DATE: July 28, 2017 TO: County Directors and Tribal Administrators Child Care Assistance Program County and Tribal Administrative Contacts FROM: SUBJECT: Minnesota Department of Human Services, Child Care Assistance Program The 2018-2019 Child Care Assistance Program County and Tribal Child Care Fund Plan The Minnesota Department of Human Services (DHS) is designated under Minnesota Statutes, chapter 119B as the lead state agency for supervision of county and tribal administration of the Child Care Assistance Program (CCAP). Counties and federally recognized tribes, who administer Programs under Minnesota Statutes 119B, are required to submit a biennial County and Tribal Child Care Fund Plan to the commissioner of DHS. The Department of Human Services will review County/Tribal Child Care Fund Plans. Counties and tribes will receive plan approval letters from the commissioner of DHS. The Child Care Assistance Program rules and laws allow counties and tribes limited discretion to establish some local policies and procedures. These local policies and procedures, when included in this plan and approved by the commissioner, are considered county/tribal policy and are used to support agency decisions during appeals. The 2018-2019 County and Tribal Child Care Fund Plan is provided to you in a fillable PDF format that will allow you to save a completed version of the plan to your computer. Adobe Reader 8 or higher is the recommended version for this form. Please check with your agency IT staff if your version of Adobe reader needs to be upgraded. DHS will be providing a live video stream presentation of the Child Care Fund Plan on Tuesday August 15, 2017 at 1:30 PM. The presentation will be available if you are not able to attend one of the many sites throughout the state. The link: http://stream5.video.state.mn.us:8080/dhsplay.html?/hslive/dhslive will go live 15 minutes prior to the meeting start time of 1:30 PM. For more information, please refer to the memo regarding the videoconference sent July 25, 2017. Refer to the attached summary of DHS created documents for CCAP when completing section IX.B Agency developed forms. INSTRUCTIONS FOR FILLING OUT THE PDF DOCUMENT: 1. Open the PDF document at: http://edocs.dhs.state.mn.us/lfserver/public/dhs-5107-eng 2. Type in your county/tribal name on the line provided on the first page.
3. Pressing Tab will move the cursor forward or Shift+Tab will move the cursor backward among the fields. You can also move your cursor by using your mouse over the fill-able area. 4. When you have completed your plan, do a Save As to save the plan to a designated folder in your computer. By doing this you will be able to save the finished document and update the document as needed for corrections during the review process. Amendments may also be made using this process after the plan has been approved. Amended plans must be submitted to DHS for approval. 5. IMPORTANT: Return completed plans by September 19, 2017. Do not include private data in your plan, as this is a public document. Plans may be submitted earlier than September 19, 2017.
The effective date of the 2018-2019 County and Tribal Child Care Fund Plan is January 1, 2018. Please submit your agency plan and attachments via email, using the Submit by email button included at the end of the plan. You may also use the following to submit your plan and any attachments that need to be reviewed and approved: dhs.ccap@state.mn.us. If you have questions about the County and Tribal Child Care Fund Plan, please contact your DHS CCAP Policy Specialist. DHS Contact: Regions 1, 2, 3, 4, 5, 7E, 11 Kisha Dixon (651) 431-4036 kisha.dixon@state.mn.us Regions 6E, 7W, 9, Tribal Andrea Aga (651) 431-4045 andrea.aga@state.mn.us Regions 6W, 8, 10 Angela Carlson (651) 431-4047 angela.r.carlson@state.mn.us
Form numbers and descriptions Form Number Form Name Date of Last DHS-0033 Appeal to State Agency May 2014 Application form used to initiate a human services appeal of a county or state action. An appeal request must be in writing, but use of the form is not required by client. DHS-0035 State Agency Appeals Summary May 2010 This form is used by state and county and tribal agencies to summarize the facts and reasons for the decision they made that is being appealed by an applicant or recipient. DHS-2146 Authorization for Release of Employment Information April 2013 Consent form allowing release of employment information required for the determination of eligibility for human service programs. DHS-2338 Cooperation with Child Support Enforcement August 2015 Form that client completes about cooperating with child support to receive public assistance.
