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

Defines eligibility, services, authorization, documentation, allowable providers, and billing codes for Assisted Living Facility (ALF) Transitions Community Support intended to facilitate transition from nursing facilities or remain-in-community supports to assisted living settings and to prevent institutionalization.

Policy Summary

Payermhn

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

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit required documentation; initial authorization will be issued for up to six months following receipt of all required documentation; transitions from an acute setting have a seven-day presumptive authorization period.

SourceLink

POLICY UPDATE CHANGES

No material changes

2Program components (time-limited transition; ongoing assisted living services)

60+Nursing facility residency eligibility threshold

6 moInitial authorization maximum duration

Coverage Summary

This ALF Transitions Community Support program facilitates transitions from nursing facilities to Assisted Living Facilities (ALF) — including Residential Care Facilities for the Elderly (RCFE) and Adult Residential Facilities (ARF) — and supports members who choose to remain in the community by providing ALF-based alternatives to institutional care. Coverage stance: covered with criteria. Initial authorizations are issued for up to 6 months following receipt of all required documentation (with a 7-day presumptive authorization for transitions from an acute setting).

Key quick facts

Nursing facility residency duration>= 60 days

Initial authorization maximum durationUp to 6 months following receipt of all required documentation

Program componentsTime-limited transition services; Ongoing assisted living services

Medical Necessity / Eligibility Criteria

Eligible members - Transition from nursing facility

Members residing in a nursing facility who meet ALL of the following:

ALL of the following

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

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Eligible members - Remain in community

Members residing in the community who meet ALL of the following:

ALL of the following

Are interested in remaining in the community
Are willing and able to reside safely in an ALF
Meet the minimum criteria to receive nursing facility level of care (LOC) services and, 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

Documentation requirements for referral/authorization

Submit required documentation (ALL of the following depending on transition type):

Transition from a nursing facility (any of these required)

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

Remain in community (any of these acceptable documentation options)

Documentation of authorization for Community-Based Adult Services (CBAS)
Documentation of authorization for In-Home Supportive Services (IHSS)

Authorization, Documentation & Billing Actions

Prior Authorization

Initial authorization submission

Submit required documentation; 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.

T2038
H2022

Prior Authorization

Reauthorization requirements

To extend beyond the initial authorization, submit a new referral form including reason for authorization extension, individual plan of care, and status of Assisted Living Waiver (ALW) application (if applicable).

T2038
H2022

Documentation Required

Documentation to establish eligibility

Provide admission face sheet and individual plan of care for transitions from a nursing facility. For community-to-ALF transitions, provide one 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, or a medical provider order for nursing facility level of care (LOC).

Billing Rule

Room and board exclusion

Room and board expenses are not included in this service and must not be billed under ALF Transitions.

Documentation Required

Avoid duplicate state-funded programs

Members cannot receive both the Assisted Living Waiver (ALW)/California Community Transitions (CCT) program and the Plan's ALF Transition program simultaneously. Document participation in state-funded programs and avoid duplication of benefits.

Billing Codes

Covered HCPCS / Per serviceHCPCSCovered

T2038

Community transition; per service

Covered HCPCS / Per diemHCPCSCovered

H2022

Community wraparound services, assisted living services, per diem

Definitions & Background

ALF Transitions is a Community Support service designed to help members with nursing-facility level of care either move from a nursing facility into an assisted living setting or avoid nursing facility admission by receiving services in an ALF. The program includes two components: time-limited transition services to establish residency in an ALF (excluding room and board) and ongoing assisted living services provided after transition; ALF includes RCFEs and ARFs.

ALF: Assisted Living Facility — includes Residential Care Facility for the Elderly (RCFE) or an Adult Residential Facility (ARF).

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

Time-limited transition services: Services and expenses that enable establishment of residency in an ALF (excluding room and board); these services end once the member establishes residency.

Ongoing assisted living services: Post-transition services such as assistance with ADLs/IADLs, meal preparation, transportation, medication administration/oversight, companion services, therapeutic programming, and 24-hour direct care staff.

Policy Summary

Payermhn

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

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

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Documentation of enrollment in Long-Term Services and Supports (LTSS) or a qualified waiver program

Medical provider order for nursing facility level of care (LOC)