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Minnesota DHS Alternative Care Program: A Guide for Seniors & Families

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Overview

The landscape of long-term care can be complex, especially when considering options for seniors who prefer to live at home rather than in a nursing facility. In Minnesota, the Department of Human Services (DHS) offers two key programs designed to support this choice: the Elderly Waiver (EW) and the Alternative Care (AC) program. Both programs aim to provide home and community-based services (HCBS) for individuals aged 65 and older who require a level of care typically provided in a nursing home, but who wish to remain in their communities. These programs are crucial for promoting independence and delaying or preventing the need for nursing facility care.

The core mission of both the Elderly Waiver and the Alternative Care program is to facilitate community living and independence. Services and supports are tailored to meet the unique needs and preferences of each individual, empowering them to maintain a high quality of life in their chosen setting. For the Elderly Waiver program, the benefits extend beyond what is typically available through standard Medical Assistance (MA), offering a more comprehensive support system.

To clarify the distinction between these two vital programs:

  • Elderly Waiver (EW) Program: This is a federally funded Medicaid waiver program. It is designed for seniors aged 65 and older who are eligible for Medical Assistance (MA), require nursing home level care, and choose to live in a community setting. Individuals enrolled in the Elderly Waiver program can access a broad range of waiver services in addition to the standard MA services, often through a managed care organization (MCO) like Minnesota Senior Care Plus (MSC+) or Minnesota Senior Health Options (MSHO).

  • Alternative Care (AC) Program: This program is funded by the state of Minnesota. It provides a more limited set of home and community-based services. The Alternative Care program is specifically for seniors aged 65 and older who do not qualify for Medical Assistance (MA) due to financial reasons but meet the program’s financial and service eligibility criteria. These individuals generally have modest incomes and assets but are not yet eligible for full MA benefits. The Alternative Care program serves as a crucial stepping stone for those who need support but are navigating the complexities of MA eligibility.

Accessing Assessments

Anyone can initiate the process of accessing these programs by requesting an assessment. Whether you are inquiring for yourself or on behalf of a loved one, the first step is to contact the local lead agency. These lead agencies, which we will discuss in more detail below, are responsible for determining program eligibility. It’s important to note that the Elderly Waiver and the Alternative Care program have distinct application processes, financial eligibility requirements, and the range of services they cover. Understanding these differences is key to navigating the application process effectively.

Eligible Members

Eligibility for both the Elderly Waiver and the Alternative Care program hinges on meeting specific service criteria for the relevant HCBS program. For detailed information regarding Medical Assistance (MA) and general eligibility requirements, it is advisable to consult the MHCP Provider Manual and the Programs and Services section on the DHS website.

To specifically qualify for each program:

  • Elderly Waiver (EW) Eligibility: Applicants must not only meet the service eligibility criteria for HCBS but also be eligible for Medical Assistance (MA). This dual eligibility is a cornerstone of the Elderly Waiver program.

  • Alternative Care (AC) Eligibility: For the Alternative Care program, applicants must demonstrate that they would become financially eligible for MA within 135 days of entering a nursing facility. This determination is made by a case manager and is a critical aspect of AC program eligibility. Essentially, the Alternative Care program is designed for individuals who are on the cusp of MA eligibility but need immediate support to remain at home.

Roles within the Programs

The administration and delivery of services within the Elderly Waiver and Alternative Care program frameworks involve several key roles, each with distinct responsibilities.

Lead Agency Responsibilities

The lead agency is central to the operation of both programs. These agencies are responsible for determining financial eligibility for Elderly Waiver services. Lead agency staff are also tasked with conducting asset assessments, a necessary step in evaluating financial eligibility for both the Alternative Care program and the Elderly Waiver.

For the Elderly Waiver program, lead agencies can be counties, tribal nations, or Managed Care Organizations (MCOs), also known as health plans. In contrast, for the Alternative Care program, lead agencies are typically counties or tribal nations. A lead agency can be a local public health agency, a human service agency, or a social service agency, depending on the community structure.

