CurrentmhnPolicy N/A

Assisted Living Facility (ALF) Transitions – English (PDF)

Defines eligibility, covered services (time-limited transition services and ongoing assisted living services), documentation requirements, authorization periods, billing codes, allowable providers, exclusions/overlaps, and operational notes for ALF Transitions Community Support for Medi‑Cal enrollees served by the plan.

Policy Summary

Payermhn

PolicyAssisted Living Facility (ALF) Transitions – English (PDF)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit required documentation (admission face sheet, individual plan of care, ALW application copy if applicable, or one of CBAS/IHSS/LTSS authorization or medical provider order) to obtain authorization for up to six months.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage or criteria.

2Service Components

60+Minimum NF residency for NF-to-ALF eligibility

7Presumptive authorization for acute-to-ALF transitions

Coverage Summary

ALF Transitions Community Support helps Medi‑Cal members with a nursing facility level of care transition to or remain in an Assisted Living Facility (ALF) — which includes Residential Care Facilities for the Elderly (RCFE) and Adult Residential Facilities (ARF) — by supporting movement into and ongoing residency in a home‑like, community setting.

Eligibility and Authorization Criteria

Eligible Members - Residents in a Nursing Facility

Covered when ALL of the following are met:

ALL of the following

Have resided for 60+ days in a nursing facility
Are willing to live in an assisted living setting as an alternative to a nursing facility
Are able to reside safely in an ALF

Eligible Members - Members Residing in the Community

Covered when ALL of the following are met:

ALL of the following

Are interested in remaining in the community
Are willing and able to reside safely in an ALF
AND
- Meet the minimum criteria to receive nursing facility level of care (LOC) as defined in Section 51124 of Title 22 of the California Code of Regulations
- In lieu of going into a facility, choose to remain in the community and continue to receive medically necessary nursing facility LOC services at an ALF

Members Receiving Acute or Post-Acute Facility-Level Care

Covered when ALL of the following are met:

ALL of the following

Member is receiving facility level health care services on an acute or post-acute care basis (such as hospitalization or a short-term skilled nursing facility stay)
Member otherwise meets the eligibility criteria above (nursing facility residents or community-residing members meeting nursing facility LOC and willing/able to reside safely in ALF)

Required Documentation for Transition from Nursing Facility

Authorization requires submission of:

ALL of the following

Admission face sheet
Individual plan of care
Copy of Assisted Living Waiver (ALW) application (if member has applied for the ALW)

Required Documentation for Remain-in-Community (community to ALF)

Authorization requires ONE of the following:

ANY of the following

Documentation of authorization for Community-Based Adult Services (CBAS)
Documentation of authorization for In-Home Supportive Services (IHSS)
Documentation of enrollment in Long-Term Services and Supports (LTSS) or a qualified waiver program
Medical provider order for nursing facility level of care

Authorization Periods and Extensions

Authorization rules:

ALL of the following

Initial authorization: will be issued for up to six months following receipt of all required documentation
Reauthorization: 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
If an extension is needed, a new referral form must be submitted and include: 1) Reason for authorization extension; 2) Individual plan of care; 3) Status of ALW application (if member has applied for the ALW)

Covered Services & Examples

Service Components

Covered services include BOTH of the following components:

ALL of the following

Time-limited transition services and expenses to enable a person to establish a residence in an ALF (transition services end once member establishes residency); allowable expenses exclude room and board
Ongoing assisted living services provided after transition into the ALF for as long as the member maintains residency

Examples of covered items/services (not exhaustive)

Assessing housing needs and presenting options
Assessing service needs to determine need for enhanced onsite services at the ALF
Assisting in securing an ALF residence including completion of facility applications and securing required documentation (e.g., Social Security card, birth certificate, prior rental history)
Moving expenses (movers/moving supplies) and necessary private/personal articles to establish an ALF residence; see ALF Referral Form for eligible moving items
Communicating with facility administration and coordinating the move
Establishing procedures and contacts to retain housing at the ALF
Assistance with activities of daily living (ADLs) and instrumental ADLs (IADLs)
Meal preparation
Transportation
Medication administration and oversight
Companion services
Therapeutic social and recreational programming in a home-like environment
24-hour direct care staff onsite at the ALF to meet unpredictable needs, provide supervision, safety, security; care coordination to screen for eligibility and support enrollment into Enhanced Care Management and other Community Supports

Exclusions and Overlap Restrictions

Exclusions / Overlap Restrictions

Not covered/limited when the following apply:

ANY of the following

Member is participating in duplicative state, local, or federally funded programs where activities are not distinct
Member is enrolled in ALW (Assisted Living Waiver) / California Community Transitions (CCT) program simultaneously with the Plan's ALF Transition program (cannot receive both)
Room and board expenses are not included in this service (members may seek room/board assistance from other sources)
Services that are state services to be avoided: skilled nursing facility services, inpatient hospital services, psychiatric inpatient stays (examples of services to avoid overlap)

Denial Risk

Denial for duplicative programs or ALW/CCT overlap

Claims or authorization requests may be denied if the member is participating in duplicative state, local, or federally funded programs or is concurrently enrolled in the Assisted Living Waiver (ALW) or California Community Transitions (CCT) program while seeking the Plan's ALF Transition services.

Claims may be denied if member participates in duplicative state, local, or federally funded programs where activities are not distinct
Claims may be denied if member is enrolled in ALW or CCT concurrently with the Plan's ALF Transition program

Provider Requirements & Authorization Actions

Prior Authorization

Submit required documentation for authorization

Providers must submit required documentation to obtain authorization for up to six months.

For nursing facility to ALF transitions: admission face sheet; individual plan of care; copy of Assisted Living Waiver (ALW) application (if member has applied)
For community-to-ALF (remain-in-community): documentation of authorization for CBAS or documentation of authorization for IHSS or documentation of enrollment in LTSS or a qualified waiver program or medical provider order for nursing facility level of care
Affected codes: T2038 U4, H2022 U5

Prior Authorization

Seven-day presumptive authorization for acute-to-ALF transitions

Transition from an acute setting to an ALF has a seven-day presumptive authorization period; full authorization requires submission and receipt of all required documentation.

Documentation Required

Extension request requirements

To request an extension beyond the initial authorization, submit a new referral form and include the reason for the extension, the individual plan of care, and the status of the ALW application (if the member has applied).

Definitions & Background

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

Nursing facility level of care (LOC) is as defined in Section 51124 of Title 22 of the California Code of Regulations.

ALF Transitions services provide time‑limited transition supports (excluding room and board) and ongoing assisted living services to members who have a nursing facility LOC and choose assisted living as an alternative to long‑term nursing facility placement. Services support establishing residency (application assistance, documentation, moving expenses) and ongoing needs (ADL/IADL assistance, medication oversight, meal preparation, transportation, companion services, therapeutic programming, and 24‑hour onsite direct care).

OpenPayer

Assisted Living Facility (ALF) Transitions – English (PDF)

Coverage Summary

Eligibility and Authorization Criteria

Covered Services & Examples

Exclusions and Overlap Restrictions

Billing Codes

Provider Requirements & Authorization Actions

Definitions & Background

T2038 U4	Community transition; per service.
H2022 U5	Community wraparound services, assisted living services, per diem.