DHS-3131 Notice of Intentional Program Violation - Waiver of ADH Feb 2015 Notice to client that they are being referred for an Administrative Disqualification Hearing because of intentional program violations in specified programs. The form also allows client to waive the ADH. DHS-3131A CCAP Provider Notice of Intentional Program Violation - Waiver of ADH Aug 2012 Notice to CCAP providers that they are being referred for an Administrative Disqualification Hearing because of intentional program violations in the Child Care Assistance Program. The form also allows providers to waive the ADH. DHS-3132 Request for Administrative Disqualification Hearing Feb 2014 Agency form used to request an Administrative Disqualification Hearing and to summarize the facts and circumstances of the allegation. DHS recommends checking with agency fraud staff about use of this form. DHS-3132A CCAP - Request for Provider Administrative Disqualification Hearing Nov 2009 Agency form used to request a Provider Administrative Disqualification Hearing and to summarize the facts and circumstances of the allegation. DHS recommends checking with agency fraud staff about use of this form.
DHS-3134 Notice of Program Disqualification Feb 2015 Notice to client that they are being disqualified for specific programs, the effective date and the penalty period. DHS recommends checking with agency fraud staff about use of this form. DHS-3134A CCAP Notice of Disqualification for CCAP Providers July 2012 Notice to provider that they are being disqualified for Child Care Assistance Program payments, which gives the effective date of the disqualification and the penalty period. DHS recommends checking with agency fraud staff about use of this form. DHS-3163B Referral to Support and Collections Dec 2014 This form is used by MinnesotaCare, Medical Assistance and Child Care Assistance recipients for referral to the local child support agency for the purpose of establishing paternity or child support enforcement services DHS-3165 DWP/MFIP Status Form Sept 2014 Agency form used by DWP, MFIP, ES and Child Care staff to exchange case status information. DHS-3195 Inter Agency Case Transfer Form April 2013 Agency form used by county and tribal staff when transferring cases between agencies to summarize the current status of the case.
DHS-3335A Fraud Prevention Investigation Referral Feb 2016 Agency form used to refer cases for fraud investigation and exchange information on cases involved in a fraud investigation. DHS recommends checking with agency fraud staff about use of this form. DHS-3335B Summary of Investigative Findings Mar 2003 Agency form used by fraud investigator to summarize findings of the investigation. DHS recommends checking with agency fraud staff about use of this form. DHS-3429 Disqualification Consent Agreement Feb 2014 Fraud notice designed to inform clients of intentional program violations, the consequences for the violations and client agreement to disqualification. DHS recommends checking with agency fraud staff about use of this form. DHS-3429A CCAP Disqualification Consent Agreement May 2006 Fraud notice designed to inform providers of intentional CCAP program violations, the consequences for the violations and provider agreement to disqualification. DHS recommends checking with agency fraud staff about use of this form. DHS-3436 Request for Investigative Subpoena June 2006 County or tribal request form for a subpoena to get information from third parties. Optional use by the investigator/fraud staff or county attorney staff.
DHS-3550 Program Application Mar 2017 The Program Application is used to apply for the child care assistance programs. DHS-3551 Do you need help paying for child care? Sept 2016 Brochure providing basic child care information and explaining the basic program requirements of the Child Care Assistance Program. DHS-3552 Direct Deposit for the Minnesota Child Care Assistance Program May 2008 Brochure explaining the benefits of directly depositing child care payments to bank accounts. The brochure includes a Direct Deposit Authorization form. DHS-3627 Important Information about Your Request for a Child Support Good Cause Exemption May 2010 CCAP workers provide this form to clients when the client requests to claim a good cause exemption from the requirement to cooperate with child support services. The form acknowledges the request for a good cause exemption and explains the process for determining a good cause exemption.
DHS-3628 Notice of Denial of Child Support Good Cause Exemption Aug 2015 CCAP workers provide this form to a client when the client's request to claim a good cause exemption from the requirement to cooperate with child support services is denied. Use when system does not create notice. DHS-3629 Notice of Child Support Good Cause Approval May 2010 CCAP workers provide this form to a client when the client's request to claim a good cause exemption from the requirement to cooperate with child support services is provided. Use when system does not create notice. DHS-3768A LNL Provider Notification Feb 2017 Notification for legal nonlicensed providers of new federal training requirements that must be completed to receive CCAP after September 30, 2017. This letter was sent to legal nonlicensed providers registered by CCAP in February 2017. CCAP agencies should send a copy of this letter and DHS-3769A to all legal nonlicensed providers who register for CCAP until further notice.
