The Minnesota DHS-6790G customized living worksheet is a Rate Management Worksheet that licensed providers use to give their lead agency the staffing, nursing, and service-component information needed to set an individual’s rate for Customized Living Services or 24-Hour Customized Living Services under a Home and Community-Based Services waiver. It is part of the Disability Waiver Rate System (DWRS), and you complete it after a person is already enrolled in a waiver, not as part of applying for benefits.
What the Form Is and Isn’t
DHS-6790G belongs to the DHS-6790 series of rate management worksheets published by the Minnesota Department of Human Services. Each lettered variant covers a different service type in the DWRS; the “G” version covers customized living and 24-hour customized living, delivered to adults age 18 and older in qualifying settings such as assisted living facilities.
This is not the application a person uses to request Medical Assistance or long-term care coverage. Individuals apply for MA through their county human services office or tribal agency. DHS-6790G comes into play only once a person is enrolled in a waiver and a provider needs to establish or update the rate for their customized living services.
The worksheet itself does not produce the final rate. It is a communication tool. The lead agency takes the values you enter and feeds them into the Rates Management System (RMS), which applies the DWRS framework and returns the reimbursement rate. The statutory basis for all of this is Minnesota Statutes section 256B.4914.
Which Waivers It Covers
Customized living is funded under three Minnesota waivers, and the worksheet supports rate-setting for all of them:
- Brain Injury (BI) Waiver, where customized living is a framework service and the lead agency sets rates through the MnCHOICES Support Plan.
- Community Access for Disability Inclusion (CADI) Waiver, also a framework service with rates set through MnCHOICES.
- Elderly Waiver (EW), where the lead agency uses the Elderly Waiver Residential Services Rate Tool within MnCHOICES. Updated component rates and daily limits reach people on EW only when the lead agency completes a new rate tool for that person.
What Data You Enter
The worksheet captures the specific values Minnesota Statutes section 256B.4914, subdivision 4, requires for rate calculation. For each person, you record:
- Shared staffing hours (time a staff member spends with multiple residents at once) and individual staffing hours (one-on-one time).
- Direct registered nurse (RN) hours and direct licensed practical nurse (LPN) hours.
- Staffing ratios during shared service delivery.
- Documentation supporting the variable service level within each framework.
- Whether unit-based services are shared or individualized, and the staffing ratio involved.
- Number of trips and miles for transportation.
- Service hours delivered through remote monitoring technology rather than in-person staff.
These entries reflect the person’s assessed needs across the six covered service categories: activities of daily living assistance; mental health, cognitive, or behavioral support; health-related assistance; home management tasks; non-medical transportation; and socialization. Some categories carry acuity-based caps written into statute. For example, mental health management is limited to two hours per day for people assessed at case mixes A, D, or G, and daily living assistance is capped at four hours per day for case mix B.
Any component from the mental health, cognitive, or behavioral category included in the person’s support plan requires assessment by an appropriate professional, and you must have a plan to implement and monitor the support and to train staff on the person’s specific needs. Service levels must be discussed with the person’s support team, as defined in Minnesota Statutes section 245D.02, before the rate is finalized.
Downloading and Completing the Worksheet
DHS-6790G is available from the DHS eDocs library at edocs.dhs.state.mn.us. The PDF will not open directly in a browser. Download it and open it in Adobe Reader or Adobe Acrobat. Downloads default to the filename “form.pdf,” so rename the file right away if you work with more than one DHS form.
Before you enter anything, pull the person’s current MnCHOICES Support Plan and any assessments that feed into it. The support plan drives the service component hours on the worksheet. For each of the six service categories, record staffing hours, whether staffing is shared or individual, and any RN, LPN, or monitoring technology hours that apply. Cross-check every entry against the assessed case mix and the statutory caps. If the values you submit don’t match the support plan or the assessment, the lead agency will flag the discrepancy before setting a rate.
How to Submit It to the Lead Agency
DHS does not set a single submission method. Each lead agency, usually the county or tribal agency responsible for the person’s waiver, decides how it wants worksheets delivered. Follow their instructions.
One rule is firm: do not send a completed worksheet by unencrypted email. It contains protected information about the service recipient. Common secure options are uploading through a lead agency portal, mailing a physical copy, or hand-delivering the form. If your lead agency hasn’t told you how to submit, ask before you send anything. Keep a copy for your records, along with any confirmation of receipt.
What Happens After You Submit
The lead agency uses your worksheet entries as inputs to the RMS, which applies the current DWRS framework values and produces the individual rate. DHS publishes an updated framework each year once it is approved by the Centers for Medicare and Medicaid Services. The 2026 Customized Living and 24-Hour Customized Living framework is available as an Excel file from the DHS rate-setting frameworks page at mn.gov/dhs.
When framework values change, rates for people already receiving services are not updated automatically on the effective date. The change reaches an individual only when the lead agency completes a new rate tool for that person. If you believe a person’s current rate does not reflect the latest framework, ask the lead agency to recalculate.
When Framework Rates Aren’t Enough: Rate Exceptions
If a person’s needs generate costs above what the standard framework rate covers, the provider and lead agency can pursue a DWRS rate exception. This is a separate track from the DHS-6790G worksheet, but the two connect: the worksheet establishes the baseline rate, and the exception addresses documented costs beyond it.
To request one, document the specific cost drivers that are not included in or exceed the framework values. Use dollars where the framework component is expressed in dollars and percentages where it uses percentages. The provider and lead agency jointly submit the Disability Waiver Rates System Exception Request Application (DHS-5820), together with the Lead Agency Provider Tool for DWRS Exceptions for customized living (DHS-5820E). The lead agency must agree that the person’s extraordinary needs justify the higher rate.
Who Can Submit a DHS-6790G Worksheet
Only properly licensed providers may deliver customized living services and submit these worksheets. A provider must hold one of the following:
- An assisted living facility license under Minnesota Statutes Chapter 144G, including assisted living facilities with dementia care.
- A comprehensive home care provider license under Minnesota Statutes Chapter 144A, but only when services are delivered in an affordable housing setting as defined in Minnesota Statutes section 256S.20.
Providers operating in affordable housing settings must also comply with consumer protection requirements under Minnesota Statutes Chapter 325F.722. On the BI and CADI waivers, providers without a foster care license who serve settings of one to four people, or five with an approved fifth-bed license or variance, must hold the Chapter 144G assisted living license and follow additional foster care rules under Minnesota Rules 9555.6205 and 9555.6225.