1.1 	A bill for an act
1.2 	relating to human services; modifying service plan review and evaluation 
1.3 	requirements for waiver service providers; modifying the required elements of 
1.4 	long-term care consultation services; modifying requirements for waiver case 
1.5 	management; directing the commissioner of human services to modify the 
1.6 	MnCHOICES assessment tool;amending Minnesota Statutes 2018, sections 
1.7 	256B.092, subdivision 1a; 256B.49, subdivision 16; Minnesota Statutes 2019 
1.8 	Supplement, sections 245D.071, subdivision 5; 256B.0911, subdivisions 1a, 3a; 
1.9 	256B.092, subdivision 1b; 256B.49, subdivisions 13, 14.
1.10 	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

1.11 	Section 1. Minnesota Statutes 2019 Supplement, section 245D.071, subdivision 5, is 
1.12 	amended to read:
1.13 		Subd. 5.Service plan review and evaluation. (a) The license holder must give the 
1.14 	person or the person's legal representative and case manager an opportunity to participate 
1.15 	in the ongoing review and development of the service plan and the methods used to support 
1.16 	the person and accomplish outcomes identified in subdivisions 3 and 4. At least once per 
1.17 	year, or within 30 days of a written request by the person, the person's legal representative, 
1.18 	or the case manager, the license holder, in coordination with the person's support team or 
1.19 	expanded support team, must meet with the person, the person's legal representative, and 
1.20 	the case manager, and participate in service plan review meetings following stated timelines 
1.21 	established in the person's coordinated service and support plan or coordinated service and 
1.22 	support plan addendum. The purpose of the service plan review is to determine whether 
1.23 	changes are needed to the service plan based on the assessment information, the license 
1.24 	holder's evaluation of progress towards toward accomplishing outcomes, or other information 
1.25 	provided by the support team or expanded support team.
2.1 	(b) At least once per year, the license holder, in coordination with the person's support 
2.2 	team or expanded support team, must meet with the person, the person's legal representative, 
2.3 	and the case manager to discuss how technology might be used to meet the person's desired 
2.4 	outcomes. The coordinated service and support plan addendum must include a summary of 
2.5 	this discussion. The summary must include a statement regarding any decision made related 
2.6 	to the use of technology and a description of any further research that must be completed 
2.7 	before a decision regarding the use of technology can be made. Nothing in this paragraph 
2.8 	requires the coordinated service and support plan addendum to include the use of technology 
2.9 	for the provision of services.
2.10 	(c) At least once per year, the license holder, in coordination with the person's support 
2.11 	team or expanded support team, must meet with a person receiving residential supports and 
2.12 	services, the person's legal representative, and the case manager to discuss options for:
2.13 	(1) transitioning out of a community residential setting, family adult foster care residence, 
2.14 	or supervised living facility and into a community-living setting as defined under section 
2.15 	256B.49, subdivision 23; and
2.16 	(2) transitioning from residential supports and services as described in section 245D.03, 
2.17 	subdivision 1, paragraph (c), clause (3), to integrated community supports as described in 
2.18 	section 245D.03, subdivision 1, paragraph (c), clause (8).
2.19 	(d) The coordinated service and support plan addendum must include a summary of the 
2.20 	discussion required in paragraph (c). The summary must include a statement about any 
2.21 	decision made regarding clauses (1) and (2) and a description of any further research that 
2.22 	must be completed before a decision regarding clauses (1) and (2) can be made.
2.23 	(e) At least once per year, the license holder, in coordination with the person's support 
2.24 	team or expanded support team, must meet with a person receiving day services, the person's 
2.25 	legal representative, and the case manager to discuss options for transitioning to an 
2.26 	employment service described in section 245D.03, subdivision 1, paragraph (c), clauses (5) 
2.27 	to (7).
2.28 	(f) The coordinated service and support plan addendum must include a summary of the 
2.29 	discussion required in paragraph (e). The summary must include a statement about any 
2.30 	decision made concerning transition to an employment service and a description of any 
2.31 	further research that must be completed before a decision regarding transitioning to an 
2.32 	employment service can be made.
2.33 	(g) The license holder must summarize the person's status and progress toward achieving 
2.34 	the identified outcomes and make recommendations and identify the rationale for changing, 
3.1 	continuing, or discontinuing implementation of supports and methods identified in 
3.2 	subdivision 4 in a report available at the time of the progress review meeting. The report 
3.3 	must be sent at least five working days prior to the progress review meeting if requested by 
3.4 	the team in the coordinated service and support plan or coordinated service and support 
3.5 	plan addendum.
3.6 	(d) (h) The license holder must send the coordinated service and support plan addendum 
3.7 	to the person, the person's legal representative, and the case manager by mail within ten 
3.8 	working days of the progress review meeting. Within ten working days of the mailing of 
3.9 	the coordinated service and support plan addendum, the license holder must obtain dated 
3.10 	signatures from the person or the person's legal representative and the case manager to 
3.11 	document approval of any changes to the coordinated service and support plan addendum.
