CurrentmhnPolicy N/A

Assisted Living Facility (ALF) Transitions

Governance of time-limited transition services and ongoing assisted living services to support members transitioning from nursing facilities or remaining in the community by establishing or maintaining residency in an Assisted Living Facility (ALF). Applies to members eligible for nursing facility level of care and to providers coordinating ALF placement and services in North Carolina where specified.

Policy Summary

Payermhn

PolicyAssisted Living Facility (ALF) Transitions

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit required documentation (admission face sheet, individual plan of care, ALW application if applicable) to obtain initial authorization for up to six months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsInitial authorization maximum duration

7 daysPresumptive authorization period

T2038 U4, H2022 U5Billing codes listed

ExcludedRoom & board

Coverage Criteria for ALF Transitions

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Eligibility criteria for ALF Transitions

Covered when ALL of the following member-specific conditions are met

Residence in nursing facility -> transition: Members residing in a nursing facility who have resided for 60+ days in a nursing facility AND are willing to live in an assisted living setting as an alternative to a nursing facility AND are able to reside safely in an ALF.60+ days

Community members -> remain in community via ALF: Members residing in the community who are interested in remaining in the community AND are willing and able to reside safely in an ALF AND meet the minimum criteria to receive nursing facility LOC services and choose to receive those services at an ALF.meet NF LOC criteria

Covered service types

Covered services components

Time-limited transition services: Services and allowable expenses to establish residence in an ALF (except room and board), including housing needs assessment, securing ALF residence and documentation, moving expenses, communication with facility administration, and establishing procedures to retain housing.time-limited until residency established

Ongoing assisted living services: Ongoing services after transition including assistance with ADLs/IADLs, meal preparation, transportation, medication administration and oversight, companion services, therapeutic social and recreational programming, and 24-hour direct care onsite.ongoing while resident maintains ALF residency

The ALF Transitions service excludes room and board expenses; these costs are not reimbursed as part of transition services and members may seek assistance for room and board from other sources. In addition, services that duplicate state, local, or federally funded programs are excluded — for example, members cannot simultaneously receive the Plan's ALF Transition program and the Assisted Living Waiver (ALW)/California Community Transitions (CCT) program. Providers should avoid authorizing services that overlap with funded state services such as skilled nursing facility care, inpatient hospital care, or psychiatric inpatient stays.

Admission Criteria

residential

From nursing facility to ALF admission: Member has resided 60+ days in a nursing facility; is willing to live in an ALF as an alternative; and is able to reside safely in an ALF; required documentation includes admission face sheet, individual plan of care, and ALW application if applicable.

From community to ALF admission: Member is interested in remaining in the community; willing and able to reside safely in an ALF; meets minimum criteria for nursing facility LOC (per Title 22 Section 51124); and has documentation of authorization for CBAS or IHSS or enrollment in LTSS/waiver program or a medical provider order for nursing facility LOC.

Provider Actions and Authorization Requirements

Prior Authorization

Authorization Duration and Reauthorization Requirements

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

Initial authorization duration: up to 6 months
7-day presumptive authorization for acute-to-ALF transitions

Denial Risk

Program Overlap and Duplication Exclusion

Members cannot concurrently receive the Assisted Living Waiver (ALW) or California Community Transitions (CCT) program and the Plan's ALF Transition program. Time-limited transition services may be provided alongside Housing Transition Navigation Services and are designed to complement Enhanced Care Management (ECM). Services that duplicate state, local, or federally funded programs are not available through this program. Room and board expenses are not covered by this service.

No concurrent participation in ALW or CCT and ALF Transition program
Avoid duplication with other state/local/federal programs
Room and board not included

Documentation Required

Required Documentation for Initial Authorization and Reauthorization

Required documentation must be submitted with the initial referral and for any reauthorization request. Include all applicable items below depending on the member's transition origin.

Transition from a nursing facility: Admission face sheet; Individual plan of care; Copy of Assisted Living Waiver (ALW) application (if member has applied)
Remain in community (community-to-ALF): Documentation of authorization for Community-Based Adult Services (CBAS) OR documentation of authorization for In-Home Supportive Services (IHSS) OR documentation of enrollment in Long-Term Services and Supports (LTSS) or a qualified waiver program OR medical provider order for nursing facility level of care (as defined in Section 51124 of Title 22, California Code of Regulations)
Reauthorization / extension requests must include: Reason for authorization extension; Individual plan of care; Status of ALW application (if member has applied)

Denial Risk

Duplication Exclusion

Services are unavailable when the member is participating in duplicative state, local, or federally funded programs (examples include skilled nursing facility services, inpatient hospital services, and psychiatric inpatient stays).

Exclude members in duplicative programs (state/local/federal)
Examples of services to avoid: skilled nursing facility, inpatient hospital, psychiatric inpatient stays

Definitions

inv-10: Assisted Living Facility (ALF) — definition including RCFE/ARF and 24-hour direct care

Definition of ALFIncludes a residential care facility for the elderly (RCFE) or an adult residential facility (ARF) providing 24-hour direct care staff, supervision, safety, security, and services to support members requiring nursing facility level of care

24-hour direct care24-hour direct care staff onsite at the ALF to meet unpredictable needs and provide supervision, safety, and security

Services provided in ALFAssistance with ADLs/IADLs, meal preparation, transportation, medication administration and oversight, companion services, and therapeutic social and recreational programming

Role in avoiding institutionalizationDesigned to assist individuals to live in the community and avoid long-term placement in a nursing facility by providing an assisted living option for those needing nursing facility LOC

inv-11: Nursing facility level of care (LOC) — referenced definition (Title 22 Section 51124)

Referenced LOC definitionNursing facility level of care (LOC) as defined in Section 51124 of Title 22 of the California Code of Regulations

Documentation showing LOCMedical provider order for nursing facility LOC can be used as documentation for remaining in community to enter ALF

Background

The ALF Transitions program supports members who require nursing facility level of care to either move from a nursing facility into an assisted living facility or to remain in the community by establishing or maintaining ALF residency. The program has two components: time-limited transition services — allowable expenses and activities that enable a person to establish residence in an ALF (for example, housing needs assessment, assistance securing facility placement, and moving expenses) — and ongoing assisted living services provided after transition (for example, ADL/IADL assistance, meal preparation, transportation, medication administration/oversight, companion services, therapeutic programming, and 24-hour direct care onsite). The time-limited component ends once the member establishes ALF residency; services are designed to complement, not duplicate, other state or federally funded programs.

OpenPayer

Assisted Living Facility (ALF) Transitions

Coverage Criteria for ALF Transitions

Admission Criteria

Continued Stay Criteria

Discharge Criteria

Billing and Coding

Provider Actions and Authorization Requirements

Authorization Durations and Day Limits

Definitions

Background

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