Waivered Services

Publication:
Waivered Services Program for
Persons With Mental Retardation or Related Conditions:
  Title XIX Home and Community-Based Services

Published as a Joint Effort by The Arc of Minnesota and the Minnesota Department of Human Services:
Revised November 2000

Please click on any of the following items (or any underlined text) to be taken directly to a description of the item.

What are Waivered Services?

In 1981 Congress passed a law which created the Title XIX Home and Community-Based Services Program.  This act allows the federal government to waive, meaning to make an exception for, the traditional Medicaid requirements.  It gives states the option of applying for a waiver to use Medicaid funds to provide home and community-based services as an alternative to institutional settings.  Examples of institutional settings include hospitals, Intermediate Care Facilities for Persons with Mental Retardation or Related Conditions (ICF/MR), and nursing facilities.  In 1984, Minnesota began its home and community-based services program for persons with mental retardation and related conditions, also referred to as the MR/RC Waiver.

The goal of the MR/RC waiver program is to provide necessary services and support that are meaningful to the person receiving the services, respectful of the person’s beliefs and customs, and cost-effective.  Waivered services are different from institutional care services in that they are uniquely developed based on a person's needs, and are available or can be developed in the community.  Waivered services help a person to become involved in the community where he or she lives and works and to develop skills to be as independent as possible.  Waivered services may also be modified at any time when the person's needs change.

The MR/RC Waiver provides a variety of services to persons who meet eligibility requirements (click here or see below).

What Services are Available Through the Waiver?

There are a wide variety of services that may be provided to a person using the MR/RC Waiver program. The type of service(s) a person may receive will depend upon his/her needs and desires, the availability of the service(s) the person chooses, and whether the service(s) are cost-effective.

A case manager who represents the county usually assists in selecting the services.  An explanation of how to obtain case management is provided later on this page.

These are the services that are available through the MR/RC Waiver program:

Adult Day Care: Adult day care programs provide integrated supervision, care, assistance, training, and activities that are age appropriate to help a person to be as involved in the community as possible and have meaningful social experiences with non-disabled peers.  Meals and transportation are covered by this service.  Specialized therapies and adaptive equipment may also be provided.  It is intended to help the person maintain skills, and to prevent or delay the use of institutional services.  A person can choose adult day care services instead of DT&H services when it has been decided that DT&H services are no longer appropriate to meet the person’s needs.

Assistive Technology: Assistive technology refers to devices, equipment, or a combination of these which improve a person’s ability to perform activities of daily living, to control or access the environment, or to communicate.  This service may include evaluation for an assistive device, equipment rental during a trial period, and obtaining and customizing devices, as well as training and technical assistance to the person, caregivers, and staff to teach the person how best to use the device or equipment.  This service will also cover the cost of maintenance and repair of devices and rental of equipment while a device is being repaired.

Caregiver Living Expenses: This service provides payment for rent and food that may be reasonably attributed to a live-in personal caregiver.  The live-in personal caregiver also provides one of the following waivered services: residential habilitative services; personal support services; extended personal care attendant services; or consumer-directed community supports.

Caregiver Training and Education: This service provides training for a person who is a primary caregiver, such as a parent, on a variety of topics such as developmental disabilities, community integration, parent skills, family dynamics, stress management, intervention, and mental health.  The training can be provided by individuals, agencies, or educational facilities.  The service allows for the cost of enrollment fees, materials, mileage, lodging and meal expenses to be paid so that a parent or primary caregiver can attend the training session.

Case Management: This service is available to all persons with mental retardation or a related condition.  The purpose of this service is to help locate, coordinate and monitor social and daily living activities, medical services, and other services needed to meet the specific needs of a person and his/her family.

Chore Services: This service supports or assists a person or his/her primary caregiver to keep his/her home clean and safe.  Examples include: washing floors, windows and walls, basic home maintenance, or moving heavy items of furniture in order to provide safe entry and exit.  Chore services are provided when the person who is regularly responsible for these activities is temporarily absent or is unable to manage the home and care for themselves or others in the home.