The core responsibilities of lead agencies encompass several key areas:

Long-Term Care Consultation (LTCC): Lead agencies provide Long-Term Care Consultation services, which are vital for individuals seeking program assistance. These services include:

  • A comprehensive assessment of the needs of the MHCP member. This assessment is the foundation for developing a personalized support plan.
  • Assistance throughout the application process. Navigating government programs can be challenging, and lead agencies provide crucial support in completing applications and understanding requirements.
  • Development of a community support plan. Based on the assessment, a tailored plan is created to outline the specific services and supports the individual will receive.

Case Management: Individuals approved for either the Elderly Waiver or the Alternative Care program are assigned a case manager or care coordinator. This professional, who may be a public health nurse, registered nurse, or social worker, plays a critical role in coordinating care. The case manager’s responsibilities include:

  • Assisting with access to and navigation of social, health, educational, and other community and natural supports and services. This holistic approach ensures individuals receive support across various aspects of their lives.
  • Providing information necessary for the person to make informed choices. Empowering individuals to make decisions about their care is a central tenet of these programs.

For a more detailed understanding of case management responsibilities, refer to the Community-Based Services Manual (CBSM).

Program Access and Administration: Lead agencies are also responsible for the broader program access and administration, which includes:

  • Partnering with the Department of Human Services (DHS) and other organizations to provide information, services, and assistance to individuals seeking HCBS services. This collaborative approach ensures a wide reach and effective service delivery.
  • Providing comprehensive case management or care coordination services, encompassing:
    • Assessing program eligibility, ensuring individuals meet the necessary criteria.
    • Developing and implementing support plans tailored to individual needs.
    • Assisting individuals in accessing, coordinating, and evaluating available services. This ongoing support is crucial for effective service utilization.
    • Informing individuals about the option to self-direct their own services, offering greater control over their care.
    • Generating additional copies of provider service authorization (SA) letters when needed, streamlining administrative processes.
    • Inputting member enrollment data and service authorization information into the DHS Medicaid Management Information System (MMIS), maintaining accurate records.
    • Authorizing and monitoring services to ensure health and safety, safeguarding participant well-being.
    • Monitoring the ongoing provision of individual services for efficiency, consumer satisfaction, and continued eligibility, making adjustments as necessary for optimal outcomes.
    • Monitoring provider performance and quality, ensuring high standards of service delivery.
    • Verifying that all providers meet state standards relevant to their service area, have signed provider agreements with DHS, and meet provider qualifications, especially when the lead agency itself is a service provider.
    • Ensuring provider compliance with DHS requirements when reviewing and approving non-enrolled providers to deliver EW and AC services (refer to CBSM –Lead agency oversight of waiver/AC approval-option service vendors).
    • Authorizing funds for all HCBS services provided to those eligible for MHCP enrollment, managing program finances effectively.

Notice of Action: Both lead agencies and the state are legally required to provide proper notification before making changes to services. Specifically:

Informed Choice: A cornerstone of both programs is ensuring informed choice for participants. Lead agencies are responsible for:

  • Providing individuals seeking EW or Alternative Care program services with all necessary information to make informed choices about available services for which they are eligible.
  • Informing individuals and their legal representatives when the individual is likely to require institutional level care (hospital or nursing home) and presenting home and community-based supports as a viable alternative.
  • Taking reasonable steps to present information in an understandable format and offering a choice of service providers for all services, empowering individuals to direct their care.

Lead Agency Case Managers

Lead agency case managers have a specific role in the Alternative Care program. They are directly responsible for determining financial eligibility for payment of Alternative Care program services. This role is crucial in ensuring that the Alternative Care program effectively serves those who meet the financial criteria.

Eligible Providers

Providers who wish to offer services and receive MHCP payment for Elderly Waiver and Alternative Care program services must formally enroll with MHCP and meet specific quality standards. To initiate the enrollment process and become a provider for waiver or Alternative Care program services, detailed instructions are available in the Home and Community-Based Services (HCBS) Programs Provider Enrollment section of the DHS website.

