CurrentHealth NetPolicy N/A

Community or Home Transition Services — Coverage Criteria

Defines authorization, covered services, limits, provider types, and documentation requirements for time-limited transition services and non-recurring set-up expenses to help Medi‑Cal members move from licensed nursing facilities to private residences or subsidized housing in California.

Policy Summary

PayerHealth Net

PolicyCommunity or Home Transition Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain physician order, discharge assessment, and orders for home health, durable medical equipment, and prescriptions to support authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$7,500total lifetime max ($)

T2038billing code

60+minimum stay (days)

Per serviceunit

Coverage Criteria

Policy Summary

PayerHealth Net

PolicyCommunity or Home Transition Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain physician order, discharge assessment, and orders for home health, durable medical equipment, and prescriptions to support authorization.

SourceLink

On This Page

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Eligibility and necessity: Member is currently receiving medically necessary nursing facility Level of Care (LOC) services and in lieu of remaining in the nursing facility or recuperative care setting chooses to transition home while continuing to receive medically necessary nursing facility LOC services; member has lived 60+ days in a nursing home and/or recuperative care setting; member is interested in moving back to the community; and member is able to reside safely in the community with appropriate and cost-effective supports and services.>= 60 days

From eligibility section

Covered transition services: Time-limited transition services such as assisting with housing search and applications, securing required documentation, assessing housing needs and options, communicating with landlords and coordinating moves, arranging non-emergency non-medical transportation for move-in, establishing housing retention procedures, coordinating funding for environmental modifications, and non-recurring set-up expenses necessary to establish a basic household (security deposits, utility set-up fees and up to six months utility arrears, air conditioner/heater, pre-occupancy pest eradication/one-time cleaning, necessary repairs to meet housing quality standards, and adaptive aids) when these items are not otherwise available under Medi‑Cal.

From program overview items

Safety and necessity: Services must be necessary to ensure the health, welfare and safety of the member; without these services the member would be unable to move to a private residence or public subsidized housing and would require continued or re-institutionalization.

From restrictions

Non-recurring set-up expenses are intended to establish a basic household and do not constitute room and board. Examples include security deposits, utility set‑up fees and up to six months of utility arrears, climate control equipment (air conditioner or heater), one‑time pest eradication or cleaning prior to occupancy, necessary repairs to meet applicable quality standards, and adaptive aids when not otherwise available under Medi‑Cal.

Coding and Unit Rules

Covered HCPCS CodesHCPCSCovered

T2038

community transition, waiver, US

inv-06: Minimum nursing facility stay — >= 60 days

Minimum nursing facility/recuperative stayMember must have lived 60+ days in a nursing home and/or Recuperative Care setting

Eligibility contextMember is currently receiving medically necessary nursing facility Level of Care (LOC) services and is choosing to transition home while continuing to receive nursing facility LOC services

Member intentMember is interested in moving back to the community

Safety requirementMember must be able to reside safely in the community with appropriate and cost‑effective supports and services

Authorization, Documentation & Provider Actions

Documentation Required

Required documentation

Required documentation includes a physician order, discharge assessment, and orders for home health, durable medical equipment (DME), and prescription medications.

Physician order
Discharge assessment
Order for home health, DME and prescription medications

Note

Prioritize other community supports

Before funding home modifications or transition expenses, providers must first connect members to other applicable community supports when eligible and available. Prioritize Environmental Accessibility Adaptations (Home Modifications) Community Support for home modification needs. If the member has reached the lifetime maximum for Environmental Accessibility Adaptations, non‑recurring set‑up funds may be used for similar modifications. Members receiving Community or Home Transition Services may also be eligible for other Community Support services (for example, Housing Deposits and Housing Transition Navigation Services) if activities provided are distinct and not duplicative. Community Transition Services are time‑limited and designed to complement Enhanced Care Management (ECM). A member cannot be enrolled in more than one program at the same time when services would duplicate.

Prioritize Environmental Accessibility Adaptations (Home Modifications) Community Support for home modifications
If lifetime maximum for Environmental Accessibility Adaptations is reached, non‑recurring set‑up funds may be used for similar modifications
Members may receive Housing Deposits and Housing Transition Navigation Services at the same time as Community Transition Services only if activities are distinct
Community Transition Services complement Enhanced Care Management (ECM)
A member cannot be enrolled in more than one duplicative program at the same time

Background

Community or Home Transition Services support members transitioning from licensed nursing facilities to private residences or public subsidized housing by providing time‑limited transition coordination and non‑recurring set‑up expenses necessary to establish a basic household and ensure health and safety on move‑in. Covered activities include housing search assistance and application support, securing required documentation, landlord communication and move coordination, non‑emergency non‑medical transportation for move‑in, establishing housing retention procedures, coordinating funding for environmental modifications and adaptive aids when not otherwise available under Medi‑Cal, and non‑recurring set‑up expenses such as security deposits, utility set‑up/arrears (up to six months), pest eradication/one‑time cleaning, necessary repairs, and climate control equipment. Services must be necessary to ensure the health, welfare and safety of the member so they can reside safely in the community; otherwise the member would require continued or re‑institutionalization.

Definitions

inv-12: Community or Home Transition Services — definition/key attributes

DefinitionCommunity or Home Transition Services support members transitioning from a licensed nursing facility to a private residence or public subsidized housing and include time‑limited transition coordination and non‑recurring set‑up expenses

Key componentsHousing search and applications, securing required documentation, assessing housing needs, communicating with landlords, and coordinating moves and move‑in activities

Non‑recurring set‑up expensesSecurity deposits, utility set‑up fees and up to six months of utility arrears, air conditioners/heaters, pre‑occupancy pest eradication/one‑time cleaning, necessary repairs to meet quality standards, and adaptive aids when not available under Medi‑Cal

Transportation and retention supportsNon‑emergency, non‑medical transportation for move‑in and establishing procedures/contacts to retain housing

Environmental modificationsIdentifying, coordinating, securing or funding environmental modifications to install necessary accessibility accommodations when not available through Medi‑Cal