Deficit Reduction Act, 2005 (PL 109) §6071 (PDF), Patient Protection and Affordable Care Act, 2010 §2403 (PDF), Minn. Stat. §256B.04, subd. 20

Home care training – family and non-family (previously known as post-discharge case consultation and collaboration): An MHM service that covers comprehensive evaluation and consultation sessions with a credentialled provider to support the person’s transition plan after they have moved to a qualified community residence. The service must be:

Credentialled provider: Health care professional who passed the credentialing process and is allowed to provide care to people (e.g., physicians, nurses and other allied health care professionals).

Demonstration case management (DCM): MHM service a person may receive after moving to the community. This service monitors and evaluates the person’s MHM community services and supports as they adjust in the community. DCM must be:

Transition coordination: MHM service that provides coordination of activities to support a person who resides in a qualified institution to gain access to medical, social, education, financial, housing and other services and supports that are necessary to move to the community. For more information, refer to MHM Manual – Transition coordination.

Transition coordinator: Professional who carries out the transition coordination service and supports a person to move from a qualified institution to the community with MHM.

Lead agency: County, tribal nation or managed care organization (MCO).

A person is eligible to receive MHM home care training – family and non-family for up to 365/366 days after their move into the community if they meet all the following criteria:

Waiver interaction

If the person enrolls in a home and community-based services (HCBS) waiver program, they can receive this MHM service in addition to their waiver services.

MHM home care training – family and non-family covers comprehensive evaluations and consultation sessions with a credentialled provider to support and adjust a person’s TPT after their move to the community. Covered activities include:

MHM home care training – family and non-family does not cover:

Note: The MHM home care training – family and non-family provider is responsible to coordinate the delivery of this MHM service with other services.

Before the service

Before an MHM home care training session can begin, the transition coordinator, care coordinator and/or case manager must:

After the service

After an MHM home care training session, the transition coordinator, care coordinator and/or case manager must document service delivery in the following ways:

MHM home care training – family and non-family:

A transition coordination provider or case manager/care coordinator must be present if the provider delivers MHM home care training – family and non-family in person with the person present.

Consultation and collaboration must be directly related to the credentialed provider’s specialty or profession. The credentialed provider cannot consult on subjects beyond their licensure.

The provider must:

License requirements

Either the credentialled provider or the transition coordination provider/lead agency billing on behalf of the credentialled provider must be an enrolled Minnesota Health Care Programs (MHCP) provider. The entity billing must be one of the following:

Service authorization

The lead agency (or transition coordinator if the person does not have a lead agency) assigns an MHM demonstration case manager. The demonstration case manager is responsible to authorize the person’s MHM post-transition community services.

This service requires a service authorization. DHS pays the provider as indicated on the service agreement.

For instructions about authorizing MHM community services and how to receive prior authorization, refer to MHM Manual – Services.

Rate

The lead agency or transition coordination provider should use specific components of the person’s service and support needs to work with the provider to determine an appropriate agreed upon service rate for an MHM home care training – family and non-family session. The following items may be appropriate components to consider when setting a session rate:

The lead agency or provider claims the actual cost of the consultation, limited to the actual cost per session not to exceed $1,500 per session. The rates cannot exceed the rate limit in Long-Term Services and Supports (LTSS) Service Rate Limits, DHS-3945 (PDF).

Billing

If the credentialled provider is not enrolled as an MHCP provider for MHM home care training – family and non-family, the lead agency or transition coordination provider must be enrolled as an MHM home care training – family and non-family provider to serve as a pass-through biller for the service.