Moving Home Minnesota (MHM)

Overview

Moving Home Minnesota (MHM) is a Federal demonstration project. The goal of MHM is to create opportunities for Minnesotans to move from institutions to their own home in the community. MHM promotes the development and implementation of transition plans that reflect the preferences of those receiving services and the opportunity to receive services in the most integrated setting.

Lead agencies (counties, Tribes, or health plans) assign a transition coordinator to each person receiving MHM services. The transition coordinator helps create a plan to transition the person back to the community.

PrimeWest Health covers MHM for members age 65 and over.

Participant Eligibility

PrimeWest Health members that are age 65 and over who receive MHM services must be transitioning from a qualified institution where they have resided for 60 days or more to a qualified community residence. They must also be eligible for Medical Assistance (Medicaid) prior to discharge and maintain eligibility. The 60-day requirement may be fulfilled through sequential stays in multiple qualifying institutions. The days before and after a Medicare-paid stay both count as being a continuous stay, as long as both were in a qualified institution. 

All MHM services require an evaluation to determine the person’s needs and eligibility for MHM services. The assessment is completed by the appropriate lead agency using the MnCHOICES assessment.

Members Age 65 and Over

All MHM-enrolled members age 65 or over must enroll in the Elderly Waiver (EW) program in order to access MHM services unless the member is eligible to enroll in a disability waiver program. For additional information on EW exceptions, refer to the 65 years of age section of the Waiver, AC, and ECS general processes and procedures page in the Minnesota Department of Human Services (DHS) Community-Based Services Manual (CBSM).

For members age 65 and over who are enrolled in either PrimeWest Senior Health Complete or Minnesota Senior Care Plus (MSC+), PrimeWest Health serves as the lead agency and is responsible for transition service coordination. PrimeWest Health may arrange for another entity such as a private relocation services provider or a county agency to serve in this capacity.

For all other members, the county or Tribe serves as the lead agency. Refer to the Lead Agency Responsibilities section of the DHS Provider Manual and the DHS Moving Home Minnesota Program Manual for more information.

Qualified Institution

A qualified institution can be any of the following:

• Hospital
• Nursing facility
• Intermediate Care Facility for people with Developmental Disabilities (ICF/DD)
• Institution for Mental Diseases (IMD), such as Anoka Metro Regional Treatment Center. An individual residing in an IMD is eligible to the extent that the services are covered by Federally funded Medical Assistance (Medicaid), as referenced in the Eligibility Policy Manual: Program for People Living in Institutions for Mental Diseases (section 2.5.4).
• Community behavioral health hospitals
• 1115 Substance Use Disorder (SUD) System Reform Demonstration services delivered in an institutional setting

Qualified Community Residences

People receiving MHM services must live in a qualified community residence. This includes the following:

• A home owned or leased by the person or the person’s family
• An apartment with an individual lease and living areas over which the individual or individual's family has control
• An assisted-living residence that provides an apartment with separate living, sleeping, bathing, and cooking areas; lockable entrance and exit doors
• A home in a residential setting in which no more than four unrelated individuals live

Lead Agency Responsibilities

To receive MHM services, a MnCHOICES assessment or applicable screening document must be completed by the lead agency to determine program eligibility and provide the member with informed choice. Applicants must meet the hospital or institutional level of care to be eligible to receive MHM services. Review for more information on entering assessments into Medicaid Management Information System (MMIS). Review the MHM services section of the DHS Moving Home Minnesota Program Manual for more information on authorizing MHM services using the MnCHOICES assessment or other applicable screening document.

If a member screens eligible for and chooses to receive MHM services, a MHM Intake Form (DHS-5032) should be submitted to DHS to confirm the member meets Federal eligibility requirements. The MHM service begin date, which is the date the member consents to begin receiving MHM transition coordination services identified on the intake form, cannot be a date during which the member is currently receiving any other form of Targeted Case Management (TCM). Refer to Noncovered Services in the Moving Home Minnesota (MHM) section of the DHS Provider Manual for a list of TCM services considered to be duplicative.

