Understanding the Recuperative Care Program: A Comprehensive Guide

Overview of Recuperative Care Services

Recuperative care services offer crucial support for eligible members of Minnesota Health Care Programs (MHCP) who are experiencing homelessness. These programs are designed to be a vital intervention, preventing unnecessary hospital admissions and providing essential medical care and support for individuals who are unable to recover from illness while living in shelters or without stable housing. Recuperative care bridges a critical gap for MHCP members who require medical attention but do not necessitate hospitalization or more intensive levels of care.

To access recuperative care services, MHCP members need a referral from a hospital or clinic, ensuring that individuals are appropriately directed to this beneficial program.

Eligible Providers: Becoming a Recuperative Care Facility

For facilities to become eligible recuperative care providers, they must officially enroll with MHCP. Detailed enrollment information, including specific criteria and necessary forms, can be found in the Recuperative Care Enrollment Criteria and Forms section of the MHCP Provider Manual, under Provider Basics. Each location intending to offer recuperative care must be registered as a recuperative care facility.

Recuperative Care Facility Service Requirements:

Recuperative care can be delivered in various settings, such as homeless shelters, group living environments, single-room occupancy buildings, or supportive housing. However, to qualify, these facilities must guarantee MHCP members the following provisions within their designated setting:

24/7 Bathroom Access: Unrestricted access to a bathroom that includes a shower, sink, and toilet. Bathroom facilities may be shared among residents.
24/7 Bed Access: Continuous access to a bed to ensure rest and recovery.
Single Occupancy Rooms (Recommended): While not mandatory, single-occupancy rooms are highly recommended to enhance privacy, security, and infection control.
Three Daily Meals: Provision of three meals each day, tailored to meet the member’s dietary needs. These meals are included in the per diem rate.
Environmental Services: Regular cleaning and sanitation services to maintain a healthy environment.
Telephone Access: Access to a telephone for communication needs.
Secure Belongings Storage: A safe and secure space for members to store their personal belongings.
On-site Staff and Wellness Checks: Facility staff must be available on-site 24 hours a day to conduct in-person wellness checks as needed, with a minimum of once every 24 hours.
Staffing Assurance: At least one staff member must be present at the facility at all times, 24/7.
Regular Member Checks: Members must be checked on, preferably through in-person visits, at least once every 24 hours to monitor their well-being.
Staff Identification: Staff members responsible for conducting wellness checks must be clearly identified on the Recuperative Care Provider Assurance Statement (DHS-8486) (PDF).
Wellness Check Reimbursement: Reimbursement for wellness checks is incorporated into the room and board charge; providers are not separately reimbursed for these checks.

Eligible Providers: Health Services and Supervision

Advanced Practice Provider Supervision for Recuperative Care Health Services:

All recuperative care health services must be overseen by an advanced practice provider who is enrolled with MHCP. The following professionals are qualified to supervise recuperative care health services:

Advanced Practice Registered Nurses (APRNs), including Nurse Practitioners (NPs) and Clinical Nurse Specialists (CNSs)
Physicians (Medical Doctor – MD, Doctor of Osteopathic Medicine – DO)
Physician Assistants (PAs)

Qualified Professionals Providing Recuperative Care Health Services:

The following licensed healthcare professionals are authorized to deliver recuperative care health services within a facility that meets the specified recuperative care facility requirements:

Registered Nurses (RNs)
Licensed Practical Nurses (LPNs)
Social Workers (SWs)
Case Managers (RN or SW)
Mental Health Counselors
Community Health Workers
- For Community Health Worker enrollment details, refer to the Community Health Worker Enrollment Criteria and Forms.
- Community health workers are defined under Minnesota Statutes, 256B.0625, subdivision 49.

Alternatively, if a recuperative care facility partners with a licensed health services group provider that is enrolled with MHCP, the health services should be provided by the caregiving team listed on the Recuperative Care Provider Assurance Statement (DHS-8486) (PDF). These providers may be affiliated with home care or public health service groups collaborating with the recuperative care facility to deliver health services. Affiliated health service groups will have a designated advanced practice provider for supervision.

