1.1 	A bill for an act
1.2 	relating to human services; modifying requirements and timelines for completing 
1.3 	community support plans and coordinated service and support plans; amending 
1.4 	Minnesota Statutes 2016, sections 256B.0915, subdivision 6; 256B.092, subdivision 
1.5 	1b; Minnesota Statutes 2017 Supplement, sections 256B.0911, subdivisions 1a, 
1.6 	3a, 3f; 256B.49, subdivision 13.
1.7 	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

1.8 	Section 1. Minnesota Statutes 2017 Supplement, section 256B.0911, subdivision 1a, is 
1.9 	amended to read:
1.10 		Subd. 1a.Definitions. For purposes of this section, the following definitions apply:
1.11 	(a) Until additional requirements apply under paragraph (b), "long-term care consultation 
1.12 	services" means:
1.13 	(1) intake for and access to assistance in identifying services needed to maintain an 
1.14 	individual in the most inclusive environment;
1.15 	(2) providing recommendations for and referrals to cost-effective community services 
1.16 	that are available to the individual;
1.17 	(3) development of an individual's person-centered community support plan;
1.18 	(4) providing information regarding eligibility for Minnesota health care programs;
1.19 	(5) face-to-face long-term care consultation assessments, which may be completed in a 
1.20 	hospital, nursing facility, intermediate care facility for persons with developmental disabilities 
1.21 	(ICF/DDs), regional treatment centers, or the person's current or planned residence;
2.1 	(6) determination of home and community-based waiver and other service eligibility as 
2.2 	required under sections 256B.0913, 256B.0915, and 256B.49, including level of care 
2.3 	determination for individuals who need an institutional level of care as determined under 
2.4 	subdivision 4e, based on assessment and community support plan development, appropriate 
2.5 	referrals to obtain necessary diagnostic information, and including an eligibility determination 
2.6 	for consumer-directed community supports;
2.7 	(7) providing recommendations for institutional placement when there are no 
2.8 	cost-effective community services available;
2.9 	(8) providing access to assistance to transition people back to community settings after 
2.10 	institutional admission; and
2.11 	(9) providing information about competitive employment, with or without supports, for 
2.12 	school-age youth and working-age adults and referrals to the Disability Linkage Line and 
2.13 	Disability Benefits 101 to ensure that an informed choice about competitive employment 
2.14 	can be made. For the purposes of this subdivision, "competitive employment" means work 
2.15 	in the competitive labor market that is performed on a full-time or part-time basis in an 
2.16 	integrated setting, and for which an individual is compensated at or above the minimum 
2.17 	wage, but not less than the customary wage and level of benefits paid by the employer for 
2.18 	the same or similar work performed by individuals without disabilities.
2.19 	(b) Upon statewide implementation of lead agency requirements in subdivisions 2b, 2c, 
2.20 	and 3a, "long-term care consultation services" also means:
2.21 	(1) service eligibility determination for state plan home care services identified in:
2.22 	(i) section 256B.0625, subdivisions 7, 19a, and 19c;
2.23 	(ii) consumer support grants under section 256.476; or
2.24 	(iii) section 256B.85;
2.25 	(2) notwithstanding provisions in Minnesota Rules, parts 9525.0004 to 9525.0024, 
2.26 	determination of eligibility for case management services available under sections 256B.0621, 
2.27 	subdivision 2, paragraph (4), and 256B.0924 and Minnesota Rules, part 9525.0016;
2.28 	(3) determination of institutional level of care, home and community-based service 
2.29 	waiver, and other service eligibility as required under section 256B.092, determination of 
2.30 	eligibility for family support grants under section 252.32, semi-independent living services 
2.31 	under section 252.275, and day training and habilitation services under section 256B.092; 
2.32 	and
3.1 	(4) obtaining necessary diagnostic information to determine eligibility under clauses (2) 
3.2 	and (3).
3.3 	(c) "Long-term care options counseling" means the services provided by the linkage 
3.4 	lines as mandated by sections 256.01, subdivision 24, and 256.975, subdivision 7, and also 
3.5 	includes telephone assistance and follow up once a long-term care consultation assessment 
3.6 	has been completed.
