The landscape of long-term care can be complex, especially when exploring options for elderly loved ones who wish to remain in their homes and communities. In Minnesota, two key programs, the Elderly Waiver (EW) and the Mn Alternative Care Program, offer crucial support for seniors. While both aim to provide home and community-based services (HCBS) as an alternative to nursing homes, they cater to different eligibility criteria and funding structures. This article delves into the specifics of the MN Alternative Care Program, outlining its purpose, eligibility requirements, covered services, and how it differs from the Elderly Waiver. Understanding these nuances is essential for families and caregivers seeking the best care solutions for seniors in Minnesota.
Understanding Minnesota’s Elderly Waiver (EW) and Alternative Care (AC) Programs
Minnesota offers two primary pathways to access home and community-based services for individuals aged 65 and older who require nursing home level care but prefer to live in a community setting: the Elderly Waiver (EW) program and the Alternative Care (AC) program, often referred to as the MN Alternative Care Program. These programs are designed to empower seniors to maintain their independence and quality of life by providing the necessary support and services within their own homes or community-based settings. The overarching goal is to delay or prevent the need for nursing facility care, promoting community living and honoring individual choices.
The Elderly Waiver (EW) program operates as a federal Medicaid waiver program. This means it is jointly funded by the federal government and the State of Minnesota. To be eligible for the EW program, individuals must meet several criteria:
- Be 65 years of age or older.
- Qualify for Medical Assistance (MA) in Minnesota.
- Require a level of care equivalent to that provided in a nursing home.
- Choose to reside in the community rather than a nursing facility.
Enrollment in the EW program opens access to a broader range of services beyond those typically covered by Medical Assistance. Importantly, individuals in the EW program can also receive standard MA services, often managed through a Managed Care Organization (MCO) such as Minnesota Senior Care Plus (MSC+) or Minnesota Senior Health Options (MSHO).
The Alternative Care (AC) program, the focus of this article as the MN Alternative Care Program, is a state-funded initiative. It serves as a vital support system for seniors who are not yet financially eligible for Medical Assistance but still require a nursing home level of care and have limited income and assets. The MN Alternative Care Program provides a more focused set of home and community-based services compared to the EW program. It acts as a crucial bridge, offering support to individuals who are nearing MA eligibility but need immediate assistance to remain in their homes.
Assessments for EW and AC Programs
The first step to accessing either the Elderly Waiver or the MN Alternative Care Program is to request an assessment. Anyone, whether for themselves or on behalf of another person, can initiate this process by contacting their local lead agency. These lead agencies are typically county, tribal, or in the case of EW, Managed Care Organizations. The lead agency plays a central role in determining program eligibility.
It’s important to note that while both programs serve similar populations, the application processes, financial eligibility requirements, and the specific services covered differ between the EW program and the MN Alternative Care Program. Understanding these distinctions is critical for navigating the application and service selection process effectively.
Eligibility for the MN Alternative Care Program
To be considered for the MN Alternative Care Program, applicants must meet specific service eligibility criteria that are common across HCBS programs in Minnesota. Detailed information regarding Medical Assistance and general eligibility for these programs can be found in the MHCP Provider Manual and the Programs and Services section of the Minnesota Department of Human Services website.
A key differentiator for the MN Alternative Care Program is its financial eligibility requirement. Unlike the Elderly Waiver, which requires MA eligibility, the AC program is designed for individuals who are not yet eligible for MA but are likely to become financially eligible within 135 days of entering a nursing facility. This “135-day rule” is a critical aspect of AC eligibility, demonstrating the program’s intent to support those with limited financial resources who are on the cusp of needing more comprehensive assistance through Medical Assistance. A case manager assesses this financial eligibility based on established criteria.
In summary, eligibility for the MN Alternative Care Program hinges on:
- Age 65 or older.
- Requiring a nursing home level of care.
- Not currently eligible for Medical Assistance.
- Projected to become financially eligible for MA within 135 days of nursing facility admission.
- Choosing to live in the community.