3.12 	(e) (i) If, within ten working days of submitting changes to the coordinated service and 
3.13 	support plan and coordinated service and support plan addendum, the person or the person's 
3.14 	legal representative or case manager has not signed and returned to the license holder the 
3.15 	coordinated service and support plan or coordinated service and support plan addendum or 
3.16 	has not proposed written modifications to the license holder's submission, the submission 
3.17 	is deemed approved and the coordinated service and support plan addendum becomes 
3.18 	effective and remains in effect until the legal representative or case manager submits a 
3.19 	written request to revise the coordinated service and support plan addendum.

3.20 	Sec. 2. Minnesota Statutes 2019 Supplement, section 256B.0911, subdivision 1a, is 
3.21 	amended to read:
3.22 		Subd. 1a.Definitions. For purposes of this section, the following definitions apply:
3.23 	(a) Until additional requirements apply under paragraph (b), "long-term care consultation 
3.24 	services" means:
3.25 	(1) intake for and access to assistance in identifying services needed to maintain an 
3.26 	individual in the most inclusive environment;
3.27 	(2) providing recommendations for and referrals to cost-effective community services 
3.28 	that are available to the individual;
3.29 	(3) development of an individual's person-centered community support plan;
3.30 	(4) providing information regarding eligibility for Minnesota health care programs;
4.1 	(5) face-to-face long-term care consultation assessments, which may be completed in a 
4.2 	hospital, nursing facility, intermediate care facility for persons with developmental disabilities 
4.3 	(ICF/DDs), regional treatment centers, or the person's current or planned residence;
4.4 	(6) determination of home and community-based waiver and other service eligibility as 
4.5 	required under chapter 256S and sections 256B.0913, 256B.092, and 256B.49, including 
4.6 	level of care determination for individuals who need an institutional level of care as 
4.7 	determined under subdivision 4e, based on assessment and community support plan 
4.8 	development, appropriate referrals to obtain necessary diagnostic information, and including 
4.9 	an eligibility determination for consumer-directed community supports;
4.10 	(7) providing recommendations for institutional placement when there are no 
4.11 	cost-effective community services available;
4.12 	(8) providing access to assistance to transition people back to community settings after 
4.13 	institutional admission; and
4.14 	(9) providing information about competitive employment, with or without supports, for 
4.15 	school-age youth and working-age adults and referrals to the Disability Linkage Line and 
4.16 	Disability Benefits 101 to ensure that an informed choice about competitive employment 
4.17 	can be made. For the purposes of this subdivision, "competitive employment" means work 
4.18 	in the competitive labor market that is performed on a full-time or part-time basis in an 
4.19 	integrated setting, and for which an individual is compensated at or above the minimum 
4.20 	wage, but not less than the customary wage and level of benefits paid by the employer for 
4.21 	the same or similar work performed by individuals without disabilities.;
4.22 	(10) providing information about independent living to ensure that a fully informed 
4.23 	choice about independent living can be made; and
4.24 	(11) providing information about self-directed services and supports, including 
4.25 	self-directed funding options, to ensure that a fully informed choice about self-directed 
4.26 	options can be made.
4.27 	(b) Upon statewide implementation of lead agency requirements in subdivisions 2b, 2c, 
4.28 	and 3a, "long-term care consultation services" also means:
4.29 	(1) service eligibility determination for the following state plan services identified in:
4.30 	(i) personal care assistance services under section 256B.0625, subdivisions 19a and 19c;
4.31 	(ii) consumer support grants under section 256.476; or
4.32 	(iii) community first services and supports under section 256B.85;
5.1 	(2) notwithstanding provisions in Minnesota Rules, parts 9525.0004 to 9525.0024, 
5.2 	gaining access to case management services available under sections 256B.0621, subdivision 
5.3 	2, clause (4), 256B.0924, and Minnesota Rules, part 9525.0016;
5.4 	(3) determination of eligibility for semi-independent living services under section 
5.5 	252.275; and
5.6 	(4) obtaining necessary diagnostic information to determine eligibility under clauses (2) 
5.7 	and (3).
5.8 	(c) "Long-term care options counseling" means the services provided by the linkage 
5.9 	lines as mandated by sections 256.01, subdivision 24, and 256.975, subdivision 7, and also 
5.10 	includes telephone assistance and follow up once a long-term care consultation assessment 
5.11 	has been completed.
5.12 	(d) "Minnesota health care programs" means the medical assistance program under this 
5.13 	chapter and the alternative care program under section 256B.0913.
5.14 	(e) "Lead agencies" means counties administering or tribes and health plans under 
5.15 	contract with the commissioner to administer long-term care consultation assessment and 
5.16 	support planning services.
5.17 	(f) "Person-centered planning" is a process that includes the active participation of a 
5.18 	person in the planning of the person's services, including in making meaningful and informed 
5.19 	choices about the person's own goals, talents, and objectives, as well as making meaningful 
5.20 	and informed choices about the services the person receives. For the purposes of this section, 
5.21 	the settings in which the person receives them, and the setting in which the person lives.