Beyond general enrollment, providers must also determine which specific program services they are qualified to deliver. Detailed provider qualifications for each service are outlined within the service descriptions in this manual. The HCBS Programs Service Request Form (DHS-6638) (PDF) also provides a comprehensive list of qualifications for various services.

It’s important to note that certain waiver services mandate specific requirements for providers, which may include:

  • License(s) from DHS or the Minnesota Department of Health (MDH). Licensing ensures providers meet regulatory standards for service delivery.
  • Medicare certification. For certain healthcare-related services, Medicare certification may be necessary.
  • Other certifications or registrations. Depending on the service type, additional certifications or registrations may be required to ensure provider competency and quality.

For more detailed information regarding provider eligibility and qualifications, it’s recommended to contact:

  • The lead agency in the area where services will be provided. Lead agencies can provide localized guidance and specific requirements.
  • DHS Licensing directly at 651-431-6500 for licensing-related inquiries.
  • Minnesota Department of Health at 651-201-5000 for general health-related information and potential certifications.

Covered Services

The Elderly Waiver and Alternative Care program offer a comprehensive range of services designed to support seniors in their homes and communities. For detailed policy information on each service, including legal references, service descriptions, covered and non-covered aspects, and provider standards and qualifications, please refer to the Community Based Services Manual (CBSM) policy page for each linked service below. For services without direct CBSM links in the table below, service descriptions, billing codes, and provider standards are detailed in the sections following this table.

Service EW AC
Adult companion services X X
Adult day services X X
Adult day services bath X X
Adult foster care X
All MA covered services X
Case management X X
Case management aide (Paraprofessional) X X
Chore services X X
Consumer Directed Community Supports (CDCS) X X
Conversion case management X
Customized living X
Environmental accessibility adaptations X X
Family adult day services X X
Family caregiver services Caregiver counseling Caregiver training X X
Home care – extended services HHA, home care nursing, PCA X X
Home-delivered meals X X
Homemaker X X
Individual community living supports (ICLS) X X
EW and AC transportation X X
Nutrition services X
Respite care X X
RN supervision of PCA X
Specialized equipment and supplies X X
Tele-homecare X X
Transitional services – EW Program Only X

Note: “X” indicates the service is covered under the respective program (EW = Elderly Waiver, AC = Alternative Care Program).

These listed services represent the minimum guidelines. Lead agencies have the discretion to consult the Community-Based Services Manual (CBSM) for more detailed information and specific program implementations.

Extended Home Care Services – EW Program Only

The Elderly Waiver program offers extended home care services to provide more intensive support when needed.

Service and HCPCS EW
Home Health Aide Extended
T1004 – 15 minutes		 X
LPN Regular Extended
T1003 with modifier UC – 15 minutes (LPN Regular)
T1003 with modifiers TT and UC – 15 minutes (LPN Shared 1:2)		 X
LPN Complex Extended
T1003 with modifiers TG & UC – 15 minutes		 X
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		 X
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)		 X
RN Complex, Extended
T1002 with modifiers TG and UC – 15 minutes		 X

Important Notes on Extended Home Care Services:

  • Extended home care services encompass extended PCA, extended home health aide services, and extended home care nursing (RN or LPN) services. These are designed to augment standard home care when needs exceed typical levels.
  • To access extended home care benefits through the Elderly Waiver program, MHCP members must first utilize their standard MA home care service benefits, either through Fee-For-Service (FFS) or managed care. This ensures that standard benefits are maximized before waiver funds are applied.
  • Home care services that are not covered by MA home care can be billed to the waiver as extended MA services, provided they remain within the individual’s waiver budget limit. This allows for flexibility in meeting specific care needs.

For more in-depth information about extended home care services under the Elderly Waiver program, please refer to the dedicated section on extended home care services.

Home Health Services – AC Program Only

The Alternative Care program provides specific home health services to support participants in their home settings.

