CurrentHealth NetPolicy N/A

Assisted Living Facility (ALF) Transitions authorization

Governance of authorization, documentation, and coverage for time-limited transition services and ongoing assisted living services enabling members to move to or remain in an ALF instead of institutional nursing facility care; applies to Health Net members in North Carolina where specified.

Policy Summary

PayerHealth Net

PolicyAssisted Living Facility (ALF) Transitions authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit required documentation to obtain initial authorization; authorizations are issued for up to six months after receipt of all required documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

up to 6 monthsauthorization period

7 dayspresumptive auth

T2038, H2022billing codes

60+ daysmin NF residency

Coverage and Service Criteria

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Eligibility criteria

Covered when ALL of the following are met for the respective candidate group

Members transitioning from a nursing facility: Member has resided for 60+ days in a nursing facility; is willing to live in an assisted setting as an alternative to a nursing facility; and is able to reside safely in an ALF.

Members residing in the community: Member is interested in remaining in the community; meets the minimum criteria to receive nursing facility level of care and, in lieu of entering a facility, chooses to receive nursing facility LOC services at an ALF; and is willing and able to reside safely in an ALF.

Covered service elements

Covered services components

Time-limited transition services: Services and allowable expenses to establish ALF residency (excluding room and board), including assessing housing and service needs; assisting with facility applications and required documentation; moving expenses and necessary personal articles; communicating with facility administration and coordinating the move; and establishing procedures/contacts to retain housing.

Ongoing assisted services: Long-term services after transition including meal preparation, transportation, medication administration and oversight, companion services, therapeutic social and recreational programming, and 24-hour direct care onsite to support supervision, safety, and care coordination.

Authorization, Documentation, and Provider Requirements

Prior Authorization

Authorization timeframe and extensions

Initial authorization will be issued following receipt of all required documentation. Reauthorization will be issued for up to six months. For transitions from an acute setting to an assisted living facility (ALF), a seven-day presumptive authorization period applies.

Reauthorization period: up to six months after required documentation received
Seven-day presumptive authorization for acute-to-ALF transitions

Denial Risk

Duplicate program participation and program overlap

Do not authorize or continue ALF Transition services when the member is currently enrolled in a duplicative state, local, or federally funded program (for example: Assisted Living Waiver (ALW) when receiving the Plan's ALF Transition program or the California Community Transitions (CCT) program). Room and board expenses are not covered by this service; members may receive room and board assistance from other sources concurrently. Avoid overlap with services that are substitutive such as skilled nursing facility care, inpatient hospital services, and psychiatric inpatient stays.

Member participation in duplicative programs may result in denial of ALF Transition services
Room and board are excluded from coverage under this service

Documentation Required

Required documentation for authorization

Submit the following documentation with the authorization request. For transitions from a nursing facility to an ALF: admission face sheet, individual plan of care, and a copy of the Assisted Living Waiver (ALW) application if the member has applied. For members remaining in the community (transitioning from community to ALF): documentation of authorization for Community-Based Adult Services (CBAS) OR documentation of enrollment in Long-Term Services and Supports (LTSS) or a qualified waiver program OR documentation of authorization for In-Home Supportive Services (IHSS), OR a medical provider order demonstrating nursing facility level of care per Section 51124 of Title 22, California Code of Regulations. If requesting an extension, submit a new referral form with the reason for extension, the current individual plan of care, and the status of the ALW application (if applicable).

Nursing facility to ALF: admission face sheet; individual plan of care; copy of ALW application (if applied)
Community to ALF: CBAS authorization OR LTSS/waiver enrollment documentation OR IHSS authorization OR medical provider order for nursing facility level of care (Title 22, §51124)
Extension requests: new referral form + reason for extension + individual plan of care + ALW application status

Discharge and Transition Out Criteria

Discharge from ALF Transitions is implicit when the member no longer requires transition or ongoing assisted-living supports, no longer maintains residency in the ALF, becomes eligible for a duplicative state-funded program (e.g., Assisted Living Waiver/California Community Transitions), or otherwise no longer meets program requirements. For facility-to-ALF transitions, the member’s file should include the admission face sheet, individual plan of care, and, if applicable, copy of the Assisted Living Waiver application; for community-to-ALF admissions, include documentation such as CBAS authorization, LTSS/waiver enrollment, IHSS authorization, or a medical provider order confirming nursing facility level of care per Title 22 §51124 to support discharge decisions and records.

Key Definitions

ALF — definition

DefinitionAssisted Living Facility (ALF) includes residential care facilities for the elderly (RCFE) and adult residential facilities (ARF).

Service goalFacilitate nursing facility transition back into a home-like, community setting and/or prevent nursing facility admissions for members who need nursing facility level of care.

ScopeCommunity Support service intended for members with nursing facility level of care who prefer assisted living as an alternative to long-term nursing facility placement.

Nursing facility level of care — regulatory reference

Regulatory referenceNursing facility level of care is defined in Section 51124 of Title 22 of the California Code of Regulations.

Use in eligibilityMedical provider order for nursing facility level of care (per Title 22 §51124) may be required documentation for community-to-ALF admissions.

ContextApplies when determining member meets minimum criteria to receive nursing facility level of care for ALF Transitions services.

Background and Purpose

The ALF Transitions program provides two service components: time-limited transition services to establish assisted living residency (services and allowable expenses that enable a member to move into an ALF, excluding room and board) and ongoing assisted services provided after transition to help maintain community residence (examples include meal preparation, transportation, medication administration/oversight, companion services, therapeutic social/recreational programming, and 24-hour onsite direct care). The program is intended for members who meet nursing facility level of care and prefer assisted living as an alternative to long-term nursing facility placement. Note that ALF Transitions are designed to complement other services (for example, Enhanced Care Management) but cannot be provided concurrently with duplicative state programs such as the ALW/CCT when funding overlaps.