5.22 	(g) "Informed choice" means a voluntary choice of services, settings, and living 
5.23 	arrangement  by a person from all available service and setting options based on accurate 
5.24 	and complete information concerning all available service and setting options and concerning 
5.25 	the person's own preferences, abilities, goals, and objectives. In order for a person to make 
5.26 	an informed choice, all available options must be developed and presented to the person in 
5.27 	a way the person can understand to empower the person to make decisions fully informed 
5.28 	choices.
5.29 	(h) "Available service and setting options"  or "available options," with respect to the 
5.30 	home and community-based waivers under chapter 256S and sections 256B.092 and 256B.49, 
5.31 	means all services and settings defined under the waiver plans.
5.32 	(i) "Independent living" means living in a setting that is not an institution, a community 
5.33 	residential setting, a family adult foster care residence, or a supervised living facility.

6.1 	Sec. 3. Minnesota Statutes 2019 Supplement, section 256B.0911, subdivision 3a, is 
6.2 	amended to read:
6.3 		Subd. 3a.Assessment and support planning. (a) Persons requesting assessment, services 
6.4 	planning, or other assistance intended to support community-based living, including persons 
6.5 	who need assessment in order to determine waiver or alternative care program eligibility, 
6.6 	must be visited by a long-term care consultation team within 20 calendar days after the date 
6.7 	on which an assessment was requested or recommended. Upon statewide implementation 
6.8 	of subdivisions 2b, 2c, and 5, this requirement also applies to an assessment of a person 
6.9 	requesting personal care assistance services. Face-to-face assessments must be conducted 
6.10 	according to paragraphs (b) to (i).
6.11 	(b) Upon implementation of subdivisions 2b, 2c, and 5, lead agencies shall use certified 
6.12 	assessors to conduct the assessment. For a person with complex health care needs, a public 
6.13 	health or registered nurse from the team must be consulted.
6.14 	(c) The MnCHOICES assessment provided by the commissioner to lead agencies must 
6.15 	be used to complete a comprehensive, conversation-based, person-centered assessment. 
6.16 	The assessment must include the health, psychological, functional, environmental, and 
6.17 	social needs of the individual necessary to develop a person-centered community support 
6.18 	plan that meets the individual's needs and preferences.
6.19 	(d) The assessment must be conducted in a face-to-face conversational interview with 
6.20 	the person being assessed. The person's legal representative must provide input during the 
6.21 	assessment process and may do so remotely if requested. At the request of the person, other 
6.22 	individuals may participate in the assessment to provide information on the needs, strengths, 
6.23 	and preferences of the person necessary to develop a community support plan that ensures 
6.24 	the person's health and safety. Except for legal representatives or family members invited 
6.25 	by the person, persons participating in the assessment may not be a provider of service or 
6.26 	have any financial interest in the provision of services. For persons who are to be assessed 
6.27 	for elderly waiver customized living or adult day services under chapter 256S, with the 
6.28 	permission of the person being assessed or the person's designated or legal representative, 
6.29 	the client's current or proposed provider of services may submit a copy of the provider's 
6.30 	nursing assessment or written report outlining its recommendations regarding the client's 
6.31 	care needs. The person conducting the assessment must notify the provider of the date by 
6.32 	which this information is to be submitted. This information shall be provided to the person 
6.33 	conducting the assessment prior to the assessment. For a person who is to be assessed for 
6.34 	waiver services under section 256B.092 or 256B.49, with the permission of the person being 
6.35 	assessed or the person's designated legal representative, the person's current provider of 
7.1 	services may submit a written report outlining recommendations regarding the person's care 
7.2 	needs the person completed in consultation with someone who is known to the person and 
7.3 	has interaction with the person on a regular basis. The provider must submit the report at 
7.4 	least 60 days before the end of the person's current service agreement. The certified assessor 
7.5 	must consider the content of the submitted report prior to finalizing the person's assessment 
7.6 	or reassessment.
7.7 	(e) The certified assessor and the individual responsible for developing the coordinated 
7.8 	service and support plan must complete the community support plan and the coordinated 
7.9 	service and support plan no more than 60 calendar days from the assessment visit. The 
7.10 	person or the person's legal representative must be provided with a written community 
7.11 	support plan within the timelines established by the commissioner, regardless of whether 
7.12 	the person is eligible for Minnesota health care programs.
7.13 	(f) For a person being assessed for elderly waiver services under chapter 256S, a provider 
7.14 	who submitted information under paragraph (d) shall receive the final written community 
7.15 	support plan when available and the Residential Services Workbook.
7.16 	(g) The written community support plan must include:
7.17 	(1) a summary of assessed needs as defined in paragraphs (c) and (d);
7.18 	(2) the individual's options and choices to meet identified needs, including:
7.19 	(i) all available options for case management services and providers, including;
7.20 	(ii) all available options for employment services, settings, and providers;
7.21 	(iii) all available options for living arrangements;
7.22 	(iv) all available options for self-directed services and supports, including self-directed 
7.23 	budget options; and
7.24 	(v) service provided in a non-disability-specific nondisability-specific setting;
7.25 	(3) identification of health and safety risks and how those risks will be addressed, 
7.26 	including personal risk management strategies;
7.27 	(4) referral information; and
7.28 	(5) informal caregiver supports, if applicable.