The lead agency is responsible for assigning a MHM transition provider if the lead agency will not be providing the transition coordination services. The lead agency is also responsible for identifying if the member is eligible for waiver services and will assign a waiver case manager to assist the member when they transition into the community. For more information on MHM community-based services, refer to Community-Based Participation and Transition to the Community - Service Authorization in the Moving Home Minnesota (MHM) section of the DHS Provider Manual.

Member Enrollment

Members may begin the enrollment process to receive MHM transition services at any point during their institutional stay by completing the online MHM Intake Form (DHS-5032). The intake form can also be faxed to 1-651-431-7745 or mailed to:

Moving Home Minnesota
P.O. Box 64250
St. Paul, MN 55164-0250

The Senior LinkAge Line^® (1-800-333-2433), Disability Hub MN™ (1-866-333-2466), the member’s  county or Tribal human services agency, or PrimeWest Health care coordinator are also available to help provide information on assistance with enrollment in MHM.

MHM Eligibility and Enrollment provide notification of program eligibility and approval determinations to all pertinent parties via encrypted email to lead agencies and transition coordination providers and via paper copies delivered to the member’s most current address upon confirming the following:

1. A lead agency assessor has completed an assessment showing the person is eligible for and has elected to receive MHM services.
   1. If the person has had a MnCHOICES or long-term care consultation (LTCC) assessment, the lead agency can authorize MHM within 365 days from the date of the assessment
   2. If the person has had a developmental disabilities (DD) screening, the lead agency can authorize MHM within six months from the date of the assessment
2. DHS received an MHM Intake Form (DHS-5032) and reviewed it for Federal eligibility criteria.

Review the Eligibility and enrollment section of the DHS Moving Home Minnesota Program Manual for more information. Contact MHM Eligibility and Enrollment at movinghomemn.mfp@state.mn.us or 1-651-431-3951 with questions.

Transition Coordinator Responsibilities

If a transition coordinator is not already working with a member approved to receive MHM services, the lead agency will assign one. Review the Moving Home Minnesota (MHM) transition coordinators section of the DHS Moving Home Minnesota Program Manual for a list of enrolled and active MHM transition coordinators.

The transition coordinator must complete and keep on record the following forms:

1. Moving Home Minnesota Informed Consent Form (DHS-6759I) to review the member’s rights and responsibilities
2. Moving Home Minnesota Transition Planning Tool (DHS-6759J) to assist in identifying what’s important to and for the member as part of the planning for the member’s transition to a qualified residence in the community.
3. Moving Home Minnesota Housing Transitions Worksheet (DHS-6759G) to assist the member in choosing a qualified residence.

When a residence in the community has been selected, the transition coordinator must submit the online Moving Home Minnesota Communication Form (DHS-6759H) and select the option “Assurance of Qualified Community Residence” for the Reason for Communication. The transition coordinator must provide the information requested and submit the form to MHM for review to ensure that the location is a qualified residence. Contact movinghomemn.mfp@state.mn.us or 1-651-431-3951 with questions.

If you have questions about how to complete the Moving Home Minnesota Communication Form (DHS-6759H), please contact MHM Eligibility and Enrollment at movinghomemn.mfp@state.mn.us or 1-651-431-3951.

Community-Based Participation

When the member has successfully transitioned to the community, the transition coordinator must notify MHM Eligibility and Enrollment by submitting the online Moving Home Minnesota Communication Form (DHS-6759H). Select the option “Participant has transitioned to the community” for the reason for communication and provide the information requested and submit the form. When the member moves into a qualified residence, the move-in date will serve as the start date for the member’s 365 days of MHM community-based service eligibility.

When a MHM member is not receiving waiver case management, the lead agency assigns a MHM Demonstration Case Management (DCM) provider. The MHM DCM provider completes the MHM Service Authorization using the Community Support Plan with Coordinated Services and Supports Plan (DHS-6791B)  and submits this via secure email to MHM Eligibility and Enrollment at movinghomemn.mfp@state.mn.us.

