case management without habilitation for a maximum of 60 calendar days. During this timeframe, the case manager must check in with the person at least monthly (e.g., phone calls or in-person visits).

If the lead agency does not authorize habilitation during the 60-day timeframe, the person must exit the waiver until the person becomes eligible and the lead agency can authorize habilitation.

Exception

If the reason for not authorizing habilitation within 60 days is that the person is transitioning between providers, services or settings, DHS allows an additional 60 days to authorize habilitation. During this timeframe, the case manager must check in with the person at least monthly (e.g., phone calls or in-person visits).

If the lead agency does not authorize habilitation during the additional 60 days (120 days total), the person must exit the waiver until the person becomes eligible and the lead agency can authorize habilitation.

Additional types of case management

Some people who receive waiver, AC and ECS case management may be eligible for other types of case management (e.g., mental health case management). In these situations, DHS recommends the waiver, AC and ECS case manager/care coordinator:

If the person has more than one type of case manager/care coordinator (e.g., person also has a mental health case manager), the waiver, AC and ECS case manager/care coordinator is responsible for all covered waiver, AC and ECS case management services.

Excluded types of case management

People who receive waiver, AC and ECS case management are not eligible for the following types of case management:

For more information about types of case management, see CBSM – Case management/care coordination.

Provision of case management

People may request to receive waiver, AC and ECS case management services from a lead agency other than the lead agency responsible for managing the person's waiver, AC or ECS. If a lead agency subcontracts with a qualified provider, choice of provider should be given to the person.

BI, CAC, CADI and DD

Waiver case management for people on BI, CAC, CADI and DD is arranged by the county or tribal nation of financial responsibility (CFR).

AC, ECS and EW

For people who receive AC, ECS or EW case management, the county of residence or tribal nation is responsible to provide access to and arrange for the provision of case management services. For people enrolled in MSHO and MSC+, the MCO is responsible to provide case management services.

Financial interest

The case manager, care coordinator or case management aide cannot have a personal financial interest in the services provided to the person.

Additionally, case management/case management aide services cannot be provided by a private agency that has a financial interest in the services provided to the person.

The timelines below represent the minimum required frequencies for face-to-face visits. The frequency of face-to-face visits should increase based on the person's needs.

BI, CAC, CADI and DD

The waiver case manager must have a minimum of two face-to-face contacts with the person within the 12-month period. The person’s annual reassessment may count as one face-to-face contact when case management activities are performed at the time of the visit.

AC, ECS and EW

The waiver, AC and ECS case manager/care coordinator must conduct at least one face-to-face visit per 12-month period. This visit can be included as part of the person's annual reassessment if the assessor is also the case manager/care coordinator.

AC, BI, CAC, CADI, ECS and EW

The lead agency may employ or contract with the following people to provide case management:

Public health nurse and registered nurse

A public health or registered nurse providing case management must be licensed under Minn. Stat. §148.171 – §148.285.

Social worker

A social worker providing case management must either:

For lead agencies that use the Minnesota Merit System or a county civil service system, social workers must:

For more information, see DHS – About the Merit System.

Care coordinator

Qualifications for MCO care coordinators are outlined in the contracts between DHS and MCOs. For more information, see DHS – Managed care contracts.

DD

A case manager must have:

Registered nurse requirement

A registered nurse must be designated as either the case manager or the qualified developmental disability professional (QDDP) for people who are both:

Tribal nations

For services provided by tribal governments, alternative credentialing standards can be applied under Minn. Stat. §256B.02, subd. 7. For more information, see CBSM – Tribal administration and management of HCBS programs.

BI, CAC, CADI and DD training requirement

If a case manager works with a person on the BI, CAC, CADI or DD waiver, they must complete 10 hours of case management education and disability-related training each year. The education and training must include person-centered planning. Training may be provided by DHS, a lead agency or providers approved by a lead agency. The lead agency must monitor and record completion of case manager training.