7.29 	For a person determined eligible for state plan home care under subdivision 1a, paragraph 
7.30 	(b), clause (1), the person or person's representative must also receive a copy of the home 
7.31 	care service plan developed by the certified assessor.
8.1 	(h) A person may request assistance in identifying community supports without 
8.2 	participating in a complete assessment. Upon a request for assistance identifying community 
8.3 	support, the person must be transferred or referred to long-term care options counseling 
8.4 	services available under sections 256.975, subdivision 7, and 256.01, subdivision 24, for 
8.5 	telephone assistance and follow up.
8.6 	(i) The person has the right to make the final decision:
8.7 	(1) between institutional placement and community placement after the recommendations 
8.8 	have been provided, except as provided in section 256.975, subdivision 7a, paragraph (d).;
8.9 	(2) between living in a community residential setting as defined in section 245D.02, 
8.10 	subdivision 4a, and available options for living independently after the recommendations 
8.11 	have been provided; and
8.12 	(3) regarding available options for self-directed services and supports, including 
8.13 	self-directed funding options.
8.14 	(j) The lead agency must give the person receiving assessment or support planning, or 
8.15 	the person's legal representative, materials, and forms supplied by the commissioner 
8.16 	containing the following information:
8.17 	(1) written recommendations for community-based services and consumer-directed 
8.18 	options;
8.19 	(2) documentation that the most cost-effective alternatives available were offered to the 
8.20 	individual. For purposes of this clause, "cost-effective" means community services and 
8.21 	living arrangements that cost the same as or less than institutional care. For an individual 
8.22 	found to meet eligibility criteria for home and community-based service programs under 
8.23 	chapter 256S or section 256B.49, "cost-effectiveness" has the meaning found in the federally 
8.24 	approved waiver plan for each program;
8.25 	(3) the need for and purpose of preadmission screening conducted by long-term care 
8.26 	options counselors according to section 256.975, subdivisions 7a to 7c, if the person selects 
8.27 	nursing facility placement. If the individual selects nursing facility placement, the lead 
8.28 	agency shall forward information needed to complete the level of care determinations and 
8.29 	screening for developmental disability and mental illness collected during the assessment 
8.30 	to the long-term care options counselor using forms provided by the commissioner;
8.31 	(4) the role of long-term care consultation assessment and support planning in eligibility 
8.32 	determination for waiver and alternative care programs, and state plan home care, case 
9.1 	management, and other services as defined in subdivision 1a, paragraphs (a), clause (6), 
9.2 	and (b);
9.3 	(5) information about Minnesota health care programs;
9.4 	(6) the person's freedom to accept or reject the recommendations of the team;
9.5 	(7) the person's right to confidentiality under the Minnesota Government Data Practices 
9.6 	Act, chapter 13;
9.7 	(8) the certified assessor's decision regarding the person's need for institutional level of 
9.8 	care as determined under criteria established in subdivision 4e and the certified assessor's 
9.9 	decision regarding eligibility for all services and programs as defined in subdivision 1a, 
9.10 	paragraphs (a), clause (6), and (b); and
9.11 	(9) the person's right to appeal the certified assessor's decision regarding eligibility for 
9.12 	all services and programs as defined in subdivision 1a, paragraphs (a), clauses (6), (7), and 
9.13 	(8), and (b), and incorporating the decision regarding the need for institutional level of care 
9.14 	or the lead agency's final decisions regarding public programs eligibility according to section 
9.15 	256.045, subdivision 3. The certified assessor must verbally communicate this appeal right 
9.16 	to the person and must visually point out where in the document the right to appeal is stated.; 
9.17 	and
9.18 	(10) documentation that available options for employment services, independent living, 
9.19 	and self-directed services and supports were offered to the individual.
9.20 	(k) Face-to-face assessment completed as part of eligibility determination for the 
9.21 	alternative care, elderly waiver, developmental disabilities, community access for disability 
9.22 	inclusion, community alternative care, and brain injury waiver programs under chapter 256S
9.23 	and sections 256B.0913, 256B.092, and 256B.49 is valid to establish service eligibility for 
9.24 	no more than 60 calendar days after the date of assessment.
9.25 	(l) The effective eligibility start date for programs in paragraph (k) can never be prior 
9.26 	to the date of assessment. If an assessment was completed more than 60 days before the 
9.27 	effective waiver or alternative care program eligibility start date, assessment and support 
9.28 	plan information must be updated and documented in the department's Medicaid Management 
9.29 	Information System (MMIS). Notwithstanding retroactive medical assistance coverage of 
9.30 	state plan services, the effective date of eligibility for programs included in paragraph (k) 
9.31 	cannot be prior to the date the most recent updated assessment is completed.
9.32 	(m) If an eligibility update is completed within 90 days of the previous face-to-face 
9.33 	assessment and documented in the department's Medicaid Management Information System 
10.1 	(MMIS), the effective date of eligibility for programs included in paragraph (k) is the date 
10.2 	of the previous face-to-face assessment when all other eligibility requirements are met.