Consumer-Directed Community Supports: Consumer-directed community supports are services which provide support, care and assistance to a person, prevent the person’s institutionalization and allow the person to live an inclusive community life.  Consumer-directed community supports are designed to build, strengthen or maintain informal networks of community supports for the person.  Consumer-directed community support services are available when local agencies have memorandums of understanding with DHS to demonstrate the feasibility and effectiveness of the consumer-directed community support option.

Consumer Training and Education: This service provides training and education to a person to strengthen his/her self-advocacy skills, to learn how to better exercise his/her civil rights, and/or to acquire skills that strengthen his/her ability to exercise control and responsibility over services and supports. The training can be provided by individuals, agencies, or educational facilities.  The service allows for the cost of enrollment fees, materials, mileage, hotel and meal expenses.  It can also include  person-centered planning assistance from individuals or agencies other than county case managers.

Crisis Respite: Crisis respite services are specialized services that provide short-term care and intervention.  Crisis respite services give needed relief and support to the caregiver and protect the person or others living with him/her. Crisis respite services include activities; assessment; development of an intervention plan; consultation and training to providers and/or caregivers; development and implementation of a transition plan if out of home crisis respite was provided; ongoing technical assistance to the caregiver or provider; and recommendations for revisions to the Individual Service Plan (ISP).

Day Training and Habilitation: Day training and habilitation (DT&H) provides training, supervision, and assistance to help a person develop and maintain vocational and daily life skills and become more involved in the community.  These services are coordinated with residential services.

Environmental Modifications: Environmental modifications are equipment and physical adaptations to a person’s home and/or vehicle that allow the person greater independence.  This service includes only modifications to the home or vehicle that are of direct and specific benefit to the person due to his or her disability.

Extended Personal Care Attendant: This service provides a continuation of personal assistant services when the need for service exceeds the scope and duration of the service available through the state plan service option.  It includes assistance with eating, bathing, dressing, personal hygiene, and other activities of daily living such as meal preparation.

Homemaker Services: General household activities are provided through this service by a trained homemaker when the person who is regularly responsible for these activities is temporarily absent or is unable to manage the home and care for him/herself or others in the home.

Housing Access Coordination: The purpose of this service is to help a person make choices about where to live, the type of home the person wishes to have, and who will be a roommate(s), if anyone.  This service helps the person to identify affordable, accessible housing and assures that housing needs are provided for separately from other service needs.  It may also include assistance in identifying options and making choices, planning for ongoing maintenance and/or repair of the home, and identification of financial resources such as eligibility for housing subsidies and other benefits.

In-Home Family Support: This service provides training and support to a person and his/her family, including extended family, in the family home and in the community.  It is designed to increase the family’s ability to care for and support the person in the family home.

Personal Support: This service helps a person increase independence, productivity, and involvement in the community.  Personal support services provide more flexible and less formal, intensive support than supportive living services.  It includes supervision and assistance to help a person find and use community services and to participate in community activities.  This service may be provided in a person’s home or in the community.

Respite Care: This service provides short-term care to a person when the family member(s) or primary caregiver cannot be there or needs a rest from his/her responsibilities.  Respite care may be provided in the person’s home or in a different residence that has been approved by the county.  Respite care may include day and overnight services.

Specialist Services: Specialist Services includes services that are not available through regular Medical Assistance (MA).  These are specific services to meet the unique needs of the person which provide assessment, program development, training and supervision of staff and caregivers, monitoring of how programs are provided, and evaluation of service outcomes to assure that staff and caregivers are able to meet the needs of the person.

Supported Employment Services: Supported employment services provide ongoing training and support to the person while he/she is a paid employee working at an existing business or industry in the community.  This provides the opportunity to work with people who do not have disabilities and who are not paid caregivers or service providers.

Supported Living Services (SLS): The purpose of this service is to teach specific skills to a person who requires daily intervention.  Daily intervention means providing ongoing supervision, training or assistance to help the person reach his/her individual goals in the following areas: self-care, sensory/motor development, interpersonal skills, communication, reduction and/or elimination of challenging behaviors, community living, mobility, health care, leisure and recreation, money management and household chores.

