Source: http://www.dhs.mn.gov/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=ID_056766
Timestamp: 2018-01-22 00:45:13
Document Index: 353386611

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MHCP Provider Manual - Elderly Waiver & Alternative Care
Elderly Waiver (EW) and Alternative Care (AC) Program
Revised: 12-22-2017
• Authorization of Services and Service Authorization/Agreement Letters (SAL)
• Billing for Waiver and Alternative Care (AC) Program
• Specialized Equipment & Supplies Authorization & Billing Responsibilities
• Service Descriptions, Billing Codes, Provider Standards
• Adult Day Services and Adult Day Services Bath
• Adult Foster Care Services
• Case Management Aide or Paraprofessional
• Chore Services
• Companion Services - Adult
• Consumer Directed Community Supports (CDCS)
• Customized Living Services
• Environmental Accessibility Adaptations
• Family Caregiver
• Extended State Plan Home Health Services – EW Program Only
• Home Health Services – AC Program Only
• Individual Community Living Support (ICLS)
• Nutrition Services – AC Program Only
• Specialized Equipment and Supplies
• Transitional Services
• EW and AC Transportation
• Provider Quick Reference
• Legal References and Resources
• HCBS Waiver and AC Home Page
Elderly Waiver (EW) and Alternative Care (AC) programs fund home and community-based services (HCBS) for people 65 years old and older who require the level of care provided in a nursing home, but choose to live in the community. These programs provide services and supports for people to live in their homes or a community setting, and may delay or prevent nursing facility (NF) care. The purpose of these programs is to promote community living and independence with services and supports designed to address each person’s individual needs and choices. In the case of EW, the additional services go beyond what is otherwise available through Medical Assistance (MA).
• The Elderly Waiver (EW) program is a federal Medicaid waiver program that funds home and community-based services for people 65 years old and older who are eligible for Medical Assistance (MA), require the level of care provided in a nursing home, and choose to live in the community. EW recipients can receive waiver services and MA services funded through a managed care organization (MCO). This can be through Minnesota Senior Care Plus (MSC+) or Minnesota Senior Health Options (MSHO).
• The Alternative Care (AC) program is a state-funded program that supports limited home and community-based services for people 65 years old and older who are not financially eligible for MA, but who meet AC financial and service eligibility requirements and require the level of care provided in a nursing home. People eligible for AC have low levels of income and assets but are not yet eligible for MA.
Anyone may request an assessment for themselves or another person by contacting the local lead agency. The lead agency will determine program eligibility. EW and AC have different application processes, financial eligibility requirements and covered services.
All applicants must meet the service eligibility criteria for the specific HCBS program in which they anticipate receiving services. Refer to the MHCP Provider Manual, Programs and Services for more information about MA and eligibility.
• To be eligible for EW services, applicants must also be eligible for MA.
• To be eligible for AC, applicants would be financially eligible for MA within 135 days of entering a nursing facility as determined by a case manager.
County Financial Worker
County financial workers determine financial eligibility for payment of Elderly Waiver services. Financial workers will also conduct asset assessments as needed for determination of AC and EW financial eligibility.
Lead Agency Case Managers
Lead agency case managers determine financial eligibility for payment of Alternative Care services.
For EW, the lead agencies can be counties, tribes or health plans. For AC, lead agencies can be counties or tribes. A lead agency can be the local public health agency, human service agency or social service agency. Lead agencies are responsible for the following:
The lead agency provides long-term care consultation (LTCC) services, including the following:
• A community assessment of the needs of the recipient
• Assistance with the application process
• Development of a community support plan
A recipient approved for EW or AC will receive case management or care coordination from a public health nurse or social worker who does the following:
• Helps develop the community support plan based on the person’s needs
• Implements and monitors the community support plan (The community support plan must ensure that the health and safety needs of the recipient are reasonably met.)
• Assures informed choice and consent
• Helps with referrals
• Arranges for and coordinates service delivery
Program Access and Administration
Lead agencies are responsible for providing program access and administration, which includes the following:
• Working in partnership with DHS and other organizations to provide information, services and assistance to people who request and wish to gain HCBS access
• Providing recipient case management or care coordination services, including the following:
• Assessing program eligibility
• Developing a service plan
• Assisting recipients to access, coordinate and evaluate available services
• Generating additional copies of provider service agreement (SA) letters, if needed
• Inputting recipient enrollment data (for example, screening document) and service authorization, as required, into the DHS Medicaid Management Information System (MMIS)
• Authorizing and monitoring services to reasonably assure health and safety
• Monitoring the ongoing provision of individual services for efficiency, consumer satisfaction, and continued eligibility, and adjusting these provisions as necessary
• Managing the contract(s) and systematic monitoring of provider performance
• Assuring that all providers meet state standards relevant to their area of service and have signed provider agreements.
• Authorizing funds for all HCBS services provided to the eligible recipient
By law, the lead agency or state must notify the recipient anytime services are denied, terminated, reduced or suspended. Notification must be in writing and sent at least 10 days before the action is taken. Lead agencies must use the Notice of Action (DHS-2828) (PDF) to notify the recipient of impending changes to the waiver services.
The lead agency will do the following:
• Provide individuals seeking EW or AC services the necessary information to make informed choices among the services for which they are eligible.
• Inform the recipient and legal representative when a recipient is likely to require the level of care provided in an institution, such as a hospital or nursing home, of home and community based supports as an alternative.
• Document that the above information was given.
• Take reasonable steps to provide the information in a format the recipient can understand and with a choice of service providers for all services.
• Inform a recipient nearing age 65 of the other community support options so that the recipient can choose which alternative will best meet his or her needs. A recipient receiving waiver services before age 65 remains eligible for the respective waiver after turning 65 years old if he or she meets all other eligibility criteria. Other options may include the EW, remaining on their current HCBS waiver or other alternatives that may meet the needs and preferences of the recipient. For information about HCBS waivers for people under age 65 refer to the Community-Based Services Manual.
There are many advantages for both providers and lead agencies to coordinate efforts to ensure that a recipient receives necessary services, and that providers receive timely payments for services rendered. Providers who are contracting with health plans to provide services should receive instructions from the health plan on how to ensure payment.
Enrollment, Licensure and Certification
EW and AC program providers must enroll with MHCP and meet specific standards to bill and receive payment for waiver services. To enroll in MHCP to provide waiver or AC program services, follow the instructions in the Home and Community Based Services (HCBS) Waiver and Alternative Care Provider Enrollment section.
Providers must also determine which program services they are qualified to provide. Specific provider qualifications are found in this manual within each service description. The HCBS Programs Service Request Form (DHS-6638) (PDF) also lists qualifications.
Some waiver services require one or more of the following:
• License(s) from DHS or the Minnesota Department of Health
• Medicare certification
• Other certification or registration
For more information, refer to one or more of the following:
• The lead agency in which you will be providing services
• DHS Licensing at 651-431-6500
• Minnesota Department of Health at 651-201-5000 for general information
Authorization of Services and Service Authorization or Agreement Letters (SAL)
A completed screening document that opens the EW or AC eligibility span must be entered into MMIS.
EW and AC services require service authorization from a lead agency case manager in the form of a completed service agreement (SA).
County and tribal agencies initiate the service authorization and enter it into MMIS. This ensures provider payment. If the rate, procedure code(s), or begin and end dates on the SA are incorrect, providers must contact the case manager. If an SA line item is changed and approved, DHS will automatically generate a revised SA letter to the provider. MMIS generates a letter overnight that is sent the following day to the provider’s MN–ITS mailbox.
The SA allows the provider to provide services and then bill DHS and receive payment. MHCP will pay only services on the SA; however, an approved SA is not a guarantee of payment. The case manager is ultimately responsible to ensure that the SA is accurate when it is entered in MMIS. When the provider receives the SA letter, they should review it for accuracy.
Each line item on the SA lists the following:
• MHCP-enrolled provider who is authorized to provide the needed services
• Rate of payment for the service
• Number of units approved or total amount
• Date or date span of service
• Approved procedure code(s)
• MA home care services of SNV, HHA, Home Care Nursing , and PCA that must be utilized before EW extended services
The EW and AC service agreement displays units, duration and rates. All authorized services need to stay within the published case mix budget caps and published state maximum rates for services.
Providers must verify program eligibility for each recipient each month through the MHCP phone-based eligibility verification system (EVS) or online via MN–ITS.
To bill for EW and AC services, refer to the Billing for Waiver and Alternative Care (AC) Program section.