DHS-3768B License Exempt provider Notification Letter Feb 2017 Notification for license exempt centers of new federal training requirements that must be completed to receive CCAP after September 30, 2017. This letter was sent to license exempt centers registered by CCAP in February 2017. CCAP agencies should send a copy of this letter and DHS- 3769B to all license exempt centers who register for CCAP until further notice DHS-3768C Licensed Family Provider Notification Letter Feb 2017 Notification for licensed family child care providers of new federal training requirements that must be completed to receive CCAP after September 30, 2017. This letter was sent to licensed family child care providers registered by CCAP in February 2017. CCAP agencies should send a copy of this letter to all licensed family child care providers who register for CCAP until further notice.
DHS-3768D Licensed Center Provider Notification Letter Feb 2017 Notification for licensed family child care providers of new federal training requirements that must be completed to receive CCAP after September 30, 2017. This letter was sent to licensed family child care providers registered by CCAP in February 2017. CCAP agencies should send a copy of this letter to all licensed family child care providers who register for CCAP until further notice. DHS-3769A LNL Provider Training Documentation Form July 2017 LNL providers must submit this form to DHS to demonstrate compliance with new federal training requirements. This form was sent to legal nonlicensed providers registered by CCAP in February 2017. CCAP agencies should send a copy of this form and DHS-3768A to all legal nonlicensed providers who register for CCAP until further notice
DHS-3769B License Exempt Provider Acknowledgement Form Feb 2017 License exempt providers must submit this form to DHS to demonstrate understanding of new federal training requirements. This form was sent to license exempt centers registered by CCAP in February 2017. CCAP agencies should send a copy of this form and DHS-3768B to all license exempt centers who register for CCAP until further notice. DHS-3813 User Agreement for MEC² PRO Electronic Billing April 2017 Counties use information provided on this form to grant individual users access to submit bills to the Child Care Assistance Program (CCAP) using MEC² PRO. Complete a separate form for each person. Required to register MEC 2 PRO users. DHS-3979 Notice of Privacy Practices Nov 2016 General Notice of Privacy Practices advising clients of how their private information may be used, disclosed and how they can get this information. DHS-3985 Notice of Privacy Practices for Child Care Providers Feb 2011 Notice for child care providers informing them of their privacy rights.
DHS-4003 Child Care Status Transmittal to Child Support Feb 2015 The transmittal notice is used by child care workers to communicate case information to child support workers. Use to send updates to Child Support for children who do not have open Service Authorizations in MEC². DHS-4018 Important Information for Child Care Providers July 2016 Appeal rights information for child care providers. Use when system does not create notice. DHS-4079 Child Care Provider Responsibilities and Rights Nov 2015 Child Care Assistance Programs (CCAP) information sheet explaining child care providers rights and responsibilities. DHS-4194 CCAP Special Needs Rate Variance Request- Parent and Provider Request Aug 2012 Child Care Assistance Program (CCAP) special needs request form for parents and providers to submit to county. DHS-4195 CCAP Special Needs Rate Variance Request- County Recommendation Form Aug 2016 Child Care Assistance Program (CCAP) special needs request form for counties to submit to DHS with special needs rate request.
DHS-4602 CCAP Medical Condition Documentation Form Feb 2014 This form is used to verify a medical condition that resulted in a child s absence from child care. DHS-4794 CCAP Change Report Form Nov 2016 Reporting form used by Child Care Assistance Program clients to report income and circumstance changes usually on a non-scheduled basis. DHS-4795 CCAP Quality Differential Rate Request Form Feb 2016 This form requests verification of child care provider qualifications that are needed for determining if the provider qualifies for the 15 percent quality differential. Required to receive higher rate for quality but only for eligible providers. DHS-5107 Administration of the CCAP County Child Care Plan July 2017 County and tribal plan document used for the Child Care Assistance Program. DHS-5107A Child Care Assistance Program County and Tribal Child Care Plan Amendment July 2015 County and tribal agencies use this form to amend a County Child Care Plan for provisions allowed under Minnesota Statutes, section 119B.13, subdivision 6, paragraph(d).
