The absence and utilization percentage contained in the framework are:
Leave days must exceed this percentage at a rate that affects a provider’s ability to maintain its business. Providers must review the operation as a whole and take into account the number of people receiving services who don’t use the leave days accounted for in the framework. The request for leave days should not replace service planning to address the issue resulting in an increased number of days away from the residential setting.
If a “leave day” exception is requested the absence and utilization percentage in the framework will be adjusted by the DHS exceptions team.
For example: In addition to the 14 days in the Community Residential Services calculated rate, the provider has requested 40 leave days because of the frequent hospital stays of the person served. Together these total 54 days, so the absence and utilization component value needed in the rate framework to account for additional leave days is 14.79% (54 / 365 = 14.79%). A new rate will be calculated by the DHS exceptions team based on the increased component value. Once the exception is approved, lead agencies will authorize the new rate multiplied by the planned number of authorized days (365 - 40 = 325 days, in this example). The 40 additional leave days requested are added to the existing 14 leave days in the framework when authorizing 365 days.
DWRS is a prospective system and not a cost-reimbursement system. Lead agencies should not add more days to the authorization once this calculation is done.
It depends. The start date for the rate exception will be the date of the person’s change in support, or the date the request for an exception is received by the lead agency, whichever is later.
A provider can request an exception through the person’s lead agency. However, only lead agencies can submit the rate exception to DHS.
No. The lead agency must submit all exception requests on the DWRS Exception Request Application, DHS-5820, and attach any supporting documentation that is not accounted for in the CSSP. The provider should use the following forms to submit necessary cost documentation to the lead agency:
This process ensures that the lead agency is aware of, and in agreement with, the person’s extraordinary needs and the cost drivers behind a rate exception request.
If DHS receives an exception request directly from a provider, DHS will notify the provider (and copy the lead agency) that all exception requests must be routed through the lead agency for submission to DHS. DHS will not review the request unless submitted by the lead agency.
State law requires lead agencies to submit exceptions. The provider and lead agency must work together to submit the Disability Waiver Rates System Exception Request Application, DHS-5820 (PDF), and the lead agency must agree that the extraordinary need and the extraordinary costs incurred by the provider result in a rate necessary to meet the needs of the person. In addition, the lead agency must review its waiver budget in preparation to support the exception.
The lead agency will receive an email confirmation from DHS if the exception is approved. This email will have the approved rate and instructions for how to proceed in RMS to document the approved exception rate. The lead agency will then:
Lead agencies must renew service agreements annually. This renewal is meant to be a time to review a person’s needs and make any necessary changes. If a renewal does not occur annually, the person’s change in need may not be identified. A lead agency should fill out the DHS-5820; if the cost driver information and the rate is the same as the originally approved exception, the lead agency should check “renewal” on the DHS-5820. No attachments are required when the rate is the same as the prior year’s approval. Lead agencies are responsible for tracking exceptions and ensuring that the service need and the service based response has continued before renewing an exception.
Lead agencies must review service agreements annually at a minimum. Under DHS policy, an exception rate will expire after one year from the approved start date of the exception rate.
Yes. However, lead agencies must wait to receive the approval notice for the original exception request before submitting a renewal to line up MnCHOICES reassessment/renewal dates. If a lead agency submits a renewal request before the original exception is approved, DHS will deny the renewal and the lead agency will have to resubmit the renewal once it receives the approval letter for the original exception request.
If the change results in a rate that is lower than the approved exception rate, the lead agency may submit an abbreviated exception renewal stating what has changed. For example, “fewer hours of staffing are needed because the person now attends a day program, but still needs staff with increased wages and/or training.”
If the change results in a need for a rate that is higher than the approved exception rate, the lead agency must submit an exception request marked “renewal” with the increased cost drivers and supporting reasons for the increase.
If the requested rate, cost drivers or RMS inputs have changed, the request is still considered a renewal. The lead agency will submit a DHS-5820 to DHS with supporting documentation and cost driver information to support the change.
The lead agency may complete a new calculation in RMS showing the current (non-exceptional) need. The lead agency may then authorize the final rate produced by RMS, and the exception rate will automatically expire after one year. You do not need to notify DHS if the exception need lapses before the one year mark.
Yes, a lead agency should deny an exception request if:
The lead agency must inform DHS of its denial. The lead agency must submit an exception request application and check “lead agency denies this request”. DHS will document the denial and will only conduct further review if the conditions above were present and the lead agency did not comply with Minn. Stat. §256B.4914, subd. 14.
Ultimately, the provider and lead agency should work together to address this through discussion and/or service planning. If a provider feels it is being treated unjustly, it may email the DHS response center.
Yes, but DHS makes every effort to work with the lead agency and provider to determine whether a person is eligible for an exception, if the person is in need of an exception, and if the cost drivers match the extraordinary needs of the person. If those connections cannot be made, DHS will deny the exception.
Denials at any level are only appealable by the person under Minnesota statute. A provider, however, may ask a lead agency to correct erroneous entries in RMS that affect a waiver rate.
The RMS framework rates include component values determined by extensive research. These costs reflect the costs determined by that research to provide specific services. If a person has needs that are outside of the determined component values, the provider must clearly identify and document those needs and how the RMS component values don’t meet the standard. For more information, see the Disability waivers rate setting frameworks page
Providers decide the wages they pay their staff as part of their business practice. The component values in the RMS do not set staff wage levels. Providers use the RMS as a tool to calculate what an entire service costs, so the component values do not reflect what providers actually pay their staff.
At this time, minimum wage is not an eligible reason for an exception, as it is not directly related to the needs of the person.
The provider must provide written documentation of the incurred cost drivers that are not included or are above the cost drivers in the RMS framework. Specific costs related to the extraordinary needs of the person are necessary to support an exception request. See the Lead agency provider tool for DWRS exceptions (residential), DHS-5820C (PDF) or the Lead agency provider tool for DWRS exceptions (day or unit), DHS-5820D (PDF) for definitions and component values. Providers must provide cost driver documentation that speaks the language of the rate tool. For example; use dollars for component values that are represented in dollars and use percentages where the component value is represented in percentages.
No. A service rate cannot be the sole reason for demission of a person from service. Minn. Stat. §245D.10, subd. 3 and 3a identify how and when services may be disrupted and what is required when a provider determines it can no longer serve a person. DHS encourages providers and lead agencies to work together to best meet the needs of the person and to involve DHS, as necessary, before demitting a person.
Statute outlines when a person is eligible for an exception. If these criteria are not met, DHS cannot approve an exception. Lead agencies, people or families with concerns should contact the DHS Response Center for help if necessary.
Lead agencies have the authority to work on service planning and if appropriate depending on the type of service, increase units of service if there have been changes in the person’s need that do not require an increased rate.
The lead agency’s primary responsibility is to ensure that exception requests are made for people with extraordinary needs and the supports described in the requests meet the person's needs.
No. DHS does not need to be notified of a service change. This is considered to be working within the RMS frameworks. If this change does not meet a person’s need, an exception may be appropriate.
The lead agency and DHS cannot process an exception request without documentation of cost drivers that are not included in or are above the RMS framework component values. Ultimately, DHS must be able to show the federal Centers for Medicaid & Medicare Services (CMS) why the person’s service rate is outside of the state established methodology.
Yes, if the provider and lead agency agree that the higher rate is not needed to provide the service, the lead agency may submit an exception request for a lower rate.