Service and HCPCS AC
Home Health Aide
T1004 – 15 minutes		 X
Home Health Aide Visit
T1021		 X
LPN Regular
T1003 – 15 minutes (LPN Regular)
T1003 with modifier TT – 15 minutes (LPN Shared 1:2)		 X
LPN Complex
T1003 with modifiers TG – 15 minutes		 X
PCA
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		 X
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)		 X
RN Complex
T1002 with modifier TG – 15 minutes		 X
Skilled Nurse Visit
G0299 – Services of a skilled nurse (RN), Home Health 15 minutes
G0300 – Services of a skilled nurse (LPN), Home Health 15 minutes
T1030— Visit		 X
Tele- Homecare
T1030 with modifier GT		 X

Service Authorization (SA)

For both the Alternative Care program and the Elderly Waiver, a service authorization (SA) is a mandatory step before services can be provided and billed. This process ensures proper oversight and financial management of program resources.

The process of obtaining a service authorization involves the following key steps:

  • Lead Agency Case Manager Role: A lead agency case manager or care coordinator is responsible for initiating and completing the service authorization. They assess the individual’s needs, determine appropriate services, and document these in the SA.

  • FFS Service Authorization in MMIS: For counties and tribal nations operating on a fee-for-service (FFS) basis, the service authorization process is initiated within the MMIS system. The case manager inputs all necessary details, including service codes, rates, and dates of service.

  • Provider Responsibility for SA Accuracy: While the case manager is responsible for initiating the SA, providers play a crucial role in ensuring its accuracy. If providers identify any discrepancies in the rate, procedure codes, or service dates on the SA, they must promptly contact the case manager to request corrections. The case manager is ultimately accountable for the accuracy of the SA.

  • Revised Service Authorization Letter (SAL): If any line item on the SA is changed and subsequently approved, the MMIS system automatically generates a revised service authorization letter (SAL). This SAL is sent electronically to the provider’s MN–ITS mailbox, typically overnight, ensuring providers have the most current authorization details.

  • MCO Service Authorization Systems: Managed Care Organizations (MCOs) operate their own service authorization systems, which may differ from the FFS process. Providers working with individuals enrolled in EW through an MCO must contact the specific MCO for detailed instructions on obtaining authorizations and billing procedures. MCO contact information is available on the DHS website.

  • SA as a Prerequisite for Billing and Payment: The service authorization is essential for providers to both deliver services and subsequently bill DHS for payment. MHCP will only provide payment for services that are explicitly listed on the approved service authorization. However, it’s important to note that an approved SA does not guarantee claim payment.

Conditions for Claim Payment: For a claim to be successfully paid, several conditions must be met:

  1. Active Provider Enrollment: Providers must be actively enrolled in MHCP and maintain up-to-date credentials to provide the authorized services.
  2. Continued MHCP Eligibility: The individual receiving services must maintain their MHCP eligibility throughout the service period for the authorization to remain valid.
  3. Provider Verification of SA Accuracy: Providers are responsible for carefully reviewing their service authorization letters (SALs) upon receipt in their MN–ITS mailbox to ensure accuracy and alignment with the services they are authorized to provide.

Key Information on Each SA Line Item: Each line item on the service authorization provides critical details, including:

  • The MHCP-enrolled provider authorized to deliver the specific service.
  • The approved rate of payment for the service.
  • The number of units approved or the total authorized amount for the service.
  • The date or date span during which the service is authorized.
  • The approved procedure code(s) for billing purposes.
  • For Elderly Waiver extended services, the SA may also specify the amount of MA home care services (SNV, HHA, Home Care Nursing, and PCA) that must be utilized before EW extended services can be accessed.

Budget and Rate Limits: Service authorizations for both EW and AC display units, duration, and rates. It’s crucial that all authorized services remain within the published case mix budget caps (maximum monthly rate limit) and the established state rate limits for services. Providers can find the current long-term services and supports rate limits in the Long-Term Services and Supports Rate Limits (DHS-3945) (PDF) document.