10.3 	(n) At the time of reassessment, the certified assessor shall assess each person receiving 
10.4 	waiver residential supports and services currently residing in a community residential setting, 
10.5 	or licensed adult foster care home that is not the primary residence of the license holder, or 
10.6 	in which the license holder is not the primary caregiver, family adult foster care residence, 
10.7 	or supervised living facility to determine if that person would prefer to be served in a 
10.8 	community-living setting as defined in section 256B.49, subdivision 23, or to receive 
10.9 	integrated community supports as described in section 245D.03, subdivision 1, paragraph 
10.10 	(c), clause (8). The certified assessor shall offer the person, through a person-centered 
10.11 	planning process, the option to receive alternative housing and service options.
10.12 	(o) At the time of reassessment, the certified assessor shall assess each person receiving 
10.13 	waiver day services to determine if that person would prefer to receive employment services 
10.14 	as described in section 245D.03, subdivision 1, paragraph (c), clauses (5) to (7). The certified 
10.15 	assessor shall offer the person through a person-centered planning process the option to 
10.16 	receive employment services.
10.17 	(p) At the time of reassessment, the certified assessor shall assess each person receiving 
10.18 	nonself-directed waiver services to determine if that person would prefer an available service 
10.19 	and setting option that would permit self-directed services and supports. The certified 
10.20 	assessor shall offer the person through a person-centered planning process the option to 
10.21 	receive self-directed services and supports.

10.22 	Sec. 4. Minnesota Statutes 2018, section 256B.092, subdivision 1a, is amended to read:
10.23 		Subd. 1a.Case management services. (a) Each recipient of a home and community-based 
10.24 	waiver shall be provided case management services by qualified vendors as described in 
10.25 	the federally approved waiver application.
10.26 	(b) Case management service activities provided to or arranged for a person include:
10.27 	(1) development of the person-centered coordinated service and support plan under 
10.28 	subdivision 1b;
10.29 	(2) informing the individual or the individual's legal guardian or conservator, or parent 
10.30 	if the person is a minor, of service options, including all service options available under the 
10.31 	waiver plan;
10.32 	(3) consulting with relevant medical experts or service providers;
11.1 	(4) assisting the person in the identification of potential providers, including:
11.2 	(i) providers of services provided in a non-disability-specific nondisability-specific
11.3 	setting;
11.4 	(ii) employment service providers;
11.5 	(iii) providers of services provided in settings that are not community residential settings; 
11.6 	and
11.7 	(iv) providers of financial management services;
11.8 	(5) assisting the person to access services and assisting in appeals under section 256.045;
11.9 	(6) coordination of services, if coordination is not provided by another service provider;
11.10 	(7) evaluation and monitoring of the services identified in the coordinated service and 
11.11 	support plan, which must incorporate at least one annual face-to-face visit by the case 
11.12 	manager with each person; and
11.13 	(8) reviewing coordinated service and support plans and providing the lead agency with 
11.14 	recommendations for service authorization based upon the individual's needs identified in 
11.15 	the coordinated service and support plan.
11.16 	(c) Case management service activities that are provided to the person with a 
11.17 	developmental disability shall be provided directly by county agencies or under contract. 
11.18 	Case management services must be provided by a public or private agency that is enrolled 
11.19 	as a medical assistance provider determined by the commissioner to meet all of the 
11.20 	requirements in the approved federal waiver plans. Case management services must not be 
11.21 	provided to a recipient by a private agency that has a financial interest in the provision of 
11.22 	any other services included in the recipient's coordinated service and support plan. For 
11.23 	purposes of this section, "private agency" means any agency that is not identified as a lead 
11.24 	agency under section 256B.0911, subdivision 1a, paragraph (e).
11.25 	(d) Case managers are responsible for service provisions listed in paragraphs (a) and 
11.26 	(b). Case managers shall collaborate with consumers, families, legal representatives, and 
11.27 	relevant medical experts and service providers in the development and annual review of the 
11.28 	person-centered coordinated service and support plan and habilitation plan.
11.29 	(e) For persons who need a positive support transition plan as required in chapter 245D, 
11.30 	the case manager shall participate in the development and ongoing evaluation of the plan 
11.31 	with the expanded support team. At least quarterly, the case manager, in consultation with 
11.32 	the expanded support team, shall evaluate the effectiveness of the plan based on progress 
12.1 	evaluation data submitted by the licensed provider to the case manager. The evaluation must 
12.2 	identify whether the plan has been developed and implemented in a manner to achieve the 
12.3 	following within the required timelines:
12.4 	(1) phasing out the use of prohibited procedures;
12.5 	(2) acquisition of skills needed to eliminate the prohibited procedures within the plan's 
12.6 	timeline; and
12.7 	(3) accomplishment of identified outcomes.
12.8 	If adequate progress is not being made, the case manager shall consult with the person's 
12.9 	expanded support team to identify needed modifications and whether additional professional 
12.10 	support is required to provide consultation.
12.11 	(f) The Department of Human Services shall offer ongoing education in case management 
12.12 	to case managers. Case managers shall receive no less than ten hours of case management 
12.13 	education and disability-related training each year. The education and training must include 
12.14 	person-centered planning. For the purposes of this section, "person-centered planning" or 
12.15 	"person-centered" has the meaning given in section 256B.0911, subdivision 1a, paragraph 
12.16 	(f).

