Understanding the Alternative Care Program in Minnesota: A Comprehensive Guide

Overview

The Elderly Waiver (EW) and Alternative Care (AC) programs in Minnesota are dedicated to providing crucial home and community-based services (HCBS) for seniors aged 65 and older. These programs are designed for individuals who necessitate the level of care typically provided in a nursing home but prefer to reside within their communities. By offering comprehensive services and support, EW and AC programs aim to empower seniors to live in their own homes or community settings, effectively delaying or even preventing the need for nursing facility (NF) care. The overarching goal of these programs is to champion community living and foster independence, ensuring that services and supports are meticulously tailored to meet each person’s unique needs and preferences. Notably, the Elderly Waiver (EW) program extends beyond the standard services available through Medical Assistance (MA), offering an enhanced level of support.

• The Elderly Waiver (EW) program stands as a federal Medicaid waiver program, specifically funding home and community-based services for individuals 65 years and older. Eligibility for EW requires Medical Assistance (MA) qualification, a demonstrated need for nursing home level care, and a desire to live within the community. Participants in the EW program can access both waiver services and MA services, often coordinated through a managed care organization (MCO) such as Minnesota Senior Care Plus (MSC+) or Minnesota Senior Health Options (MSHO).

• The Alternative Care (AC) program, a state-funded initiative, provides essential home and community-based services to seniors aged 65 and older who may not meet the strict financial eligibility criteria for MA. However, to qualify for AC, individuals must fulfill specific financial and service eligibility requirements and require a level of care comparable to that of a nursing home. The Alternative Care program is particularly designed for those with limited income and assets who are nearing MA eligibility but have not yet fully qualified. This program acts as a vital safety net, ensuring access to necessary care for seniors in Minnesota.

Assessments

Initiating the process for either the Elderly Waiver or Alternative Care program begins with an assessment. Anyone, whether it’s an individual seeking assistance for themselves or on behalf of another person, can request an assessment. This can be done by simply contacting the local lead agency, which will be explained in detail in the subsequent “Lead Agency” section. The primary role of the lead agency is to determine program eligibility. It’s important to note that the EW and AC programs have distinct application processes, financial eligibility criteria, and ranges of covered services. Understanding these differences is crucial for navigating the application and eligibility determination process.

Eligible Members

To be considered eligible for either the Elderly Waiver (EW) or Alternative Care (AC) program, all applicants must rigorously meet the service eligibility criteria specific to the Home and Community-Based Services (HCBS) program they are applying for. For a comprehensive understanding of Medical Assistance (MA) and its eligibility requirements, it’s recommended to consult the MHCP Provider Manual and the Programs and Services section. These resources provide detailed information to help applicants understand the prerequisites for program enrollment.

• For Elderly Waiver (EW) services, a fundamental eligibility requirement is that applicants must also be eligible for Medical Assistance (MA). This dual eligibility ensures that the EW program serves individuals who have established financial need and meet the broader criteria for state and federal assistance programs.

• In contrast, Alternative Care (AC) program eligibility has a slightly different financial consideration. Applicants for AC must demonstrate that they would become financially eligible for MA within 135 days of entering a nursing facility. This determination is made by a case manager and is designed to capture individuals who are on the cusp of MA eligibility but require immediate assistance to avoid or delay nursing facility placement. The Alternative Care program thus serves as a crucial bridge for seniors with emerging financial needs.

Roles

Lead Agency

Lead agencies are pivotal in the administration of both the Elderly Waiver (EW) and Alternative Care (AC) programs. These agencies, staffed with human services eligibility workers, are responsible for determining financial eligibility for Elderly Waiver services. Furthermore, lead agency staff play a crucial role in conducting asset assessments, a necessary step in evaluating financial eligibility for both the AC and EW programs.

For the EW program, lead agencies can encompass a variety of entities, including counties, tribal nations, or Managed Care Organizations (MCOs), also known as health plans. The scope for AC program lead agencies is slightly narrower, limited to counties or tribal nations. A lead agency may operate as a local public health agency, human service agency, or social service agency, depending on the community structure. The comprehensive responsibilities of lead agencies include:

Long-Term Care Consultation: A primary function of lead agencies is to provide Long-Term Care Consultation (LTCC) services. These services are essential in guiding individuals through the complexities of long-term care options and include:

• Conducting a comprehensive assessment of the needs of the MHCP member to fully understand their health and support requirements.
• Providing hands-on assistance with the application process for both the EW and AC programs, making it easier for applicants to navigate administrative hurdles.
• Developing a personalized community support plan that outlines the services and resources tailored to meet the individual’s assessed needs and goals.

Case Management: Once an individual is approved for either the EW or AC program, they are assigned a dedicated case manager or care coordinator. This professional is typically a public health nurse, registered nurse, or social worker. The case manager or care coordinator serves as a central point of contact and plays a critical role in:

• Assisting with access to social, health, educational, and other community and natural supports and services, ensuring individuals can tap into all available resources.
• Navigating the often complex landscape of healthcare and social services, making it easier for individuals to receive the care they need.
• Providing essential information to empower individuals to make informed choices about their care, aligning services with their values, strengths, goals, and needs.

For a complete and detailed description of case management responsibilities and best practices, refer to the Community-Based Services Manual (CBSM).