24-Hour Emergency Assistance:  This service provides on-call counseling and problem solving and/or immediate response for assistance at the person’s home due to a health or personal emergency.  Electronic personal emergency response systems may be provided.  24-hour emergency assistance is available to persons who live in their own home or with their primary caregiver and do not receive 24-hour supervision.

Transportation: This service provides transportation that allows an individual with a disability to gain access to community services, resources, and activities.  This service is offered in accordance with the needs and preferences identified in the person’s plan of care.

Who is Eligible for Waivered Services?

A person is eligible for waivered services if he or she:

• meets the definition of  a person with mental retardation or a related condition; 
• requires the level of care provided by an ICF/MR, is currently living in an ICF/MR, or is at risk of living in an ICF/MR, meaning the person would need the same level of support as provided in an ICF/MR if waivered services were not provided; 
• requires a 24-hour plan of care and daily supports as specified in the Individual Service Plan;
• has made an informed choice requesting MR/RC waivered services instead of services in an ICF/MR; and
• meets income and asset eligibility requirements for regular Medical Assistance, except for children enrolled in the TEFRA program who are eligible regardless of family income.

Eligibility is determined through the screening process.

What Does "ICF/MR Level of Care" Mean?

An ICF/MR is a residential facility that provides 24-hour care, supervision, and ongoing habilitation services.  ICF/MR services are provided in facilities of various sizes and may be operated by private or public providers.

To be eligible for ICF/MR level of care a person must:

• have mental retardation or a related condition;
• need daily intervention, supervision and ongoing habilitation to learn necessary skills;
• require assistance to assure health and well-being; and
• be at risk of placement in an ICF/MR to receive needed services if supports are not provided in the community. 

A person who needs ICF/MR level of care may not be able to apply skills learned in one environment in new situations or environments without additional training or supervision, and may not be able to take care of most of his or her personal care needs without assistance.

In order for a person to live in his or her own home, the county must assure that the health and safety needs of the person will be met by providing necessary services and support.  This assurance will be based upon a 24-hour plan of care, which is part of the Individual Service Plan.  It outlines all the necessary services and supports that will be provided, including services and supports that are not purchased through the waiver.

Where Can Waivered Services be Provided?

Family Home:   A person living in the home of his/her family or extended family can receive waivered services.  The services can support the family as well as help the person develop and maintain daily life skills and become more involved in the community where he/she lives. 

Own Home:   A person can live in his/her own home and receive waivered services.  “Own home” means a home that is not licensed as a foster home or as an ICF/MR.  A person’s own home may include an apartment, a single-family home, or a townhouse. 

Other Home:   Other homes include licensed foster care provided by a single person or a family that provides care and supervision in their home; or by a corporation that sets up a home and hires staff to provide supported living services.   The waiver will allow a foster home to serve up to four persons.

How Can I Obtain Waivered Services?

A person interested in receiving waivered services must contact his/her case manager who represents the county and request that a MR/RC waivered services screening document be completed.  If a person does not have a case manager, an application for case management services must be made with the local county social services agency in the county where the person lives.  The county must appoint a case manager within ten (10) working days after receiving an application for services. 

Once a case manager is appointed, he/she is responsible for coordinating the completion of a comprehensive diagnostic evaluation within thirty-five (35) working days after receiving the application for services.  This diagnostic evaluation is used to determine whether the person has a diagnosis of mental retardation or a related condition and is therefore eligible to receive MR/RC waivered services.

A related condition is a condition that is found to be closely related to mental retardation, including, but not limited to, cerebral palsy, epilepsy, autism, and Prader-Willi syndrome, and that meets all of the following criteria:

(a)  is severe and chronic;

(b)  results in the impairment of general intellectual functioning or adaptive behavior similar to that of persons with mental retardation;

(c)  requires treatment or services similar to those required for persons with mental retardation;

(d)  is manifested before the person reaches 22 years of age;

(e)  is likely to continue indefinitely;

(f)  results in substantial limitations in three or more of the following areas of major life activity (1) self-care, (2) understanding and use of language, (3) learning, (4) mobility, (5) self-direction, (6) capacity for independent living; and

(g)  is not attributable to mental illness as defined in Minnesota Statutes section 245.462, subdivision 20, or an emotional disturbance as defined in section 245.4871, subdivision 15.  “Mental illness” does not include autism or other pervasive developmental disorders.

