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Moving Home Minnesota Program Manual

This manual is the primary source for Moving Home Minnesota (MHM) policy. It is a reference for lead agencies (counties, tribal nations and managed care organizations), providers, transition coordinators, licensed alcohol and drug counselors (LADCs), case managers and people who use MHM.

What is MHM?

The Money Follows the Person Rebalancing Demonstration, offered through the federal Centers for Medicare & Medicaid Services (CMS), was created as part of the Deficit Reduction Act of 2005. Minnesota’s Money Follows the Person Demonstration is called Moving Home Minnesota.

The goal of MHM is to establish services for people on Minnesota’s Medical Assistance (MA) program to move from qualified institutions to their own home in the community. MHM promotes the development and implementation of transition plans that reflect the preferences of people receiving services and the opportunity to receive services in the most integrated setting.

Lead agencies and LADCs help the person select a transition coordinator. The person works with the transition coordinator to create and implement a plan to transition back to the community in the area of their choosing. The person may also be eligible for up to 365 days (or 366 days during a leap year) of additional MHM services to support them living in the community. For more information about services, refer to MHM Policy Manual – Services.

Updated and reorganized MHM policy pages

DHS is in the process of updating and reorganizing all MHM policy pages. This includes transferring some information previously found in the Minnesota Health Care Programs (MHCP) MHM Provider Manual.

What’s new?