DHS-5163 Child Care Assistance Notice of Deduction for IRS Levy Aug 2008 Provider notice that Child Care Assistance Program payments are being reduced due to back taxes owed. DHS-5164 Child Care Assistance Notice of Deduction for Continuous Levy July 2007 Provider notice that Child Care Assistance Program payments are being reduced due to a Minnesota Department of Revenue levy. DHS-5165 Child Care Assistance Notice of Deduction for Child Support Obligation July 2007 Provider notice that Child Care Assistance Program payments are being reduced due to a Child Support obligation. DHS-5166 Child Care Assistance Notice of Deduction for Backup Withholding July 2007 Notice that Child Care Assistance Program payments are being reduced due to IRS/MN Department of Revenue backup withholding. DHS-5167 First B Notice July 2007 First notice that a provider's taxpayer identification number (TIN) does not match the files of the Social Security Administration (SSA). DHS uses this form when applicable.
DHS-5168 Second B Notice July 2007 Second notice that a provider's taxpayer identification number (TIN) does not match the files of the Social Security Administration (SSA). DHS uses this form when applicable. DHS-5190 CCAP Licensed Provider Registration and Acknowledgement Mar 2016 CCAP form used by counties to register licensed child care providers so they can be authorized to receive child care assistance payments. DHS-5191 CCAP License Exempt Provider Registration and Acknowledgement Mar 2016 CCAP form used by counties to register licensed exempt child care providers so they can be authorized to receive child care assistance payments. DHS-5192 CCAP Legal Non-Licensed Provider Registration and Acknowledgement Nov 2015 CCAP form used by counties to register legal non- licensed child care providers so they can be authorized to receive child care assistance payments. DHS-5192A Health and Safety Resource for Parents and Legal Nonlicensed Providers Aug 2016 CCAP form provided to parents and legal nonlicensed providers with health and safety resources.
DHS-5193 CCAP Authorization for Release of Background Study Sept 2016 CCAP authorization form used to give permission to share private data with other agencies. DHS-5223D Combined Application - Child Care Addendum Mar 2017 This form is used to apply for the Programs (CCAP) if clients are applying for cash assistance, SNAP (food assistance), or health care and have completed a Combined Application Form (CAF). DHS-5242 Child Care Assistance Notice of Decision May 2010 CCAP notice to providers that are no longer authorized to receive child care assistance payments. Used for manual notices, others are system generated. Use when system does not create notice. DHS-5260 CCAP Child Care Provider Guide May 2016 Guide that explains what child care providers need to know to get payment from the Department of Human Services (DHS) for families who get benefits from the Child Care Assistance Program (CCAP). DHS recommends making this resource available to providers.
DHS-5274 Child Care Assistance Program Redetermination Form Mar 2017 Form used to determine ongoing eligibility for households that are currently open on the Child CareAssistance Program. DHS-5312D Case Review - Part IV: Child Care Assistance- Family Review Feb 2008 Case management review form used by agencies for review of CCAP family eligibility determinations, case management practices and payment accuracy. Agencies may use their own review forms. DHS-5312E Case Review - Part V: Child Care Assistance- Provider Review Feb 2008 Case management review form used by agencies for review of CCAP provider authorization/registration determinations, case management practices and provider payment accuracy. Agencies may use their own version. DHS-5318 Child Care Assistance Program Financial Tracking Form March 2008 This form is used by providers to record payments for child care fees or expenses from sources other than CCAP. Requirement to keep these type of records is also included on Registration forms.
DHS-5367 Parent Acknowledgement When Choosing Legal Nonlicensed Provider Sept 2015 Acknowledgement form for parents to complete and sign when picking a legal nonlicensed provider for child care. DHS-5485 Child Care Assistance Program Authorization for Release of Information In-home Child Care Providers Feb 2015 Form for providers to complete that allows In- home provider payment information to be released to the parents. DHS-5523 Child Care Assistance Billing Form Mar 2013 Child Care Assistance Program form used as a replacement billing form. Use when system does not create notice. DHS-6584A CCAP MONTHLY Attendance Record Oct 2016 Optional monthly form used by child care providers to comply with attendance record keeping requirements and record times in and out for a particular child in care. DHS-6584B CCAP DAILY Attendance Record Oct 2016 Optional daily form used by child care providers to comply with attendance record keeping and record times in and out for all children in care for a particular day.