The comprehensive evaluation includes assessments of intellectual abilities and adaptive skills, social and developmental history, and physical and health status of the person.  Once it is determined that a person is eligible for case management services, the case manager will coordinate assessments in a number of other areas that will assist the screening team to determine whether MR/RC waivered services are necessary to meet the person’s needs.

What is the Screening Process?

The MR/RC waivered services screening process is a review of the diagnostic and assessment information to determine whether the person is eligible for waivered services.  Screenings must be completed when requested, regardless of current availability of waivered services.

Within sixty (60) working days of the request for case management services, a “screening team” is called together by the case manager to evaluate what services would best meet the person’s needs. 

The screening team consists of:

• the person with mental retardation or a related condition;
• the legal representative, if any;
• family members or others chosen by the person or their legal representative;
• an advocate, if desired;
• a Qualified Mental Retardation Professional provided by the county (this may be the same person as the case manager); and 
• the case manager. 

The screening team meeting must be on a date and at a place that allows the person and his/her legal representative, if any, to participate.  The screening team does not include anyone who directly or indirectly provides services.  Service providers participate as members of a person’s interdisciplinary team to help develop the services the screening team has chosen.

What is a Screening Document?

During the screening team meeting, the case manager will complete a screening document which records the main points, or summarizes, information from the diagnostic evaluations and assessments and the decisions made by the screening team.  It is very important to identify when waivered services are needed.

The screening document is then submitted to the Department of Human Services (DHS) as a request for authorization to use Medical Assistance funding for the planned services, including waivered services.  If it is determined at the meeting that the person with mental retardation or a related condition is in need of the level of care provided in an ICF/MR, the person and the legal representative make an informed choice between the MR/RC waivered services and ICF/MR services.  A person may choose waivered services even if there are not any currently available.    

What is Service Planning?

Based upon the results of the initial assessment of the person’s individual needs, or the annual assessment of individual needs, the service planning team develops the Individual Service Plan (ISP).  This is based on the services chosen by the person and his/her legal representative, if any. 

The ISP is a comprehensive plan developed by the service planning team that is typically made up of the same people as the screening team, or any others that the person with mental retardation or a related condition may want to add. The ISP includes:

• a summary of the main points of the diagnostic and assessment information;
• identification of necessary services and supports and the preferences as stated by the person or legal representative;
• services that will by provided if the person is placed on a waiting list for MR/RC waivered services;
• documentation of what services will be provided;
• identification of long and short term goals; and
• how needed services will be developed.

What is Informed Choice?

If it is determined at the screening team meeting that the person  is in need of the level of care provided by an ICF/MR, the person or the legal representative, if any, will be asked to make an informed choice of which services he/she would like to receive.  Informed choice means the person or legal representative has made a voluntary decision after becoming familiar with the alternatives, and has:

• chosen his/her preferred alternative from a number of other alternatives; or
• chosen an alternative which may be developed in the future; or
• refused any MR/RC waivered services at that time.

A person may be able to make an informed choice by reading information, such as this web page, or discussing alternatives  with the case manager or an advocate.  The person may want to visit an ICF/MR or a home where waivered services are provided, meet with a service provider, or speak with other persons who are receiving services.  The person may want to meet with more than one service provider.  Case managers can assist in setting up visits or meetings with service providers.

During the screening process, the case manager will assist in determining eligibility.  However, the choice of the type of service is always a decision made by the person and the legal representative, if any, from feasible alternatives. 

There also may be options available other than waivered services or ICF/MR services.  Options available to a person within their community should be explored first.  Community services are those services that are used by any individual in the community including public transportation systems, park and recreational programs, and community education. Other informal supports, provided by family members, friends, or volunteers, may not require any funding at all.

There are services for which a person may be eligible that can be paid for with Medical Assistance, such as Personal Care Assistance.   Many other services, such as respite care and Day Training and Habilitation, may also be arranged by the case manager.  Due to the high demand for MR/RC waivered services, many people have to wait for the funding before receiving specific services.  The Individual Service Plan should identify which of these services will be provided while waiting for MR/RC waivered services.

