CurrentHealth NetPolicy N/A

Assisted Living Facility (ALF) Transitions — Coverage Criteria

Governs authorization, documentation, and service components for ALF Transitions (time-limited transition services and ongoing assisted living services) for Health Net members in North Carolina (NC). Applies to members transitioning from nursing facilities or remaining in the community who meet nursing facility level-of-care criteria and choose ALF residence.

Policy Summary

PayerHealth Net

PolicyAssisted Living Facility (ALF) Transitions — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit required documentation (admission face sheet, individual plan of care, and ALW application if applicable) to request initial authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsInitial authorization period

7 daysPresumptive transition auth

T2038, H2022Billing codes

60+ daysMin NF residence

Coverage and Eligibility Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Transition from Nursing Facility

Eligibility for members residing in a nursing facility (transition to ALF):

Facility-to-ALF eligibility: Member has resided for 60+ days in a nursing facility AND is willing to live in an assisted setting as an alternative to a nursing facility AND is able to reside safely in an ALF.60+ days

Based on facility eligibility criteria

Remain in Community

Eligibility for members residing in the community (remain in community to ALF):

Community-to-ALF eligibility: Member is interested in remaining in the community AND meets the minimum criteria for nursing facility level of care AND chooses to receive nursing facility level of care services at an ALF AND is willing and able to reside safely in an ALF.meets nursing facility LOC (per Title 22 §51124)

Documentation options include CBAS/IHSS authorization, medical provider order for nursing facility LOC, or enrollment in LTSS/qualified waiver.

Members may not receive duplicative state, local, or federally funded programs that overlap with ALF Transition services. Specifically, a member cannot receive both the Assisted Living Waiver (ALW)/California Community Transitions (CCT) program and the Plan's ALF Transition program at the same time. ALF Transitions are designed to complement other supports (for example, Housing Transition Navigation Services and Enhanced Care Management), but participation in fully duplicative programs is prohibited.

Time-limited transition services and allowable expenses do not include room and board. While the program may fund relocation and setup costs needed to establish residency in an ALF (for example, moving expenses and necessary personal items), ongoing rent, board, and room charges are excluded. Members may still receive assistance for room and board from other sources while receiving ALF Transition services.

Authorization, Documentation, and Coordination Requirements

Prior Authorization

Authorization timeframe — initial and presumptive

Initial authorization will be issued for up to six months following receipt of all required documentation. Transition from an acute setting to an ALF has a seven-day presumptive authorization period.

Initial authorization: up to 6 months following receipt of all required documentation
Acute-to-ALF presumptive authorization: 7 days

Documentation Required

Required documentation — nursing facility to ALF

The nursing facility to ALF referral must include the following documentation to support the request: admission face sheet; individual plan of care; and a copy of the Assisted Living Waiver (ALW) application if the member has applied.

Admission face sheet
Individual plan of care
Copy of ALW application (if applied)

Documentation Required

Required documentation — community to ALF

For community-to-ALF referrals, submit documentation demonstrating the member meets enrollment/authorization requirements and nursing facility level of care, including one of the following: authorization for Community-Based Adult Services (CBAS), authorization for In‑Home Supportive Services (IHSS), documentation of enrollment in Long‑Term Services and Supports (LTSS) or a qualified waiver program, and a medical provider order confirming nursing facility level of care (as defined in Section 51124 of Title 22, CCR).

Documentation of authorization for CBAS OR IHSS
Documentation of enrollment in LTSS or a qualified waiver program
Medical provider order for nursing facility level of care (Section 51124, Title 22, CCR)

Documentation Required

Reauthorization documentation — items required for extension requests

If an extension (reauthorization) is needed, submit a new referral form that includes: the reason for the authorization extension, the member’s current individual plan of care, and the status of the ALW application (if the member has applied).

New referral form for extension request
Reason for authorization extension
Current individual plan of care
Status of ALW application (if applied)

Program Purpose and Scope

ALF Transitions are Community Support services intended to help members with nursing facility level-of-care needs either move to an assisted living setting or remain in the community by receiving nursing-facility-level supports in an Assisted Living Facility (such as an RCFE or ARF). The service includes two components: time-limited transition services (expenses and supports to establish residency in an ALF, ending once residency is established) and ongoing assisted services (long-term assistance with ADLs/IADLs, medication administration/oversight, meal preparation, transportation, companion services, and 24-hour onsite care as needed).

Key Definitions

ALF (Assisted Living Facility)

DefinitionIncludes residential care facility for the elderly (RCFE) or adult residential facility (ARF); intended as a community alternative to long-term nursing facility placement.

SettingResidential assisted living (community) — provides 24-hour direct care onsite to support members with nursing facility level-of-care needs.

PurposeTo facilitate transition from nursing facility to a home-like, community ALF or to prevent nursing facility admission for members living in the community.

Time-limited transition services

DefinitionServices and allowable expenses that enable a person to establish a residence in an ALF (excluding room and board).

Included activitiesAssessing housing needs and options; assisting with ALF applications and required documentation; coordinating move and communicating with facility administration.

Eligible expensesMoving expenses and necessary personal articles to establish ALF residency (room and board are excluded).

Ongoing assisted services

DefinitionLong-term services provided after transition to assist with ADLs/IADLs, medication administration/oversight, meal preparation, transportation, and companion services.

Additional supportsTherapeutic social and recreational programming and 24-hour direct care onsite to meet unpredictable needs and promote dignity and independence.

DurationProvided on an ongoing basis while the member can maintain residency in the ALF.

Admission and Initial Eligibility

ALF (from nursing facility)

Admission from nursing facility: Provide admission face sheet AND individual plan of care AND copy of Assisted Living Waiver (ALW) application if the member has applied.

ALF (from community)

Admission from community: Provide documentation of authorization for Community-Based Adult Services (CBAS) OR documentation of authorization for In-Home Supportive Services (IHSS) OR medical provider order for nursing facility level of care OR documentation of enrollment in Long-Term Services and Supports (LTSS) or a qualified waiver.

Authorization Durations and Limits

Authorization

Standard initial authorizationInitial authorization will be issued for up to six months following receipt of all required documentation.

Reauthorization requirementIf an extension is needed, submit a new referral form with reason for extension, individual plan of care, and status of ALW application if applicable.

Trigger for initial authIssued after receipt of all required documentation from the provider.

Transition authorization

Presumptive transition authorizationSeven-day presumptive authorization period for transitions from an acute setting to an ALF.

Applies toAcute-to-ALF transitions to allow immediate placement while documentation is completed.

Follow-upProviders must submit required documentation within the presumptive window to obtain standard authorization up to six months.

Policy Summary

PayerHealth Net

PolicyAssisted Living Facility (ALF) Transitions — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit required documentation (admission face sheet, individual plan of care, and ALW application if applicable) to request initial authorization.

SourceLink

On This Page

T2038 U4	Community transition; per service.
H2022 US	Community wraparound services, assisted living services, per diem.

OpenPayer

Assisted Living Facility (ALF) Transitions — Coverage Criteria

Coverage and Eligibility Criteria

Billing and HCPCS Codes

Authorization, Documentation, and Coordination Requirements

Program Purpose and Scope

Key Definitions

Admission and Initial Eligibility

Ongoing Service Eligibility

Discharge from Transition Services

Authorization Durations and Limits