Overview
The Elderly Waiver (EW) and Alternative Care (AC) programs are designed to provide crucial home and community-based services (HCBS) for individuals aged 65 and older. These programs cater to seniors who require a level of care typically found in a nursing home but prefer to live within their communities. By offering comprehensive support and services, EW and AC programs aim to facilitate community living, promote independence, and potentially delay or prevent the need for nursing facility (NF) care. The core objective of these programs is to empower older adults to maintain their independence and community engagement through tailored services and supports that address their unique needs and preferences. For the Elderly Waiver (EW) program, the services extend beyond what is typically available through standard Medical Assistance (MA).
The Elderly Waiver (EW) program operates as a federal Medicaid waiver initiative. It is specifically designed to finance home and community-based services for individuals aged 65 and over who are eligible for Medical Assistance (MA), necessitate nursing home level care, and desire to reside in a community setting. Individuals enrolled in the EW program can access both waiver services and MA services through a managed care organization (MCO), such as Minnesota Senior Care Plus (MSC+) or Minnesota Senior Health Options (MSHO).
Conversely, the Alternative Care (AC) program is a state-funded initiative providing a more limited scope of home and community-based services. It targets individuals 65 years and older who do not qualify for MA based on financial criteria but meet AC’s financial and service eligibility standards and require nursing home level care. AC is designed for those with modest incomes and assets who are not yet eligible for Medical Assistance.
Assessments
Anyone can initiate an assessment request for themselves or another individual by reaching out to the local lead agency. These lead agencies, which are detailed further in the Lead Agency section, are responsible for determining program eligibility. It is important to note that the EW and AC programs have distinct application processes, financial eligibility criteria, and covered services.
Eligible Members
To qualify for either the Elderly Waiver or Alternative Care program, all applicants must fulfill the service eligibility requirements specific to the Home and Community-Based Services (HCBS) program they are applying for. Detailed information regarding Medical Assistance (MA) and eligibility criteria can be found in the MHCP Provider Manual and the Programs and Services section.
For Elderly Waiver (EW) program eligibility, applicants must also be eligible for Medical Assistance (MA).
For the Alternative Care (AC) program, applicants must demonstrate financial eligibility for MA within 135 days of potential nursing facility admission, as determined by a case manager assessment.
Roles
Lead Agency
Lead agencies, often staffed by human services eligibility workers, are pivotal in determining financial eligibility for Elderly Waiver services. These agencies are also tasked with conducting asset assessments when necessary to establish financial eligibility for both AC and EW programs.
For the Elderly Waiver program, lead agencies can include counties, tribal nations, or Managed Care Organizations (MCOs), also known as health plans. For the Alternative Care program, lead agencies are typically counties or tribal nations. These lead agencies can be local public health, human service, or social service agencies. Their responsibilities encompass several key functions:
Long-Term Care Consultation: Lead agencies provide essential long-term care consultation (LTCC) services, including:
- Conducting comprehensive assessments of the needs of MHCP members.
- Providing assistance throughout the program application process.
- Developing personalized community support plans.
Case Management: Individuals approved for either EW or AC programs are assigned a case manager or care coordinator, who may be a public health nurse, registered nurse, or social worker. This professional provides crucial assistance in accessing and navigating social, health, educational, community, and natural supports and services tailored to the individual’s values, strengths, goals, and needs. The case manager ensures the person receives the necessary information to make informed decisions. For a complete description, refer to the Community-Based Services Manual (CBSM).
Program Access and Administration: Lead agencies are responsible for program access and administration, which includes:
- Collaborating with the Department of Human Services (DHS) and other organizations to offer information, services, and support to individuals seeking HCBS services.
- Providing case management or care coordination services, including:
- Assessing program eligibility.
- Creating and managing support plans.
- Helping individuals access, coordinate, and evaluate available services.
- Informing individuals about the option to self-direct their care.
- Generating additional copies of provider service authorization (SA) letters as needed.
- Entering member enrollment data (e.g., screening documents) and service authorizations into the DHS Medicaid Management Information System (MMIS).
- Authorizing and monitoring services to ensure health and safety.
- Continuously monitoring individual service provision for efficiency, consumer satisfaction, and ongoing eligibility, making necessary adjustments.
- Monitoring provider performance and service quality.
- Ensuring all providers meet state standards, have signed provider agreements with DHS, and fulfill provider qualifications, especially when the lead agency is the service provider.