If MHM Comprehensive Community Support Services (CCSS) are provided, the CCSS provider must be a different provider than the case management provider. The CCSS provider must communicate and collaborate with the assigned case management provider to incorporate the CCSS services into the MHM service authorization.

Changes to and Ending Enrollment with MHM

If a member receiving MHM services has a change in provider or case manager, or chooses not to utilize MHM services at any point in time after they have been approved and enrolled in MHM, the lead agency, transition coordinator, or case manager must notify MHM Eligibility and Enrollment of the change using the Moving Home Minnesota Communication Form (DHS-6759H). For specific examples of when this notification must occur, refer to the Reporting enrollment changes, reinstitutionalization and disenrollment for MHM section of the DHS Moving Home Minnesota Program Manual.

Re-institutionalization During MHM Participation

A member receiving MHM community-based services may need to return to an institution for short or long-term care, such as hospital or nursing facility rehabilitation. In these situations the lead agency, transition coordinator, or case manager must notify MHM Eligibility and Enrollment of the change using the Moving Home Minnesota Communication Form (DHS-6759H). Select the option “Moving Home Minnesota participant has been re-institutionalized”. Ongoing MHM participation will be affected depending on the length of stay:

1. 30 days or less: MHM participation and eligibility spans will not be interrupted but MHM services will not be reimbursed during this period.
2. More than 30 days: MHM participation will be suspended; however, people may:
   1. Use any time left on their 365-day eligibility span after they return to the qualified community-based residence; or
   2. Re-apply for MHM services, if they have continuously resided in a qualified institution for 60 or more days.

Provider Enrollment

Eligible providers must enroll with Minnesota Health Care Programs (MHCP). Refer to the MHM Provider Enrollment web page to complete enrollment.

To enroll with PrimeWest Health to provide MHM services, please complete the Participation Request form

Training for Newly Enrolled MHM Providers

MHM offers training to newly enrolled MHM providers to help prepare them to work with lead agencies for successful Moving Home transitions. Contact MHM at 1-651-431-3951 or 1-888-240-4756 to schedule a training.

Adding Additional MHM Services

To add additional MHM services to your current DHS enrollment record, do the following:

1. Complete the HCBS Programs Service Request Form (DHS 6638) to list the service(s) you want to provide and report your qualifications to provide the service(s)
2. Communicate with PrimeWest Health to ensure your contracts include the new service as appropriate

MHM Recipient Enrollment

Individuals may enroll for MHM services by contacting the Disability Hub MN Line^® at 1-866-333-2466 or the Senior LinkAge Line^® at 1-800-333-2433. Individuals may also contact their county case manager for assistance. They may also complete the online MHM Intake Form (DHS-5032). The intake form can also be faxed to 1-651-431-7745 or mailed to:
Moving Home Minnesota
P.O. Box 64250
St. Paul, MN 55164-0250

A MHM enrollment specialist at DHS will work with the transition coordinator to confirm the member meets eligibility requirements for MHM services. If the person is determined eligible for MHM, they must complete the Moving Home Minnesota Informed Consent (DHS-6759I) and return it to DHS before the person can begin receiving MHM services.

MHM Eligibility and Enrollment provides notification of program eligibility and approval determinations to all pertinent parties via encrypted email to lead agencies and transition coordination providers and via paper copies delivered to the member’s most current address upon confirming the following:

• A lead agency assessor has completed an assessment showing the person is eligible for and has elected to receive MHM services.
  • If the person has had a MnCHOICES or long-term care consultation (LTCC) assessment, the lead agency can authorize MHM within 365 days from the date of the assessment
  • If the person has had a developmental disabilities (DD) screening, the lead agency can authorize MHM within six months from the date of the assessment
• DHS received an MHM Intake Form (DHS-5032) and confirmed it meets Federal eligibility criteria. The MHM service begin date, which is the date the member consents to begin receiving MHM transition coordination services, identified on the intake form cannot be a date during which the member is currently receiving any other form of TCM. For more information on services considered to be duplicative, review the Moving Home Minnesota (MHM) – Noncovered Services section of the DHS Provider Manual.

