The Alternative Care (AC) program in Minnesota offers a vital lifeline for seniors aged 65 and older who require the level of care typically provided in a nursing home but prefer to live independently in their homes or within a community setting. This state-funded initiative, alongside the Elderly Waiver (EW) program, is designed to promote community living and independence, ensuring that elderly individuals receive the necessary services and support tailored to their unique needs and preferences. Both the AC and EW programs aim to delay or even prevent the need for nursing facility care by providing comprehensive home and community-based services (HCBS). While the EW program, a federal Medicaid waiver program, offers more extensive services and is available to those eligible for Medical Assistance (MA), the AC program serves as a critical support system for individuals who are not yet MA eligible but have limited financial resources.
Who is Eligible for the Alternative Care Program in MN?
Eligibility for the Alternative Care program hinges on meeting specific service and financial criteria. While both the EW and AC programs target individuals requiring a nursing home level of care, their eligibility requirements differ, particularly in financial aspects.
To be eligible for the Alternative Care program, applicants must:
- Be aged 65 years or older.
- Require a level of care comparable to that provided in a nursing home.
- Not be financially eligible for Medical Assistance (MA) at the time of application. However, crucially, applicants must be likely to become financially eligible for MA within 135 days of entering a nursing facility, as determined by a case manager assessment. This provision acknowledges that individuals may have low income and assets but might not yet meet all MA eligibility criteria.
For those who meet MA eligibility, the Elderly Waiver (EW) program becomes the relevant pathway to access home and community-based services. It’s important to note that eligibility determination involves a comprehensive assessment conducted by the local lead agency, which evaluates both service needs and financial status.
Key Roles in the Alternative Care Program
Navigating the Alternative Care program involves several key players, each with specific responsibilities to ensure eligible individuals receive the support they need.
Lead Agencies: Your Primary Point of Contact
Lead agencies are the cornerstone of both the EW and AC programs. In the context of the Alternative Care program, these are typically county or tribal human service agencies. They serve as the initial and ongoing point of contact for individuals seeking to access these services. The responsibilities of lead agencies are multifaceted and include:
- Long-Term Care Consultation (LTCC): This is a crucial initial step. The lead agency provides LTCC services, which encompass:
- Comprehensive Needs Assessment: A thorough evaluation of the applicant’s health, functional, and social needs to determine the appropriate level of care and support.
- Application Assistance: Guidance and support through the application process for the Alternative Care program.
- Community Support Plan Development: Creation of a personalized plan outlining the services and supports required to meet the individual’s needs while living in the community.
- Program Access and Administration: Lead agencies are responsible for making the AC program accessible and administering it effectively. This includes:
- Information and Assistance: Providing information about HCBS services, including the Alternative Care program, to those who inquire.
- Case Management or Care Coordination: Assigning a case manager (often a public health nurse, registered nurse, or social worker) to each approved individual.
- Eligibility Assessment: Determining both service and financial eligibility for the AC program.
- Support Plan Development and Implementation: Creating, coordinating, and overseeing the implementation of the individual’s community support plan.
- Service Coordination: Assisting individuals in accessing, coordinating, and evaluating the services outlined in their support plan.
- Informed Choice Guidance: Informing individuals about their service options, including the possibility of self-directing some services, and helping them make informed decisions.
- Service Authorization (SA) Management: Generating and managing service authorization letters, which permit providers to deliver and bill for services.
- Service Monitoring: Continuously monitoring the services provided to ensure they are efficient, meet the individual’s needs and satisfaction, and continue to be appropriate.
- Provider Oversight: Ensuring that all service providers meet state standards, have agreements with the Department of Human Services (DHS), and maintain required qualifications.
- Authorizing Funds: Approving and authorizing the funds for all HCBS services delivered under the AC program.
- Notice of Action: Lead agencies are legally required to provide written notice at least 10 days before taking actions such as denying, terminating, reducing, or suspending services. This ensures due process and allows individuals to understand and respond to such decisions.
- Informed Choice Facilitation: Lead agencies are responsible for ensuring individuals receive all necessary information to make informed choices about available services. This includes information about institutional care alternatives and the range of home and community-based support options. They must present this information in an accessible format and offer a choice of service providers.
Lead Agency Case Managers: Your Dedicated Support
Within the lead agency structure, case managers play a pivotal role. Specifically for the Alternative Care program, lead agency case managers are responsible for:
- Financial Eligibility Determination: Case managers are tasked with assessing and determining financial eligibility for the Alternative Care program. This involves evaluating the applicant’s income and assets against AC program criteria.
- Ongoing Case Management: Beyond initial eligibility, case managers provide ongoing support, monitoring, and adjustments to the individual’s care plan as needs evolve. They serve as the primary contact for coordinating services and addressing any challenges that may arise.