12.17 	Sec. 5. Minnesota Statutes 2019 Supplement, section 256B.092, subdivision 1b, is amended 
12.18 	to read:
12.19 		Subd. 1b.Coordinated service and support plan. (a) Each recipient of home and 
12.20 	community-based waivered services shall be provided a copy of the written person-centered 
12.21 	coordinated service and support plan that:
12.22 	(1) is developed with and signed by the recipient within the timelines established by the 
12.23 	commissioner and section 256B.0911, subdivision 3a, paragraph (e);
12.24 	(2) includes the person's need for service, including identification of service needs that 
12.25 	will be or that are met by the person's relatives, friends, and others, as well as community 
12.26 	services used by the general public;
12.27 	(3) reasonably ensures the health and welfare of the recipient;
12.28 	(4) identifies the person's preferences for services as stated by the person, the person's 
12.29 	legal guardian or conservator, or the parent if the person is a minor, including the person's 
12.30 	choices made on self-directed options and on, services and supports to achieve employment 
12.31 	goals, and living arrangements;
13.1 	(5) provides for an informed choice, as defined in section 256B.77, subdivision 2, 
13.2 	paragraph (o), of service and support providers, and identifies all available options for case 
13.3 	management services and providers;
13.4 	(6) identifies long-range and short-range goals for the person;
13.5 	(7) identifies specific services and the amount and frequency of the services to be provided 
13.6 	to the person based on assessed needs, preferences, and available resources. The 
13.7 	person-centered coordinated service and support plan shall also specify other services the 
13.8 	person needs that are not available;
13.9 	(8) identifies the need for an individual program plan to be developed by the provider 
13.10 	according to the respective state and federal licensing and certification standards, and 
13.11 	additional assessments to be completed or arranged by the provider after service initiation;
13.12 	(9) identifies provider responsibilities to implement and make recommendations for 
13.13 	modification to the coordinated service and support plan;
13.14 	(10) includes notice of the right to request a conciliation conference or a hearing under 
13.15 	section 256.045;
13.16 	(11) is agreed upon and signed by the person, the person's legal guardian or conservator, 
13.17 	or the parent if the person is a minor, and the authorized county representative;
13.18 	(12) is reviewed by a health professional if the person has overriding medical needs that 
13.19 	impact the delivery of services; and
13.20 	(13) includes the authorized annual and monthly amounts for the services.
13.21 	(b) In developing the person-centered coordinated service and support plan, the case 
13.22 	manager is encouraged to include the use of volunteers, religious organizations, social clubs, 
13.23 	and civic and service organizations to support the individual in the community. The lead 
13.24 	agency must be held harmless for damages or injuries sustained through the use of volunteers 
13.25 	and agencies under this paragraph, including workers' compensation liability.
13.26 	(c) Approved, written, and signed changes to a consumer's services that meet the criteria 
13.27 	in this subdivision shall be an addendum to that consumer's individual service plan.

13.28 	Sec. 6. Minnesota Statutes 2019 Supplement, section 256B.49, subdivision 13, is amended 
13.29 	to read:
13.30 		Subd. 13.Case management. (a) Each recipient of a home and community-based waiver 
13.31 	shall be provided case management services by qualified vendors as described in the federally 
13.32 	approved waiver application. The case management service activities provided must include:
14.1 	(1) finalizing the person-centered written coordinated service and support plan within 
14.2 	the timelines established by the commissioner and section 256B.0911, subdivision 3a, 
14.3 	paragraph (e);
14.4 	(2) informing the recipient or the recipient's legal guardian or conservator of service 
14.5 	options, including all service options available under the waiver plans;
14.6 	(3) assisting the recipient in the identification of potential service providers and, including:
14.7 	(i) available options for case management service and providers, including;
14.8 	(ii) providers of services provided in a non-disability-specific nondisability-specific
14.9 	setting;
14.10 	(iii) employment service providers;
14.11 	(iv) providers of services provided in settings that are not community residential settings; 
14.12 	and
14.13 	(v) providers of financial management services;
14.14 	(4) assisting the recipient to access services and assisting with appeals under section 
14.15 	256.045; and
14.16 	(5) coordinating, evaluating, and monitoring of the services identified in the service 
14.17 	plan.
14.18 	(b) The case manager may delegate certain aspects of the case management service 
14.19 	activities to another individual provided there is oversight by the case manager. The case 
14.20 	manager may not delegate those aspects which require professional judgment including:
14.21 	(1) finalizing the person-centered coordinated service and support plan;
14.22 	(2) ongoing assessment and monitoring of the person's needs and adequacy of the 
14.23 	approved person-centered coordinated service and support plan; and
14.24 	(3) adjustments to the person-centered coordinated service and support plan.