- Ensuring provider compliance with DHS requirements when reviewing and approving non-enrolled providers to deliver EW and AC services.
- Authorizing funds for all HCBS services for MHCP enrollees.
Notice of Action: Legal regulations require lead agencies or the state to issue a formal Notice of Action to MHCP members before any service denial, termination, reduction, or suspension. This written notice must be provided at least 10 days in advance of the intended action. Lead agencies (counties and tribal nations) are mandated to use specific forms, such as the Notice of Action (Assessments and Reassessments) (DHS-2828A) (PDF) and Notice of Action (Service Plan) (DHS-2828B) (PDF), for notifying individuals about changes to waiver services. MCOs have their own notification forms and procedures.
Informed Choice: Lead agencies are committed to:
- Providing individuals seeking EW or AC services with all necessary information to make informed decisions about eligible services.
- Informing individuals and their legal representatives about the option of home and community-based supports as an alternative when institutional care, such as hospital or nursing home care, is likely to be required.
- Taking reasonable steps to present information in an understandable format and offer choices among service providers for all services.
Lead Agency Case Managers
Lead agency case managers specifically determine financial eligibility for Alternative Care program payments.
Eligible Providers
Providers interested in offering and receiving MHCP payments for EW and AC waiver services must enroll with MHCP and meet specific criteria. Enrollment instructions can be found in the Home and Community-Based Services (HCBS) Programs Provider Enrollment section.
Providers must also verify their qualifications to offer specific program services. Detailed provider qualifications are available within each service description in this manual. The HCBS Programs Service Request Form (DHS-6638) (PDF) also lists required qualifications.
Certain waiver services necessitate one or more of the following:
- Licenses from DHS or the Minnesota Department of Health (MDH).
- Medicare certification.
- Other specific certifications or registrations.
For further information, providers can contact:
- The lead agency in their service area.
- DHS Licensing at 651-431-6500.
- Minnesota Department of Health at 651-201-5000 for general information.
Covered Services
For each service listed below, selecting the provided link will direct you to the Community Based Services Manual (CBSM) policy page. This page includes legal references, service descriptions, details on covered and non-covered services (where applicable), and provider standards and qualifications. Services without direct CBSM links have descriptions, billing codes, and provider standards provided 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 | 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 |
These services and requirements are presented as minimum guidelines. Lead agencies have the option to consult the Community-Based Services Manual (CBSM) for more detailed information.
Extended Home Care Services – EW Program Only
| Service and HCPCS | EW |
|---|---|
| Home Health Aide Extended | X |
| * T1004 – 15 minutes | |
| LPN Regular Extended | X |
| * T1003 with modifier UC – 15 minutes (LPN Regular) | |
| * T1003 with modifiers TT and UC – 15 minutes (LPN Shared 1:2) | |
| LPN Complex Extended | X |
| * T1003 with modifiers TG & UC – 15 minutes | |
| PCA – Extended | X |
| * 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 | X |
| * 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 | X |
| * T1002 with modifiers TG and UC – 15 minutes |
Key points about extended home care services:
- Extended home care services encompass extended PCA, extended home health aide, and extended home care nursing (RN or LPN).
- To access extended home care benefits, MHCP members must first utilize available home care service benefits through MA home care, either on a fee-for-service basis or through managed care.
- Home care services not covered by MA home care can be billed to the waiver as extended MA services within the approved waiver budget limit.
For more detailed information, refer to the extended home care services guidelines.
Home Health Services – AC Program Only
| Service and HCPCS | AC |
|---|---|
| Home Health Aide | X |
| * T1004 – 15 minutes | |
| Home Health Aide Visit | X |
| * T1021 | |
| LPN Regular | X |
| * T1003 – 15 minutes (LPN Regular) | |
| * T1003 with modifier TT – 15 minutes (LPN Shared 1:2) | |
| LPN Complex | X |
| * T1003 with modifiers TG – 15 minutes | |
| PCA | X |
| * 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 | X |
| * 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 | X |
| * T1002 with modifier TG – 15 minutes | |
| Skilled Nurse Visit | X |
| * G0299 – Services of a skilled nurse (RN), Home Health 15 minutes | |
| * G0300 – Services of a skilled nurse (LPN), Home Health 15 minutes | |
| * T1030— Visit | |
| Tele- Homecare | X |
| * T1030 with modifier GT |
Service Authorization
For both AC and EW programs, a service authorization (SA) must be completed by a lead agency case manager or care coordinator before services can be rendered.