Roles and Responsibilities in the MN Alternative Care Program
The MN Alternative Care Program, like the Elderly Waiver, relies on a network of agencies and professionals to administer and deliver services effectively. Understanding these roles is vital for both individuals seeking services and providers aiming to participate in the program.
Lead Agencies: The Gateway to AC Services
Lead agencies are central to the administration of the MN Alternative Care Program. These agencies are responsible for determining financial eligibility for AC services and conducting asset assessments to evaluate financial qualifications. For the AC program, lead agencies are typically counties or tribal nations. These can be local public health agencies, human service agencies, or social service agencies within these jurisdictions.
The core responsibilities of lead agencies in the MN Alternative Care Program include:
- Long-Term Care Consultation (LTCC): Providing comprehensive assessments of an individual’s needs. This involves evaluating the applicant’s health status, functional abilities, and support requirements to determine the appropriate level of care and services.
- Application Assistance: Guiding individuals and their families through the application process for the MN Alternative Care Program. This can involve helping with paperwork, explaining requirements, and answering questions.
- Community Support Plan Development: Creating a personalized plan of care tailored to the individual’s assessed needs and preferences. This plan outlines the specific services and supports that will be provided through the MN Alternative Care Program.
- Program Access and Administration: Serving as the primary point of contact for individuals seeking to access HCBS services through the AC program. This includes providing information about the program, eligibility criteria, covered services, and application procedures.
- Case Management or Care Coordination: Assigning a case manager (often a public health nurse, registered nurse, or social worker) to each individual enrolled in the MN Alternative Care Program.
Case Management in the MN Alternative Care Program
Case management is a cornerstone of the MN Alternative Care Program. Once an individual is approved for AC, they are assigned a case manager or care coordinator. This professional acts as a central point of contact and support, playing a crucial role in:
- Access and Navigation: Assisting individuals in accessing and navigating the complex landscape of social, health, educational, and other community and natural supports and services.
- Informed Choice: Providing the necessary information and resources to empower individuals to make informed choices about their care and services. This aligns with the principle of self-determination and person-centered care.
- Service Coordination: Working with the individual and their chosen providers to coordinate the delivery of services outlined in the community support plan.
- Ongoing Monitoring: Regularly monitoring the provision of services to ensure they are effective, meeting the individual’s needs, and ensuring consumer satisfaction.
- Eligibility Review: Periodically reassessing the individual’s ongoing eligibility for the MN Alternative Care Program and adjusting the support plan as necessary to reflect changing needs.
- Service Authorization: Initiating and managing the service authorization process, which is required for providers to bill for AC services.
The case manager serves as an advocate for the individual, ensuring they receive the appropriate services and supports to live as independently and safely as possible in their community. They are responsible for ensuring that services are not only authorized but also effectively delivered and contribute to the individual’s overall well-being.
Notice of Action and Informed Choice
Lead agencies are legally obligated to provide individuals with formal notification before taking any action to deny, terminate, reduce, or suspend MN Alternative Care Program services. This “Notice of Action” must be provided in writing at least 10 days before the intended change. County and tribal lead agencies utilize specific forms, the Notice of Action (Assessments and Reassessments) (DHS-2828A) (PDF) and Notice of Action (Service Plan) (DHS-2828B) (PDF), for this purpose.
Furthermore, lead agencies are responsible for ensuring “Informed Choice.” This means providing individuals seeking MN Alternative Care Program services with comprehensive information about available services, eligibility requirements, and their options. This includes explaining the alternative of home and community-based supports when institutional care might be considered necessary. Information must be presented in an accessible format that the individual can understand, and individuals must be given a choice of service providers for all services offered under the MN Alternative Care Program.
Becoming an Eligible Provider for the MN Alternative Care Program
For organizations and individuals interested in providing services and receiving MHCP payment through the MN Alternative Care Program, enrollment with MHCP as a provider is mandatory. Providers must also meet specific standards and qualifications to participate. The detailed instructions for enrolling in MHCP to provide waiver or AC program services are available in the Home and Community-Based Services (HCBS) Programs Provider Enrollment section of the DHS website.