It’s important to note that RNs, LPNs, social workers, and case managers do not need to enroll separately with MHCP to provide recuperative care services when working under an eligible provider or within a partnering health service group.

Eligible Members: Who Can Receive Recuperative Care?

To be eligible for recuperative care services under MHCP, a member must satisfy all of the following criteria:

Age Requirement: Be 21 years of age or older if enrolled in Medical Assistance, or 19 years of age or older if enrolled in MinnesotaCare.
Homelessness Status: Be currently experiencing homelessness or be unhoused.
Short-Term Medical Need: Require short-term medical care expected to last fewer than 60 days.
Need for Covered Services: Require assistance with one or more of the covered services provided under recuperative care.

Covered Services: What Recuperative Care Programs Offer

Facilities and providers must ensure they only deliver services that fall within their professional scope of practice. Providers can begin offering recuperative care services only after their MHCP enrollment is officially approved.

MHCP covers an array of recuperative care services, including:

Basic Nursing Care: Monitoring vital signs, physical health status, and pain levels.
Wound Care Management: Providing treatment and care for wounds.
Medication Support: Assisting with medication management and adherence.
Patient Education: Educating members about their health conditions and self-care.
Immunization Review and Updates: Reviewing immunization history and providing necessary updates.
Clinical Goal Setting and Discharge Planning: Developing clinical goals for the recuperative period and creating a comprehensive discharge plan.
Care Coordination: Initial assessments of medical, behavioral, and social needs, along with ongoing care coordination.
Care Plan Development: Creating individualized care plans tailored to each member’s needs.
Legal, Housing, and Social Service Support: Providing support and referral assistance for legal issues, housing solutions, transportation, case management, and community social services.
Healthcare and Benefit Assistance: Support and referral assistance for accessing healthcare benefits, health-related programs, and other eligible benefits.
Care Plan Implementation and Monitoring: Following up on care plan implementation and continuous monitoring of progress.
Medical, Social, and Behavioral Health Services: Delivering medical, social, and behavioral health services (including counseling and peer support) that are appropriate for the recuperative care setting.
Community Health Worker Services: Access to community health worker services as defined by Minnesota Statutes, 256B.0625, subdivision 49.

Important Note: Recuperative care services must primarily address the member’s physical medical condition. Daily room and board claims may be denied if care is not focused on the physical health condition requiring recuperative care. The recuperative facility’s primary focus cannot be on a single covered service, such as mental health services alone.

Noncovered Services: Limitations of Recuperative Care

Certain situations and needs are beyond the scope of recuperative care services. Noncovered services include instances where:

Behavioral Health Needs Exceed Setting Capacity: A member’s behavioral health needs are too complex or intensive for the provider within the recuperative care setting to manage effectively.
Lack of Independence in Daily Living: A member is not functionally independent in performing activities of daily living (ADLs). For example, recuperative care is not designed for individuals who are unable to stand or use bathroom facilities independently.

Authorization for Extended Stays and Readmissions

Recuperative Care Extended Stay Authorization:

In situations where a member requires recuperative care services beyond the standard 21-day limit, providers can request an extension. To do so, providers must complete and submit the Recuperative Care: Extended Stay Request (DHS-8513) (PDF) form, along with necessary medical documentation, to the medical reviewer. For guidance on submitting prior authorization requests, refer to the Authorization section under Provider Basics in the MHCP Provider Manual. It is important to note that extended stays are generally not expected to exceed 60 days.

Readmission Policies:

Consecutive readmissions for the same diagnosis will continue under the original 21-day limit. If a member approaches the 21-day limit and requires continued care, providers must submit the Recuperative Care: Extended Stay Request (DHS-8513) (PDF) with medical information to ensure uninterrupted payment. However, a readmission for a new, unrelated diagnosis will initiate a new 21-day coverage period.

Discharge from Recuperative Care Services:

Prior to discharging a member from recuperative care services, providers must ensure one of the following conditions is met:

Medical Condition Improvement: The member’s medical condition has demonstrably improved to a point where recuperative care is no longer necessary.
Discharge to Appropriate Setting: The member is being discharged to another setting that is equipped to meet their ongoing needs, whether it be further medical care or stable housing.