Who Provides Alternative Care Services? Eligible Providers
Providers delivering services under the Alternative Care program must meet specific qualifications and enrollment requirements to receive payment through Minnesota Health Care Programs (MHCP). To become an eligible provider, organizations or individuals must:
- Enroll with MHCP: Providers must formally enroll with MHCP, following the guidelines outlined in the Home and Community-Based Services (HCBS) Programs Provider Enrollment section (link provided in the original document).
- Meet Service-Specific Standards: Providers must demonstrate they meet the specific qualifications for each service they intend to offer. These qualifications are detailed in the MHCP Provider Manual and within each service description. The HCBS Programs Service Request Form (DHS-6638) (PDF) (link provided in the original document) also lists these qualifications.
- Licensure and Certification: Depending on the service, providers may need to hold licenses from DHS or the Minnesota Department of Health (MDH), Medicare certification, or other relevant certifications or registrations.
Prospective providers can obtain detailed information about specific requirements from the lead agency in their service area, DHS Licensing at 651-431-6500, or the Minnesota Department of Health at 651-201-5000.
Services Covered Under the Alternative Care Program
The 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. These services are carefully selected to address various needs, from personal care and daily living assistance to health-related support and environmental modifications.
The following table outlines the services covered by the Alternative Care program. Many of these services link to detailed policy pages within the Community-Based Services Manual (CBSM), which provide comprehensive information on service descriptions, coverage details, and provider standards.
| Service | AC Coverage |
|---|---|
| Adult Companion Services | ✅ |
| Adult Day Services | ✅ |
| Adult Day Services Bath | ✅ |
| Case Management | ✅ |
| Case Management Aide (Paraprofessional) | ✅ |
| Chore Services | ✅ |
| Consumer Directed Community Supports (CDCS) | ✅ |
| Conversion Case Management | ✅ |
| Environmental Accessibility Adaptations | ✅ |
| Family Adult Day Services | ✅ |
| Family Caregiver Services | ✅ |
| Home Care – Extended Services HHA, Home Care Nursing, PCA | ✅ |
| Home-Delivered Meals | ✅ |
| Homemaker | ✅ |
| Individual Community Living Supports (ICLS) | ✅ |
| EW and AC Transportation | ✅ |
| Nutrition Services | ✅ |
| Respite Care | ✅ |
| RN Supervision of PCA | ✅ |
| Specialized Equipment and Supplies | ✅ |
| Tele-Homecare | ✅ |
Key Covered Services Explained:
- Adult Day Services and Adult Day Services Bath: Provides daytime care in a group setting, offering social interaction, activities, and health-related services. Adult day services bath specifically covers bathing assistance within this setting.
- Adult Foster Care Services: Offers 24-hour care in a licensed family home setting for adults who cannot live independently. (Note: Adult Foster Care is not covered under the AC program, but is listed in the original document for comparison to EW).
- Case Management and Case Management Aide: Provides professional support to coordinate and manage services. Case management aides offer paraprofessional assistance to case managers.
- Chore Services: Assistance with household tasks to maintain a safe and sanitary living environment.
- Companion Services – Adult: Provides companionship and supervision for adults in their homes to ensure safety and well-being.
- Consumer Directed Community Supports (CDCS): Allows individuals more control over their services, including choosing providers and managing their service budget.
- Customized Living: Offers a range of supportive services in apartment settings or similar environments, tailored to individual needs. (Note: Customized Living is not covered under the AC program, but is listed in the original document for comparison to EW).
- Environmental Accessibility Adaptations: Covers modifications to the home to improve accessibility and safety, such as ramps or bathroom modifications.
- Family Caregiver Services: Provides support and resources to family members who are caregivers, including training, counseling, and respite care.
- Home-Delivered Meals: Provides nutritious meals delivered to the home for individuals who have difficulty preparing meals themselves.
- Homemaker Services: Assistance with general household tasks, such as cleaning, laundry, and meal preparation.
- Individual Community Living Supports (ICLS): Supports individuals with skills training and assistance to live independently in the community.
- Nutrition Services: Provides nutritional assessments, counseling, and dietary guidance.
- Respite Care: Temporary care provided to an individual to give their primary caregivers a break.
- Specialized Equipment and Supplies: Covers necessary equipment and supplies that are not typically covered by Medical Assistance, such as mobility aids or adaptive equipment.
- Transportation (EW and AC Transportation): Assistance with transportation to access medical appointments and community services.
- Home Health Services (AC Program Only): The AC program specifically covers a range of home health services, including:
- Home Health Aide: Assistance with personal care and health-related tasks by a home health aide.
- Home Health Aide Visit: Focused visits by a home health aide for specific tasks.