3.7 	(d) "Minnesota health care programs" means the medical assistance program under this 
3.8 	chapter and the alternative care program under section 256B.0913.
3.9 	(e) "Lead agencies" means counties administering or tribes and health plans under 
3.10 	contract with the commissioner to administer long-term care consultation assessment and 
3.11 	support planning services.
3.12 	(f) "Person-centered planning" is a process that includes the active participation of a 
3.13 	person in the planning of the person's services, including in making meaningful and informed 
3.14 	choices about the person's own goals, talents, and objectives, as well as making meaningful 
3.15 	and informed choices about the services the person receives. For the purposes of this section, 
3.16 	"informed choice" means a voluntary choice of services by a person from all available 
3.17 	service options based on accurate and complete information concerning all available service 
3.18 	options and concerning the person's own preferences, abilities, goals, and objectives. In 
3.19 	order for a person to make an informed choice, all available options must be developed and 
3.20 	presented to the person to empower the person to make decisions.

3.21 	Sec. 2. Minnesota Statutes 2017 Supplement, section 256B.0911, subdivision 3a, is 
3.22 	amended to read:
3.23 		Subd. 3a.Assessment and support planning. (a) Persons requesting assessment, services 
3.24 	planning, or other assistance intended to support community-based living, including persons 
3.25 	who need assessment in order to determine waiver or alternative care program eligibility, 
3.26 	must be visited by a long-term care consultation team within 20 calendar days after the date 
3.27 	on which an assessment was requested or recommended. Upon statewide implementation 
3.28 	of subdivisions 2b, 2c, and 5, this requirement also applies to an assessment of a person 
3.29 	requesting personal care assistance services and home care nursing. The commissioner shall 
3.30 	provide at least a 90-day notice to lead agencies prior to the effective date of this requirement. 
3.31 	Face-to-face assessments must be conducted according to paragraphs (b) to (i).
4.1 	(b) Upon implementation of subdivisions 2b, 2c, and 5, lead agencies shall use certified 
4.2 	assessors to conduct the assessment. For a person with complex health care needs, a public 
4.3 	health or registered nurse from the team must be consulted.
4.4 	(c) The MnCHOICES assessment provided by the commissioner to lead agencies must 
4.5 	be used to complete a comprehensive, person-centered assessment. The assessment must 
4.6 	include the health, psychological, functional, environmental, and social needs of the 
4.7 	individual necessary to develop a community support plan that meets the individual's needs 
4.8 	and preferences.
4.9 	(d) The assessment must be conducted in a face-to-face interview with the person being 
4.10 	assessed and. The person's legal representative must provide input during the assessment 
4.11 	process and may do so remotely if requested. At the request of the person, other individuals 
4.12 	may participate in the assessment to provide information on the needs, strengths, and 
4.13 	preferences of the person necessary to develop a community support plan that ensures the 
4.14 	person's health and safety. Except for legal representatives or family members invited by 
4.15 	the person, persons participating in the assessment may not be a provider of service or have 
4.16 	any financial interest in the provision of services. For persons who are to be assessed for 
4.17 	elderly waiver customized living or adult day services under section 256B.0915, with the 
4.18 	permission of the person being assessed or the person's designated or legal representative, 
4.19 	the client's current or proposed provider of services may submit a copy of the provider's 
4.20 	nursing assessment or written report outlining its recommendations regarding the client's 
4.21 	care needs. The person conducting the assessment must notify the provider of the date by 
4.22 	which this information is to be submitted. This information shall be provided to the person 
4.23 	conducting the assessment prior to the assessment. For a person who is to be assessed for 
4.24 	waiver services under section 256B.092 or 256B.49, with the permission of the person being 
4.25 	assessed or the person's designated legal representative, the person's current provider of 
4.26 	services may submit a written report outlining recommendations regarding the person's care 
4.27 	needs prepared by a direct service employee with at least 20 hours of service to that client. 