Contact MHM Eligibility and Enrollment at movinghomemn.mfp@state.mn.us or 1-651-431-3951 with questions.

Changes and Disenrollment from MHM

PrimeWest Health must be notified by either the lead agency, transition coordinator, or case manager if a person approved to receive MHM services chooses not to utilize MHM services, or in any of the following situations during or after transition.

During transition the person:

1. Decides he/she wants to remain at the facility
2. Is transferred to a hospital
3. Passes away
4. Leaves the facility against medical advice and does not return

Post-transition during case management the person:

1. Decides he/she wants to return to the facility
2. Is transferred to a hospital
3. Passes away
4. Is unwilling to complete paperwork to maintain Medical Assistance (Medicaid). The person must be on Medical Assistance (Medicaid) while receiving MHM services.
5. Wants to end enrollment with MHM case management or Waiver case management
6. Relocates or moves to another state
7. Moves to a non-qualified residence

MHM Transition Coordination

Eligible Providers

The transition coordinator can be any of the following:

1. Case manager
2. MCO care coordinator
3. Relocation services coordinator (RSC)
4. Other individual who meets the qualifications listed below.

Transition coordinators must meet the minimum qualifications of an RSC outlined in the MN Stat. sec. 256B.0621, subd. 5.

These services may be delivered by an organization or individual that is any of the following:

1. A lead agency (county, Tribal Nation, or MCO)
2. Under contract with a lead agency
3. An MHCP-enrolled provider of a service identified on the Moving Home Minnesota Demonstration and Supplemental Services table

Transition Coordination Services

Transition coordination services are activities that help a person in a qualified institution access medical, social, educational, financial, housing, and other services and supports needed so they can move to the community. The transition coordinator will begin meeting with the member in the institution and does all of the following:

1. Facilitates signing of enrollment and informed consent forms
2. Conducts assessment or arranges assessment within 30 days of assignment
3. Develops an individualized person-centered transition plan
4. Leads the transition planning process
5. Works with lead agency to arrange details of waiver services if appropriate
6. Works with the housing specialist to locate housing
7. Works with the Disability Linkage Line™ to identify appropriate employment supports (if necessary)
8. Sets up transportation to look for housing and/or employment for member
9. Coordinates details in order to set up home for participant
10. Coordinates meeting, medical follow-up appointment, delivery of medical equipment, etc.
11. Coordinates day of discharge. Transition coordinator is present the day of the move. Ensures medications and required services are in place.

The following are required forms for MHM enrollment and participation:

1. Intake Form: Must be completed and sent to DHS for an eligibility determination.
2. Informed Consent: Must be completed when the transition coordinator meets with the member. It is then forwarded to DHS. Once received at DHS, the member can begin to receive MHM services.
3. Moving Home Minnesota Transition Planning Tool: Must be completed with the member and the transition coordinator.
4. Communication Form: Must be completed and sent to DHS once the transition coordinator has an estimated date of when the member will be moving. DHS needs this information in order to schedule a quality of life survey with Vital Research before the member moves. The Communication Form needs to be completed a second time with the date the member moved as well as the housing information.
5. Moving Home Minnesota Housing Transitions Worksheet (DHS-6759G) – complete with the person and transition coordinator

The transition coordinator ensures an orderly transition to the case manager, community providers, or to the member to coordinate the community services. If the member will have a different case manager after transition, the transition coordinator must facilitate an in-person meeting with the participant and the community case manager.

The case manager or community provider helps with issues that come up during the year of transition and arrange support for the member in the community.

The transition care plan is person-centered to ensure a member receives the right services and supports at the right time and according to his/her wishes and needs.

Providers must complete and submit Moving Home Minnesota – Transition Planning, Transition Coordination and Demonstration Case Management Providers – Applicant Assurance Statement (DHS-3879) if they want to enroll to provide transition planning and coordination and be authorized to pay for the following:

1. Furnishing, supplies, and costs for securing housing and environmental modifications
2. Durable Medical Equipment
3. Person Emergency Response Systems
4. Tools, clothing, and equipment necessary for employment

When a residence in the community has been selected, the transition coordinator must submit the online Moving Home Minnesota Communication Form (DHS-6759H) and select the option “Assurance of Qualified Community Residence” for the “Reason for Communication.” The transition coordinator must provide the information requested and submit the form to MHM for review to ensure that the location is a qualified residence. If the transition coordinator is certain that the location the participant will be moving to is not considered to be a qualified community residence, select the option “other” for the “Reason for Communication” and notify MHM of the planned move to an unqualified residence.