Program Access and Administration: Lead agencies are also entrusted with the broader responsibilities of program access and administration. This encompasses a wide range of duties aimed at ensuring the smooth operation of the EW and AC programs and effective service delivery:

• Working collaboratively with the Department of Human Services (DHS) and other relevant organizations to disseminate information, provide services, and offer assistance to individuals seeking access to HCBS services.
• Providing direct case management or care coordination services, which include a spectrum of activities:
  • Assessing program eligibility to ensure applicants meet the necessary criteria.
  • Developing and implementing individualized support plans tailored to each participant’s needs.
  • Helping individuals access, coordinate, and evaluate the services available to them, ensuring a seamless care experience.
  • Informing people about the option to self-direct their own services, empowering them to take greater control over their care.
  • Generating additional copies of provider service authorization (SA) letters when needed, ensuring clear communication and documentation.
  • Inputting critical member enrollment data, such as screening documents, and service authorization details into the DHS Medicaid Management Information System (MMIS), maintaining accurate records.
  • Authorizing and diligently monitoring services to reasonably assure the health and safety of program participants.
  • Continuously monitoring the provision of individual services for efficiency, consumer satisfaction, and ongoing eligibility, making necessary adjustments to service provisions as circumstances change.
  • Overseeing the performance and quality of service providers to maintain high standards of care.
  • Verifying that all providers meet state standards relevant to their service area, have signed provider agreements with DHS, and fulfill provider qualifications, especially when the lead agency itself is a service provider.
  • Ensuring that all providers adhere to DHS requirements if they choose to review and approve non-enrolled providers as qualified to deliver EW and AC services, as detailed in CBSM –Lead agency oversight of waiver/AC approval-option service vendors.
  • Authorizing funds for all HCBS services provided to individuals eligible for enrollment in MHCP, ensuring financial resources are appropriately allocated.

Notice of Action: Adhering to legal requirements, the lead agency or state is mandated to provide formal notification to the MHCP member before any adverse actions are taken. This includes situations where services are denied, terminated, reduced, or suspended. The lead agency or state must issue a written notice at least 10 days in advance of such actions. Specifically:

• Lead agencies, including counties and tribal nations, are required to use the Notice of Action (Assessments and Reassessments) (DHS-2828A) (PDF) and Notice of Action (Service Plan) (DHS-2828B) (PDF) forms to officially inform individuals of impending changes to their waiver services.
• Managed Care Organizations (MCOs), on the other hand, utilize their own forms and established processes for providing notice of action.

Informed Choice: Promoting autonomy and person-centered care, lead agencies are responsible for ensuring individuals have the necessary information to make informed decisions about their care:

• Providing individuals seeking EW or AC services with comprehensive information about all eligible services, empowering them to make informed choices.
• Informing both the individual and their legal representative if the individual is likely to require institutional care, such as in a hospital or nursing home, while presenting home and community-based supports as a viable and often preferable alternative.
• Taking proactive and reasonable steps to present information in a format that is easily understandable to the individual, and offering a choice of service providers for all services, thereby enhancing person-centered care.

Lead Agency Case Managers

Lead agency case managers have a focused role in the financial aspects of the Alternative Care program. Specifically, they are responsible for determining financial eligibility for payment of Alternative Care services. This financial assessment is a critical step in ensuring that individuals who qualify for the AC program can access the necessary services and supports.

Eligible Providers

Providers who are interested in offering services and receiving MHCP payment for both Elderly Waiver (EW) and Alternative Care (AC) waiver programs must formally enroll with MHCP and fulfill specific standards. To initiate the enrollment process with MHCP for providing waiver or AC program services, it’s essential to follow the detailed instructions provided in the Home and Community-Based Services (HCBS) Programs Provider Enrollment section. This section offers a step-by-step guide for prospective providers.

Furthermore, providers must carefully determine which specific program services they are qualified to deliver. Detailed provider qualifications can be found within this manual, specifically in each service description section. The HCBS Programs Service Request Form (DHS-6638) (PDF) also provides a comprehensive list of qualifications for various services.

It is important to note that some waiver services have additional requirements, which may include one or more of the following:

• License(s) from DHS or the Minnesota Department of Health (MDH), ensuring that providers meet regulatory standards for operation and service delivery.
• Medicare certification, which may be required for certain healthcare-related services.
• Other specific certifications or registrations, depending on the nature of the services offered.

For more detailed information regarding provider eligibility and qualifications, it is recommended to reach out to the following resources:

• The lead agency in the specific area where services will be provided. Lead agencies can offer localized guidance and information on provider requirements.
• DHS Licensing at 651-431-6500. DHS Licensing can provide comprehensive information on state licensing requirements for human services providers.
• Minnesota Department of Health at 651-201-5000 for general health-related information and potential certification requirements.

Covered Services

To explore the comprehensive list of services covered under the Elderly Waiver (EW) and Alternative Care (AC) programs, please refer to the following table. For each service listed, you can click on the provided link to access the Community Based Services Manual (CBSM) policy page. Each policy page offers detailed information, including legal references, service descriptions, specifics on covered and non-covered aspects (where applicable), and provider standards and qualifications. For services that do not have a direct link to the CBSM, you will find service descriptions, billing codes, and provider standards 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