Eligibility Verification: Providers are responsible for verifying program eligibility for each member on a monthly basis. This verification can be done through the MHCP phone-based eligibility verification system (EVS) or online via MN–ITS. Regular eligibility checks are essential to ensure continued coverage and prevent billing issues.

Provider Quick Reference

This section provides a quick reference guide for providers participating in the Elderly Waiver and Alternative Care program, focusing on key aspects of service authorization and related processes.

Service Authorization Letters (SALs)

  • Case Manager Access to SALs: Case managers have the capability to generate additional copies of the provider service authorization letter (SAL) as needed. This can be helpful for record-keeping or when a provider requires another copy.
  • Case Manager Discretion on Sending SALs: Case managers have the option to suppress the DHS-generated SAL and instead send their own customized letter to the member. This might be used for personalized communication or to include additional information.
  • Electronic Delivery via MN–ITS: Providers registered with MN–ITS receive their service authorization letters electronically in their secure MN–ITS mailboxes. This system allows for efficient and timely delivery of authorizations.
  • SAL File Contents: The Service Authorization Letters (SAL) file within MN–ITS encompasses authorizations for:
    • Waiver services (Elderly Waiver)
    • Alternative Care program services
    • MA home care services
  • Prior Authorization Letters (PALs): A separate Prior Authorization Letters (PAL) file contains MA authorization letters, distinct from waiver and AC service authorizations.

Service Authorization Changes

  • Case Manager Responsibility: The case manager holds the primary responsibility for initiating and managing any changes to a member’s service authorization. This ensures that modifications are properly assessed and authorized.
  • Correcting Inaccurate SA Information: If a provider identifies inaccuracies on a service authorization, such as incorrect rates, procedure codes, or service dates, the first step is to contact the case manager. The case manager is the point of contact for initiating corrections.
  • Requesting Additional Services: If a member requires additional services beyond the scope of the current service authorization, providers must communicate with the lead agency before providing these additional services. Pre-authorization is crucial to ensure payment and program compliance.
  • Automatic Generation of Revised SALs: When a change to an SA line item is approved, the MMIS system automatically generates a revised SAL. These revised letters are typically generated overnight and sent to the provider’s MN–ITS mailbox the following day, ensuring providers are promptly informed of approved changes.

Changes in Member Status

  • Case Manager/Care Coordinator Communication: The case manager or care coordinator is responsible for informing providers and the lead agency financial worker of any changes in a member’s status. This includes changes in living arrangements, address, phone number, or correction of inaccurate birth dates. Timely communication is vital for accurate record-keeping and service delivery.
  • Lead Agency Financial Worker Notifications: Conversely, the lead agency financial worker is responsible for notifying the case manager or care coordinator of any changes in the person’s eligibility for MA or enrollment in an MCO. This ensures that the care team is aware of any shifts in funding or program access.
  • Hospitalization Notifications: Providers and lead agencies are expected to notify one another when a member is hospitalized. This is essential for accurate billing and to allow providers to adjust billing around the dates of hospitalization, avoiding claim denials.
  • Long-Term Care Facility Admission Notifications: When a member is admitted to a long-term care facility, the lead agency financial worker and case manager/care coordinator must notify each other. This triggers updates to the living arrangement in the system, and appropriate changes can be made to service authorization line items to reflect the change in care setting.

Change in Member Needs

  • Provider Responsibility to Report Changes: Providers are on the front lines of service delivery and are often the first to observe changes in a member’s needs. It is crucial for providers to contact the lead agency when they identify such changes.
  • Case Manager/Care Coordinator Reassessment: Upon notification of a change in needs, the case manager or care coordinator is responsible for reassessing the member. This reassessment leads to an amendment of the community support plan to better align with the member’s evolving requirements.
  • Types of Changes Triggering Reassessment: Changes in member needs can manifest in various ways, including:
    • Change of provider preference or need.
    • The necessity to increase or decrease the level of existing services.
    • The need to add a new service to the care plan.
    • Identification of other appropriate assessed needs that require service adjustments.