Providers of Other MHM Services

PrimeWest Health allows any providers who are currently enrolled to provide services in the Covered Services section below to provide the same services to MHM recipients. Tier 1 waiver providers must be enrolled with MHCP and contracted directly with PrimeWest Health. Qualified Tier 2 and Tier 3 waiver providers may choose to either enroll with MHCP and contract directly with PrimeWest Health or they may deliver services as lead-agency affiliate vendors. Signed service purchase agreements are required for non-enrolled Tier 2 (Community Market Services) vendors. Both Tier 2 and Tier 3 vendors must be listed on the Waiver Vendor Review and Approval Log which includes vendor name, the date approved, and verification of vendor qualifications in compliance with Federal waiver standards.

Providers who want to provide overnight assistance must complete an assurance document.

Currently Enrolled Providers

MHCP allows any providers who are currently enrolled to provide services in the covered services section below to MHM recipients. To add any additional MHM services, you must complete the HCBS Programs Service Request Form (DHS-6638).

Providers wanting to provide overnight assistance must complete an Overnight Assistance Provider Applicant Assurance Statement (DHS-6808). Contact the Provider Contact Center at 1-866-431-0802 (toll free) for details regarding seeking PrimeWest Health authorization to provide these services.

MHM Individual Application

Individuals may enroll for MHM demonstration services by contacting the Disability Linkage Line™, Senior LinkAge Line^®, or by completing the online MHM Intake Form, DHS-5032, and sending it to DHS. The intake form can also be submitted via fax to 1-651-431-7745 or mailed to:
Moving Home Minnesota
PO Box 64250
Saint Paul, MN 55164-0250

A MHM enrollment specialist at DHS will work with the transition coordinator to confirm if a member meets the eligibility requirements for the demonstration services. Once a member has been determined eligible for MHM, they must complete the Moving Home Minnesota Informed Consent (DHS-6759I) and return it to DHS before he/she can begin to receive MHM services.

MHM Evaluation

As part of the demonstration, all MHM participants will be part of a national Quality of Life (QoL) study. Each MHM participant will receive a face-to-face QoL Survey at the following three points:

1. Prior to discharge from the institution
2. At the 11th month using the program
3. At 24 months from beginning the demonstration program

This survey is intended to capture participants’ satisfaction with services prior to discharge from the institution, just before the end of their participation in the demonstration, and one year following the end of their demonstration period.

Assessment for MHM Services

All MHM services require an evaluation to determine the member’s needs and eligibility for MHM services. The assessment will be completed by the appropriate lead agency, using the appropriate home and community based screening tool. MHM will make the conversion to MnCHOICES at the time other services are converted.

Upon completion of the assessment, if approved for MHM services, the member will receive an authorization letter. The transition coordinator and the member develop a transition care plan. An individual may have been assessed prior to being referred to MHM.

People Age 65 and Over

For individuals age 65 and over who are enrolled in Minnesota Senior Health Options (MSHO) or MSC+, PrimeWest Health is responsible for Elderly Waiver services and for relocation services. In this case, PrimeWest Health will serve as the lead for transitions. PrimeWest Health may arrange for another entity such as a private relocation services provider or a county agency to serve in this capacity.

For other individuals, the county or tribe will serve as the lead agency, regardless as to whether the person is enrolled in PrimeWest Health. This includes those over the age of 65 enrolled in Special Needs BasicCare (SNBC) as well as individuals over the age of 65 who are excluded from PrimeWest Health.