4.28 	The person conducting the assessment or reassessment must notify the provider of the date 
4.29 	by which this information is to be submitted. This information shall be provided to the 
4.30 	person conducting the assessment and the person or the person's legal representative, and 
4.31 	must be considered prior to the finalization of the assessment or reassessment.
4.32 	(e) The person or the person's legal representative must be provided with a written 
4.33 	community support plan within 40 calendar days of the assessment visit the timelines 
4.34 	established by the commissioner, regardless of whether the individual is eligible for 
4.35 	Minnesota health care programs. The timeline for completing the community support plan 
5.1 	and any required coordinated service and support plan must not exceed 56 calendar days 
5.2 	from the assessment visit.
5.3 	(f) For a person being assessed for elderly waiver services under section 256B.0915, a 
5.4 	provider who submitted information under paragraph (d) shall receive the final written 
5.5 	community support plan when available and the Residential Services Workbook.
5.6 	(g) The written community support plan must include:
5.7 	(1) a summary of assessed needs as defined in paragraphs (c) and (d);
5.8 	(2) the individual's options and choices to meet identified needs, including all available 
5.9 	options for case management services and providers, including service provided in a 
5.10 	non-disability-specific setting;
5.11 	(3) identification of health and safety risks and how those risks will be addressed, 
5.12 	including personal risk management strategies;
5.13 	(4) referral information; and
5.14 	(5) informal caregiver supports, if applicable.
5.15 	For a person determined eligible for state plan home care under subdivision 1a, paragraph 
5.16 	(b), clause (1), the person or person's representative must also receive a copy of the home 
5.17 	care service plan developed by the certified assessor.
5.18 	(h) A person may request assistance in identifying community supports without 
5.19 	participating in a complete assessment. Upon a request for assistance identifying community 
5.20 	support, the person must be transferred or referred to long-term care options counseling 
5.21 	services available under sections 256.975, subdivision 7, and 256.01, subdivision 24, for 
5.22 	telephone assistance and follow up.
5.23 	(i) The person has the right to make the final decision between institutional placement 
5.24 	and community placement after the recommendations have been provided, except as provided 
5.25 	in section 256.975, subdivision 7a, paragraph (d).
5.26 	(j) The lead agency must give the person receiving assessment or support planning, or 
5.27 	the person's legal representative, materials, and forms supplied by the commissioner 
5.28 	containing the following information:
5.29 	(1) written recommendations for community-based services and consumer-directed 
5.30 	options;
5.31 	(2) documentation that the most cost-effective alternatives available were offered to the 
5.32 	individual. For purposes of this clause, "cost-effective" means community services and 
6.1 	living arrangements that cost the same as or less than institutional care. For an individual 
6.2 	found to meet eligibility criteria for home and community-based service programs under 
6.3 	section 256B.0915 or 256B.49, "cost-effectiveness" has the meaning found in the federally 
6.4 	approved waiver plan for each program;
6.5 	(3) the need for and purpose of preadmission screening conducted by long-term care 
6.6 	options counselors according to section 256.975, subdivisions 7a to 7c, if the person selects 
6.7 	nursing facility placement. If the individual selects nursing facility placement, the lead 
6.8 	agency shall forward information needed to complete the level of care determinations and 
6.9 	screening for developmental disability and mental illness collected during the assessment 
6.10 	to the long-term care options counselor using forms provided by the commissioner;
6.11 	(4) the role of long-term care consultation assessment and support planning in eligibility 
6.12 	determination for waiver and alternative care programs, and state plan home care, case 
6.13 	management, and other services as defined in subdivision 1a, paragraphs (a), clause (6), 
6.14 	and (b);
6.15 	(5) information about Minnesota health care programs;
6.16 	(6) the person's freedom to accept or reject the recommendations of the team;
6.17 	(7) the person's right to confidentiality under the Minnesota Government Data Practices 
6.18 	Act, chapter 13;
6.19 	(8) the certified assessor's decision regarding the person's need for institutional level of 
6.20 	care as determined under criteria established in subdivision 4e and the certified assessor's 
6.21 	decision regarding eligibility for all services and programs as defined in subdivision 1a, 
6.22 	paragraphs (a), clause (6), and (b); and
6.23 	(9) the person's right to appeal the certified assessor's decision regarding eligibility for 
6.24 	all services and programs as defined in subdivision 1a, paragraphs (a), clauses (6), (7), and 
6.25 	(8), and (b), and incorporating the decision regarding the need for institutional level of care 
6.26 	or the lead agency's final decisions regarding public programs eligibility according to section 
6.27 	256.045, subdivision 3.