For fee-for-service (FFS) arrangements within counties and tribal nations, service authorization is initiated in MMIS. Providers should contact the case manager to correct any inaccuracies in rates, procedure codes, or dates on the SA, as the case manager is ultimately responsible for SA accuracy. Upon approval of any SA line item changes, the case manager will generate a revised service authorization letter (SAL) overnight, which is then sent to the provider’s MN–ITS mailbox the following day.
MCOs utilize their own service authorization systems. Providers should contact the MCOs directly for specific instructions on obtaining authorizations and billing for EW services.
The SA allows providers to deliver services and subsequently bill DHS for payment. However, MHCP will only reimburse for services listed on the SA; an approved SA does not guarantee payment. For successful claim payment:
- Providers must maintain active enrollment and up-to-date credentials to provide authorized services.
- The individual must maintain MHCP eligibility for the authorization to remain valid.
- Providers are responsible for verifying the accuracy of the Service Authorization Letter (SAL) upon receipt in their MN–ITS mailbox.
Each line item on the SA details:
- The MHCP-enrolled provider authorized to deliver the service.
- The payment rate for the service.
- The number of approved units or the total authorized amount.
- The service date or date range.
- The approved procedure codes.
- For EW extended services, it specifies the MA home care services (skilled nursing visits (SNV), home health aide (HHA), Home Care Nursing, and personal care assistant (PCA)) that must be utilized before accessing EW extended services.
Service authorizations for EW and AC programs specify units, duration, and rates. All authorized services must remain within the published case mix budget caps (maximum monthly rate limit) and state rate limits for services. Current long-term services and supports rate limits are available in the Long-Term Services and Supports Rate Limits (DHS-3945) (PDF) document.
Providers are required to verify program eligibility for each member monthly through the MHCP phone-based eligibility verification system (EVS) or online via MN–ITS.
Provider Quick Reference
Service Authorization Letters
- Case managers can generate additional copies of the provider service authorization letter (SAL) as needed.
- Case managers have the option to suppress the DHS-generated SAL and send their own letters to the member.
Providers registered with MN–ITS receive SALs in their electronic mailboxes. These letters can be viewed, printed, or saved and are automatically deleted after 30 days.
The Service Authorization Letters (SAL) file includes authorizations for:
- Waiver services
- Alternative Care services
- MA home care services
The Prior Authorization Letters (PAL) file contains:
- MA authorization letters
Service Authorization Changes
Case managers are responsible for all modifications to a member’s SA.
- To correct inaccuracies in rates, procedure codes, or dates on the SA, providers must contact the case manager.
- For additional service needs, providers must communicate with the lead agency before providing any extra services.
- Upon approval of an SA line item change, MMIS automatically generates a revised SAL for the provider, typically overnight, and sends it the next day.
Changes in Member Status
- Case managers or care coordinators inform providers and lead agency financial workers about any changes in a member’s status, such as living arrangements, address, phone number, or birth date corrections.
- Lead agency financial workers notify case managers or care coordinators of any changes in a person’s MA eligibility or MCO enrollment.
- Providers and lead agencies should notify each other upon a member’s hospitalization to ensure accurate billing around hospitalization dates.
- Lead agency financial workers and case managers/care coordinators inform each other when a member is admitted to a long-term care facility to update living arrangements and adjust SA line items accordingly.
Change in Member Needs
Providers must contact the lead agency when a member’s needs change. The case manager/care coordinator is responsible for reassessing the member and revising the community support plan.
Changes may include:
- Provider changes.
- Service increases or decreases.
- Addition of new services.
- Addressing other assessed needs.
Transitioning Between MA Home Care and Waiver Services
Refer to the Home Care Services section for detailed information on transitioning between MA Home Care and Waiver Services.
Home Care Nursing Payment for Spouses
Refer to the Home Care Services section for information on home care nursing payment policies for spouses.
Hospice for Waiver Service Enrollees
Refer to the Hospice Services section for details regarding covered services when a waiver service enrollee elects hospice care.
Billing
Effective coordination between providers and lead agencies is essential to ensure MHCP members receive necessary services and providers are paid promptly. Providers under contract with an MCO should follow MCO-specific billing instructions to ensure payment.
To bill for fee-for-service Elderly Waiver and Alternative Care services, consult the Billing for Waiver and Alternative Care (AC) Program section.