Providers must carefully determine which program services they are qualified to offer, as qualifications vary depending on the service type. Specific provider qualifications are outlined within each service description in the program manuals. The HCBS Programs Service Request Form (DHS-6638) (PDF) also provides a list of qualifications for various services.
Certain services within the MN Alternative Care Program may require providers to hold specific licenses from DHS or the Minnesota Department of Health (MDH), Medicare certification, or other forms of certification or registration. Prospective providers should consult with:
- The lead agency in the region where they intend to provide services.
- DHS Licensing at 651-431-6500.
- Minnesota Department of Health at 651-201-5000 for general information.
Services Covered by the MN Alternative Care Program
The MN Alternative Care Program offers a range of home and community-based services designed to support seniors in maintaining their independence and well-being outside of a nursing home setting. The specific services covered under the AC program are somewhat different from those available under the Elderly Waiver. For detailed policy information, including legal references, service descriptions, covered and non-covered services, and provider standards and qualifications for each service, refer to the Community Based Services Manual (CBSM).
The following table outlines the services typically covered by the MN Alternative Care Program:
| 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 2. · Caregiver counseling 3. · 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.
It is important to remember that these listed services and requirements represent minimum guidelines. Lead agencies have the authority to provide more specific details and interpretations based on individual needs and local resources. Always consult the Community-Based Services Manual (CBSM) for the most comprehensive and up-to-date information.
Home Health Services Specifically Under the MN Alternative Care Program
The MN Alternative Care Program uniquely includes specific home health services to support its participants. These services are distinct from the “Extended Home Care Services” primarily associated with the Elderly Waiver. The home health services available under the AC program are outlined below:
| Service and HCPCS | AC |
|---|---|
| Home Health Aide 2. · T1004 – 15 minutes | X |
| Home Health Aide Visit 2. · T1021 | X |
| LPN Regular 2. · T1003 – 15 minutes (LPN Regular) 3. · T1003 with modifier TT – 15 minutes (LPN Shared 1:2) | X |
| LPN Complex 2. · T1003 with modifiers TG – 15 minutes | X |
| PCA 2. · 1:1 – T1019 – 15 minutes 3. · 1:2 – T1019 with modifier TT with a “Y” in the Shared Care field of the SA – 15 minutes 4. · 1:3 – T1019 with modifier HQ with a “Y” in the Shared Care field of the SA – 15 minutes 5. · RN Supervision – T1019 UA – 15 minutes | X |
| RN Regular 2. · T1002 – 15 minutes 3. · 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 2. · T1002 with modifier TG – 15 minutes | X |
| Skilled Nurse Visit 2. · G0299 – Services of a skilled nurse (RN), Home Health 15 minutes 3. · G0300 – Services of a skilled nurse (LPN), Home Health 15 minutes 4. · T1030— Visit | X |
| Tele- Homecare 2. · T1030 with modifier GT | X |
These home health services are crucial for individuals in the MN Alternative Care Program who require skilled nursing care or assistance with personal care needs in their home setting.
Service Authorization for MN Alternative Care Program Services
A critical step in accessing MN Alternative Care Program services is obtaining service authorization (SA). This process ensures that services are appropriately approved and that providers can receive payment for the care they deliver. For both the AC and EW programs, a lead agency case manager or care coordinator is responsible for initiating and completing the service authorization.
For county and tribal nations operating on a fee-for-service (FFS) basis, service authorizations are initiated within the MMIS (Medicaid Management Information System). It is essential for providers to carefully review the Service Authorization Letter (SAL) upon receipt. If any discrepancies are found regarding rates, procedure codes, or service dates, the provider must promptly contact the case manager. The case manager bears the ultimate responsibility for ensuring the accuracy of the SA. When an SA line item is modified and approved, a revised SAL is automatically generated and sent to the provider’s MN–ITS mailbox, typically overnight.
Managed Care Organizations (MCOs) involved in the Elderly Waiver program have their own service authorization systems. Providers working with EW recipients enrolled in MCOs must contact the relevant MCO directly for specific instructions on obtaining authorizations and billing procedures. A directory of MCO contacts is available on the DHS website: Contact the MCOs.
