Home and Community Based Services (HCBS) Elderly Waiver

Overview

The Elderly Waiver (EW) program funds Home and Community Based Services (HCBS) for people ages 65 and over who require the level of care provided in a nursing home but choose to reside in the community. The programs provide services and supports for people to live in their homes or a community setting and may delay or prevent nursing facility 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 (Medicaid).

Review the Minnesota Department of Human Services (DHS) Community-Based Services Manual for more information on EW services.

EW Covered Services

1. 24-hour Customized Living (CL)
2. Adult corporate foster care (monthly)
3. Adult day services
4. Adult day services bath
5. Adult family foster care (monthly)
6. Case management
7. Case management aide (paraprofessional)
8. Caregiver assessment
9. Consumer-directed community supports (CDCS) background check
10. Chore
11. Consumer-directed community supports (CDCS)
12. Companion services
13. Customized Living (CL)
14. Environmental accessibility adaptations
15. Essential Community Supports (ECS)
16. Extended personal care
17. Family caregiver counseling and training
18. Home care – extended services (home health aide [HHA], private duty nursing [PDN], personal care assistance [PCA]
19. Home delivered meals
20. Homemaker
21. Modification and adaptations
22. Non-medical transportation
23. Respite care
24. Specialized supplies and equipment
25. Telehome-care
26. Transitional supports
27. Transportation

Long-Term Care Consultation (LTCC) Assessment

The LTCC Assessment focuses on Minnesota’s long-term care information exchange system and individual choice regarding community-based options as an alternative to nursing facility placement. The LTCC incorporates several components. Preadmission Screening (PAS) is one component of the LTCC and assists in identifying supports needed to maintain the member in the community or transition him/her back into the community.

The LTCC team assesses the health and social needs of a member and completes an assessment form. The team must conduct a face-to-face assessment for members over age 65 years. The legal representative of the member, if applicable, must be present.

The local agency must complete all face-to-face LTCC screening activities for applicable people under age 65 within 30 calendar days of enrollment.

Billing for Long-Term Care Consultation (LTCC) Assessments

Counties/tribes must submit electronic claims using the 837P claim format for completed face-to-face LTCC assessment activities for people under age 65.

1. All face-to-face assessment activities eligible for payment must be combined into one claim.
2. The date of service must match the date of an approved face-to-face assessment.
3. The maximum number of units allowed for reimbursement is 96.
4. If more than one LTCC team member is involved in the assessment process, combine the units of time into one claim.

Face-to-face assessment activities are eligible for payment, including time spent by LTCC team member(s) for the following:

1. Arranging assessment(s)
2. Preparing screening document(s) before assessment
3. Travel time to and from assessment (not including mileage costs)
4. Time actually spent conducting the assessment
5. Time spent in approval of the screening document

For each activity in the member’s file, the LTCC team member must document the following:

1. Specify activity completed
2. Date the activity was completed
3. Name and role of the team member completing the activity
4. Amount of time spent on the activity

If more than one LTCC team member is involved in the assessment process, the units of time should be combined into one claim.

Any member may request an assessment by making a referral to the local lead agency. The lead agency will determine program eligibility.

Member Eligibility

All applicants must meet the service eligibility criteria for the specific HCBS program in which they anticipate receiving services. Refer to Member Eligibility and Benefits for more information about Medical Assistance (Medicaid) and eligibility.

The county provides LTCC services including a community assessment of the needs of the member, assistance with the application process, and development of a community support plan. A member approved for an HCBS waiver program will receive service coordination from a public health nurse (PHN) or social worker who implements and monitors the community support plan. The local agency must ensure that the health and safety needs of all members are reasonably met under its community support plans. In addition, the local agency also authorizes the funds for all the HCBS services provided to an eligible member.

Roles

County Financial Worker

County financial workers determine financial eligibility for payment of EW services. Financial workers will also conduct asset assessments as needed for determination of EW financial eligibility.