Re-Institutionalization during MHM Participation

An person receiving MHM community-based services may need to return to an institution for short or long-term care, such as hospital or nursing facility rehabilitation. Ongoing MHM participation will be affected depending on the length of stay:

1. 30 days or less: MHM participation will continue, but MHM services may not be reimbursed during this period.
2. More than 30 days: MHM participation will be suspended; however, people may:
   1. use any time left on their 12-month MHM program limit after they return to their home, or
   2. re-apply for another year of MHM services if they continue to reside in a qualified institution for 60 or more days.

Covered Services

Pre-transition services

The following demonstration services are available through MHM before a person transitions to the community:

• 180 days of transition coordination with extensions available on a case-by-case basis
• Costs for finding housing and employment (including transportation, meals, and lodging)
• Environmental modifications deposit
• Pantry stocking
• Pre-discharge case consultation and collaboration
• Pre-transition clean-up services
• Pre-transition non-medical transportation
• Records and fees
• Transition integration fund
• Transition plan development
• Transitional services (including furnishings, supplies and expenses associated with securing housing)

Post-transition services

The following demonstration and supplemental services are available through MHM after a person transitions to the community for a 365-day enrollment period or 366-day enrollment period in a leap year:

• Community education and integration costs
• Comprehensive community support services
• Costs for finding employment
• Environmental modifications
• Home care training (family and non-family)
• Membership fees
• MHM demonstration case management services
• Overnight assistance
• Pantry stocking
• Personal Emergency Response Systems (PERS)
• Records and fees
• Respite services
• Specialized supplies and equipment
• Transition integration fund
• Tools, clothing, and equipment necessary for employment

Service Coverage Limitations

MHM services coverage is time-limited. Members are eligible for MHM services during the following time spans and circumstances:

1. 180 days of eligibility for transition planning and transition coordination services while in a qualified institution
   1. Eligible and approved members may begin utilizing select transition services at any point during their stay in a qualified institution. Refer to the Moving Home Minnesota Demonstration and Supplemental Services Table for additional information on services allowable prior to the 60 day institutional stay requirement.
   2. The 180-day limit starts with the service date of the first paid claim.
2. 365 days of eligibility for community-based demonstration and supplemental services while in a qualified residence.

While other forms of TCM and MHM Transition Planning and Transition Coordination services can be used alternately, MHCP does not recommend this practice. MHCP recommends using one type of TCM service for the duration of the relocation effort.

Transition providers and lead agencies must work closely to avoid claim denials due to ended eligibility, exceeded service limits, or duplication of services.

Refer to the Moving Home Minnesota Demonstration and Supplemental Services Table for a complete list of MHM services, including identification of whether or not the service(s) can be provided in addition to HCBS waiver program services.

MHM may grant extensions to the 180-day transition planning and transition coordination eligibility span under certain circumstances. A transition coordinator may request an extension by submitting the Moving Home Minnesota Communication Form (DHS-6759H) and selecting the “Transition Coordination Extension Request” option from the Reason for Communication dropdown menu. The transition coordinator must provide the information requested and submit the form to MHM Eligibility and Enrollment for review and approval.

Noncovered Services

This section of noncovered services is not all-inclusive. Receiving MHM services does not make the member ineligible to receive any state plan services, as long as, the services are not duplicative or supplanting any other state plan or waiver services.

Only one type of Targeted Case Management service can be billed at any one time. A member cannot receive MHM transition planning and transition coordination services at the same time as they are receiving any of the following services:

1. Developmental Disabilities (Rule 185)
2. Relocation Service Coordination (RSC)
3. Targeted Case Management for Vulnerable Adults and Adults with Developmental Disabilities (VA/DD-TCM)
4. Waiver, Alternative Care (AC) and Essential Community Supports (ECS) case management
5. Child Welfare Targeted Case Management (CW-TCM)
6. Adult Mental Health Targeted Case Management (MH-TCM)
7. Children's Mental Health Targeted Case Management (CMH-TCM)
8. Behavioral Health Home (BHH) Comprehensive Transitional Care
9. Housing Stabilization Services (HSS) Transition Services

Noncovered Services

This section of noncovered services is not all-inclusive. Receiving MHM services does not make the member ineligible to receive any State plan services, as long as the services are not duplicative or supplanting any other State plan or waiver services.