It is crucial to understand that while a service authorization enables a provider to deliver services and bill DHS for payment, it does not guarantee claim payment. Several conditions must be met for a claim to be successfully paid:
- Active Provider Enrollment: Providers must be actively enrolled in MHCP and maintain up-to-date credentials.
- Ongoing Member Eligibility: The individual receiving services must maintain their MHCP eligibility throughout the service period for the authorization to remain valid.
- SA Accuracy Verification: Providers are responsible for verifying the accuracy of the SA upon receiving their Service Authorization Letter (SAL) in their MN–ITS mailbox.
Each line item on the Service Authorization details key information, including:
- The MHCP-enrolled provider authorized to deliver the service.
- The approved payment rate for the service.
- The number of service units authorized or the total approved amount.
- The authorized date or date range for service delivery.
- The approved procedure code(s) for billing.
- For EW, details of MA home care services (SNV, HHA, Home Care Nursing, PCA) that must be utilized before accessing EW extended services.
Service authorizations for both EW and AC programs specify units, duration, and rates. All authorized services must adhere to published case mix budget caps (maximum monthly rate limits) and state rate limits for services. Current long-term services and supports rate limits are published in the Long-Term Services and Supports Rate Limits (DHS-3945) (PDF) document.
Providers are also required to verify program eligibility for each member monthly. This verification can be done through the MHCP phone-based eligibility verification system (EVS) or online via MN–ITS. This step is essential to ensure that the individual remains eligible for the MN Alternative Care Program and that services are appropriately billed.
Provider Quick Reference for MN Alternative Care Program
To facilitate efficient service delivery and billing, the MN Alternative Care Program provides several quick reference points for providers.
Service Authorization Letters (SALs)
Case managers have the capability to generate additional copies of the provider service authorization letter (SAL) as needed. In some instances, case managers may choose to suppress the DHS-generated SAL and send their own customized letter to the member.
Providers registered with MN–ITS receive their SALs electronically in their MN–ITS mailboxes. These letters can be viewed, printed, saved, and are automatically purged after 30 days. The SAL file within MN–ITS contains authorization letters for Waiver programs, Alternative Care, and MA home care services. A separate Prior Authorization Letters (PAL) file exists for MA authorization letters.
Managing Service Authorization Changes
The case manager is solely responsible for initiating and managing any changes to a member’s Service Authorization. If a provider identifies inaccuracies in the rate, procedure code(s), or service dates on an SA, they must contact the case manager to request corrections. Should additional services become necessary, providers must communicate with the lead agency and obtain authorization before providing those additional services. When an SA line item is revised and approved, MMIS automatically generates a revised SAL, which is typically sent to the provider the following day.
Responding to Changes in Member Status
Effective communication is crucial when a member’s status changes. The case manager or care coordinator is responsible for informing providers and the lead agency financial worker of any relevant status changes, such as changes in living arrangements, address, phone number, or birth date corrections. Conversely, the lead agency financial worker notifies the case manager or care coordinator of any changes affecting the individual’s MA eligibility or MCO enrollment. Providers and lead agencies should also communicate with each other when a member is hospitalized to ensure accurate billing around hospitalization dates. Similarly, 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 to update living arrangements and make necessary adjustments to SA line items.
Addressing Changes in Member Needs
Providers play a vital role in identifying changes in a member’s needs. When a member’s needs evolve, providers are expected to contact the lead agency. The case manager/care coordinator is then responsible for reassessing the member’s situation and amending the community support plan accordingly. Changes in needs may encompass various scenarios, including:
- Change of provider.
- Increase or decrease in service frequency or duration.
- Addition of new services.
- Other newly identified assessed needs.
Transitioning Between MA Home Care and Waiver Services
The MN Alternative Care Program and Elderly Waiver program are often intertwined with MA home care services. Detailed information regarding transitions between MA home care and waiver services (and vice versa) can be found in the Home Care Services section of the DHS website. This resource is particularly relevant when individuals’ eligibility or service needs change, requiring adjustments between different funding streams.