14.25 	(c) Case management services must be provided by a public or private agency that is 
14.26 	enrolled as a medical assistance provider determined by the commissioner to meet all of 
14.27 	the requirements in the approved federal waiver plans. Case management services must not 
14.28 	be provided to a recipient by a private agency that has any financial interest in the provision 
14.29 	of any other services included in the recipient's coordinated service and support plan. For 
14.30 	purposes of this section, "private agency" means any agency that is not identified as a lead 
14.31 	agency under section 256B.0911, subdivision 1a, paragraph (e).
15.1 	(d) For persons who need a positive support transition plan as required in chapter 245D, 
15.2 	the case manager shall participate in the development and ongoing evaluation of the plan 
15.3 	with the expanded support team. At least quarterly, the case manager, in consultation with 
15.4 	the expanded support team, shall evaluate the effectiveness of the plan based on progress 
15.5 	evaluation data submitted by the licensed provider to the case manager. The evaluation must 
15.6 	identify whether the plan has been developed and implemented in a manner to achieve the 
15.7 	following within the required timelines:
15.8 	(1) phasing out the use of prohibited procedures;
15.9 	(2) acquisition of skills needed to eliminate the prohibited procedures within the plan's 
15.10 	timeline; and
15.11 	(3) accomplishment of identified outcomes.
15.12 	If adequate progress is not being made, the case manager shall consult with the person's 
15.13 	expanded support team to identify needed modifications and whether additional professional 
15.14 	support is required to provide consultation.
15.15 	(e) The Department of Human Services shall offer ongoing education in case management 
15.16 	to case managers. Case managers shall receive no less than ten hours of case management 
15.17 	education and disability-related training each year. The education and training must include 
15.18 	person-centered planning. For the purposes of this section, "person-centered planning" or 
15.19 	"person-centered" has the meaning given in section 256B.0911, subdivision 1a, paragraph 
15.20 	(f).

15.21 	Sec. 7. Minnesota Statutes 2019 Supplement, section 256B.49, subdivision 14, is amended 
15.22 	to read:
15.23 		Subd. 14.Assessment and reassessment. (a) Assessments and reassessments shall be 
15.24 	conducted by certified assessors according to section 256B.0911, subdivision 2b. The 
15.25 	certified assessor, with the permission of the recipient or the recipient's designated legal 
15.26 	representative, may invite other individuals to attend the assessment. With the permission 
15.27 	of the recipient or the recipient's designated legal representative, the recipient's current 
15.28 	provider of services may submit a written report outlining their recommendations regarding 
15.29 	the recipient's care needs prepared by a direct service employee who is familiar with the 
15.30 	person. The provider must submit the report at least 60 days before the end of the person's 
15.31 	current service agreement. The certified assessor must consider the content of the submitted 
15.32 	report prior to finalizing the person's assessment or reassessment.
16.1 	(b) There must be a determination that the client requires a hospital level of care or a 
16.2 	nursing facility level of care as defined in section 256B.0911, subdivision 4e, at initial and 
16.3 	subsequent assessments to initiate and maintain participation in the waiver program.
16.4 	(c) Regardless of other assessments identified in section 144.0724, subdivision 4, as 
16.5 	appropriate to determine nursing facility level of care for purposes of medical assistance 
16.6 	payment for nursing facility services, only face-to-face assessments conducted according 
16.7 	to section 256B.0911, subdivisions 3a, 3b, and 4d, that result in a hospital level of care 
16.8 	determination or a nursing facility level of care determination must be accepted for purposes 
16.9 	of initial and ongoing access to waiver services payment.
16.10 	(d) Recipients who are found eligible for home and community-based services under 
16.11 	this section before their 65th birthday may remain eligible for these services after their 65th 
16.12 	birthday if they continue to meet all other eligibility factors.
16.13 	(e) At the time of reassessment, the certified assessor shall assess each person receiving 
16.14 	waiver residential supports and services currently residing in a community residential setting, 
16.15 	family adult foster care residence, or supervised living facility to determine if that person 
16.16 	would prefer to be served in a community-living setting as defined in subdivision 23 or to 
16.17 	receive integrated community supports as described in section 245D.03, subdivision 1, 
16.18 	paragraph (c), clause (8). The certified assessor shall offer the person through a 
16.19 	person-centered planning process the option to receive alternative housing and service 
16.20 	options.
16.21 	(f) At the time of reassessment, the certified assessor shall assess each person receiving 
16.22 	waiver day services to determine if that person would prefer to receive employment services 
16.23 	as described in section 245D.03, subdivision 1, paragraph (c), clauses (5) to (7). The certified 
16.24 	assessor shall offer the person through a person-centered planning process the option to 
16.25 	receive employment services.
16.26 	(g) At the time of reassessment, the certified assessor shall assess each person receiving 
16.27 	nonself-directed waiver services to determine if that person would prefer an available service 
16.28 	and setting option that would permit self-directed services and supports. The certified 
16.29 	assessor shall offer the person through a person-centered planning process the option to 
16.30 	receive self-directed services and supports.

16.31 	Sec. 8. Minnesota Statutes 2018, section 256B.49, subdivision 16, is amended to read:
16.32 		Subd. 16.Services and supports. (a) Services and supports included in the home and 
16.33 	community-based waivers for persons with disabilities shall meet the requirements set out 
17.1 	in United States Code, title 42, section 1396n. The services and supports, which are offered 
17.2 	as alternatives to institutional care, shall promote consumer choice, community inclusion, 
17.3 	self-sufficiency, and self-determination.