Transitioning Between MA Home Care and Waiver Services

  • Navigating Service Transitions: For guidance on transitioning between MA Home Care services and Waiver Services, or vice versa, providers should refer to the Home Care Services section on the DHS website. This section provides specific procedures and considerations for these types of service transitions.

Home Care Nursing Payment for Spouses

  • Spousal Payment Guidelines: For information regarding payment policies for home care nursing services provided to spouses, providers should consult the Home Care Services section. This section clarifies the specific rules and regulations related to this scenario.

People Enrolled in Waiver Services Electing Hospice

  • Hospice Service Coordination: When a member enrolled in waiver services elects to receive hospice care, specific coordination and billing procedures apply. Providers should refer to the Hospice Services section for detailed information on covered services and billing protocols in hospice situations.

Billing Information

Effective billing practices are crucial for providers to receive timely payments for services rendered under the Elderly Waiver and Alternative Care program. Coordinated efforts between providers and lead agencies are essential to ensure MHCP members receive necessary services and that providers are compensated accurately and promptly.

For providers who have contracts with Managed Care Organizations (MCOs) to deliver services, it is imperative to obtain specific billing instructions directly from the respective MCO. MCOs have their own billing protocols and systems that providers must adhere to.

For billing Fee-For-Service (FFS) Elderly Waiver and Alternative Care program services, providers should consult the dedicated section on Billing for Waiver and Alternative Care (AC) Program. This section provides detailed guidance on FFS billing procedures.

Specifically for extended home care services that have been approved on the waiver authorization, providers must submit claims using the 837I Institutional Outpatient transaction format via MN–ITS. These claims should be submitted following the established home care billing guidelines to ensure proper processing and payment.

As a reminder, MCOs operate independent service authorization systems. Providers need to contact the relevant MCOs directly for specific instructions on obtaining authorizations and billing for Elderly Waiver services provided through managed care.

Authorized Services vs. Non-Authorized Services on Claims

It is critically important to segregate services that require a service authorization (SA) from those that do not when submitting claims. Do not bill for services that require an SA on the same claim as services that do not require an SA. Mixing these service types on a single claim can lead to processing errors and payment delays.

For instance, for individuals eligible for MA, certain home care therapy services (physical therapy, occupational therapy, respiratory therapy, and speech therapy) do not require a service authorization. These services cannot be billed on the same claim as waiver services, such as adult day services, which do require an SA. Maintain separate claims for authorized and non-authorized services to ensure accurate and efficient claim processing.

Payment Rates for Services

Lead agencies play a central role in authorizing both service delivery and the associated provider payment rates. The DHS establishes rate limits for both Alternative Care program and Elderly Waiver services. These rate limits are publicly available in the Long-Term Services and Supports Service Rate Limits (DHS-3945-ENG) (PDF) document. It is imperative that the service rates authorized and subsequently claimed by providers do not exceed these established limits.

The majority of Alternative Care program and Elderly Waiver services are authorized and paid at a state-established rate. This state-established rate serves as the rate limit for the service and is published in the Long-Term Services and Supports Service Rate Limits (DHS-3945-ENG) (PDF).

However, some services are authorized and paid at a market rate, up to the state-established limit. This market rate is intended to reflect the typical price charged for the service within the community market.

Elderly Waiver residential services, specifically customized living and adult foster care, utilize a different rate determination method. These services are authorized and paid at a daily rate that is determined by the Residential Services Tool (RS Tool), which is completed by lead agencies. The RS Tool helps to assess the specific needs and characteristics of the residential setting to establish an appropriate daily rate.

For more comprehensive information regarding payment rates and methodologies, providers can consult the Rate methodologies for AC, ECS and EW service authorization web page in the CBSM. Additionally, it is advisable to regularly review the long-term services and supports rates changes web page for the most up-to-date information about any changes to rate limits.

Elderly Waiver Customized Living Services Rate Adjustment

Recent legislative changes in Minnesota have introduced a rate floor adjustment, or minimum daily rate, specifically for customized living services providers that are designated as disproportionate share facilities. This adjustment aims to provide enhanced financial support to eligible facilities.