For extended home care services approved on the waiver or AC authorization, submit claims using the 837I Institutional Outpatient transaction, following home care billing guidelines.
Health plans have their own service authorization systems. Service providers who are contracting with health plans need to contact the health plan for instructions on how to submit claims. South Country Alliance health plan contracts with MHCP to act as the third party administrator (TPA) for submitting claims and receiving reimbursements for EW services. Contact the health plan for particular instructions when obtaining authorizations and billing for EW services.
Diagnosis Codes (ICD)
MHCP requires agencies to enter the most current, most specific, primary diagnosis code when submitting claims for most waiver and AC services.
Service authorization or agreement letters to the provider that display the diagnosis code of the recipient are required for billing. The diagnosis is pulled from the primary diagnosis field on the last approved screening document. It is not necessary to use the diagnosis code listed on the service authorization or agreement letter if you have a more recent or correct diagnosis code. Use the ICD-10 codes for services provided October 1, 2015, or later.
Authorized Services vs. Non-Authorized Services
Services that require an SA cannot be billed on the same claim as services that do not require an SA. For example, for MA eligible recipients, home care therapy services (physical, occupational, respiratory and speech therapy) do not require an SA and cannot be billed on the same claim form as a waiver service, such as, adult day services.
Lead agencies authorize service and provider payment rates. DHS establishes upper rate limits for AC and EW services. Service rates authorized and claimed may not exceed the DHS published maximum allowable service rates, and, for some market rate services must be determined based on the lowest cost effective bid within the limits.
Bill the following services provided on or after July 1, 2014, at the statewide maximum rate:
• AC Nutrition Services S9470
• Adult Day Service Bath S5100 TF
• Adult Day Service S5100, S5102, S5100 U7, S5102 U7
• Chore S5120
• Companion Services S5135
• County-provided case management T1016, T1016 UC, T1016 UC TF, and T2041
• Family Caregiver Coaching and Counseling S5115 TF
• Home Delivered Meals S5170
• Homemaker or Assistance with Personal cares (S5130 TG, S5130 TF), Home Management (S5131 TG, S5131 TF) and Homemaker Services or Cleaning (S5130, S5131)
• Respite in Home S5150, S5151
• Respite out-of-home H0045
Information about service rate changes and limits for EW and AC services are available through publication of bulletins. Review the long-term services and supports rates changes web page for the most up-to-date information about current rate limits.
Clients Leaving Nursing Facilities (Conversion Rates)
A person receiving EW services may access a higher monthly budget if the person is a resident of a certified nursing facility and has lived there for 30 consecutive days. Refer to the Bulletin Elderly Waiver-Monthly Conversion Budget Limits and Maintenance Needs Allowance Changes (PDF).
Elderly Waiver Obligation
Eligibility for EW is based on two income limits:
• People with incomes equal to or less than the Special Income Standard (SIS) are eligible for EW without an MA spenddown. They must contribute any income over the maintenance needs allowance and other applicable deductions to the cost of services received under EW. This is known as the waiver obligation.
• People with incomes greater than the SIS may still be eligible for EW but they will have an MA spenddown. The lead agency’s financial assistance unit is responsible for determining the financial obligation of the EW client. The client receives a notice if they have a waiver obligation or will be responsible for a spenddown.
The waiver obligation is:
• Deducted from the cost of services received under the Elderly Waiver; the full amount of the waiver obligation does not have to be met each month.
• The amount the client is responsible to pay towards the services the client used that month, which may be a portion of the waiver obligation or the entire waiver obligation.
A MA spenddown may be met with any combination of MA services, including HCBS services. MA spenddowns must be met each month.
The county financial worker enters the waiver obligation into MMIS. DHS will report the amount the provider can bill the recipient on their remittance advice. Claims that are reduced due to the EW obligation will show claim adjustment reason code PR 142 on the remittance advice. Health plans also receive reports on their recipients who have waiver obligations. Each health plan has a process for informing providers on amounts of waiver obligations. See the Special Income Standards (SIS), section 22.10, of the Health Care Programs Manual.
A recipient can designate a provider to whom they will pay the obligation. The recipient must notify the financial worker if he or she wishes to choose this option. Recipients who receive waiver services through a health plan cannot use the designated provider option that is available through the financial worker request.
Maximizing Other Payors
EW and AC recipients are expected to maximize access to other federal or private program benefits for primary health care coverage through Medicare benefits, private insurance, Medicare supplemental policies, or long-term care insurance policies.
Home Care Services provided for an MA-eligible Recipient Receiving EW Services
All recipients receiving EW services must first access MA home care services to the highest extent before adding EW services to the community support plan.
MA covers the following home care services:
• Home health aide (HHA) visits
• Occupational therapy (OT)
• RN PCA supervision
• Personal care assistant (PCA)
• Physical therapy (PT)
• Respiratory therapy (RT)
• Skilled nursing visits (SNV)
• Speech therapy (ST)
Home Care and EW Waiver
• Some recipients on EW receive their EW services fee-for-service (FFS) and their MA home care through managed care, formally called the Prepaid Medical Assistance Program (PMAP).
• The managed care products that serve Elderly Waiver recipients are Minnesota Senior Care Plus (MSC+) and Minnesota Senior Health Options (MSHO).
• The FFS case manager of EW services determines the amount of home care services and approves the service agreement. When the recipient has MA services through managed care, the case manager uses a pseudo code (X5609), which authorizes the amount of home care services that are counted towards the recipient’s case mix budget.
• For managed care recipients of EW services, the designated care coordinator is responsible for approval and provision of all home care and EW services.
Home Care and AC
The case manager determines and authorizes the amount of home care services that are counted towards the recipients case mix budget. AC does not have an MA benefit.
Extended Home Care Services – EW
• Extended home care services include extended PCA, extended home health aide and extended home health nursing (RN or LPN).
• A recipient must first access needed home care service benefits through MA home care, either FFS or managed care, before “extended home care” benefits may be approved.
• Home care service needs that cannot be met within the MA home care limits may be approved and billed to the waiver as extended MA services within the budget limit available.
Refer to Home Care Services for more information about MA home care services.
Select the link below to view the Community Based Services Manual (CBSM) policy page for each service that includes the legal reference, service description, covered and noncovered services when applicable and provider standards and qualifications. If a service is not linked to the CBSM, see service descriptions, billing codes, and provider standards below the table.
Adult day services bath
Adult family foster care
All MA covered services
Case management aide (Paraprofessional)
Conversion case management
• Family caregiver coaching and counseling with assessment
• Family caregiver training and education
• Family memory care
Home care – extended services HHA, home care nursing, PCA
RN supervision of PCA
Tele-homecare
Service Descriptions, Billing Codes and Provider Standards
The following EW and AC service descriptions include:
• Provider qualifications and standards
• Secondary information (where appropriate)
These services and requirements are the minimum guidelines. Lead agencies may negotiate with providers in their contracts for any additional specific performance standards or requirements needed to meet needs of specific individuals.
Service and HCPCS
Foster Care – Corporate
• S5141 with modifier HQ – Monthly, Adult (cannot be used for dates of services on or after July 1, 2016)
• S5140 with modifier U9 – Daily (effective for dates of services on or after July 1, 2016)
Foster Care – Family
• S5141 – Monthly, Adult (cannot be used for dates of services on or after July 1, 2016)
• S5140 – Daily (effective for dates of services on or after July 1, 2016)
Foster care services are ongoing residential care and supportive services provided to a recipient living in a home licensed as foster care.
• Personal care assistant services
• Homemaker
• Medication oversight (to the extent permitted under state law) provided in a licensed home
Adult foster care is provided to recipients who receive these services in conjunction with residing in the home. Foster care services are based on the individual needs of the recipient. Beginning July 1, 2015, lead agencies must use the EW Residential Services Tool (formerly known as the Customized Living Tool) to determine rates for foster care.
When placing an adult into a licensed foster care setting, all federal, state, county, and licensing agency rules and regulations must be followed. Requirements for services and supports are identified in the community support plan of the recipient.