Date	Page	Action
2/5/26	Eligibility	Made the following changes: · Added a definition for alcohol and drug counselors (ADCs) · Clarified the person must meet an institutional level of care to be eligible for transition planning, coordination and services · Added a limitations section · Updated information in the level of care – MnCHOICES section to add initial assessment reviews
12/10/25	Guide for MHM access and substance use disorder (SUD)	Added references throughout the page to alcohol and drug counselors (ADCs) who hold a certification from the Upper Midwest Indian Council on Addictive Disorders (UMICAD) within American Indian SUD programs
11/12/25	Comparison of MHM, RSC-TCM and HSS	Made the following changes: · Removed information about housing stabilization services · Reorganized content to provide clarity about qualified institutions · Clarified information throughout the page
7/1/25	Instructions to complete MHM Service Authorization Plan, DHS-6759P	New page that is a resource for transition coordinators and demonstration case managers as they complete MHM Service Authorization Plan, DHS-6759P
7/1/25	Resource: Pantry-stocking list	New page with examples of items a person may purchase using the MHM pantry-stocking service
7/1/25	Transition integration fund	New page to provide details about the specific service
7/1/25	Records and fees	New page to provide details about the specific service
7/1/25	Pre-transition non-medical transportation	New page to provide details about the specific service
7/1/25	Pre-transition clean-up	New page to provide details about the specific service
7/1/25	Pantry stocking	New page to provide details about the specific service
7/1/25	Environmental modifications deposit	New page to provide details about the specific service
7/1/25	Community education and integration costs	New page to provide details about the specific service
7/1/25	MHM services	Made the following changes: · Added links to new service pages · Added a link to the new form, MHM Service Authorization Plan, DHS-6759P
6/3/25	Membership fees	New page to provide details about the specific service
6/3/25	MHM services	Added link to new service page
6/2/25	Transition coordination	Made the following changes: · Updated page organization to match other pages · Clarified information about limitations, provider standards and qualifications and authorization, rates and billing
5/28/25	Transition planning	New page to provide details about the specific service
5/28/25	Personal emergency response systems (PERS)	New page to provide details about the specific service
5/28/25	Environmental modifications	New page to provide details about the specific service
5/28/25	MHM services	Added links to three new service pages
5/21/25	Home care training – family and non-family	Added a documentation section
5/20/25	Respite	New page to provide details about the specific service
5/20/25	MHM services	Added links to two new service pages
5/15/25	Resources for community living	Comprehensively reviewed and updated resources
5/15/25	Pre-discharge case consultation and collaboration	New page to provide details about the specific service
5/12/25	Home care training – family and non-family	New page to provide details about the specific service
5/12/25	Overnight assistance	New page to provide details about the specific service
5/12/25	MHM services	Added links to two new service pages
5/2/25	Demonstration case management	New page to provide details about the specific service
5/2/25	MHM services	Added links to two new service pages
5/1/25	Tools, clothing and equipment	New page to provide details about the specific service
5/1/25	Specialized supplies and equipment	New page to provide details about the specific service
4/17/25	Transitional services	New page to provide details about the specific service
4/17/25	Costs for finding housing and employment	New page to provide details about the specific service
4/17/25	Comprehensive community support services (CCSS)	New page to provide details about the specific service
4/17/25	MHM services	Added links to three new service pages
2/21/25	MHM services	Made the following changes: · Added definitions of “demonstration services” and “supplemental services” · Clarified information about access, service authorizations, MnCHOICES and MMIS · Added a section about DHS approval for extensions or additional service units
2/4/25	Eligibility	Made the following changes: · Added a definition of “authorized leave of absence” and a new section to explain that policy · Updated the qualified institutions section to clarify information about institutes for mental disease (IMDs) for people age 21 to 64 · Updated the qualified community residences section to add a note that sober living homes and sober living environments are not considered qualified community residences · Updated the additional resources section to add a link to MHM Communication Form, DHS-6759H
10/8/24	Eligibility	Added information to the level of care section to provide MnCHOICES instructions for managed care organizations (MCOs)
8/9/24	MHM transition coordination	Comprehensively reviewed and made the following changes: · Added definitions for transition coordinator and lead agency · Added more detail about covered services and information about services for out-of-state moves · Added more detail to the roles and responsibilities and qualifications sections · Created new sections to describe non-covered services, communication with DHS and extensions
8/8/24	Lead agency responsibilities for MHM	Comprehensively reviewed and made the following changes: · Added definitions for county of financial responsibility, managed care organization, managed care products, licensed alcohol and drug counselor (LADC), screening document and transition coordinator · Clarified that the information on this page does not apply to LADCs · Expanded on and clarified information in the lead agency roles and responsibilities section
7/30/24	MHM program interactions	For information about these updates, refer to the July 30, 2024, eList announcement.
7/12/24	Reporting enrollment changes, reinstitutionalization and disenrollment for MHM	Comprehensively reviewed and made the following changes: · Added definitions for short-, medium- and long-term stays · Simplified the definition of reinstitutionalization · Added more examples to the enrollment changes section about changes during transition and changes post-transition · Clarified that reporting reinstitutionalization during MHM via MHM Communication Form, DHS-6759H is required, even if the reinstitutionalization is for one day
7/11/24	MHM documents and forms	Comprehensively reviewed and made the following changes: · Added additional information about using MHM Communication Form, DHS-6759H · Added MHM Transition Planning Tool Part 2: Risk Mitigation and Emergency Backup Planning, DHS-6759K (PDF) · Added MHM Substance Use Disorder (SUD) Referral Form, DHS-6759N · Added Professional Statement of Need, DHS-7122 (PDF)
7/11/24	Home page (current page)	Comprehensively reviewed and made the following changes: · Added references to licensed alcohol and drug counselors (LADCs) · Clarified information in the “What is MHM?” section
5/6/24	Guide for MHM access and substance use disorder (SUD)	Created new page that is a resource for people seeking transition services while receiving residential SUD services in qualified institutions
5/6/24	Enrollment	Created new page focused on the enrollment process
5/6/24	Eligibility	Comprehensively reviewed, clarified information throughout the page and added a section about level of care
11/13/23	Transition services provider contact list	New page that combines provider lists for relocation service coordination – targeted case management (RSC-TCM) and MHM transition coordination services. For more information, refer to the Dec. 12, 2022, eList announcement.
8/1/23	MHM transition coordinators	Added Ace Community Connect to provider list
7/13/23	MHM transition coordinators	Added Cardinal Home Services to provider list
7/5/23	Eligibility and enrollment	Updated information about assisted-living residences in the qualified community residences section
4/14/23	MHM services	Made the following updates: · Clarified information in the HCBS services section · Added information about BRASS codes
1/25/23	MHM transition coordinators	Updated the address and contact information for Oak Tree Support Services
1/20/23	MHM transition coordinators	Updated the address for Independent Living Placement
1/9/23	MHM transition coordinators	Made the following changes: · Added a website for Hope Outreach Solutions · Added Independent Living Placement as a provider
1/5/23	Comparison of MHM, RSC-TCM and HSS	Corrected an error in the age requirements for people who reside in an institution for mental disease (IMD) and receive Housing Stabilization Services (HSS)
12/15/22	MHM transition coordinators	Made the following changes: · Updated the provider list · Added information about location for providers also certified to provide relocation service coordination targeted case management (RSC-TCM)
12/14/22	Comparison of MHM, RSC-TCM and HSS	Corrected an error in the age requirements for people who reside in an institution for mental disease (IMD)
11/29/22	MHM services	Comprehensive review with the following changes: · Reorganized the page for clarity · Added information about how to enter an LTC screening document into MMIS that no longer requires the document to produce a 110 edit · Updated required criteria for when the MHM indicator can equal “Y” in MMIS on a LTC screening document
10/26/22	Comparison of MHM, RSC-TCM and HSS	Added a clarification about residing in an institution for mental disease (IMD) for MHM
10/21/22	Reporting enrollment changes, reinstitutionalization and disenrollment for MHM	New page with instructions about reporting changes to DHS
10/7/22	Comparison of MHM, RSC-TCM and HSS	New page that compares MHM with relocation service coordination – targeted case management (RSC-TCM) and Housing Stabilization Services (HSS)
10/7/22	MHM program interactions	New page with information about accessing MHM in conjunction with other programs/services
10/3/22	Lead agency responsibilities	New page with information about lead agency responsibilities related to MHM and scenarios that provide additional details
9/2/22	MHM transition coordinators	New page with a list of providers screened and enrolled as Minnesota Health Care Programs (MHCP) providers for MHM transition coordination services
8/8/22	Eligibility and enrollment	Comprehensive review with the following changes: · Added a definition of “lead agency” · Updated the organization of content for clarity · Updated the page title to include “enrollment”
8/1/22	MHM documents and forms	Comprehensive review with the following changes: · Reorganized the page for clarity · Added information about the purpose of the forms and who should complete them
7/27/22	Additional resources for community living	Comprehensive review with the following changes: · Reorganized the page for clarity · Added more resources

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Moving Home Minnesota Program Manual

What is MHM?

Updated and reorganized MHM policy pages

What’s new?

Date

Page

Action