Local Agency

Local agencies can be county public health agencies, county human services agencies, tribes, counties, or health plans. Lead agencies are responsible for the following:

1. LTCC
   The LTCC focuses on Minnesota’s long-term care information exchange system and individual choice regarding community-based options as an alternative to NF placement. The LTCC incorporates several components. Preadmission Screening (PAS) is one component of the LTCC and assists in identifying supports needed to maintain the member in the community or transition him/her back into the community.
   
   The LTCC team assesses the health and social needs of a member and completes an assessment form. The team must conduct a face-to-face assessment for members under age 65 years. The legal representative of the member, if applicable, must be present.
   
   The local agency must complete all face-to-face LTCC screening activities for applicable people under age 65 within 30 calendar days of enrollment.

2. Case Management
   Case management for a member approved for an EW program will be provided by a PHN or social worker who implements and monitors the community support plan and is also responsible for reassessment of the individual’s level of care and the review of the community support plan. The lead agency must ensure that the health and safety needs of all members are reasonably met under their community support plans. Members may refuse case management services at any time after enrollment. Members must inform the county case manager or PrimeWest Health care coordinator of their refusal. Such refusal can be a verbal or written notification. The county case manager implements and monitors the comprehensive plan of care and is also responsible for reassessment of the individual’s level of care and the review of the comprehensive plan of care. The lead agency must ensure that the health and safety needs of all members are reasonably met under their comprehensive plan of care.

3. Program Access and Administration
   Lead agencies are responsible for providing program access and administration, which includes the following:
   1. Working in partnership with the Minnesota Department of Human Services (DHS) and other organizations to provide information, services, and assistance to people who request and wish to gain HCBS access
   2. Providing member case management or care coordination services, which includes the following:
      1. Assessing program eligibility
      2. Developing a service plan
      3. Assisting members with accessing, coordinating, and evaluating available services
   3. Generating additional copies of provider Service Agreement letters, if needed
   4. Inputting member enrollment data (e.g., screening document) and Service Authorization, as required, into the DHS Medicaid Management Information System (MMIS)
   5. Authorizing and monitoring services to reasonably ensure health and safety
   6. Monitoring the ongoing provision of individual services for efficiency, consumer satisfaction, and continued eligibility, and adjusting these provisions as necessary
   7. Managing the contract(s) and systematic monitoring of provider performance
   8. Ensuring that all providers meet State standards relevant to their area of service and have fully negotiated provider agreements
   9. Authorizing funds for all HCBS services provided to the eligible member

Notice of Action

By law, the lead agency/State is required to notify the member any time 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) to notify the member of impending changes to the waiver services.

Informed Choice

Individuals seeking waiver services will be provided, by the county local agency as required by PrimeWest Health, with the necessary information to make an informed choice among the services for which they are eligible, and the county agency will document the information given. Ensuring that a member is given informed choices is an important responsibility of the case manager.

When a member is likely to require the level of care provided in an institution such as a hospital or nursing home, the case manager must inform the member and his/her legal representative of home and community based services and supports as an alternative. The local agency will do the following:

1. Provide individuals seeking EW services the necessary information to make informed choices among the services for which they are eligible
2. Inform the member and legal representative when a member is likely to require the level of care provided in an institution, such as a hospital or nursing home, of home and community based services and supports as an alternative
3. Document that the above information was given
4. Take reasonable steps to provide the information in a format the member can understand and with a choice of service providers for all services
5. Inform a member nearing age 65 of the other community support options so that the member can choose which alternative will best meet his/her needs. A member receiving waiver services before age 65 remains eligible for the respective waiver after his/her 65th birthday if all other eligibility criteria are met. Other options may include EW, remaining on the member’s current HCBS waiver, or other alternatives that may meet the needs and preferences of the member.

Provider Information

There are many advantages for both providers and local agencies to coordinate efforts to ensure that a member receives necessary services and that providers receive timely payments for services rendered. Providers who contract with PrimeWest Health to provide services will receive instructions from PrimeWest Health on how to ensure timely payment.

