Page posted: 11/14/16

Legal authority

Minn. Stat. §256B.0911, subd. 3a and 5

Overview

This page provides information about the applicability of and timelines for long-term services and supports (LTSS) assessments. For more information about assessments, including who does them and how, refer to CBSM – MnCHOICES.

This page includes information about:

When an in-person assessment is needed

A person needs an in-person assessment when they:

Examples of when the lead agency must consider an in-person assessment include:

When a remote reassessment is allowed

Remote reassessments conducted by interactive video or telephone may substitute for in-person reassessments in certain circumstances. For more information, refer to the remote reassessments section lower on this page.

Initial assessment

Who needs it

An initial assessment is completed for a person who is not currently receiving waiver services.

In some situations, a person needs an annual initial assessment. This includes a person who:

Note: Due to Medicaid Management Information System (MMIS) constraints, all CFSS assessments are coded as “initial assessments.” For policy purposes, annual assessments for people who receive CFSS services are considered reassessments.

Who requests it

A person or their legal representative may request an initial assessment at any time, whether they live in an institution or in the community.

Third-party requests

When a third party requests an assessment on behalf of a person, the lead agency must contact the person to confirm it is the person’s choice to have an assessment. If the person does not agree to an assessment, the lead agency does not complete one. If the person is not able to communicate actively about their agreement to have an assessment, the lead agency should use professional judgment in honoring the third party’s request.

Timeline

The lead agency must complete an in-person assessment no later than 20 business days after the date an assessment was requested or recommended. The assessor must provide the person with an estimated timeline of the completion of the assessment, either verbally or in writing.

The lead agency must conduct assessments in a timely manner and expedite urgent referrals and requests. The lead agency should evaluate urgent requests based on the person’s needs and potential risks if the assessment is delayed.

The following sections include timelines for specific situations.

Admission to ICF/DD

The lead agency must complete an in-person assessment and evaluate the person’s need within five business days of an emergency admission to an ICF/DD.

Admission to NF

The county/Tribal Nation must conduct an assessment within 80 calendar days of admission to an NF for all people younger than age 65.

If the person leaves the NF for another institutional setting (e.g., hospital) for any amount of time after admission, the 80-day timeline resets when the person reenters the NF.

Minnesota Aging Pathways unable to determine level of care for NF admission

When Minnesota Aging Pathways is unable to make a level of care determination, they send a referral to the lead agency. The lead agency must complete the assessment before the person’s admission to the NF and expedite the assessment to meet the person’s needs.

45-day temporary start of service

When a provider requests a 45-day temporary start of service for PCA/CFSS services, the lead agency must complete a telephone assessment with the person to determine the person’s needs before services start. Then, the lead agency must complete an in-person assessment within the 45-day authorization period. For more information, refer to CFSS Manual – 45-day temporary start of PCA/CFSS services.

Note

Each time a person opens or reopens to a waiver program, the lead agency must apply the conversion or diversion definitions to determine the waiver type. For more information, refer to:

Assessment validity

Initial assessments

Initial assessments are valid for 365 days after the date of the in-person assessment interview to:

The lead agency must determine the outcome for all LTSS assessments within 60 days from the date of the assessment interview. If a person is found ineligible for a program, they will need a new assessment activity (e.g., initial assessment, IAR). For more information, refer to CBSM – IAR for HCBS.

Reassessments

All other assessment types are valid for 60 days. Lead agencies must act on the assessment within 60 days of the assessment activity date.

Note: If eligible, the person can access state plan home care services throughout the year without a new assessment. For more information, refer to the CFSS Policy Manual.

Need-based services

A person can start need-based services (e.g., CFSS) and move to waiver services without receiving a new assessment within 60 days of the initial assessment date. The waiver span cannot overlap with the CFSS service agreement. The lead agency must close the type B service agreement before opening a waiver. If it has been more than 60 days from the initial assessment, the person needs an IAR to open to a waiver. For more information, refer to PartnerLink – IAR: Detailed guide.

Initial assessment review (IAR)

An IAR is a remote activity that follows an initial assessment. The assessor can use it to document new changes and open a person to a program. For more information, refer to CBSM – IAR for HCBS.

Annual reassessment

Who needs it

A person needs an annual reassessment if they are on:

Note: In some situations, a person needs an annual initial assessment. Due to MMIS constraints, all CFSS assessments are coded as “initial assessments.” For policy purposes, annual assessments for people who receive CFSS services are considered reassessments.

