Care Coordination Resources
Minnesota Senior Care Plus (MSC+) and Minnesota Senior Health Options (MSHO)
Care Coordinators foster ongoing primary and preventative care, create a person-centered support plan and assist with communication between all members of the interdisciplinary care team.
To find product-specific tools and forms, select the desired plan from the "Please select" drop-down and click "Select Plan" to explore each category and its contents.
Community Elderly Waiver Care Coordination Requirements Grid (Revised 10/1/2024)
Community Non-Elderly Waiver Care Coordination Requirements Grid (Revised 10/1/2024)
Institutionalized Care Coordination Requirements Grid (Revised 10/1/2024)
MSC+ and MSHO
Appointment Reminder Letter (New 5/20/2024)
EW Provider Support Plan Cover Letter (Revised 3/4/2024)
EW Provider Support Plan Summary Letter (Revised 3/4/2024)
Health Resource Letter (New 10/18/2024) Hmong | Somali | Spanish
PCP/ICT/Support Plan Cover Letter (Revised 11/15/2024)
PCP/ICT Support Plan Fax Cover Sheet (Revised 9/17/2024)
Provider Engagement Letter (Revised 7/6/2022)
Support Plan Letter (Revised 6/14/2024) Arabic | Hmong | Russian | Somali | Spanish | Vietnamese
Support Plan Signature Letter (Revised 6/14/2024) Arabic | Hmong | Russian | Somali | Spanish | Vietnamese
Unable to Reach Member Letter (Revised 11/6/2024) | Hmong | Somali | Spanish
Unable to Reach Member Letter - Support Staff (New 7/1/2024) | Hmong | Somali | Spanish
MSC+
Change in Care Coordinator Letter (Revised 8/26/2022) | Hmong | Somali | Spanish
Change in Contact Info for Care Coordinator (Revised 8/26/2022)
Member Elderly Waiver Service Change Letter
Refusal Letter (Revised 8/18/2023)
Welcome Letter (Revised 12/5/2024) | Hmong | Somali | Spanish
Welcome Letter - Member in Nursing Home (Revised 8/26/2022)
Welcome Letter (Waiver) (Revised 12/19/2024)
MSHO
Change in Care Coordinator Letter (Revised 8/26/2022) | Hmong | Somali | Spanish
Change in Contact Info for Care Coordinator (Revised 8/26/2022)
Member Elderly Waiver Service Change Letter
Refusal Letter (Revised 8/18/2023)
Welcome Letter (Revised 8/2/2022) | Hmong | Somali | Spanish
Welcome Letter - Member in Nursing Home (Revised 8/26/2022)
Welcome Letter - Member on CAC, CADI, DD, or TBI (Revised 8/2/2022)
Assessment and Support Plan Forms
2024 Monthly Activity Log (Revised 9/3/2024)
Institutional Health Risk Assessment (New 1/1/2024) | Word | PDF | Example
Institutional Support Plan (New 1/1/2024) | Word | PDF | Example
Refusal Support Plan (Revised 12/6/2024) | Word | PDF
Transfer Member Health Risk Assessment (Revised 10/31/2023) | Word | PDF
UTR Support Plan (Revised 12/6/2024) | Word | PDF
Other Forms
Additional or Substitute Home and Community Based Service Exception Request
Death Notification Form (Revised 8/1/2024)
ILOS Request Form (Revised 10/2/2024) | ILOS Job Aid (New 9/12/2024)
Nursing Facility Coverage Guide (Revised 1/1/2024)
PCC Change Form | Process Flow
Release of Information Form (Revised 7/3/2024)
Support Plan Translation Request (New 7/1/2024)
Transitions of Care Log (Revised 12/30/22)
TOC Log Instructions (Revised 12/28/22)
Transition of Care (TOC) Notification to PCP (Revised 6/3/2024)
Transition of Care Talking Points
EW Service Authorization
Waiver Service Approval Form (Revised 7/9/2024)
Waiver Service Approval Form - T2029 (Revised 6/28/2024)
EW T2029 Equipment and Supplies Guide (New 6/28/2024)
EW T2029 Equipment and Supplies Coverage Process (New 6/28/2024)
Home Health Communication Form
Request to Exceed Case Mix Cap
EW Budget Tool (Revised 12/4/2024)
CBSM EW Conversion Rates
Elderly Waiver Capitation Dates
CDCS Toolkit
Care Coordinator CDCS Guidelines (New 8/1/2024)
CC CDCS Plan Approval Checklist (New 8/1/2024)
CDCS DHS 6532 CSP Change Form (New 8/1/2024)
CDCS Member Agreement and Checklist (Revised 12/17/2024)
Consumer Directed Community Supports (CDCS) Policy Manual
Member Guide to CDCS Allowed Expenditures (New 8/1/2024)
Notice of Technical Assistance (New 8/1/2024)
EW DTR Form and Instructions
Elderly Waiver DTR Form | Instructions (Revised 10/4/2024)
EW DTR Reason Code Tool (Revised 1/1/2024)
Home Health Communication Form | HHC Example
Care Coordination resources
CFSS Care Coordination Guidelines (Revised 12/19/2024)
CFSS FAQ (Revised 12/4/2024)
PCA/CFSS Communication Form (Revised 12/3/2024) | Instructions (Revised 12/3/2024)
Other links
DHS CFSS Policy Manual
UCare PCA/CFSS Provider Forms