6.28 	(k) Face-to-face assessment completed as part of eligibility determination for the 
6.29 	alternative care, elderly waiver, developmental disabilities, community access for disability 
6.30 	inclusion, community alternative care, and brain injury waiver programs under sections 
6.31 	256B.0913, 256B.0915, and 256B.49 is valid to establish service eligibility for no more 
6.32 	than 60 calendar days after the date of assessment.
7.1 	(l) The effective eligibility start date for programs in paragraph (k) can never be prior 
7.2 	to the date of assessment. If an assessment was completed more than 60 days before the 
7.3 	effective waiver or alternative care program eligibility start date, assessment and support 
7.4 	plan information must be updated and documented in the department's Medicaid Management 
7.5 	Information System (MMIS). Notwithstanding retroactive medical assistance coverage of 
7.6 	state plan services, the effective date of eligibility for programs included in paragraph (k) 
7.7 	cannot be prior to the date the most recent updated assessment is completed.
7.8 	(m) If an eligibility update is completed within 90 days of the previous face-to-face 
7.9 	assessment and documented in the department's Medicaid Management Information System 
7.10 	(MMIS), the effective date of eligibility for programs included in paragraph (k) is the date 
7.11 	of the previous face-to-face assessment when all other eligibility requirements are met.
7.12 	(n) At the time of reassessment, the certified assessor shall assess each person receiving 
7.13 	waiver services currently residing in a community residential setting, or licensed adult foster 
7.14 	care home that is not the primary residence of the license holder, or in which the license 
7.15 	holder is not the primary caregiver, to determine if that person would prefer to be served in 
7.16 	a community-living setting as defined in section 256B.49, subdivision 23. The certified 
7.17 	assessor shall offer the person, through a person-centered planning process, the option to 
7.18 	receive alternative housing and service options.

7.19 	Sec. 3. Minnesota Statutes 2017 Supplement, section 256B.0911, subdivision 3f, is amended 
7.20 	to read:
7.21 		Subd. 3f.Long-term care reassessments and community support plan updates.
 7.22 	Reassessments must be tailored using the professional judgment of the assessor to the 
7.23 	person's known needs, strengths, preferences, and circumstances. Reassessments provide 
7.24 	information to support the person's informed choice and opportunities to express choice 
7.25 	regarding activities that contribute to quality of life, as well as information and opportunity 
7.26 	to identify goals related to desired employment, community activities, and preferred living 
7.27 	environment. Reassessments allow for a review of the current coordinated service and 
7.28 	support plan's effectiveness, monitoring of services, and the development of an updated 
7.29 	person-centered community support plan. Reassessments verify continued eligibility or 
7.30 	offer alternatives as warranted and provide an opportunity for quality assurance of service 
7.31 	delivery. Face-to-face assessments reassessments must be conducted annually or as required 
7.32 	by federal and state laws and rules. For reassessments, the certified assessor and the individual 
7.33 	responsible for developing the coordinated service and support plan must ensure the 
7.34 	continuity of care for the person receiving services and complete the updated community 
8.1 	support plan and the updated coordinated service and support plan within the timelines 
8.2 	established by the commissioner.