Only one type of Targeted Case Management service can be billed at any one time. A member cannot receive MHM transition planning and transition coordination services at the same time as they are receiving any of the following services:

• Relocation Service Coordination (RSC)
• Targeted Case Management for Vulnerable Adults and Adults with Developmental Disabilities (VA/DD-TCM)
• Waiver, Alternative Care (AC) and Essential Community Supports (ECS) case management
• Child Welfare Targeted Case Management (CW-TCM)
• Adult Mental Health Targeted Case Management (MH-TCM)
• Children's Mental Health Targeted Case Management (CMH-TCM)
• Behavioral Health Home (BHH) Comprehensive Transitional Care
• Housing Stabilization Services (HSS) Transition Services

MHM State Plan Services

MHM recipients may also be eligible to receive State plan services based upon medical necessity and the eligibility requirements for the services. These services include, but are not limited to, the following:

1. Home care
   1. Skilled nurse visits
   2. Home health aide visits
   3. Home care nursing
   4. Home care therapies
   5. PCA
2. Adult mental health rehabilitation services

1. Assertive Community Treatment (ACTS)
2. Adult Rehabilitative Mental Health Services (ARMHS)
3. Adult crisis response services

Authorization

All MHM services require an assessment when a person applies for MHM to determine the recipient’s needs. Authorization is required for any combination of procedure codes T2019 (U6) and T2018 (U6) up to 180 days. Additional 90-day periods are allowed as needed with State approval to not exceed 360 total days.

Members must apply for MHM by completing an application and an informed consent form. The member will receive an authorization letter confirming his/her enrollment in the program. He/she will also receive a letter if he/she is determined to be ineligible for the MHM program. Once the individual is approved for the program, the transition coordinator and the member shall develop a transition care plan. The transition care plan is to be developed in a manner consistent with person-centered principles, which means that the member’s preferences and choices shall be identified and reflected in the plan.

After the 12-month transition period, people continue to receive the same services through State plan or waiver. If demonstration services are needed for a limited time beyond the 12 months, DHS may cover the costs using State-only funds. The MHM Enrollment Specialist must authorize use of demonstration services beyond the 12-month enrollment period. These requests can be made by the individual receiving the services or anyone acting on the individual’s behalf such as a transition coordinator or case manager.

Most of the MHM services require a service agreement, with the exception of those that occur prior to discharge, including the following:

1. Transition planning and coordination
2. Pre-discharge case consultation
3. Costs associated with finding housing or employment

Service Authorization Letters

After services are approved, MHCP will provide the member, the provider of service(s), and the case manager a copy of the Service Authorization letter. The provider and the case manager will each receive the Service Authorization letter in their MN–ITS SAL mailbox.

The letter shows the services authorized through MHM. Providers must enter the Service Authorization number when submitting claims.

The lead agency and the MHM provider are responsible for reviewing the Service Authorization letter for accuracy before rendering and billing for services.

Pre-Transition

MHM services requires a Service Authorization with the exception of those that occur prior to discharge from the qualified institution, including the following:

1. Transition planning and coordination
2. Pre-discharge case consultation
3. Costs associated with finding housing or employment
4. Furnishing supplies and expenses associated with securing housing

Transition to the Community – Service Authorization

All MHM services require a MnCHOICES assessment or applicable screening document as identified in the Screening documents and service agreements section of the CBSM to determine the member’s service needs.

The member’s living arrangement in MMIS must be updated to show the member has moved to the community for community-based claims to pay. Refer to the Moving Home Minnesota Demonstration and Supplemental Services Table for additional guidelines and instructions on entering time spans for MHM Service Authorizations.

When a member is not participating in a waiver program, the lead agency may choose to assign a provider to deliver MHM DCM services in place of a lead agency waiver case manager. MHM DCM providers are required to submit a Community Support Plan with Coordinated Services and Supports Plan (6791B) located on the Long-Term Services and Supports (LTSS) Forms page of the CBSM and submit this via secure email to MHM Eligibility and Enrollment at movinghomemn.mfp@state.mn.us. MHM enters Service Authorization information for non-waiver participants only.