Adult Foster Home Size
The total number of people (including waiver recipients) living in the home cannot exceed four when all residents are:
• Diagnosed with a serious and persistent mental illness or a developmental disability
• Not related to the principal care provider
The total number of people (including waiver recipients) living in the home cannot exceed five when all residents:
• Do not have a diagnosis of serious and persistent mental illness or developmental disability
• Are not related to the principal care provider
Adult foster care homes provide the following:
• Household services
• Medication assistance (as permitted under state law)
• Assistance safeguarding cash resources
• Personal care assistance
• Oversight and supervision
Payment for EW foster care service does not include the following:
• Duplication of services paid by other sources
• Items of comfort or convenience
• Costs of facility maintenance, upkeep and improvement
• Payment for foster services when the recipient is not in the foster setting
• Separate payment for homemaker or chore services
• Payment for foster care services when a recipient is a resident of a different foster care setting
Payments will be made only to those entities or recipients that meet current legal Foster Care licensure requirements found in Minnesota Rules, parts 9555.5050 – 9555.6265 and Minnesota Statutes, section 245A or Community Residential Setting (CRS) under Minnesota Statutes 245D.
Adult foster care providers may be licensed for up to five adults per home if all foster care recipients are 55 years old or older, and have neither serious persistent mental illness nor any developmental disability.
• T1016 with modifier UC – 15 minutes
Case Management Conversion
• T1016 – 15 minutes
This service will help people gain access to needed EW, AC and MA services, as well as needed medical, social, educational and other services, regardless of the funding source.
Case management for MSHO and MSC+ enrollees receiving EW services that coordinate the provision of health and long-term care services to an enrollee among different health and social service professionals and across settings of care includes, but is not limited to, needs assessment, prior approval, care communication, coordination and risk assessments.
• Ongoing monitoring of the provision of services included in the plan of care or community support plan
• Development of a service plan
• Providing information to the recipient or the recipient’s legal guardian or conservator
• Assisting the recipient in the identification of potential providers and choice of providers
• Assisting the recipient to access services and choice of services including referrals
• Coordination of services
• Assessment and reassessment of the individuals level of care and the review of the plan at least annually
AC conversion case management service is available when the client has been admitted to a nursing facility, including certified boarding care facilities and hospitals, and it is anticipated that the client will return to the community with AC as the payer of services to address the client’s long-term needs. The activities of AC conversion case management are designed to help a person who lives in an institution to gain access to services and supports that are necessary to move from the institution to the community.
Activities include, but are not limited to the following:
• Development and implementation of a relocation plan
• Coordination of referrals and helping a person to access services
• Coordination and monitoring of the overall implementation of a relocation plan
• Coordination of efforts with the discharge planner at the institution and others
Access to this service is limited to 180 consecutive days. The 180-day limit is a “per admission” limit meaning that a person may receive another 180 days of conversion case management if he or she are readmitted to an eligible institution.
All case management services billed to the EW or AC programs must be based on a service actually provided to the recipient. Services must be planned and delivered based on individual need and may not be billed based on averages of the number of billable units provided to a recipient, nor across program populations.
Some recipients receiving case management services may also be determined to be eligible for other forms of case management (such as hospice or mental health). In these situations, DHS recommends the following:
• One of the case managers is designated as the primary contact
• Active coordination among the case managers so services are not duplicated
• Roles and responsibilities of each case manager are clearly defined so efforts are not duplicated
Recipients eligible for and receiving case management under EW are not concurrently eligible for the following forms of case management services:
• Targeted case management for vulnerable adults and adults with developmental disabilities (VA/DD-TCM)
• Relocation service coordination (RSC)
Case Management Administrative Activities
Case management administrative activities are not billable under any HCBS program. Case management administrative activities include the following:
• Responding to requests for conciliation conferences and appeals
• Review of eligibility for services
• Screening activity
• Service authorization
• Determines financial eligibility, assesses fees and assists with the collection of overdue fees (AC clients)
Recipients receiving services under the EW and AC programs may choose to receive case management services from qualified and approved vendors that have provider agreements and contracts with the lead agency or state. The lead agency is responsible for monitoring the terms of the contract. If the provider is a federally recognized tribal government, the case management contract may be between the tribal government and the department. For contracts between a tribal government and DHS, DHS is responsible for monitoring the terms of the contracts. Managed care organizations can also contract for case management services or provide case management services.
The recipient may choose to receive case management services from another county or lead agency. This applies to case management service activities only. Administrative activities are not directly billable under any individual program. The provider of case management services must not have a financial interest in other services provided to a recipient.
• Case managers, with the exception of county or tribal agency employees, must not have a financial interest in the provision of services
• If the case manager is not a county or tribal employee, then the provider of services will be required to execute a contract with the agency in order to provide case management
The lead agency may employ or contract with the following people to provide case management:
• Public health nurse or registered nurse licensed under Minnesota Statutes, sections 148.171 – 148.285
• Social worker graduate of an accredited four year college with a major in social work, psychology, sociology, or a closely related field; or be a graduate of an accredited four year college with a major in any field and one year experience as a social worker in a public or private social service agency. Social workers must also pass a written exam through the Minnesota Merit System or a county civil service system in Minnesota. Standards are authorized under Minnesota Rules 9575.0010 to 9575.1580. Authority to set personal standards is granted under Minnesota Statutes, section 256.012.
• Physicians, physician’s assistants and nurse practitioners – must meet all state standards and possess all professional licenses necessary to practice
• Alternative credentialing standards may be applied to services provided by tribal governments under Minnesota Statutes, section 256B.02, subdivision 7
• For MSHO and MSC+ enrollees, the managed care organization may establish alternative credentialing standards consistent with their DHS contracts
Case Management Aide or Paraprofessional
Case Management Aide/Paraprofessional
• T1016 with modifiers TF & UC – 15 minutes
Paraprofessional and case management aides help the case manager carry out administrative activities of the case management function.
Case management aides must perform only those tasks delegated and supervised by the case manager, which do not involve professional expertise or judgment, per Minnesota Statutes, section 256B.49, subdivision 13.
Examples of duties case aides may perform include the following:
• Contacts to vendors to schedule services
A case management aide must not do the following:
• Assume responsibilities that require professional judgment
• Conduct assessments
• Conduct reassessments
• Develop service plans
The case management aide must understand, respect and maintain confidentiality concerning all details of each case. The case aide cannot have a financial interest in the services provided to the individual. The case manager is responsible for providing oversight to the case aide.
The case management aide must meet the following criteria:
• Have one year of experience as a case aide or in a closely related field or one year of education beyond high school (for example, business school or college)
• Be employed by the agency providing case management
• Receive oversight by the case manager of delegated tasks
• All nonprofessional case management related tasks must be billed as case aide services and not as case management services
• Duplicate payments will not be made for case aide management services by more than one provider
• T2028 with modifier U1 for Personal Assistance
• T2028 with modifier U2 for Medical Treatment and Training
• T2028 with modifier U3 for Environmental Modifications and Provisions
• T2028 with modifier U4 for Self-Direction Support Activities
• T2028 with modifier U8 for Flexible Case Management
• T2040 – each check for Background Checks
• T2041–15 minutes for Required Case Management
A person who wishes to receive CDCS must meet all eligibility criteria for the EW or AC programs, and be determined eligible or already receiving EW or AC services. CDCS may include traditional goods and services provided by EW or AC including alternatives that support individuals and which are a part of the community support plan.
CDCS covers four service categories:
• Treatment and training
• Environmental modifications and provisions
• Self-direction support activities
Individuals can hire, terminate, manage and direct their own support workers.
The individual may purchase these functions through a Fiscal Support Entity (FSE). People or entities providing goods or services covered by CDCS must have a written agreement with and bill through the FSE.
Services provided to people living in licensed foster care settings, settings licensed by DHS or MDH, or registered as a housing with services establishment.
For more information, refer to the DHS public web pages listed here:
• CDCS Overview
• CDCS Comparison (PDF)
• Consumer Directed Community Support Lead Agency Operations Manual (DHS-4270) (PDF)
• T2030 – monthly (cannot be used for dates of services on or after July 1, 2016)
• T2030 with modifier TG for 24 HR CL(cannot be used for dates of services on or after July 1, 2016)
• T2031- Daily (effective for dates of services on or after July 1, 2016)
• T2031 with modifier TG for 24 HR CL – Daily (effective for dates or services on or after July 1,2016)
EW providers must not bill for full days in which the recipient is absent. See Comprehensive Policy on EW Residential Services (PDF).
Customized living is an individualized package of regularly scheduled health-related and supportive services provided to a person residing in a qualified residential center that is a registered housing with services under Minnesota Statutes, chapter 144D.