17.4 	(b) Beginning January 1, 2003, the commissioner shall simplify and improve access to 
17.5 	home and community-based waivered services, to the extent possible, through the 
17.6 	establishment of a common service menu that is available to eligible recipients regardless 
17.7 	of age, disability type, or waiver program.
17.8 	(c) Consumer directed community support services shall be offered as an option to all 
17.9 	persons eligible for services under subdivision 11, by January 1, 2002.
17.10 	(d) Services and supports shall be arranged and provided consistent with individualized 
17.11 	written plans of care for eligible waiver recipients.
17.12 	(e) A transitional supports allowance shall be available to all persons under a home and 
17.13 	community-based waiver who are moving from a licensed setting to a community
17.14 	community-living setting or who are transitioning from residential supports and services to 
17.15 	integrated community supports. "Transitional supports allowance" means a onetime payment 
17.16 	of up to $3,000, to cover the costs, not covered by other sources, associated with moving 
17.17 	from a licensed setting to a community community-living setting or a setting in which the 
17.18 	provision of integrated community supports are permitted under the waiver plans. Covered 
17.19 	costs include:
17.20 	(1) lease or rent deposits;
17.21 	(2) security deposits;
17.22 	(3) utilities setup costs, including telephone;
17.23 	(4) essential furnishings and supplies; and
17.24 	(5) personal supports and transports needed to locate and transition to community settings.
17.25 	(f) The state of Minnesota and county agencies that administer home and 
17.26 	community-based waivered services for persons with disabilities, shall not be liable for 
17.27 	damages, injuries, or liabilities sustained through the purchase of supports by the individual, 
17.28 	the individual's family, legal representative, or the authorized representative with funds 
17.29 	received through the consumer-directed community support service under this section. 
17.30 	Liabilities include but are not limited to: workers' compensation liability, the Federal 
17.31 	Insurance Contributions Act (FICA), or the Federal Unemployment Tax Act (FUTA).

18.1 	Sec. 9. DIRECTION TO COMMISSIONER OF HUMAN SERVICES; 
18.2 	ASSESSMENTS AND CASE MANAGEMENT.
 18.3 		Subdivision 1.Update MnCHOICES. By January 1, 2021, the commissioner of human 
18.4 	services shall make the MnCHOICES assessment tool consistent with state and federal 
18.5 	statutes and rules, including the requirements of Minnesota Statutes, section 256B.0911, 
18.6 	subdivision 3a, paragraphs (n) to (p).
18.7 		Subd. 2.Implement person-centered planning procedures. By January 1, 2021, the 
18.8 	commissioner shall implement required procedures that certified assessors and case managers 
18.9 	must follow when conducting person-centered planning. The procedures must ensure that 
18.10 	waiver participants are fully informed of all the service and setting options available under 
18.11 	the waiver plans and that each waiver participant can make a fully informed choice regarding 
18.12 	employment, living arrangement, and self-directed services.
18.13 		Subd. 3.Implement informed decision-making process. By January 1, 2021, the 
18.14 	commissioner shall develop and implement materials and procedures for certified assessors 
18.15 	and case managers to use during person-centered planning to aide waiver participants in 
18.16 	becoming fully informed of all service and setting options available under the waiver plans. 
18.17 	The procedures developed by the commissioner must include a requirement that each wavier 
18.18 	recipient be educated about all the employment, housing, and self-directed options available 
18.19 	under the waivers before having the recipient's needs and preferences in these areas assessed 
18.20 	and before the recipient's community support plans, coordinated service and support plans, 
18.21 	and coordinated service and support plan addendums are developed.
18.22 		Subd. 4.Implement training to improve inter-assessor reliability. (a) By January 1, 
18.23 	2021, the commissioner shall develop and implement modifications to the training and 
18.24 	certification process required under Minnesota Statutes, section 256B.0911, subdivision 
18.25 	2c, to improve inter-assessor reliability.
18.26 	(b) By January 1, 2021, the commissioner shall develop and implement a methodology 
18.27 	for measuring inter-assessor reliability and tracking changes over time in the measurements 
18.28 	of inter-assessor reliability.
18.29 		Subd. 5.Implement continuous process improvement. (a) By January 1, 2021, the 
18.30 	commissioner shall develop and implement a continuous improvement plan for the entire 
18.31 	process of long-term care consultation services, case management for persons receiving 
18.32 	long-term services and supports, and provider-developed service plans for long-term services 
18.33 	and supports. The commissioner shall base the continuous improvement plan on the principles 
18.34 	of Lean Six Sigma or similar continuous improvement methodology.
19.1 	(b) In developing a continuous improvement plan, the commissioner shall pay particular 
19.2 	attention to ensuring that the process of assessment, case management, and service planning 
19.3 	and delivery supports a presumption that people receiving long-term services and supports 
19.4 	will receive those services and supports in the most integrated, independent, and self-directed 
19.5 	manner consistent with the person's expressed preferences and fully informed choices.