Transition Coordination Services in Minnesota assist individuals with disabilities in moving from institutional settings, such as nursing homes or long-term care facilities, to community-based living arrangements. These services help ensure a smooth and successful transition, promoting independence and community integration. Transition Coordination Services are available under Minnesota’s Home and Community-Based Services (HCBS) Waivers.

1. GOVERNING AGENCIES

Agency: Minnesota Department of Human Services (DHS)

Role: Administers Medicaid programs, including transition coordination services under HCBS Waivers

Agency: Centers for Medicare & Medicaid Services (CMS)

Role: Provides federal oversight and ensures waiver compliance

2. TRANSITION COORDINATION SERVICE OVERVIEW

Transition Coordination Services support individuals in planning and preparing for a successful move from institutional to community living. Services are personalized according to the Individual Transition Plan (ITP) or Person-Centered Plan (PCP) and may include:

• Assessment of individual needs and preferences
• Identification of community-based housing options
• Assistance with setting up housing and basic utilities
• Coordination of healthcare, social, and support services
• Training in daily living skills and community navigation
• Follow-up and ongoing support after transition

3. LICENSING & PROVIDER APPROVAL REQUIREMENTS

Prerequisites:

• Register business with the Minnesota Secretary of State
• Obtain EIN from the IRS and NPI (Type 2)
• Enroll as a Medicaid provider with the Minnesota Department of Human Services
• Maintain liability insurance and staff qualification records
• Obtain certification as a Transition Coordinator if required

4. MEDICAID PROVIDER ENROLLMENT PROCESS

Step 1: Pre-Application Contact

• Contact the Minnesota Department of Human Services for provider requirements related to transition coordination

Step 2: Application Submission

• Submit business registration, certification, liability insurance, and service descriptions

Step 3: License Verification

• Verify compliance with state regulations regarding transition coordination

Step 4: Approval and Medicaid Number Assignment

• Once approved, receive a Medicaid provider number and authorization to deliver services

5. REQUIRED DOCUMENTATION

• Articles of Incorporation or Business Name Registration
• IRS EIN Letter
• NPI confirmation
• Transition Coordinator Certification (if applicable)
• Liability insurance certificate

Policy & procedure manual including:

• Client intake and assessment protocols
• Service planning and coordination guidelines
• Housing and utility setup procedures
• Safety planning and risk management documentation
• Staff training logs and follow-up support records

6. STAFFING REQUIREMENTS

Role: Transition Coordinator / Program Manager

Requirements: Experience in social work, case management, or community integration

Role: Support Specialist / Housing Navigator

Requirements:

• Background in human services or rehabilitation
• CPR/First Aid certification
• Background check and TB clearance

Training Requirements:

• Person-centered planning and transition coordination
• Housing access and community resource navigation
• Client safety and risk management
• Documentation and follow-up care coordination

7. MEDICAID WAIVER SERVICES

Transition Coordination Services in Minnesota are available through:

• 1915(c) HCBS Waiver for the Elderly and Disabled
• Community Access for Disability Inclusion (CADI) Waiver
• Brain Injury (BI) Waiver

Approved providers may deliver:

• Pre-transition planning and skills training
• Housing identification and coordination
• Post-transition support and follow-up care

8. TIMELINE TO LAUNCH

Phase: Business Formation

Timeline: 1–2 weeks

Phase: Medicaid Provider Enrollment

Timeline: 60–90 days

Phase: Staff Hiring and Training

Timeline: 30–45 days

Phase: Community Partnership Development

Timeline: 2–4 weeks

9. CONTACT INFORMATION

Minnesota Department of Human Services (DHS)

Website: https://mn.gov/dhs

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10. SCOPE OF WORK

• Business registration and licensing assistance
• Medicaid provider enrollment
• Policy & procedure manual for transition coordination operations
• Templates for transition plans, client intake, and housing setup
• Website, domain, and email setup
• Staff credentialing and training documentation
• Client intake packet and transition assessment forms
• Risk management and community integration planning
• Referral networking with housing agencies and social support organizations