Customized living services include individualized supports that are chosen and designed specifically for each person’s needs. The services include the following:
• Arranging for or providing transportation
• Helping the person with personal funds
• Helping the person with setting up meetings or appointments
• Home management tasks including cleaning, laundry and meal preparation and service
• Up to 24-hour supervision and oversight
• Help with personal care or mobility
• Continence
• Wheeling
• Medication administration, including insulin injections
• Medication set-ups, including insulin draws
• Delegated nursing tasks as ordered by a physician and described in the plan
• Help with therapeutic or passive range of motion exercises
• Performing other routine delegated medical or nursing or assigned therapy
• Active behavior or cognitive support for behavioral or cognitive needs that have been assessed by an appropriate professional, and for which there is a plan to implement and monitor the support
• Device to summon help and response to calls for help within timeframes established in the individual customized living plan, but not to exceed 10 minutes
• Service delivery is directed by the recipient or provider, with oversight from the case manager
• The case manager is the primary party that is responsible to assure that the needs of the recipient are met through the community support plan and customized living plan that is created specifically for that recipient
• All homemaker and chore services needed by a recipient are included in the customized living services package. Homemaker, chore, respite and consumer directed community services may not be separately authorized or billed
• Customized living services may be provided in any number of living units within a housing with services establishment
• Customized living services are covered under the EW program costs. Room and board, or raw food (groceries), and rent, while a recipient receives customized living services, are paid by the recipient’s income, which may include Supplemental Security Income, RSDI and other retirement. If the recipient has inadequate income for room and board or rent charges, he or she may be eligible for a Group Residential Housing (GRH) payment to the provide
• Lead agencies develop individual customized living plans and rates using the DHS-issued EW Residential Services Tool (formerly known as the EW Customized Living Tool)
• Management of the congregate living setting or providers under contract with the management or lead agency, must provide customized living services. People receiving customized living services are not eligible for homemaking in addition to customized living services
• Providers may not request supplemental payment for covered services. Minnesota Statutes, section 256B.0915, subdivision 3e, paragraph (g) states, “A provider may not bill or otherwise charge an elderly waiver participant or their family for additional units of any allowable component service beyond those available under the service rate limits described in paragraph (d), nor for additional units of any allowable component service beyond those approved in the service plan by the lead agency.” See also Minnesota Statutes, section 256B.0915, subdivision 3h, paragraph (i)
• Socialization when it is diversional or recreational
• EW funded homemaker, chore and respite are not billable services during the period that the person is receiving customized living services
• EW providers cannot bill for full days on which the recipient is absent
• Customized living services when the recipient is not in the setting
The state agency requires that the customized living service providers meet the standards of licensure, certification or registration where they exist in state law and administrative rule.
A provider who holds a comprehensive home care license must furnish the services in a registered housing with services establishment.
Customized living service providers who are not licensed under Minnesota Rules, parts 9555.5105 – 9555.6265 (Adult Foster Care), and who provide services in settings of one to five residents, must comply with Minnesota Rules, part 9555.6205, subparts 1 – 3; part 9555.6215, subparts 1 and 3; and parts 9555.6225, subparts 1, 2, 6 and 10.
Home care licenses are issued under Minnesota Statutes, section 144A.043 and Minnesota Rules, chapters 4668 and 4669.
• Staff providing health-related services must meet qualifications under a comprehensive home care license
• Staff providing supervision, oversight and supportive services must meet the following requirements:
• Be able to read, write and follow written or oral instructions
• Have had experience or training in caring for people with functional limitations
• Have good physical and mental health, and maturity of attitudes toward work assignments
• Have the ability to converse on the telephone, to work under intermittent supervision, to deal with minor emergencies arising in connection with the assignment, and work under stress in a crisis situation
• Understand, respect and maintain confidentiality
• Have a valid state driver’s license and insurance coverage in accordance with state requirements if they provide transportation to waiver clients
• Have ongoing awareness of the participant’s needs and activities. Recognize the need for and provide help required or be able to summon appropriate help within the timeframe required to meet participant’s needs or within 10 minutes, whichever is less
• Not be a recipient of services within the setting
24-Hour Customized Living (CL) Rate Limit
To be eligible for 24-hour customized living rate limit, recipients must meet eligibility requirements and the provider must meet the applicable provider standards.
To be eligible for the 24-hour CL rate limit, the provider must meet all customized living provider requirements and have qualified staff:
• Working onsite within the housing with services establishment 24 hours per day
• Whose primary responsibility is providing customized living services
To be eligible for the 24-hour CL rate limit, the lead agency must document that one or more of the following criteria have been assessed as a need of the recipient:
• Cognitive or behavioral intervention
• Clinical monitoring with special treatment
• Staff assistance in toileting, positioning or transferring (single dependency)
• Help with medication management, plus at least 50 hours of customized living service per month and have a dependency in at least three of the following activities of daily living (ADL’s): bathing, dressing, grooming, walking or eating (when eating is scored as 3 or greater). “Fifty hours of service” means 50 hours of direct component services per month approved to be part of the 24-hour customized living plan as the assessor, case manager or care coordinator, along with the waiver participant, determine
Extended State Plan Home Health Services – EW Program Only
Home Health Aide Extended
• T1004 – 15 minutes
LPN Regular Extended
• T1003 with modifier UC – 15 minutes (LPN Regular)
• T1003 with modifiers TT and UC – 15 minutes (LPN Shared 1:2)
LPN Complex Extended
• T1003 with modifiers TG & UC – 15 minutes
PCA – Extended
• 1:1 – T1019 with modifier UC – 15 minutes
• 1:2 – T1019 with modifier UC & TT with a “Y” in the Shared Care field of the SA – 15 minutes
• 1:3 – T1019 with modifier UC & HQ with a “Y” in the Shared Care field of the SA – 15 minutes
RN, Regular, Extended
• T1002 with modifier UC – 15 minutes
• T1002 with modifiers TT and UC and a “Y” in the Shared Care field of the SA – 15 minutes (RN Regular Shared 1:2)
RN Complex, Extended
• T1002 with modifiers TG and UC – 15 minutes
See Home Care Services section for more information about MA State Plan services.
Home Health Services – AC Program Only
Home Health Aide Visit
• T1021
LPN Regular
• T1003 – 15 minutes (LPN Regular)
• T1003 with modifier TT – 15 minutes (LPN Shared 1:2)
LPN Complex
• T1003 with modifiers TG – 15 minutes
• 1:1 – T1019 – 15 minutes
• 1:2 – T1019 with modifier TT with a “Y” in the Shared Care field of the SA – 15 minutes
• 1:3 – T1019 with modifier HQ with a “Y” in the Shared Care field of the SA – 15 minutes
• RN Supervision – T1019 UA – 15 minutes
RN Regular
• T1002 – 15 minutes
• T1002 with modifier TT and a “Y” in the Shared Care field of the SA – 15 minutes (RN Regular Shared 1:2)
RN Complex
• T1002 with modifier TG – 15 minutes
• G0154—15 minutes (cannot be used for date of service after December 31, 2015)
• G0299 – Services of a skilled nurse (RN), Home Health 15 minutes (use for dates of service on or after January 1, 2016)
• G0300 – Services of a skilled nurse (LPN), Home Health 15 minutes (use for dates of service on or after January 1, 2016)
• T1030— Visit
Tele- Homecare
• T1030 with modifier GT
• S5130 Homemaker/Cleaning – 15 minutes
• S5130 with modifier TF, Homemaker/Home Management – 15 minutes
• S5130 with modifier TG, Homemaker/ Assistance with Personal Cares – 15 minutes
• S5131 Homemaker/Cleaning – per diem (cannot be used for services provided after July 1, 2015)
• S5131 with modifier TF, Homemaker/Home Management – per diem (cannot be used for services provided after July 1, 2015)
• S5131 with modifier TG, Homemaker/Assistance with Personal Cares – per diem (cannot be used for services provided after July 1, 2015)
EW and AC provide homemaker services when a recipient is unable to manage general cleaning and household activities or when the person regularly responsible for these activities is temporarily absent or unable to manage the household activities. Homemaker services range from light household cleaning to household cleaning with minor help with home management and activities of daily living. All homemakers may help monitor the client’s well-being in the home, including home safety.
Homemaker cleaning services includes light housekeeping tasks. Homemaker cleaning services must meet the needs defined in the client’s community support plan and not duplicate other homemaker or cleaning services. Homemaker or cleaning providers exclusively deliver home cleaning services.
Homemaker or home management activities may include help with the following:
• Meal prep
• Shopping for food
• Clothing and supplies
• Simple household repairs
• Arranging for transportation
Homemaker or assistance with activities of daily living (ADL) includes help with the following:
Homemaker or assistance with activities of daily living providers deliver cleaning and services and while onsite, provide help as needed with activities of daily living.