DHS-5588 Child Care Assistance Notice of Decision - Denial Dec 2009 Manual denial notice from CCAP workers to applicants when the application is received more than 15 days from date of signature. Use when system does not create notice DHS-5588A Child Care Assistance Notice of Decision - Termination Dec 2009 Manual termination notice for CCAP workers to send to recipients whose CCAP is being terminated. Use when system does not create notice. DHS-5665 Child Care Assistance Program - Direct Service Expenditure Adjustment Form Jan 2017 Form used by CCAP workers to report expenditure adjustments to CCAP payments originally made through the MEC² Integrated System. DHS-5671 Child Care Basic Sliding Fee Monthly Waiting List Feb 2016 Form used by counties and tribes to report their agency s monthly Child Care Basic Sliding Fee waiting list information to DHS. DHS-5776 CCAP Integrated Full-Day Head Start Services Payment Application Oct 2013 Application form used to establish program or provider eligibility for up to a full day payment for CCAP eligible children. Provider must complete.
DHS-6305 Child Care Assistance Program Parent Medical Condition Form May 2015 Form used to verify that a parent or another parentally responsible individual (PRI) in the household has a medical condition and is unable to provide care for their child(ren). DHS-6217A Child Care Notice of Decision - Service Authorization for families Nov 2016 Manual Service Authorization (SA) for Child Care Assistance Program (CCAP) workers to send to families to authorize child care assistance when there are too many children or providers for the system to issue an accurate SA. Required if MEC² SA does not include all children. DHS-6217B Child Care Assistance Notice of Decision - Service Authorization for providers Nov 2016 Manual Service Authorization (SA) for Child Care Assistance Program (CCAP) workers to send to providers to authorize child care assistance when there are too many children or providers for the system to issue an accurate SA. Required if MEC² SA does not include all children. DHS-6413E Minnesota CCAP Copayment Schedules (Effective October 10, 2016) Oct 2016 Program table listing the family copayment fee based on family size and income after allowable deductions.
DHS-6419 CCAP Training Requirements for Legal Nonlicensed Family Providers Feb 2014 Question and answer information sheet explaining the training requirements for Legal Nonlicensed Family Providers. Information is also included in Registration forms. DHS-6441B Minnesota CCAP Standard Maximum Rates - No Quality Differential (Effective February 3, 2014) June 2014 Program table listing the maximum rates that non-accredited providers can charge for Family Child Care/LNL and for Child Care centers. DHS-6442B Program - 15 Percent Quality Differential Maximum Rates (Effective February 3, 2014) June 2014 Table listing the differential maximum hourly, daily and weekly reimbursement rates for child care providers who serve families participating in CCAP and who hold certain accreditations or credentials and have a 3-Star Parent Aware Rating. DHS-6443 Minnesota CCAP Maximum Child Care Registration Fees (Effective November 28, 2011) May 2012 Program table listing the maximum fees that a provider can charge for CCAP.
DHS-6475 CCAP Parent Request for In- Home Child Care July 2014 Child Care Assistance Program form completed by parents to request authorization for payment of in-home child care. DHS-6650 Resources for Minnesota families with children Sept 2016 Resources to help Minnesota families choose appropriate child care. DHS-6804 CCAP Override Monitoring Form May 2016 Form used by agencies to report their Child Care Assistance Program override case information to DHS DHS-6811 Child Care Provider Investigations Communication Form Sept 2014 Form for communication of child care provider investigations. DHS-6824 Program 20 Percent Quality Differential Maximum Rates Jan 2014 table listing the 20 Percent Quality Differential Maximum Rates child care providers can be paid to serve families participating in CCAP and have a 4-Star Parent Aware Rating. DHS-6953 Reporting Responsibilities for CCAP Families Aug 2016 Brochure explaining the basic reporting requirements for the Program (CCAP).