8.3 	Sec. 4. Minnesota Statutes 2016, section 256B.0915, subdivision 6, is amended to read:
8.4 		Subd. 6.Implementation of coordinated service and support plan. (a) Each elderly 
8.5 	waiver client shall be provided a copy of a written coordinated service and support plan 
8.6 	which that:
8.7 	(1) is developed with and signed by the recipient within ten working days after the case 
8.8 	manager receives the assessment information and written community support plan as 
8.9 	described in section 256B.0911, subdivision 3a, from the certified assessor the timelines 
8.10 	established by the commissioner. The timeline for completing the community support plan 
8.11 	under section 256B.0911, subdivision 3a, and the coordinated service and support plan must 
8.12 	not exceed 56 calendar days from the assessment visit;
8.13 	(2) includes the person's need for service and identification of service needs that will be 
8.14 	or that are met by the person's relatives, friends, and others, as well as community services 
8.15 	used by the general public;
8.16 	(3) reasonably ensures the health and welfare of the recipient;
8.17 	(4) identifies the person's preferences for services as stated by the person or the person's 
8.18 	legal guardian or conservator;
8.19 	(5) reflects the person's informed choice between institutional and community-based 
8.20 	services, as well as choice of services, supports, and providers, including available case 
8.21 	manager providers;
8.22 	(6) identifies long-range and short-range goals for the person;
8.23 	(7) identifies specific services and the amount, frequency, duration, and cost of the 
8.24 	services to be provided to the person based on assessed needs, preferences, and available 
8.25 	resources;
8.26 	(8) includes information about the right to appeal decisions under section 256.045; and
8.27 	(9) includes the authorized annual and estimated monthly amounts for the services.
8.28 	(b) In developing the coordinated service and support plan, the case manager should 
8.29 	also include the use of volunteers, religious organizations, social clubs, and civic and service 
8.30 	organizations to support the individual in the community. The lead agency must be held 
8.31 	harmless for damages or injuries sustained through the use of volunteers and agencies under 
8.32 	this paragraph, including workers' compensation liability.

9.1 	Sec. 5. Minnesota Statutes 2016, section 256B.092, subdivision 1b, is amended to read:
9.2 		Subd. 1b.Coordinated service and support plan. (a) Each recipient of home and 
9.3 	community-based waivered services shall be provided a copy of the written coordinated 
9.4 	service and support plan which that:
9.5 	(1) is developed with and signed by the recipient within ten working days after the case 
9.6 	manager receives the assessment information and written community support plan as 
9.7 	described in section 256B.0911, subdivision 3a, from the certified assessor the timelines 
9.8 	established by the commissioner. The timeline for completing the community support plan 
9.9 	under section 256B.0911, subdivision 3a, and the coordinated service and support plan must 
9.10 	not exceed 56 calendar days from the assessment visit;
9.11 	(2) includes the person's need for service, including identification of service needs that 
9.12 	will be or that are met by the person's relatives, friends, and others, as well as community 
9.13 	services used by the general public;
9.14 	(3) reasonably ensures the health and welfare of the recipient;
9.15 	(4) identifies the person's preferences for services as stated by the person, the person's 
9.16 	legal guardian or conservator, or the parent if the person is a minor, including the person's 
9.17 	choices made on self-directed options and on services and supports to achieve employment 
9.18 	goals;
9.19 	(5) provides for an informed choice, as defined in section 256B.77, subdivision 2, 
9.20 	paragraph (o), of service and support providers, and identifies all available options for case 
9.21 	management services and providers;
9.22 	(6) identifies long-range and short-range goals for the person;
9.23 	(7) identifies specific services and the amount and frequency of the services to be provided 
9.24 	to the person based on assessed needs, preferences, and available resources. The coordinated 
9.25 	service and support plan shall also specify other services the person needs that are not 
9.26 	available;
9.27 	(8) identifies the need for an individual program plan to be developed by the provider 
9.28 	according to the respective state and federal licensing and certification standards, and 
9.29 	additional assessments to be completed or arranged by the provider after service initiation;
9.30 	(9) identifies provider responsibilities to implement and make recommendations for 
9.31 	modification to the coordinated service and support plan;
10.1 	(10) includes notice of the right to request a conciliation conference or a hearing under 
10.2 	section 256.045;
10.3 	(11) is agreed upon and signed by the person, the person's legal guardian or conservator, 
10.4 	or the parent if the person is a minor, and the authorized county representative;
10.5 	(12) is reviewed by a health professional if the person has overriding medical needs that 
10.6 	impact the delivery of services; and
10.7 	(13) includes the authorized annual and monthly amounts for the services.