Homemaker services must be listed in the community support plan.
Criminal background studies apply to individuals and organizations providing these services:
Homemaker and cleaning service
• Providers must comply with the standards outlined in Minnesota Statutes, chapter 245C on criminal background studies
• Providers must be able to perform the cleaning duties expected and provide a cost-effective means of meeting the client’s home cleaning needs
Homemaker service and assistance with ADL’s
• Providers must be licensed under Minnesota Statutes, chapter 245D or Class B, C, or F licensure unless excluded from DHS licensure under Minnesota Statutes, section 245A.03, subdivision 2, paragraph (a), clauses (1) and (2)
• Providers licensed as a class A, B, C or F home care provider must meet the requirements of Minnesota Statutes, chapter 144A
• Home care providers must meet the requirements of Minnesota Statutes, sections 144A.43 – 144A.46
Homemaker service and home management
• Providers must be licensed under Minnesota Statutes, chapter 245D or Class A, B, C or F licensure unless excluded from DHS licensure under Minnesota Statutes, section 245A.03, subdivision 2, paragraph (a), clauses (1) and (2)
• Providers licensed as a Class B, C or F home care provider must meet the requirements of Minnesota Statutes, chapter 144A
Nutrition Services – AC Program Only
• S9470 – visit
Nutrition services include nutrition education and nutrition counseling to address a recipient’s nutritional needs. The goal of this service is to improve or maintain a recipient’s nutritional status, and to improve management of the older adult’s chronic diseases or conditions.
Nutrition education is one or more individual or group sessions which provide formal and informal opportunities for recipients to acquire knowledge and skills in managing their diet and nutritional needs.
• Food selection
• Preparing normal and therapeutic diets
• Tips for eating well on a limited budget
Nutrition counseling is one or more individual sessions to advise and help individuals on appropriate nutritional intake.
Nutrition counseling includes:
• Assessment of a recipient’s nutritional needs that results in an individualized plan with goals
• Follow-up on established nutritional goals
Nutrition counseling can assist recipients with:
• Managing therapeutic diets (for example, diabetic, low sodium, low cholesterol, renal or gluten free)
• Providing weight management strategies for recipients who are chronically underweight or overweight
• Severe weight loss or gain
• Other nutritional care issues
Nutrition services are tied to a specific goal and authorized in the older adult’s community support plan. All services are consistent with the recipient’s cultural background.
• Licensed dietitians
• Licensed nutritionists
• Registered dietitians who meet education and practice requirements specified in Minnesota Statutes, section 148.621 and Minnesota Rules, chapter 3250
• Other professionals who are exempt from licensure, according to Minnesota Statutes, section 148.632, and perform service incidental to their practice, such as a diabetic nurse practitioners when nutrition practice is incidental to their practice or registered nurses
• T2032 – monthly
DHS is in the process of discontinuing this service. For additional details about the current status of this change, see CBSM – residential care waiver service update.
Supportive and health supervision services provided to people in a residential care home as documented in the community support plan. The person or provider directs the service delivery with oversight by the case manager.
Supportive services for the recipient include the following:
• Up to 24-hour supervision
• Individualized home management tasks
• Assistance in setting up meetings and appointments
• Assistance in arranging medical and social services
• Assistance with management of personal funds
Health supervision services are limited to minimal help with the following:
• Dressing, grooming and bathing
• Reminding a person to take medications that are self-administered
• Storing medications, if requested
The lead agency assures the needs of the person are fully met through the package created specifically for that person. Beginning July 1, 2015, lead agencies must use the EW Residential Services Tool (formerly known as the Customized Living Tool CL Tool) to determine rates for residential care.
• Homemaking billed separately
• Chore service billed separately
• Services duplicated by other MA covered services or EW services
• Respite billed separately
• Costs for room and board (items paid for under room and board cannot be duplicated in residential care costs)
Residential care services are provided to recipients in residential care homes licensed as board and lodging establishments that are registered with the Minnesota Department of Health as board and lodge with special services. The standards for residential care services are defined in Minnesota Statutes, sections 157.15 – 157.17. The residential care home must meet the appropriate local building codes.
Management of the residential care home must provide residential services.
Staff is required to have eight hours of training and orientation by a registered nurse in providing help with the following:
• Medication reminders or storage of medications. If medications are to be distributed or stored, a registered nurse must supervise this process.
Staff providing supervision and supported services must meet the following criteria:
• Be able to read and write and follow written and oral instructions
• Have experience or training in caring for people with disabilities
• Have good physical and mental health
• Be able to converse on the phone
• Work with only intermittent supervision
• Deal with emergencies
• Work under stress in a crisis situation
• Have a valid Minnesota state driver’s license if providing transportation for a person receiving waiver services
• S5150 –15minutes
• S5151 – per diem
• S5150 with modifier UB – 15 minutes
• H0045 – per diem (Includes hospital and other certified facilities providing 24-hour overnight service)
Services provided to recipients unable to care for themselves, provided on a short-term basis because of the absence or need for relief of the person who normally provides the care. This person is not paid or is paid only for a portion of the total time of care or supervision he or she provides. The unpaid caregiver does not need to live in the same house as the recipient.
• A recipient can receive respite care in settings that have appropriate licensure and qualifications, including a private home that is identified by the recipient.
• Respite care is limited to 30 consecutive days per respite stay in an out-of-home placement according to the care plan.
• Recipients living in corporate or family foster care settings or receiving 24-hour customized living services cannot receive respite care separately.
• Room and board payments cannot be made for respite care provided in the recipient’s home or other private residence.
Facilities providing respite care must meet all licensing and certification requirements. One of the following facilities approved by the lead agency must provide respite care:
• Licensed adult foster home
• Non-MA certified facility if the facility meets applicable state licensure standards
Respite care may be provided in a private unlicensed home when the lead agency determines that the service and setting can safely meet the recipient’s needs. The lead agency must take into account the accessibility and condition of the physical site; ability and skill level of the caregiver; and the recipient’s needs and preferences. The unlicensed home and caregiver cannot otherwise be in the business or routine practice of providing respite services.
In a community emergency or disaster that requires an emergency need to relocate a participant, out of-home respite services may be provided regardless of whether the primary caregiver lives at the same address as the participant or is paid, provided the commissioner approves the request as a necessary expenditure related to the emergency or disaster. This does not allow the primary caregiver to provide respite services. The commissioner may waive other limitations on this service to ensure that necessary expenditures related to protecting the health and safety of participants are reimbursed. In an emergency involving relocation of waiver participants, the commissioner may approve the provision of respite services by unlicensed providers on a short-term, temporary basis.
In-Home Respite Care Providers
Must be provided by the following:
• Registered or licensed practical nurses
• Personal care assistants specifically trained to provide care to the recipient
• A home health aide or PCA must be under the supervision of an RN who assures the respite care worker is able to read, write, follow instructions and has the skill level to meet the person’s needs.
• A currently registered housing with services establishment when services are delivered by a licensed home care agency
Respite care providers must meet the licensing and certification standards specific to the level of care they are providing and must receive supervision as required by their respective license or service standard.
Lead agencies must define in the contract the unit of service to be billed. Use daily rates when respite care is provided for 12 or more hours or for overnight respite.
Respite Care Services: Provider Standards and Qualifications
I: Indicates an in-home provider/location
O: Indicates an out-of-home provider/location
Certified Hospitals – Hospitals are acute care institutions defined in Minnesota Statutes, section 144.696, subdivision 3 and licensed under Minnesota Statutes, sections 144.50 – 144.56. Providers must be licensed under Minnesota Statutes, chapter 245D or 144A, unless they are excluded under Minnesota Statutes, section 245A.03, subdivision 2, paragraph (a), clause (7). Agencies licensed under Minnesota Statutes, chapter 144A as a home care provider must meet the HCBS provider standards in Minnesota Statutes, chapter 245D.