Billing Considerations for the MN Alternative Care Program
Efficient billing practices are essential for providers participating in the MN Alternative Care Program. Coordination between providers and lead agencies is key to ensuring that members receive necessary services and that providers are compensated promptly for the services they render. Providers who have contracts with MCOs for service delivery should obtain specific billing instructions directly from the MCO.
For billing fee-for-service (FFS) MN Alternative Care Program and Elderly Waiver services, providers should consult the Billing for Waiver and Alternative Care (AC) Program section. For extended home care services authorized under the Elderly Waiver, claims should be submitted using the 837I Institutional Outpatient transaction (via MN–ITS), adhering to home care billing guidelines. Again, providers working with MCOs for EW services should contact the MCO for specific billing procedures.
Authorized vs. Non-Authorized Services in Billing
It is critical to avoid billing for services requiring a service authorization on the same claim as services that do not require authorization. For instance, for individuals eligible for MA, home care therapy services (physical, occupational, respiratory, and speech therapy) do not necessitate an SA and should not be billed on the same claim as waiver services like adult day services. Maintaining separate claims for authorized and non-authorized services is essential for proper claim processing and payment.
Payment Rates for AC Services
Lead agencies are responsible for authorizing both service and provider payment rates within the MN Alternative Care Program. DHS establishes rate limits for both AC and EW services, publishing these limits in the Long-Term Services and Supports Service Rate Limits (DHS-3945-ENG) (PDF) document. Service rates authorized and claimed cannot exceed these established limits.
Most services under the MN Alternative Care Program are authorized and paid at a state-established rate, which corresponds to the rate limit published by DHS. However, some services may be authorized and paid at a market rate, up to the state-established limit, based on the typical price for similar services in the community market. EW residential services (customized living and adult foster care) utilize a daily rate determined by the Residential Services Tool (RS Tool) completed by lead agencies.
More detailed information about payment rate methodologies for AC, ECS, and EW service authorization is available on the Rate methodologies for AC, ECS and EW service authorization web page in the CBSM. Providers should also regularly review the long-term services and supports rates changes web page for the most current updates on rate limit changes.
Elderly Waiver Customized Living Services Rate Adjustment
A specific rate adjustment exists for customized living services within the Elderly Waiver program, particularly for facilities designated as disproportionate share facilities. This adjustment, approved by the Minnesota Legislature, aims to provide a minimum daily rate for eligible facilities. The eligibility criteria for this rate adjustment are quite specific, focusing on facilities that:
- Were approved for the disproportionate share rate adjustment in application year 2023 and are receiving payments in 2024.
- Have at least 83.5% of residents who are customized living residents using EW, BI, or CADI waivers.
- Have at least 70% of those customized living residents using the EW waiver.
The Legislature-approved minimum daily rate adjustment for calendar year 2025 is $141. Qualified facilities receive adjustments up to this minimum daily rate for claims related to individuals using EW and receiving 24-hour customized living services from January 1, 2025, to December 31, 2025. This adjustment does not apply to claims for residents using Brain Injury (BI) or Community Access for Disability Inclusion (CADI) waivers. The minimum daily rate is adjusted annually, and historical rates are available in the original document.
Eligible facilities can apply for this adjustment using the Disproportionate Share Facility Application, DHS-8157 (PDF) between September 1st and September 30th, 2024. Facilities must submit a separate application for each licensed assisted living facility or building with a unique street address (for exempt providers). DHS may request census lists to verify resident numbers during the application review process. Designation of eligible facilities occurs by October 15th, with rate adjustments taking effect from January 1st to December 31st of the following year. Lead agencies can find further information in the Customized living (including 24-hour customized living) section of the CBSM or by contacting [email protected].
Elderly Waiver Obligation and MA Spenddown
Eligibility for the Elderly Waiver program is also tied to income limits, with two distinct scenarios:
- Income ≤ Special Income Standard (SIS): Individuals with incomes at or below the Special Income Standard (SIS) are eligible for EW without an MA spenddown. However, they have a “waiver obligation,” meaning they must contribute any income exceeding the maintenance needs allowance and other applicable deductions towards the cost of EW services.