Note: Members have the right to choose discharge even if they do not have a housing option secured at the time of discharge.

Billing for Recuperative Care Services

Recuperative care providers are eligible for reimbursement through both a recuperative care health services rate and a recuperative care facility rate. Providers can only bill for services rendered after their MHCP enrollment has been officially approved.

For detailed definitions and current payment rates, please consult the relevant MHCP resources.

Recuperative Care Health Services Rate:

The recuperative care health services rate is a bundled per diem payment, currently set at $300.00 per day. This bundled payment covers all covered services provided to the member during their recuperative care period.

Note: For members with both Medicare and Medical Assistance coverage, billing should be directed to MHCP, as Medicare does not cover the recuperative care health services bundled payment.

Recuperative Care Health Services Claim (Professional Claim):

Claims must be submitted using the 837P claim format. Refer to the MN–ITS 837P Professional User Guides for detailed instructions.
Use CPT code T2033 to bill for the recuperative care bundled payment.
Include all relevant CPT or HCPCS codes for services provided on the same date of service (DOS) and claim, each with a $0.00 charge. These line items will be processed as zero pay, but provide detailed service information.
Report the NPI of the enrolled MHCP MD, PA, or APRN who is supervising the health services as the rendering provider. This supervising provider must be identified on the Recuperative Care – Health Services Provider Acknowledgment (DHS-8562).
Facility Affiliation with Advanced Practice Professional: If the recuperative care facility is affiliated with an advanced practice professional, the facility can bill for the recuperative care health services claim (professional claim) and should report their affiliated MHCP-enrolled advanced practice provider as the rendering provider on the claim.
Facility Affiliation with Health Services Group Provider: If the facility partners with a health services group provider, the health services group provider will bill for the recuperative care health services (professional claim). The health service group should report their supervising MHCP-enrolled advanced practice provider on the claim as the rendering provider. In this scenario, the recuperative care facility cannot bill for the health services rate as they did not directly provide the service.
Homelessness Diagnosis Code: Claims must include one of the ICD-10 diagnosis codes specifically indicating homelessness. It is the provider’s responsibility to select the appropriate diagnosis code that accurately reflects the service provided.

Recuperative Care Facility Rate:

The recuperative care facility rate, which covers room and board, is approximately $34.00 per day.

Recuperative Care Facility Claim:

Facility claims should be submitted using the 86X Residential Facility claim format. Refer to the MN–ITS 837I Institutional User Guides for guidance.
Facility claims must include one of the ICD-10 diagnosis codes for homelessness and condition code 17. Providers are responsible for determining the correct diagnosis code for the services rendered.

Note: The recuperative care health services (professional) claim must be submitted and processed by MHCP before a recuperative care facility claim can be submitted. Reimbursement for the facility rate is contingent upon the prior reimbursement of the health services rate. Providers have the option to only seek reimbursement for the health services rate. The standard eligibility criteria outlined in chapter 256I do not apply to the recuperative care facility rate.

Documentation Requirements:

Providers are required to maintain comprehensive health records for each member receiving recuperative care. Refer to Minnesota Rules, 9505.2175 for detailed information regarding health service records documentation standards.

Managed Care Considerations for Recuperative Care

Managed Care Organization (MCO) Enrollees:

If a member is enrolled in a Managed Care Organization (MCO), the recuperative care health services claim must be submitted directly to the member’s MCO. Recuperative care providers are required to contact the specific MCO for enrollment requirements, billing protocols, and coverage policies applicable to MCO enrollees. For provider inquiries regarding coverage or contract issues with MCOs, contact the MCO directly.

Carve-Out Service for Facility Rate:

The recuperative care facility rate (covering room and board) is designated as a carve-out service. Claims for recuperative care facility services are processed through MHCP fee-for-service and should be billed directly to MHCP. Payment will be issued from state funds at a rate equivalent to the medical assistance room and board rate in effect at the time the recuperative care services were provided.

Legal References for Recuperative Care Programs

Minnesota Statutes, 256B.0701 (Recuperative Care Services) provides the legal framework and statutory basis for recuperative care services within Minnesota.