Agencies meeting the licensing exclusions of Minnesota Statutes, section 245A.03, subdivision 2, paragraph (a), clauses (1) and (2) must also meet the following statutory requirements:
• Service recipient rights under Minnesota Statutes, section 245D.04, subdivision 1, clause (4); subdivision 2, clauses (1), (2), (3) and (6); and subdivision 3
• Health services and medication monitoring under Minnesota Statutes, sections 245D.05 and 245D.051
• Incident reporting and prohibited and restricted procedures under Minnesota Statutes, section 245D.06
• Emergency use of manual restraint under Minnesota Statutes, section 245D.061
• Staffing standards under Minnesota Statutes, section 245D.09, subdivisions 1, 2, 3, 4a, 5a, 6 and 7
Licensed Practical Nurses and Registered Nurses must be licensed under Minnesota Statutes, sections 148.171 – 148.283. Providers must be licensed under Minnesota Statutes, chapters 245D or 144A, unless they are excluded under Minnesota Statutes, section 245A.03, subdivision 2, paragraph (a), clauses (1) and (2). Individuals licensed under Minnesota Statutes, Chapter 144A as a home care provider must meet the provider standards in Minnesota Statutes, chapter 245D.
People meeting the licensing exclusions of Minnesota Statutes, section 245A.03, subdivision 2, paragraph (a), clauses (1) and (2) must also meet the following statutory requirements:
Adult Foster Care is licensed under Minnesota Rules, parts 9555.5105 – 9555.6265 and Minnesota Statutes, section 245A or Community Residential Setting (CRS) under Minnesota Statutes 245D. Providers must be licensed under Minnesota Statutes, chapters 245D or 144A, unless they are excluded under Minnesota Statutes, section 245A.03, subdivision 2, paragraph (a), clauses (1) and (2) to provide respite service.
Agencies licensed under Minnesota Statutes, chapter 144A as a home care provider must meet the HCBS provider standards in Minnesota Statutes, chapter 245D.
Providers meeting the licensing exclusions of Minnesota Statutes, section 245A.03, subdivision 2, paragraph (a), clauses (1) and (2) must also meet the following statutory requirements:
Personal care provider organizations and personal care assistants employed by the agencies must meet the standards under Minnesota Statutes, section 256B.0659 and Minnesota Rules, part 9505.0335. Providers must be licensed under Minnesota Statutes, chapters 245D or 144A, unless they are excluded under Minnesota Statutes, section 245A.03, subdivision 2, paragraph (a), clauses (1) and (2). Agencies licensed under Minnesota Statutes, chapter 144A as a home care provider must meet the HCBS provider standards in Minnesota Statutes, chapter 245D.
Home Health Aides must meet the standards under Minnesota Rules, part 9505.0290, subpart 3, item B. Home health agencies in-home respite care providers, including nurses employed by home health agencies, must be licensed under Minnesota Statutes, sections 148.171 – 148.283. Providers must be licensed under Minnesota Statutes, chapters 245D or 144A, unless they are excluded under Minnesota Statutes, section 245A.03, subdivision 2, paragraph (a), clauses (1) and (2).
Home health agencies must have a class A license and must meet the standards under Minnesota Rules, part 9505.0290, subpart 3, item B; Minnesota Rules, chapter 4668; and Minnesota Statutes, sections 144A.45, 144A.46, 144.461, and 144.465.
Certified Nursing facilities–Nursing facilities must meet the standards under Minnesota Rules, part 9505.0175, subpart 23. Facilities providing respite care outside of the enrollee's home must be licensed according to Minnesota Statutes, chapter 144A. Providers must be licensed under Minnesota Statutes, chapters 245D or 144A, unless they are excluded under Minnesota Statutes, section 245A.03, subdivision 2, paragraph (a), clauses (1) and (2). Providers licensed under Minnesota Statutes, chapter 144A as a home care provider must meet the HCBS provider standards in Minnesota Statutes, chapter 245D.
Customized Living Services Providers must be licensed as a home care provider and meet the standards as delineated in Customized Living waiver service descriptions. Out-of-home providers must meet the standards in Minnesota Statutes, chapter 144D and be licensed as a comprehensive home care provider under Minnesota Rules, parts 4668.0002 – 4668.0870. Providers must be licensed under Minnesota Statutes, chapters 245D or 144A, unless they are excluded under Minnesota Statutes, section 245A.03, subdivision 2, paragraph (a), clauses (1) and (2). Agencies licensed under Minnesota Statutes, chapter 144A as a home care provider must meet the HCBS provider standards in Minnesota Statutes, chapter 245D.
Residential Care Facilities – Residential Care Providers must meet all applicable licensing standards and the standards delineated in Residential Care waiver service description. Providers must be licensed under Minnesota Statutes, chapters 245D or 144A, unless they are excluded under Minnesota Statutes, section 245A.03, subdivision 2, paragraph (a), clauses (1) and (2).
Home of an unlicensed caregiver – an unlicensed caregiver may provide services in their home when the lead agency and family agree that the caregiver has met criteria to assure the health and safety of the recipient. In these situations, MHCP will not pay room and board payment as part of the respite rate. Providers must be licensed under Minnesota Statutes, chapters 245D or 144A, unless they are excluded under Minnesota statutes, section 245A.03, subdivision 2, paragraph (a), clauses (1) and (2). Individuals providing in-home respite services must demonstrate to the case manager that they are able to provide, on a temporary, short-term basis, the care and services needed by the enrollee.
The case manager must evaluate and document whether the provider meets the standards to provide respite services. In addition, in-home respite providers who are excluded from licensing requirements must meet the following qualifications to ensure the health and safety of the enrollee:
• Is physically able to care for the enrollee
• Has completed training identified as necessary in the care plan
• Complies with monitoring procedures as described in the care plan
• T2029 – Per Item negotiated based on the needs of the person and county or lead agency contract
• E1399 – Per Item negotiated based on the needs of the person and agency contract
Devices, controls or appliances, specified in the plan of care, that enable the person to increase his or her ability to:
• Perform activities of daily living
• Perceive, control or interact with the environment or communicate with others
Equipment and supplies include durable medical equipment and supplies provided as a necessary adjunct to direct treatment or remediation of the recipient’s condition. These may include grab bars, handrails and stair lifts if these items are essential to keep the recipient in the community.
EW Covered Services
See Equipment and Supplies section for clarification about covered and noncovered items and regulations. Recipients must first access MA benefits, as appropriate. Medical equipment and supplies are defined under Minnesota Rules, part 9505.0310.
• Items necessary for life support
• Equipment and supplies necessary for the proper functioning of such life support items
• Durable medical equipment not available or denied under MA state plan that provides direct medical or remedial benefit to the individual
Items reimbursed with waiver funds are in addition to any medical equipment and supplies furnished under MA equipment and supplies that exceed the limits set for MA covered services may be covered through the waiver.
Equipment purchase (S5162) for personal emergency response systems (PERS) when the system does not entail changes to the physical structure and does not become a permanent part of the participant’s home which is not easily removed should be authorized as specialized equipment and supplies. (PERS equipment that is not easily removable should be authorized as environmental accessibility adaptation.) PERS equipment purchase is subject to a $1,500 annual limit. PERS monthly services fees (S5161) are limited to $110 per month. PERS installation (S5160) is limited to $500. The total annual authorization for PERA is $3,000 during a participant’s “waiver” year. For EW and AC participants, the waiver year begins each time an opening, reopening, or reassessment screening document is approved.
Items and services not covered under PERS include:
• Participants receiving 24-hour customized living except for use outside of their residence
• Telehealth and biometric monitoring devices
• Supervision or monitoring of activities of daily living which are provided to meet the requirements of another service
• Equipment used in the delivery of MA or other waivered service
Authorization Criteria
Case managers must ensure and document in the community support plan before purchase of the equipment or supply that the item meets all of the following criteria:
• Cannot be funded through any other source. If an item is never covered by MA, it is not necessary to seek a written denial from MA. If an item may be covered by MA, the medical supplier must seek authorization from MA before seeking authorization of coverage under the EW program
• Specified in a community support plan as necessary to avoid institutionalization
• Meant for the sole use of the recipient
• Determined by prevailing community standards or customary practice and usage to be:
• Either medically necessary (appropriate and effective for the medical needs and health and safety of the recipient); or remedially necessary (appropriate to assist a recipient in increased independence and integration in their environment or community)
• Appropriate and effective for the medical needs, diagnosis and condition of the recipient
• Of an acceptable quality
• Timely (that is, the accommodation is provided at the time it is needed)
• The most cost-effective health service available to meet the medical needs of the recipient
• An effective and appropriate use of MA waiver funds
When cost-effective funding is available for the following with extended equipment and supplies:
• Individual evaluation or assessment
• Purchase or rental
Medical equipment and supplies are available through MA but with limitations. When MA covers an item, bill MA first to the extent of the limitations. If MA never covers an item, the case manager may decide to cover this item under the EW or AC if it meets criteria. After an item is purchased, it becomes the property of the recipient it is purchased for.