What if a Person Needs Legal Representation?

The need for legal representation is an area that should be assessed annually prior to the screening team meeting.  It must be part of the assessments arranged for by the case manager and must be done before the case manager completes the screening document with the screening team.

A parent is the legal guardian of his/her child only while the child is a minor, meaning under the age of eighteen (18) years, at which time a parent’s natural legal status as guardian ends.  The person is then considered to be his/her own legal representative unless a guardian or conservator is appointed by a court order.  The person’s parent(s) or other interested person(s) may seek to be appointed as guardian or conservator.

An assessment evaluates the need for a guardian or conservator to be appointed by the court to make informed choices on the person’s behalf.  It also evaluates the need for possibly modifying, or changing, an existing guardianship or conservatorship to assure that it is the least restrictive legal representation provided.  The need for a guardian or conservator must be based on the person’s skills and abilities to make decisions on his or her own behalf, and not simply because he or she has a diagnosis of mental retardation or a related condition.

“Assessing the Need for Guardianship or Conservatorship: A Family Resource Guide” is available from The Arc of Minnesota and may help determine the need for a conservator or guardian.  If a person is unable to make an informed choice, the court must appoint a legal representative before the screening process for waivered services can take place.

What are My Appeal Rights?

If you are determined to be ineligible for case management services or are denied a request for a MR/RC waivered services screening, you may appeal that decision.  Appeal rights must be provided to you when services are requested, denied, changed, or terminated.  An appeal is a formal way to resolve problems.  Although an appeal is not a court hearing, the Minnesota Department of Human Services will assign a referee to make a decision after hearing testimony from the person filing the appeal and from the county representative.

A social services appeal hearing must be requested in writing within thirty (30) days of receiving notice that an application for assistance is denied or not acted upon with reasonable promptness, or when services are denied, reduced, suspended or terminated.

If you do not wish to appeal, you may request a conciliation conference.  A county is required to hold a conciliation conference when a person or his/her legal representative requests one because he/she disagrees with the county’s action or failure to take action.  The purpose of a conciliation conference is to allow the person or legal representative and the county to reach agreement on how to settle the issue(s) they disagree on.  This process includes identifying issues or barriers, problem solving, and negotiating an agreement.  Other interested people may participate in the conciliation conference if requested by the person or the legal representative.

Examples of reasons for which a person may request a conciliation conference include: the county fails to take action when a service provider is not carrying out the goals and services of the person’s ISP; or the county says that it will not or cannot complete a screening document for the services an eligible person wants because the county says the service is not currently available.

The county must prepare a written summary report of the conference results and submit the report to the people who attended the meeting within thirty (30) days of the request for a conference.  If the person is not satisfied with the results of the conciliation conference or the county does not do what was agreed upon, the person may appeal. 

A written request for a social services appeal hearing must be received from the person or the legal representative within ninety (90) days of receiving written notice of a county’s decision.  After receiving the request, DHS will set a date for a social services appeal hearing and will notify all parties of the time and place.   An appeals referee will make a decision on what action must be taken to resolve the problem after hearing from both sides.  The appeal referee’s decision is based on the requirements of the applicable law.

For further information regarding your appeal rights, contact the case manager from the county social services agency.  You may also contact one of the advocacy agencies listed below for more information or support on appeals or services.

For further information please contact:

• your county social services agency
• your county case manager
• the Minnesota Department of Human Services
• Community Supports for Minnesotans with Disabilities, 444 Lafayette Road, St. Paul, Minnesota  55155-3857
   Policy Line (651) 296-9747
   TDD (651) 282-5436
• Arc Minnesota, 770 Transfer Road, Suite 26, St. Paul, Minnesota  55114
  (651) 523-0823 or toll-free within Minnesota (800) 582-5256
• the Minnesota Disability Law Center, 430 1st Avenue North, Suite 430, Minneapolis, Minnesota 55401-1780
  (612) 332-1441 or toll-free (800) 292-4150