DHS-6960A Child Care Assistance Program Payments for Children of Center Employees - Questions and Answers Jan 2016 This notice provides questions and answers for child care providers about why the Child Care Assistance Program (CCAP) cannot pay for some children to attend a child care center when more than half of the children who attend the center get CCAP and have a parent who works there. DHS-6960B Child Care Assistance Program payments for Children of Center Employees - Center Documentation Form Feb 2016 This form is used when records from the Minnesota Department of Human Services (DHS) show that more than half of the CCAP children at your center are children of employees at your center, but you think that your center is following the law. DHS-6960C Child Care Assistance Payments for Children of Center Employees - Questions and Answers for Parents Jan 2016 This notice provides questions and answers for parents about why the Child Care Assistance Program (CCAP) cannot pay for some children to attend a child care center when more than half of the children who attend the center get CCAP and have a parent who works there.
DHS-7054 MFIP/DWP Employment Services Child Care Request Form Mar 2015 A communication tool for job counselors to communicate child care needs to CCAP workers. DHS-7056 Information for Child Care Providers: How Early Learning Scholarships Work with the Child Care assistance Program Sept 2016 This information document is for providers who serve children on Child Care Assistance Program and also receive Early Learning Scholarships. Information includes how to layer funds, document third party payments and assist families in accessing scholarships. DHS-7195 Licensed Family Child Care Provider Registration and Acknowledgement Nov 2015 Child Care Assistance Program (CCAP) form used by counties agencies to register licensed family child care providers so they can be authorized to receive child care assistance payments. DHS-7196 CCAP Provider Registration Change Form Nov 2016 CCAP form used by providers to report changes to their provider registration to agencies.
DHS-7197 Corrective Action Form CCAP Case Review May 2016 Report for summarizing case errors and corrective actions related to CCAP eligibility audits. DHS-7199 Changes in state law that may affect providers registered with the Child Care Assistance Program Sept 2015 Notice to child care providers who care for children on the Child Care Assistance Program (CCAP) about changes to state law.
Expired forms Form Number Form Name Date of Last DHS-6413 EXPIRED - Minnesota CCAP Copayment Schedules (Effective October 1, 2011 - September 30, 2012) Oct 2012 Program table listing the family copayment fee based on family size and income after allowable deductions. Use as needed for calculation of overpayments. DHS-6413A EXPIRED - Minnesota CCAP Copayment Schedules (Effective October 1, 2012 - October 13, 2013) Oct 2013 Program table listing the family copayment fee based on family size and income after allowable deductions. Use as needed for calculation of overpayments. DHS-6413 EXPIRED - Minnesota CCAP Copayment Schedules (Effective October 14, 2013 through October 12, 2014) Aug 2013 Program table listing the family copayment fee based on family size and income after allowable deductions. Use as needed for calculation of overpayments. DHS-6413C EXPIRED - Minnesota CCAP Copayment Schedules (Effective October 13, 2014) Oct 2014 Program table listing the family copayment fee based on family size and income after allowable deductions. Use as needed for calculation of overpayments.
DHS-6413D EXPIRED - Minnesota CCAP Copayment Schedules (Effective October 12, 2015) Oct 2015 Program table listing the family copayment fee based on family size and income after allowable deductions. Use as needed for calculation of overpayments. DHS-6441 EXPIRED - Minnesota CCAP Standard Maximum Rates - Nonaccredited (Effective July 1, 2006 - November 27, 2011) May 2012 Program table listing the maximum rates that non-accredited providers can charge for Family Child Care/LNL and for Child Care centers. DHS-6441A EXPIRED - Minnesota CCAP Standard Maximum Rates - Nonaccredited (Effective November 28, 2011 - February 2, 2014) Feb 2014 Program table listing the maximum rates that non-accredited providers can charge for Family Child Care/LNL and for Child Care centers. DHS-6442 EXPIRED - Minnesota CCAP Standard Maximum Rates - Accreditation/Credential Differential (Effective July 1, 2006 - November 27, 2011) May 2012 Program table listing the maximum rates that accredited/credentialed providers can charge for Family Child Care/LNL and for Child Care centers.
DHS-6442A EXPIRED - Minnesota CCAP Standard Maximum Rates - Accreditation/Credential Differential (Effective November 28, 2011 - February 2, 2014) Feb 2014 Program table listing the maximum rates that accredited/credentialed providers can charge for Family Child Care/LNL and for Child Care centers.