For extended home care services authorized under the waiver, claims should be submitted using the 837I Institutional Outpatient transaction (via MN–ITS), following home care billing guidelines.
MCOs have their own service authorization systems. Providers should contact the MCOs for specific instructions on obtaining authorizations and billing for EW services.
Authorized vs. Non-Authorized Services
Services requiring an SA should not be billed on the same claim as services that do not require an SA.
For instance, MA-eligible individuals receiving home care therapy services (physical, occupational, respiratory, and speech therapy), which do not require an SA, cannot have these services billed on the same claim as waiver services like adult day services.
Payment Rates
Lead agencies authorize service and provider payment rates, while DHS sets rate limits for AC and EW services, published in the Long-Term Services and Supports Service Rate Limits (DHS-3945-ENG) (PDF). Service rates authorized and claimed must not exceed these limits.
Most AC and EW services are authorized and paid at state-established rates, which are the rate limits published in the Long-Term Services and Supports Service Rate Limits (DHS-3945-ENG) (PDF). Some services are paid at a market rate, up to the state limit, based on typical community market prices. EW residential services, including customized living and adult foster care, are paid a daily rate determined by the Residential Services Tool (RS Tool).
Further details on payment rates can be found on the Rate methodologies for AC, ECS and EW service authorization web page in the CBSM. For the latest updates on rate limit changes, refer to the long-term services and supports rates changes web page.
Elderly Waiver Customized Living Services Rate Adjustment
The 2024 Minnesota Legislature approved changes to the rate floor adjustment for customized living services providers designated as disproportionate share facilities.
Eligible facilities: To qualify for customized living services minimum daily rate adjustment payments in 2025, facilities must meet specific criteria by September 1, 2024, including eligibility for the disproportionate share rate adjustment in 2023, a resident population of at least 83.5% customized living residents using EW, BI, or CADI waivers, and at least 70% of those using EW. Only facilities eligible in the September 2023 application period can apply.
Adjustment amount: The minimum daily rate adjustment for 2025 is set at $141. Qualified facilities will receive adjustments up to this minimum for EW recipients receiving 24-hour customized living services from January 1 to December 31, 2025. This adjustment does not apply to BI and CADI waiver claims.
Minimum daily rate payments for disproportionate share facilities began in 2022, with annual adjustments on January 1. The minimum daily rates are:
| 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 |
How to apply: Currently approved, eligible facilities can apply using the Disproportionate Share Facility Application, DHS-8157 (PDF), submitting applications between September 1 and 30, 2024. Refer to the Billing section for more details.
Each licensed assisted living facility must submit a separate application. Facilities licensed as assisted living facility campuses must submit one application per campus. Providers exempt from assisted living licensure must apply for each building with a unique address. DHS will verify resident numbers by requesting a secure, encrypted census list of waiver program members.
DHS will designate eligible facilities by October 15, with adjustments applied from January 1 to December 31 of the following year.
For lead agency information, consult the Customized living (including 24-hour customized living) section of the Community-Based Services Manual (CBSM) or contact [email protected].
Elderly Waiver Obligation and MA Spenddown
EW eligibility is determined by two income limits:
- Individuals with incomes at or below the Special Income Standard (SIS) are EW eligible without an MA spenddown but must contribute income above the maintenance needs allowance to service costs, known as the waiver obligation.
- Those with incomes exceeding the SIS may still qualify for EW but will have an MA spenddown. The lead agency’s financial unit determines the EW member’s financial obligation, and members receive notice of any waiver obligation or spenddown responsibilities.
The waiver obligation:
- Is deducted from the cost of EW services; it does not need to be fully met monthly.
- Represents the member’s payment responsibility for services used each month, which may be a portion or the entirety of the waiver obligation.
An MA spenddown can be met through any combination of MA services, including HCBS, and must be met monthly.
Lead agency financial workers enter waiver obligations or MA spenddowns into MMIS. DHS remittance advice will indicate the billable amount to the member. Claim adjustments due to EW obligations or spenddowns will show reason code PR 142. MCOs also receive reports on enrollees with these obligations and have processes to inform providers. Refer to the Special Income Standards (SIS) in Appendix F of the MHCP Eligibility Policy Manual.
MA-eligible individuals can designate a provider to receive their obligation payments by notifying the financial worker. This option is not available to members receiving waiver services through an MCO.