Enrollment/Licensure/Certification

Certain HCBS providers, known as Tier 1 providers, must enroll with Minnesota Health Care Programs (MHCP) and PrimeWest Health and must meet specific standards in order to bill and receive payment for waiver services. More information about provider enrollment can be found on the MHCP website. For other providers, known as Tier 2 or Tier 3 providers, enrollment with MHCP and PrimeWest Health is optional. Refer to the DHS Community Based Services Manual.

Providers must also determine which program services they are qualified to provide utilizing an Applicant Assurance Statement. Specific provider qualifications are found in this manual within each service description. Complete information is found in the HCBS Waiver Services section of the DHS Provider Manual. Some waiver services require proof of one or more of the following:

1. License(s) and or registrations from DHS or the Minnesota Department of Health (MDH)
2. Medicare certification
3. Other certification or registration as applicable

1. Training
2. Criminal background checks

For more information, please refer to one or more of the following:

1. Community Based Services Manual (CBSM)
2. The lead agency that serves the county(ies) in which you will be providing services
3. DHS Licensing at 1-651-431-6500
4. Minnesota Department of Health at 1-651-201-5000 for general information

Home and Community Based Services (HCBS) for People with Disabilities Age 65 or Over – MN Stat. Chap. 245D Provider Enrollment

PrimeWest Health contracts for certain home and community based services provided to members with disabilities and those age 65 and over. These services are currently unlicensed or are developmental disability services licensed under MN Stat. Chap. Chapter 245B. Most of the services are funded under one of Minnesota’s Medicaid waiver programs.

The HCBS standards under MN Stat. Chap. 245D were passed by the 2013 Minnesota Legislature.

Provider Quick Reference

Service Agreement Changes

The case manager is responsible for any changes made to the service agreement of any member.

1. If the rate, procedure code(s), or begin and end dates on the service agreement are incorrect, contact the case manager to initiate corrections.
2. If additional services are necessary, the provider must communicate with the case manager before providing any additional services.

Service Agreement Letters

The case manager has the ability to generate additional copies of the provider service agreement letters as needed.

Multiple Providers Providing the Same Service at the Same Time

More than one provider may be authorized to provide the same service for the same member. Each provider has a separate line item on the member’s service agreement.

Some services may also be provided by more than one provider, on the same date of service, except if the service has a daily or monthly procedure code.

If two providers are providing the same service to one member, services must be coordinated.

1. Each provider bills for the actual dates of service.
2. Use date spans on claims when services are provided on consecutive days.

In addition, the case manager should contact all providers who will bill for the same daily or monthly procedure over the same period to coordinate services.

Changes in the Status of a Member

1. The case manager informs providers and the county financial worker of any member status changes, such as the living arrangement, address, phone number, or incorrect birth date.
2. The county financial worker notifies the case manager of any changes in the member’s eligibility for Medical Assistance (Medicaid) or enrollment in managed care.
3. Providers and the lead agency notify one another when a member is hospitalized so that a provider can bill around the dates of hospitalization.
4. County financial worker and the lead agency notify one another when a member 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 service agreement line items.

Change in Member Need

Providers need to contact the case manager when a member’s needs change. The case manager is responsible for reassessing the member and amending the community support plan.

Changes may include the following:

1. Change of provider
2. Increasing or decreasing services
3. Addition of a new service
4. Other appropriate assessed needs

Waiver Services in an Institutional Setting

Waiver services are not covered during a hospital, nursing facility, or ICF/DD stay. Providers may bill PrimeWest Health for waiver services provided on the date of the admission and the date of discharge, if services were provided prior to the time of admission or after the time of discharge, except when

EW allows payment for respite care services provided in a hospital or long-term care facility utilizing respite care procedure codes. See Respite Service description.

Billing for Waiver Services for an Individual in an Institutional Setting

Waiver services are not covered for dates of service when a member is also receiving services in an inpatient hospital, nursing facility, or ICF/DD setting.

Providers may bill DHS for waiver services provided on the date of admission or the date of discharge from a hospital if they provided services before the time of admission or after the time of discharge with the appropriate 15-minute code. If the member had been previously approved for a procedure code that is a per diem or daily code, contact the case manager for authorization of the 15-minute code on the Service Authorization. If only a per diem code is entered, the claim will deny.