Choice to waive

Certain groups can waive annual assessments. Although DHS strongly encourages an annual reassessment for everyone, the following people (or their legal representatives) may waive their assessment if they are not on a waiver waiting list:

For more information, refer to CBSM – Choice to waive annual reassessment.

Timeline

AC, ECS and EW

A person must receive an annual reassessment within 60 days before the end of their current service agreement or program eligibility span, but no later than 365 days from the last assessment.

BI, CAC, CADI, DD and CFSS

A person must receive an annual reassessment within 60 days prior to the end of their current service agreement.

Programs without a service agreement

When a person does not have a service agreement, the annual reassessment must occur no later than the anniversary month of their last assessment (e.g. semi-independent living services, DD/RC case management).

Changes in need after an assessment

The lead agency may address some short-term changes after an assessment if a person already has an assessed need for supports by:

If a person only uses state plan services (i.e., not waiver services), the lead agency must complete an in-person reassessment to address needs that require more than 45 days of increased CFSS services.

If a person experiences a change in need that cannot be addressed using the above strategies, the lead agency may conduct an early reassessment or, for a person on AC/EW, complete a functional needs update (refer to the section below about functional needs updates).

The person, case manager or others (on behalf of the person) may request an early reassessment.

Timeline

The lead agency must:

Remote annual reassessments

Remote reassessments conducted by interactive video or telephone may substitute for in-person reassessments in certain circumstances. When available, DHS recommends using interactive video to allow for observation (including observation of the person’s environment) and completion of screening tools (e.g., Mini-Cog).

Note: For all programs, IARs do not count as a remote reassessment. The remote assessment policy only applies to reassessments.

AC, ECS and EW

The person may receive a remote reassessment following an in-person reassessment. The person can choose to have a remote reassessment every other year.

BI, CAC, CADI and DD

For assessments completed on or after Jan. 1, 2026, remote reassessments may substitute for four consecutive reassessments (including the 65th birthday reassessment), followed by an in-person reassessment in the fifth year. For assessments completed between Nov. 1, 2023, and Dec. 31, 2025, remote reassessments may substitute for two consecutive reassessments (including the 65th birthday reassessment), followed by an in-person reassessment in the third year.

CFSS

For assessments completed on or after July 1, 2025, remote reassessments may substitute for two consecutive reassessments, followed by an in-person reassessment in the third year.

Informed choice

If a person is eligible for a remote reassessment, the lead agency must provide information for the person to make an informed choice between a remote and in-person reassessment.

A person may only receive a remote reassessment if the lead agency provides informed choice and the person or their legal representative provides informed consent for a remote reassessment. When selecting a remote reassessment in MnCHOICES, the lead agency must document in the corresponding text box that they offered informed choice.

Considerations

Informed choice means a person understands all options available to them, including the benefits and risks of their decision. When providing information about remote and in-person reassessments, the lead agency must consider what information is important for the person to make an informed choice.

Some examples of considerations include:

For additional information about informed choice, refer to CBSM – Guide to encouraging informed choice and discussing risk.

During a remote reassessment, if the certified assessor determines an in-person reassessment is necessary, the lead agency must schedule an in-person reassessment.

Functional needs update for AC/EW

What it is

A functional needs update is a remote assessment used by the lead agency to document a change to a person’s assessed need(s) any time during the service agreement year.

The certified assessor conducts the functional needs update. DHS recommends the assessor who completed the assessment for the support plan also completes the functional needs update.

The assessor uses professional judgment to determine when a person needs an in-person reassessment. A functional needs update does not replace an annual reassessment, and it does not reset or extend a program eligibility span or service agreement span. A person may choose to receive a reassessment instead of a functional needs update.

The assessor can only use a functional needs update when the person uses:

Note: The assessor cannot use a functional needs update when the person uses a disability waiver, CFSS services or ECS services.

Who needs it

Situations in which the assessor can use a functional needs update include the need to make a change based on:

Process

After receiving a request for an assessment, the certified assessor contacts the person to determine the type of assessment needed. If the assessor determines a functional needs update is appropriate, they must:

Timeline

The lead agency must:

Addressing changes without a functional needs update

A case manager/care coordinator can work within the person’s current allocation to update their support plan and MMIS service agreement when there are changes (e.g., change in providers, change in services or amounts within the person’s current budget and/or customized living/24-hour customized living plan).