Eligibility Criteria for Facilities: To be eligible to apply for customized living services minimum daily rate adjustment payments in 2025, facilities must meet all of the following requirements as of September 1, 2024:

  1. The facility must have been deemed eligible for the disproportionate share rate adjustment in application year 2023 and be actively receiving payments in 2024.
  2. A minimum of 83.5 percent of the facility’s residents must be customized living residents who utilize EW, BI (Brain Injury waiver), or CADI (Community Access for Disability Inclusion waiver) programs.
  3. Within that customized living resident population, at least 70 percent must be recipients of the Elderly Waiver (EW).

It is important to note that only facilities that were determined eligible to be a disproportionate share facility through the September 2023 application period are eligible to apply for this rate adjustment. New applicants are not eligible at this time.

Adjustment Amount: The Legislature-approved minimum daily rate adjustment is set at $141 for the 2025 calendar year. Qualified facilities will receive adjustments up to this minimum daily rate on claims specifically for individuals who utilize the Elderly Waiver and receive 24-hour customized living services between January 1, 2025, and December 31, 2025. This payment adjustment does not apply to claims for residents who are utilizing Brain Injury (BI) and Community Access for Disability Inclusion (CADI) waivers.

The minimum daily rate payment for individual disproportionate share facilities was initially implemented in calendar year 2022. DHS is mandated to adjust the value of the minimum daily rate annually on January 1, as directed by law. The historical and current minimum daily rate amounts are as follows:

Effective Dates Minimum Rate
July 1, 2022 – December 31, 2022 $119
January 1, 2023 – December 31, 2023 $131
January 1, 2024 – December 31, 2024 $190
January 1, 2025 – December 31, 2025 $141

Application Process: Currently approved, eligible facilities can apply for the rate adjustment using the Disproportionate Share Facility Application, DHS-8157 (PDF) form. The application submission period is from September 1 to September 30, 2024. Refer to the Billing section for further information related to billing procedures for this rate adjustment.

Facilities are required to submit a separate application for each licensed assisted living facility. For facilities holding a single license for an assisted living facility campus as defined under Minnesota Statutes, 144G.08, subd. 4a, only one application is required for the entire licensed campus. Providers who are exempt from assisted living licensure must submit an individual application for each building with a unique street address. As part of the application review process, DHS will request applicants to submit a census list of waiver program members in a secure, encrypted format to verify the resident numbers provided on the application form.

DHS will designate eligible facilities by October 15, and qualified facilities will receive the minimum daily rate adjustment from January 1 through December 31 of the year immediately following the application period.

Lead Agency Information: Lead agencies seeking further information should consult the Customized living (including 24-hour customized living) section of the Community-Based Services Manual (CBSM) or contact DHS directly at [email protected].

Elderly Waiver Obligation and MA Spenddown

Eligibility for the Elderly Waiver program is determined based on two distinct income limits, each impacting financial responsibility for program participants:

  1. Special Income Standard (SIS): Individuals with incomes at or below the Special Income Standard (SIS) are eligible for the Elderly Waiver without requiring an MA spenddown. However, they are subject to a “waiver obligation.” This means they must contribute any income exceeding the maintenance needs allowance and other applicable deductions towards the cost of services received under the Elderly Waiver.

  2. Income Above SIS with MA Spenddown: Individuals with incomes exceeding the SIS may still be eligible for the Elderly Waiver, but they will be subject to an MA spenddown. In this scenario, a portion of their income must be used to cover medical expenses before MA benefits, including waiver services, are activated.

The lead agency’s financial assistance unit is responsible for determining the specific financial obligation for each Elderly Waiver member, whether it be a waiver obligation or an MA spenddown. The member will receive a formal notice outlining their financial responsibility.