Exceptions

EW allows payment for respite care services provided in a hospital or long-term care facility using respite care procedure codes. See the Respite Service description.

It is important to bill for the dates on which services were provided:

1. Example: If a member was hospitalized from January 15 through January 25, bill January 1 through January 14 or 15 on line one of the claim and January 25 or 26 through January 31 on line two. In this example, if the entire month is billed, the claim will be denied.
2. If the service is a monthly service, and the member was absent in the middle of the month, enter one prorated unit for each span.
3. In addition, if the waiver claim is paid before the hospital or long-term care facility claim is submitted, DHS will automatically take back the waiver payment when the hospital or long-term care facility claim is processed. The provider will need to resubmit their claim.

Waiver Services in a Residential Setting

The following waiver services are covered in a residential setting:

1. CL
2. 24-Hour CL
3. Foster care

Waivers do not pay for room and board. Room and board may be covered by other sources such as the following:

1. The member’s income
2. Social Security Disability Insurance (SSDI)
3. General Assistance (GA)
4. Supplemental Security Income (SSI)

When the above sources do not cover the total cost of room and board, Housing Support Supplemental Services funding may be accessed up to the base rate. The county financial worker must determine all appropriate payment sources for room and board.

Billing and Absences from a Residential Setting

Definition

Days when a member is not receiving residential services are days a member is not in the residential setting.

Providers may not bill for full days on which members are absent from the residential service setting regardless of the reason for the absence. An overnight absence of more than 23 hours is a noncovered day. An absence of less than 23 hours on the first day is covered if the day does not overlap with a long-term care facility’s admission. After the first 23 hours, each time the clock passes midnight counts as another noncovered day. Pro-rate billing to reflect noncovered days during the month.

Examples of days absent:

Regardless of calculating absence, a residential service provider may not bill for dates of service that overlap with a long-term care facility admission date.

PrimeWest Health may only make payment for waiver services actually provided to an eligible person. This does not include leave days. The overhead expense of days when the person is away from a residence is accepted by CMS as part of a waiver provider’s cost of doing business. Overhead expenses may be factored into a provider’s rate.

This policy affects the following HCBS services:

1. Customized Living
2. Foster Care

The Centers for Medicare and Medicaid Services (CMS) policy states Medicaid will pay for services actually provided to an eligible member. For more information, review Reimbursement for Overhead Expenses due to Residential Absence.

Process and Procedure

Consider a variety of overhead expenses when the rate is established using the approved rate tools. A portion of the cost of absences may be considered an overhead expense. The authorized individual monthly limits and case mix caps for the individual still apply.

Monthly Rates

1. The EW Residential Services Tool (formerly known as the Customized Living Tool) has predictable absent days built into the tool formula
2. Using the monthly procedure code, enter the authorized service rate per month (unit) on the line item of the service agreement. If applicable, adjust the rate at the end according to the process outlined in the contract.
3. Claims for the previously mentioned community services cannot include periods that overlap with a period of hospital admission, nursing facility stay, or other periods defined as “residential absence days”.

Claims must include only one line item that represents the adjusted authorized monthly service rate as identified in the rate tool. Refer to the following:

1. The unit field must be one (1)
2. The period is a time span that does not overlap with any residential absence days
3. The Total Amount field is the total number of days in the setting for that month multiplied by the adjusted monthly rate
4. A notation on the claim form must identify the period of time, minus the residential absence days, that the claim represents

Reimbursement for Overhead Expenses Due to Residential Absence

Definition

Days when the member is not receiving residential services are days a member is not in the residential setting.

Examples of residential absence include days for the following:

1. Hospitalization
2. Therapeutic leaves
3. Crisis services
4. Any days away such as home visits and vacation days

The CMS policy states Medicaid payment is made for services actually provided to an eligible member.

Waiver Transportation Services

A waiver transportation service is not covered if the service is medical transportation under the State Medical Assistance (Medicaid) plan or it is a component of another waiver service.

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Updated_10/13/2023