Add-ons vs. Upgrades
An add-on is an MA noncovered service that the provider adds to an MA-covered service. In this case, bill the MA-covered item to MA. The add-on may be billed to the waiver, or the recipient may choose to pay for the add-on out of other funding sources they have available to them.
Example: A recipient wants an MA noncovered basket added to an MA-covered walker. The supplier can bill MA for the walker and bill the recipient for the basket; or the lead agency may determine that the EW program will cover the basket. The supplier still must bill MA for the MA-covered service.
For both fee-for-service and managed care recipients, the provider may receive payment for the covered service under MA and charge the recipient or EW program for the add-on.
An upgrade is a noncovered MA service (and often a more desirable service) that may substitute for a covered service:
• The provider may choose to provide the upgrade and receive payment for the basic service as payment in full for the upgrade.
• The person may choose an upgraded service instead of an MA-covered service, even though MA will not pay for this item. The person is responsible for the entire cost of the upgraded item as long as the provider informed them that they are responsible before providing the service. In this case, DHS recommends that the provider have the person sign a waiver acknowledging that MA does not cover the item, and agreeing to pay the entire cost for the upgraded item before the service is provided.
• The case manager may authorize EW to cover the entire cost of the upgraded item if it is determined to be medically necessary.
Example: A recipient wants a total electric bed, but does not meet the medical necessity criteria for MA to cover the bed. MA will only cover a semi-electric bed.
A case manager may elect to cover the entire cost of a total electric bed under the EW program.
If the supplier will not accept MA payment for a semi-electric bed and the service coordinator does not approve the upgrade for payment under the EW program, the recipient may still get the total electric bed. The recipient is responsible for the entire charge for the bed as long as the provider informs them that they are responsible for payment before providing the item or service.
The supplier may not provide a total electric bed to the recipient, bill MA and charge the difference between the semi-electric bed and the total electric bed to the recipient, or to the EW program.
The case manager may need prior approval from DHS for some specialized equipment and supplies depending on the cost of the item. The item must be entered on the SA.
Add-ons and upgrades do not apply to the AC program.
Cost of Providing Equipment and Supplies under a Recipient’s EW or AC Cap
The cost of extended equipment and supplies must be included in the client’s cost effectiveness monthly cap amount. Costs of equipment and supply items may be averaged over the span of an SA if the person maintains program eligibility for the available span of the SA. For example, if the cost of an item is averaged for months beyond the month the cost was incurred, and the person subsequently exits the program, then payments for the item will not continue after the exit date.
Determining Appropriate Payer
1. All other private and public payers (private insurance, Medicare, Medical Assistance) are exhausted before using EW funds for coverage.
2. The local lead agency is responsible to authorize covered services according to the appropriate payer.
3. The provider is responsible to bill only the appropriate payer for the client and the item(s).
4. The provider submits copies of the denials from those payment sources to the lead agency.
5. If inappropriate billing shows up in an audit, the provider is responsible and risks payment recovery.
1. All other private and public payers (private insurance, Medicare, client's cost-sharing obligations, long-term care insurance) must be exhausted before using AC funds for coverage.
2. The AC program does not provide payment for medical equipment and supplies that are considered to be medically necessary. It does not provide items that address a client's acute, sub-acute or rehabilitative status that would otherwise be addressed through a client's primary or secondary payer coverage. In the absence of other payers to address those needs, the AC program does not provide any form of payment.
Long-Term Care Facility Providing Equipment and Supplies During Discharge Process to Home or Community Setting
The nursing facility is required to provide certain types of equipment and supplies to a person to support the transition home from the nursing facility. Providers cannot bill through EW or AC programs for extended equipment and supplies until the local lead agency opens the program span for home and community-based services in MMIS. A provider can bill for extended equipment and supplies on the date of discharge, as long as the items are provided after the time of the person’s discharge and the item is not a requirement within the NF payment rate for that person or the community setting to which the person is entering.
Rental contracts for equipment and supplies may only be approved when it is determined, for items that meet authorization criteria, as cost-effective. For example, when the item is needed for a defined amount of time and rental is less expensive than purchase.
• All rental contracts must include a “rent to purchase” clause
• The cost of renting a supply or equipment must not exceed the cost of purchase
• The written contract must also be clear that the vendor is responsible for repairs over the duration of the rental agreement
• The equipment item cannot be rented for an indefinite period of time
• New and upgraded equipment must be made available to replace the older currently rented item during the rental period
When the rental fee equals the purchase price, the item is considered to be the property of the person (normally after 10-12 months’ rental).
The HCBS program can pay for repair of equipment when the equipment meets the authorization criteria and the repair is a cost-effective alternative (that is, is expected to last, and without repair, the equipment would have to be purchased new at a higher cost). The HCBS program may purchase a maintenance agreement for items that meet authorization criteria when the maintenance agreement is expected to be cost-effective.
For example, a maintenance agreement that covers evaluating an item but not actual repair may not be cost-effective. Also consider other payment sources for repairs. MA covers the repair costs of certain items, such as communication devices, wheelchairs, etc.
Shipping, Handling, Installation, Repair Maintenance
An HCBS program may pay shipping and handling costs if the price of the item includes shipping cost, and the waiver is purchasing the item.
HCBS can cover installation regardless of who purchased the item, if the item meets HCBS program authorization criteria. If installation involves attaching an item to, or altering the existing physical structure of a home or vehicle, bill the costs under minor environmental adaptations and modifications.
Reconditioned equipment may be purchased if the county determines that all authorization criteria are met and the item is considered of adequate quality, expected to be durable, and the cost is commensurate with the age and condition of the item. For example, if a new item could be purchased at the similar cost, it may be worthwhile to purchase the new item.
• Items that are covered by MA, Medicare, private insurance or other funding resources and items that do not provide direct medical or remedial benefit to the person
• Items and services purchased before the LTCC screening and program begin date or without case manager approval are not covered
The following MA enrolled providers meet the standards and qualifications:
• Medical suppliers (including wheelchair and oxygen vendors)
Lead Agencies, Tribal Human Services and managed care organizations (MCOs) may approve non-enrolled vendors who meet state service standards to deliver specialized equipment and supply services. Non-enrolled vendors approved by the local lead agencies must sign a service purchase agreement.
Provider participation is defined under Minnesota Rules, part 9505.0195.
Before billing for specialized equipment and supplies, the lead agency and the provider must fulfill the Specialized Equipment and Supplies Authorization and Billing Responsibilities when authorizing and requesting reimbursement.
EW and AC Transportation
• T2003 with modifier UC – Per one-way trip
• S0215 with modifier UC – Per mile
• T2003 – Per one-way trip
Definition and Covered Services
The case manager may approve transportation services to enable recipients to gain access to EW and AC services, along with other community services, activities and resources. The case manager must specify the goals and needs for the service in the plan of care. Whenever possible, use family, neighbors, friends or community agencies that provide this service without charge.
Transportation and adult companion services may be authorized and billed when the services are provided by the same provider on the same day. The provider may not bill both companion as well as transportation for the same period of time.
Transportation and individual community living support (ICLS) services may be authorized and billed when the services are provided by the same provider on the same day. The provider may not bill both ICLS as well as transportation for the same period of time.
Adult day services and transportation are always separately covered, but in order and not provided at the same time.
For EW the adjective “extended” is not applicable as a waiver service because waiver transportation services are not an extension of MA access (i.e., medical) transportation service but rather a separate and distinct service.
Special transportation services (STS) for transporting a recipient with physical or mental impairment who is unable to safely use a common carrier and does not require ambulance service may be provided.
Physical or mental impairment means:
• A physiological disorder
• Mental disorder that prohibits access to, or safe use of common carrier transportation
An example includes a wheelchair accessible van for a person with mobility limitations.
EW or AC Noncovered Services
• Transportation reimbursement already included in the contracted rate for other services
• Noncovered services for a personal vehicle include:
• Any payment beyond negotiated mileage or trip reimbursement
• Reimbursement to a person for the purpose of transporting themselves or the use of his or her own vehicle
Additional EW Noncovered Services
Access transportation as defined in the Provider Requirements section.