- Income > SIS: Individuals with incomes exceeding the SIS may still qualify for EW but will have an MA spenddown. The lead agency’s financial assistance unit determines the financial obligation (waiver obligation or spenddown) of the EW member and provides notification.
The waiver obligation is deducted from the cost of EW services, and the full amount does not need to be met each month. It represents the member’s responsibility to pay towards the services they utilized in a given month. In contrast, an MA spenddown must be met each month and can be satisfied through any combination of MA services, including HCBS. The lead agency financial worker enters the waiver obligation or MA spenddown into MMIS, and DHS reports the billable amount to the provider on the remittance advice. Claims reduced due to EW obligation or spenddown will show claim adjustment reason code PR 142 on the remittance advice. MCOs also receive reports on enrollees with waiver obligations and spenddowns and have their own processes for informing providers. More details on SIS are available in Appendix F of the MHCP Eligibility Policy Manual.
Members enrolled in MHCP can designate a provider to whom they will pay their obligation, by notifying their financial worker. However, this designated provider option is not available to members receiving waiver services through an MCO.
Home Care Services for MA-Eligible Members Receiving EW Services
A fundamental principle of the Elderly Waiver program is that individuals must first utilize all available MA home care services before accessing EW-funded services. MA covers a comprehensive range of home care services, including:
- 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 the EW Waiver
Minnesota Senior Care Plus (MSC+) and Minnesota Senior Health Options (MSHO) are the managed care products that serve members on the Elderly Waiver. For EW members enrolled in an MCO, the MCO manages both state plan home care and waiver services. For fee-for-service (FFS) EW members, state plan home care is also FFS. In managed care scenarios, the designated care coordinator is responsible for approving and providing all home care and EW services, while for FFS EW, the county or tribal case manager handles these responsibilities.
Home Care and the AC Program
In contrast to the Elderly Waiver, the MN Alternative Care Program does not have an MA benefit component. The lead agency case manager determines and authorizes the amount of home care services that are counted towards the member’s case mix budget within the AC program.
Legal and Regulatory References for MN Alternative Care Program
The MN Alternative Care Program and related services operate within a framework of Minnesota Statutes and Rules, as well as relevant federal regulations. Key legal references include:
- Minnesota Statutes, 245A (Human Services Licensing)
- Minnesota Statutes, 256B.0913 (Alternative Care Program)
- Minnesota Statutes, 256S (Medical Assistance Elderly Waiver)
- Minnesota Rules, 9555.5050 – 9555.6265 (Adult Foster Care Services and Licensure)
- Minnesota Rules, 4668 (Home Care Licensure)
- Code of Federal Regulations, title 42, part 441, subpart G, 441.310(a)(2)(ii) (Limits on Federal Financial Participation [FFP])
This list is not exhaustive, and a comprehensive understanding of the legal basis for these programs requires consultation with the full text of these statutes and rules. The original document provides a more extensive list of legal references for further research.
Conclusion: The MN Alternative Care Program as a Vital Resource
The MN Alternative Care Program serves as a critical resource within Minnesota’s long-term care system. It provides essential home and community-based services to seniors who require a nursing home level of care but are not yet eligible for Medical Assistance. By offering a targeted set of services and supports, the AC program empowers seniors to remain in their homes and communities, promoting independence and delaying or preventing the need for nursing facility placement.
Understanding the eligibility criteria, covered services, administrative processes, and the distinctions between the MN Alternative Care Program and the Elderly Waiver is crucial for seniors, families, caregivers, and healthcare providers in Minnesota. This comprehensive guide aims to clarify these aspects, providing valuable information for navigating the landscape of long-term care and accessing the support needed to ensure the well-being of elderly individuals in Minnesota. For the most detailed and up-to-date information, always refer to the official resources provided by the Minnesota Department of Human Services and consult with local lead agencies.