10.8 	(b) In developing the coordinated service and support plan, the case manager is 
10.9 	encouraged to include the use of volunteers, religious organizations, social clubs, and civic 
10.10 	and service organizations to support the individual in the community. The lead agency must 
10.11 	be held harmless for damages or injuries sustained through the use of volunteers and agencies 
10.12 	under this paragraph, including workers' compensation liability.
10.13 	(c) Approved, written, and signed changes to a consumer's services that meet the criteria 
10.14 	in this subdivision shall be an addendum to that consumer's individual service plan.

10.15 	Sec. 6. Minnesota Statutes 2017 Supplement, section 256B.49, subdivision 13, is amended 
10.16 	to read:
10.17 		Subd. 13.Case management. (a) Each recipient of a home and community-based waiver 
10.18 	shall be provided case management services by qualified vendors as described in the federally 
10.19 	approved waiver application. The case management service activities provided must include:
10.20 	(1) finalizing the written coordinated service and support plan within ten working days 
10.21 	after the case manager receives the plan from the certified assessor the timelines established 
10.22 	by the commissioner. The timeline for completing the community support plan under section 
10.23 	256B.0911, subdivision 3a, and the coordinated service and support plan must not exceed 
10.24 	56 calendar days from the assessment visit;
10.25 	(2) informing the recipient or the recipient's legal guardian or conservator of service 
10.26 	options;
10.27 	(3) assisting the recipient in the identification of potential service providers and available 
10.28 	options for case management service and providers, including services provided in a 
10.29 	non-disability-specific setting;
10.30 	(4) assisting the recipient to access services and assisting with appeals under section 
10.31 	256.045; and
11.1 	(5) coordinating, evaluating, and monitoring of the services identified in the service 
11.2 	plan.
11.3 	(b) The case manager may delegate certain aspects of the case management service 
11.4 	activities to another individual provided there is oversight by the case manager. The case 
11.5 	manager may not delegate those aspects which require professional judgment including:
11.6 	(1) finalizing the coordinated service and support plan;
11.7 	(2) ongoing assessment and monitoring of the person's needs and adequacy of the 
11.8 	approved coordinated service and support plan; and
11.9 	(3) adjustments to the coordinated service and support plan.
11.10 	(c) Case management services must be provided by a public or private agency that is 
11.11 	enrolled as a medical assistance provider determined by the commissioner to meet all of 
11.12 	the requirements in the approved federal waiver plans. Case management services must not 
11.13 	be provided to a recipient by a private agency that has any financial interest in the provision 
11.14 	of any other services included in the recipient's coordinated service and support plan. For 
11.15 	purposes of this section, "private agency" means any agency that is not identified as a lead 
11.16 	agency under section 256B.0911, subdivision 1a, paragraph (e).
11.17 	(d) For persons who need a positive support transition plan as required in chapter 245D, 
11.18 	the case manager shall participate in the development and ongoing evaluation of the plan 
11.19 	with the expanded support team. At least quarterly, the case manager, in consultation with 
11.20 	the expanded support team, shall evaluate the effectiveness of the plan based on progress 
11.21 	evaluation data submitted by the licensed provider to the case manager. The evaluation must 
11.22 	identify whether the plan has been developed and implemented in a manner to achieve the 
11.23 	following within the required timelines:
11.24 	(1) phasing out the use of prohibited procedures;
11.25 	(2) acquisition of skills needed to eliminate the prohibited procedures within the plan's 
11.26 	timeline; and
11.27 	(3) accomplishment of identified outcomes.
11.28 	If adequate progress is not being made, the case manager shall consult with the person's 
11.29 	expanded support team to identify needed modifications and whether additional professional 
11.30 	support is required to provide consultation.