The case manager/care coordinator must communicate any changes in the person’s needs to the assessor using MnCHOICES Reassessment Communication Form, DHS-6791E (PDF) at the time of the next reassessment.

For more information, refer to CBSM – Support planning for LTSS.

65th birthday reassessment

The county/Tribal Nation must conduct reassessments for all people when they turn 65 years old if they are on one of the following waivers:

The person may be eligible for a remote reassessment on or after Nov. 1, 2023. For more information, refer to the remote reassessments section on this page.

Counties and Tribal Nations receive a quarterly report from DHS that identifies people who are turning 65 years old. DHS emails this report to the specific workers who subscribe to it.

During the person’s 64th year, the county/Tribal Nation must have a discussion with the person about service options and the implications of the person’s choice. During this discussion, the assessor and/or case manager should review the person’s need for services not offered by EW (e.g., employment services, independent living skills [ILS]).

Both the assessor and the case manager have a role in helping the person make an informed choice from all the available options.

At the 65th birthday reassessment, a person who receives disability waiver services may choose to:

Timeline

The county/Tribal Nation has a four-month window to conduct the 65th birthday reassessment. The four-month window includes the two months before the birthday month, the birthday month and one month after. For example, if the person turns 65 years old in January, the county/Tribal Nation can conduct the reassessment in November, December, January or February.

Recommendation

For people who are likely to transition to EW, it is best to conduct the assessment within 60 days of the person’s birthday. The county/Tribal Nation should:

How to document

To document the reassessment, the county/Tribal Nation enters a new screening document into MMIS using activity type 08.

The county/Tribal Nation should consult with the person about how this reassessment might affect the service authorization. After entering the in-person reassessment, the county/Tribal Nation can leave the current service authorization in place. This requires the lead agency to complete another assessment at the person’s typical annual reassessment time.

The lead agency can use the in-person 65th birthday reassessment to renew a service authorization in the following circumstances:

Additional information

People who turn 65 years old (including people enrolled in an MCO) can remain on, return to or move to another disability waiver if they are eligible to do so. For more information, refer to CBSM – Waiver, AC and ECS general processes and procedures.

There is no 65th birthday assessment for the DD Waiver. People age 65 or older who exit the DD Waiver may return to it because people of any age can access it if they meet eligibility requirements. For more information, refer to CBSM – DD Waiver.

Returning to a disability waiver for people age 65 or older

If a person age 65 or older was previously on a BI, CAC, CADI or DD waiver (including people enrolled in an MCO or on EW), the person might be eligible to move to another disability waiver or return to a disability waiver if they meet certain eligibility requirements. The county/Tribal Nation of location completes the assessment for all people seeking a disability waiver.

Process

The assessor is responsible to:

Eligible to return to a BI, CAC or CADI waiver

For instructions, refer to CBSM – Waiver, AC and ECS general process and procedures.

Not eligible to return to a BI, CAC or CADI waiver

If the person is not eligible to return to the BI, CAC or CADI waiver, the assessor should determine the person’s eligibility for EW, DD Waiver or other non-waiver services.

If the person is enrolled in an MCO, the MCO must use the assessment completed by the county/Tribal Nation. If the person chooses to receive EW, the MCO authorizes the renewal or return to EW.

Additional resources

Policy

CBSM – Activity timelines for reassessments when the COR and CFR are different
CBSM – Choice to waive annual reassessment
CBSM – DD screening
CBSM – IAR for home and community-based services
CBSM – Long-term care consultation
CBSM – MnCHOICES
CBSM – Reassessments when the COR and CFR are different
CBSM – Rule 185 case management
CBSM – Support planning for LTSS
CBSM – Tribal administration and management of HCBS programs
CBSM – Waiver, AC and ECS general processes and procedures
CBSM – Waiver/AC case management
CFSS Manual – 45-day temporary increase of CFSS services
CFSS Manual – 45-day temporary start of CFSS services

Forms

CBSM – Forms for LTSS assessment, eligibility and support plans
Assessment Summary Worksheet, DHS-6791A (PDF)
HCBS Waiver, AC and ECS Case Management Transfer and Communication Form: Scenarios for People on AC, EW or ECS, DHS-6037A (PDF)
HCBS Waiver, AC and ECS Case Management Transfer and Communication Form: Scenarios for People on a Disability Waiver: BI, CAC, CADI and DD, DHS-6037B (PDF)
Instructions for Completing and Entering the LTCC Screening Document and Service Agreement into MMIS, DHS-4625 (PDF)