Additional AC Noncovered Services
EW or AC common carrier transportation standards:
• Bus, taxicab, or other commercial carriers, private automobile, or a lead agency owned or leased vehicle
• Private individuals may be designated to provide transportation when they meet the recipient’s needs and preferences in a cost-effective manner. Examples may include supports such as family, neighbors, friends, community agencies, volunteer driver programs or companion service providers
• Drivers must have a valid driver’s license and adequate insurance coverage as required by Minnesota Statutes, chapter 65B
EW or AC Special Transportation Standards
Minnesota Department of Transportation under Minnesota Statutes, sections 174.29 – 174.30, must certify providers of special transportation services not excluded in Minnesota Statutes, section 174.30. The driver must provide driver-assisted services. Driver-assisted services include passenger pickup at and return to the individual’s residence or place of business, assistance in securing passengers, wheelchairs and stretchers in the vehicle.
With EW special transportation provider standards, providers not excluded in Minnesota Statutes, section 174.30, must be certified by the Minnesota Department of Transportation under Minnesota Statutes, sections 174.29 – 174.30.
AC Special Transportation Standards (Exceptions)
• AC providers are not required to participate in the Minnesota Non-Emergency Transportation (MNET) program
• AC recipients are not required to have an additional level of need (LON) assessment
• The AC case manager determines if the recipient requires special transportation and if the provider meets the recipient’s individual needs
Responsibilities of the EW/AC Case Manager or Care Coordinator
The EW or AC case manager or service coordinator is responsible for assessing and planning access to services as follows:
• Help recipients understand available transportation services through MA and the EW and AC programs
• Help recipients select transportation services through EW or AC that support their community participation and access to resources and social networks
• Determine if the contracted rate for the other needed and authorized services does or does not include transportation
• Clearly and accurately describe in the care plan transportation provided by different entities
• Determine and document in the care plan if recipient will use a family member, friend, neighbor, common carrier, special transportation and if a non-driver attendant is required
• Determine if the need for transportation meets MA state plan criteria
• Confirm recipient eligibility for special transportation using MHCP
DHS recommends that the case manager review the Transportation section of the MHCP Provider Manual for the MA state plan transportation services and the certification for use of special transportation.
Authorization Billing
• The intent of the transportation service mileage rate is to pay for the vehicle, not the associated staff time.
• The negotiated trip rate may or may not include staff time.
• The mileage rate and the trip rate cannot be authorized and billed for the same trip.
• The mileage rate cannot be used when payment for transportation is received for more than one rider for any portion of the trip regardless of payer.
• The mileage rate cannot be authorized or billed for miles when the recipient is not in the vehicle.
The trip rate may be used when transporting and receiving payment for more than one person on any portion of a trip.
Factors to consider when negotiating one-way trip rates:
• Number of individuals transportation payment is received for
• Special vehicle
• Driver requirements
Use transportation services funded through the Older Americans Act only when the service or amount of service needed cannot be authorized within their community budget cap.
The case manager or care coordinator completes the service agreement by adding the vendor’s name, the provider’s NPI or UMPI, appropriate HCPCS code, and number of units and locally negotiated rate authorized.
Provider Quick Reference
Service Agreement Changes
The case manager is responsible for any changes made to the SA of any recipient.
• If the rate, procedure code(s) or begin and end dates on the SA are incorrect, contact the case manager to initiate corrections.
• If additional services are necessary, the provider must communicate with the lead agency before providing any additional services.
• If an SA line item is changed and approved, MMIS will automatically generate a revised SA letter to the provider. Letters are generated overnight and sent the following day.
Service Agreement Letters
• The case manager has the ability to generate additional copies of the provider SA letters as needed.
• The case manager may suppress the DHS-generated service agreement letter and send his or her own letter to the recipient.
Providers registered with MN–ITS receive their service agreement letters (SAL) in their electronic mailboxes. Letters may be viewed, printed, or saved to a disc or computer hard drive and are automatically purged after 30 days.
SAL file contains:
• MA home care
PAL file contains:
• MA authorization letters
Changes in the Status of a Recipient
• The case manager informs providers and the county financial worker of any status changes of the recipient, such as the living arrangement, address, phone number or incorrect birth date.
• The county financial worker notifies the case manager of any changes in the person’s eligibility for MA or enrollment in managed care.
• Providers and lead agency notify one another when a recipient is hospitalized, so that a provider can bill around the dates of hospitalization.
• County financial worker and lead agency notify one another when a recipient is admitted to a long-term care facility, so the financial worker can update the living arrangement and appropriate changes can be made to the SA line items.
Change in Recipient Need
Providers need to contact the lead agency when a recipient’s needs change. The case manager is responsible for reassessing the recipient and amending the community support plan.
• Change of provider
• Increasing or decreasing services
• Addition of a new service
• Other appropriate assessed needs
Transitioning from MA Home Care to Waiver Services OR Waiver Services to MA Home Care Services
Refer to the Home Care Services section for more information.
Home Care Nursing Payment for Spouses
Waiver Recipient Who Elects Hospice
Refer to the Hospice Services section for more information regarding covered services.
Legal References and Resources
Minnesota Statutes, sections 245A.01 – 245A.16 (Human Services Licensing)
Minnesota Statutes, section 245A.143 (Family Adult Day Services)
Minnesota Rules, parts 9555.9600 – 9555.9730 (Social Services for Adults)
Minnesota Rules, parts 9555.5050 – 9555.6265 (Social Services for Adults)
Minnesota Statutes, section 245A.03 (Who Must Be Licensed)
Minnesota Statutes, sections 148.171 – 148.285 (Public Health Occupations)
Minnesota Rules, parts 9575.0010 – 9575.1580 (Merit System)
Minnesota Statutes, section 256.012 (Minnesota Merit System)
Minnesota Statutes, section 256B.02, subdivision 7 (Definitions - Vendor of Medical Care)
Minnesota Statutes, section 256B.0913 (Alternative Care Program)
Minnesota Statutes, section 256B. 0915 (Medicaid Waiver for Elderly Services)
Minnesota Statutes, section 144D.025 (Optional Registration)
Minnesota Rules, parts 9555.5105 – 9555.6265 (Social Services for Adults)
Minnesota Rules, part 9555.6205, subparts 1 – 3, part 9555.6215, subparts 1 and 3, and part 9555.6225, subparts 1, 2, 6 and 10 (Social Services for Adults)
Minnesota Rules, chapters 4668 (Home Care Licensure) – 4669 (Home Care Licensure Fees)
Minnesota Statutes, chapter 144D (Housing with Services Establishment)
Minnesota Rules, part 4668.0100, subpart 2 and subpart 5 (Home Health Aide Tasks)
Minnesota Statutes, section 326B.802, subdivision 11 (Definitions - Residential Building Contractor)
Minnesota Rules, chapter 4626 (Food Code; Food Managers)
Minnesota Statutes, chapter 245C (Human Services Background Studies)
Minnesota Statutes, chapter 245D (Home and Community-Based Services Standards)
Minnesota Statutes, section 245A.03, subdivision 2, paragraph (a), clauses (1) – (2) (Exclusion from licensure)
Minnesota Statutes, chapter 144A (Nursing Homes and Home Care)
Minnesota Statutes, sections 144A.43 – 144A.46 (Nursing Homes and Home Care)
Minnesota Statutes, section 148.621 (Definitions) and Minnesota Rules, chapter 3250 (Licensure and Practice)
Minnesota Statutes, section 148.623 (Duties of the Board)
Minnesota Statutes, section 157.17 (Additional Registration Required for Boarding and Lodging Establishments or Lodging Establishments)
Minnesota Statutes, section 144.696, subdivision 3 (Definitions) licensed under Minnesota Statutes, sections 144.50 (Hospitals, Licenses; Definitions) – 144.58 (Interpreter Services Quality Initiative)
Minnesota Statutes, section 256B.0659 (Personal Care Assistance Program) and Minnesota Rules, part 9505.0335 (Personal Care Services)
Minnesota Rules, part 9505.0290, subpart 3, item B (Home Health Agency Services)
Minnesota Rules. part 9505.0175, subpart 23 (Definitions – Long-term Care Facility)
Minnesota Rules, part 9505.0310 (Medical Equipment and Supplies)
Minnesota Rules, part 9505.0195 (Provider Participation)
Minnesota Statutes, chapter 65B (Automobile Insurance)
Minnesota Statutes, section 174.30 (Operating Standards for Special Transportation Service)
Minnesota Statutes, sections 174.29 – 174.30 (Department of Transportation)
Code of Federal Regulations, title 42, chapter IV, subchapter C, part 441, subpart G, section 441.310, paragraph (a)(2)(ii) (Limits on Federal financial participation (FFP)
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