Home Care Services for MA-eligible EW Recipients
Individuals on EW must first maximize their use of MA home care services before adding EW services to their community support plan.
MA covers these home care services:
- Home care nursing
- 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
- Minnesota Senior Care Plus (MSC+) and Minnesota Senior Health Options (MSHO) are managed care options for Elderly Waiver members.
- For EW members in managed care, the MCO manages both state plan home care and waiver services.
- For fee-for-service (FFS) EW, state plan home care is also FFS.
- For managed care EW members, the care coordinator approves and provides all home care and EW services. For FFS EW members, the county or tribal case manager handles approval and provision.
Home Care and AC
Lead agency case managers authorize the amount of home care services counted towards the member’s case mix budget. AC does not include an MA benefit.
Legal References
Minnesota Statutes, 245A (Human Services Licensing)
Minnesota Statutes, 245A.143 (Family Adult Day Services)
Minnesota Rules, 9555.9600 – 9555.9730 (Adult Day Services Center Licensure)
Minnesota Rules, 9555.5050 – 9555.6265 (Adult Foster Care Services and Licensure)
Minnesota Statutes, 245A.03 (Who Must Be Licensed)
Minnesota Statutes, 148.171 – 148.285 (Public Health Occupations)
Minnesota Rules, 9575.0010 – 9575.1580 (Merit System)
Minnesota Statutes, 256.012 (Minnesota Merit System)
Minnesota Statutes, 256B.02, subdivision 7 (Definitions – Vendor of Medical Care)
Minnesota Statutes, 256B.0913 (Alternative Care Program)
Minnesota Statutes, 256S (Medical Assistance Elderly Waiver)
Minnesota Statutes, 144D.025 (Optional Registration)
Minnesota Rules, 9555.5105 – 9555.6265 (Social Services for Adults)
Minnesota Rules, 9555.6205, subparts 1 – 3, 9555.6215, subparts 1 and 3, and 9555.6225, subparts 1, 2, 6 and 10 (Social Services for Adults)
Minnesota Rules, 4668 (Home Care Licensure)
Minnesota Rules, 4669 (Home Care Licensure Fees)
Minnesota Statutes, 144D (Housing with Services Establishment)
Minnesota Statutes, 256B.0653 (Home Health Agency Services)
Minnesota Statutes, 326B.802, subdivision 11 (Definitions – Residential Building Contractor)
Minnesota Rules, 4626 (Food Code; Food Managers)
Minnesota Statutes, 245C (Human Services Background Studies)
Minnesota Statutes, 245D (Home and Community-Based Services Standards)
Minnesota Statutes, 245A.03, subdivision 2, (a)(1) – (2) (Exclusion from licensure)
Minnesota Statutes, 144A (Nursing Homes and Home Care)
Minnesota Statutes, 144A.43 – 144A.45 (Nursing Homes and Home Care)
Minnesota Statutes, 148.621 (Definitions)
Minnesota Rules, 3250 (Licensure and Practice)
Minnesota Statutes, 148.623 (Duties of the Board)
Minnesota Statutes, 157.17 (Additional Registration Required for Boarding and Lodging Establishments or Lodging Establishments)
Minnesota Statutes, 144.696, subdivision 3 Definitions -– Minnesota Statutes, 144.50 (Hospitals, Licenses; Definitions)
Minnesota Statutes, 144.058 (Interpreter Services Quality Initiative)
Minnesota Statutes, 256B.0659 (Personal Care Assistance Program)
Minnesota Rules, 9505.0335 (Personal Care Services)
Minnesota Rules, 9505.0290, subpart 3B (Home Health Agency Services)
Minnesota Rules. 9505.0175, subpart 23 (Definitions – Long-term Care Facility)
Minnesota Rules, 9505.0310 (Medical Equipment and Supplies)
Minnesota Rules, 9505.0195 (Provider Participation)
Minnesota Statutes, 65B (Automobile Insurance)
Minnesota Statutes, 174.30 (Operating Standards for Special Transportation Service)
Minnesota Statutes, 174.29 – 174.30 (Department of Transportation)
Code of Federal Regulations, title 42, part 441, subpart G, 441.310(a)(2)(ii) (Limits on Federal Financial Participation [FFP])
Laws of Minnesota, 2022 Regular Session, Chapter 98, Article 7, Section 31 or 2022 Minnesota Statutes, 256S.205 (Customized Living Services; Disproportionate Share Rate Adjustments)