- LPN Regular and LPN Complex: Nursing services provided by Licensed Practical Nurses (LPNs), with complex care indicating more specialized nursing needs.
- PCA (Personal Care Assistant): Personal care assistance with activities of daily living.
- RN Regular and RN Complex: Nursing services provided by Registered Nurses (RNs), with complex care indicating more specialized nursing needs.
- Skilled Nurse Visit: Visits by skilled nurses (RN or LPN) for specific health needs.
- Tele-Homecare: Remote monitoring and support services delivered via technology.
It is important to note that this list provides a general overview. For precise details on each service, including specific coverage rules and limitations, referring to the Community-Based Services Manual (CBSM) through the provided links is essential.
Service Authorization: Getting Services Approved
To access Alternative Care program services, a service authorization (SA) is required. This process ensures that services are necessary, appropriate, and aligned with the individual’s support plan.
Key aspects of Service Authorization:
- Case Manager Role: A lead agency case manager or care coordinator is responsible for initiating and completing the service authorization in the Minnesota Medicaid Management Information System (MMIS).
- FFS System (Fee-For-Service): For counties and tribal nations operating under the FFS model, the SA is initiated directly in MMIS. Providers must communicate with the case manager if there are discrepancies in the SA, as the case manager is ultimately responsible for its accuracy.
- MCO Systems (Managed Care Organizations): Managed Care Organizations (MCOs) have their own SA systems and processes. Individuals enrolled in EW through an MCO should contact their MCO for specific authorization and billing instructions.
- Service Authorization Letter (SAL): Once an SA is approved, a Service Authorization Letter (SAL) is generated. For FFS, this is sent electronically to the provider’s MN–ITS mailbox. MCOs have their own notification methods.
- What the SA Includes: Each line item on the SA details critical information:
- Authorized MHCP-enrolled provider.
- Payment rate for the service.
- Number of units approved or total authorized amount.
- Service dates or date range.
- Approved procedure code(s).
It’s crucial to understand that while an approved SA allows a provider to deliver and bill for services, it doesn’t guarantee payment. Payment is contingent on factors such as the provider’s active MHCP enrollment, the individual’s continued MHCP eligibility, and accurate claim submission. Providers are responsible for verifying the accuracy of the SAL upon receipt.
Billing for Alternative Care Services
Efficient billing practices are essential for providers to receive timely payments for services delivered under the Alternative Care program.
Key Billing Guidelines:
- FFS Billing: For fee-for-service Alternative Care services, providers should consult the Billing for Waiver and Alternative Care (AC) Program section (link provided in the original document) for detailed instructions.
- Extended Home Care Billing: For extended home care services authorized under the EW program (and billed to AC in some cases, depending on the service), claims are submitted using the 837I Institutional Outpatient transaction (via MN–ITS), following home care billing guidelines (link provided in the original document).
- MCO Billing: Providers contracted with MCOs for EW services must follow the specific billing procedures provided by each MCO. Contact the relevant MCO directly for these instructions.
- Authorized vs. Non-Authorized Services: It is critical not to bill for services requiring an SA on the same claim as services that do not require one. This separation ensures proper claim processing.
- Payment Rates: Lead agencies authorize service and provider payment rates, adhering to DHS-established rate limits for AC and EW services. These rate limits are published in the Long-Term Services and Supports Service Rate Limits (DHS-3945-ENG) (PDF) document (link provided in the original document). Rates can be state-established or market-based, depending on the service.
Understanding these billing procedures and rate structures is crucial for providers to ensure accurate and timely reimbursement for their services.
Staying Informed and Compliant
The Alternative Care program, like other healthcare programs, involves ongoing updates and changes. Staying informed about these changes and maintaining compliance is essential for both individuals receiving services and providers delivering them.
Key Areas for Ongoing Attention:
- Provider Manual Updates: Regularly review the Minnesota Health Care Programs (MHCP) Provider Manual and related webpages for the latest news, policy additions, forms, and quick links. This is the primary source for program updates and requirements.
- Rate Limit Changes: Monitor the long-term services and supports rates changes webpage (link provided in the original document) for the most up-to-date information on rate limit adjustments.
- Legal References: Familiarize yourself with the legal references governing the Alternative Care program and related services. These are listed in the “Legal References” section of the original document and provide the statutory and regulatory foundation for the program.
- Lead Agency Communication: Maintain open communication with the lead agency and case manager. They are your primary resources for program-specific guidance, eligibility questions, and service-related issues.
By staying informed and proactive, both individuals receiving Alternative Care services and providers delivering them can ensure a smooth and effective program experience. The Alternative Care program in Minnesota is a valuable resource, promoting independence and community living for seniors. Understanding its intricacies is key to maximizing its benefits.