Waiver Obligation Details:

  • The waiver obligation is deducted from the total cost of services received under the Elderly Waiver. It is important to note that the full waiver obligation amount does not necessarily have to be met each month.
  • The waiver obligation represents the amount the member is responsible for paying towards the services they used in a given month. This payment may be a portion of the total waiver obligation or, in some cases, the entire waiver obligation amount, depending on service utilization.

MA Spenddown Details:

  • An MA spenddown, in contrast to a waiver obligation, must be met each month to maintain MA eligibility and access services.
  • The MA spenddown can be met through any combination of MA-covered services, which includes HCBS services provided under the Elderly Waiver. This provides flexibility in meeting the spenddown requirement.

The lead agency financial worker is responsible for entering the calculated waiver obligation or MA spenddown amount into the MMIS system. DHS will then report the amount that the provider can bill the member directly on the remittance advice (payment statement). Claims that are reduced due to the EW obligation or spenddown will display claim adjustment reason code PR 142 on the remittance advice, providing transparency in payment adjustments.

MCOs also receive reports on their enrollees who have waiver obligations and spenddowns to ensure coordinated financial management. Each MCO has its own specific process for informing providers about the amounts of member waiver obligations and spenddowns. Providers working with MCOs should familiarize themselves with the MCO’s communication protocols. Further details about the Special Income Standards (SIS) can be found in Appendix F of the MHCP Eligibility Policy Manual.

Members enrolled in MHCP have the option to designate a specific provider to whom they will make their waiver obligation payments. If a member wishes to utilize this option, they must formally notify their financial worker of their chosen designated provider. It is important to note that members receiving waiver services through an MCO are not eligible to use the designated provider option that is available through a financial worker request. This option is primarily for members in the Fee-For-Service (FFS) system.

Home Care Services Provided for MA-Eligible Members Receiving EW Services

A foundational principle of the Elderly Waiver program is that all individuals receiving EW services must first maximize their access to and utilization of standard MA home care services before incorporating EW-funded services into their community support plan. This ensures that existing resources are fully leveraged before waiver funds are applied.

MA covers a comprehensive range of essential home care services, including:

  • Home care nursing services
  • Home health aide (HHA) visits
  • Occupational therapy (OT)
  • RN PCA supervision
  • Personal care assistant (PCA) services
  • Physical therapy (PT)
  • Respiratory therapy (RT)
  • Skilled nursing visits (SNV)
  • Speech therapy (ST)

Home Care and EW Waiver Program Interaction

  • Managed Care Products: The primary managed care products that serve members enrolled in the Elderly Waiver are Minnesota Senior Care Plus (MSC+) and Minnesota Senior Health Options (MSHO). These MCOs play a significant role in service coordination and management.
  • MCO Management of Services: If a member is enrolled in the Elderly Waiver and is served by an MCO, the MCO assumes responsibility for managing both the state plan home care services and the waiver services. This integrated management approach ensures streamlined care coordination.
  • Fee-For-Service (FFS) EW and Home Care: Conversely, if a member is enrolled in Fee-For-Service (FFS) Elderly Waiver, then their state plan home care services are also delivered on a Fee-For-Service basis. This maintains consistency in service delivery and payment mechanisms.
  • Care Coordinator Role: For members receiving Elderly Waiver services through managed care, the designated care coordinator within the MCO is responsible for both the approval and provision of all home care and EW services. For members receiving FFS EW services, this responsibility rests with the county or tribal case manager. The care coordinator or case manager serves as the central point of contact and care management for the member.

Home Care and Alternative Care (AC) Program Interaction

In the Alternative Care program, the lead agency case manager takes on the responsibility of determining and authorizing the amount of home care services that will be counted towards the member’s overall case mix budget. It is important to note that the Alternative Care program itself does not have a direct Medical Assistance (MA) benefit component. Home care service utilization within the AC program is managed and authorized within the program’s budgetary framework.

Legal References

The Elderly Waiver and Alternative Care program are governed by a comprehensive set of legal statutes and rules at both the state and federal levels. These legal references provide the framework for program operations, eligibility criteria, service standards, and regulatory oversight. Key legal references include:

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