MHM covers the cost of both waiver and non-waiver services during the 365 days of eligible community-based placement.

Follow the Billing for Waiver and Alternative Care (AC) Program guidelines for MHM services approved through the HCBS waiver programs. Refer to the Moving Home Minnesota Demonstration and Supplemental Services Table for additional guidelines and instructions on entering time spans for MHM service authorizations.
 

Billing

To submit claims for home care and mental health services, follow the billing guidelines in the home care services and mental health services sections of the PrimeWest Health Provider Manual.

1. Submit MHM services approved on a waiver authorization and all other MHM services using the Professional (837P) claim transaction.
2. Enter the diagnosis code on the claim.
3. Submit claims only after the services have been delivered.
4. Submit claims for MHM services according to the additional instruction in the table above.

PrimeWest Health is responsible for EW services and for relocation services coordination for members age 65 and over who are enrolled in PrimeWest Senior Health Complete or MSC+. In this case, PrimeWest Health will serve as the lead agency for transitions. PrimeWest Health may arrange for another entity, such as a private relocation services provider or a county agency, to serve in this capacity.

Bill only for services already provided to the member and approved on the Service Authorization when required.

Bill claims for MHM services according to the Moving Home Minnesota Demonstration and Supplemental Services Table.

Submitting Claims

To submit claims for MHM services in MN–ITS, follow the MN–ITS Direct Data Entry (DDE) Professional (837P) user guide.

MHM Supported Employment Services (MHM SES)

Overview

Moving Home Minnesota Supported Employment Services (MHM SES) prepare and help people age 60 or under find competitive employment in the community. This is an individualized approach to employment planning and job development—one person at a time, one employer at a time.

Providers offering SES to MHM participants must enroll with Minnesota Health Care Programs (MHCP) and meet specific standards to bill and receive payment for the SES services.

Enrollment, Licensing, and Certification

A qualified provider must hold a current license for SES under Minnesota Stat. Chap. 245D. This licensure is a requirement for funding SES using the waiver benefit set.

Required Training for Eligible Providers

The Association of Community Rehabilitation Educators (ACRE) must approve an employment services training curriculum for providers of SES to MHM participants through the Money Follows the Person (MFP) demonstration.

Approving MHM Certified Providers

After you complete ACRE training and DHS approves the enrollment to provide MHM SES, providers are added to the MHM certified provider list. For more information about the MHM program, refer to the MHM Program Manual.

All applicants must meet the service eligibility criteria for the specific MHM project in which they anticipate receiving MHM services. MHM services are not intended to duplicate, supplant, or extend services that are already covered with a person’s Medical Assistance (Medicaid) or waiver benefit set. If the service is already available under the participant’s waiver, it is not available under MHM.

Covered Services

The following are covered services under MHM SES:

• Customized employment
• Flexible services offered on a one-to-one ratio to help people secure wage jobs or start their own business
• Benefits planning
• Support in maintaining employment

Billing

Billing for the incentive benchmark payment for supported employment (T2018 U6) is a two step-process:

1. Submit a claim for MHM SES.
2. Complete and submit the Moving Home Minnesota Employment Milestone Payment (DHS-6759L) for each Incentive Benchmark payment along with the required attachments

Three equal milestone Incentive Benchmark Payments (T2018 [U6])

• Discovery: This information about the job seeker includes a description of the person, a list of the person’s ideal conditions of employment, and three vocational themes.
• Job Hire: The first complete, paid shift worked by the person in an integrated community business setting.
• Retention: Successful placement in the community for 90 consecutive days. If the person loses his or her job during the first 365 days in MHM, no additional milestone payments will be made.

The Incentive Benchmark Payment for Supported Employment T2018 (U6) cannot be billed on the same day as Supported Employment T2019 (U6).

PrimeWest Health uses the following HCPCS codes and modifiers for reimbursement of MHM SES.

HCPCS Codes and Modifiers

PW_11-19_544
Updated_08/26/2025