CurrentmhnPolicy N/A

Assisted Living Facility (ALF) Transitions authorization

Governs authorization requirements, covered services, eligibility, documentation, and coding for ALF transition and ongoing assisted living services for Medi‑Cal enrollees in Imperial County served by CHPIV/Health Net. Affects providers arranging transitions from nursing facilities or the community into ALFs and those providing ongoing ALF services.

Policy Summary

Payermhn

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 (admission face sheet, individual plan of care, and ALW application if applicable) to obtain initial authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsinitial authorization duration

7 dayspresumptive authorization

T2038, H2022billing codes

60+ daysNF residency minimum

Coverage and Eligibility Criteria

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Eligibility criteria

Covered when ALL of the following member-specific conditions are met (two distinct pathways):

Nursing facility resident pathway: Member has resided >=60 days in a nursing facility AND is willing to live in an assisted living setting as an alternative to a nursing facility AND is able to reside safely in an ALF.60+ days

NF-to-ALF pathway

Community resident pathway: Member is interested in remaining in the community AND is willing and able to reside safely in an ALF AND meets the minimum criteria to receive nursing facility level-of-care services and chooses to receive those LOC services in an ALF instead of entering a facility.meets nursing facility LOC

Community-to-ALF pathway

Members who are concurrently enrolled in duplicative state, local, or federally funded programs are excluded from receiving 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. Additionally, room and board expenses are excluded from this service; members may receive assistance for room and board from other sources but not as part of ALF Transitions.

Authorization, Documentation, and Concurrent Program Rules

Prior Authorization

Prior Authorization Required

Initial authorizations are issued for up to six months once all required documentation is received. Note: transitions from an acute setting to an Assisted Living Facility (ALF) have a seven-day presumptive authorization period — providers may begin services during this window while full documentation is finalized.

Initial authorization period: up to six months following receipt of all required documentation
Acute-to-ALF transitions: 7-day presumptive authorization period

Documentation Required

Reauthorization & Continuation Rules

To request a reauthorization (extension), the provider must submit a new referral form and include: the reason for the authorization extension, the member's current individual plan of care, and the status of the Assisted Living Waiver (ALW) application if the member has applied. Reauthorization must be supported by clinical documentation demonstrating ongoing need.

Required for reauthorization: new referral form
Include: reason for extension; individual plan of care; ALW application status (if applicable)

Documentation Required

Documentation Required for Initial Authorization and Reauthorization

Providers must supply documentation at intake and for reauthorization. Required documents include admission face sheet, individual plan of care, and a copy of the Assisted Living Waiver (ALW) application if the member has applied. For members transitioning from the community, acceptable documentation includes authorization for CBAS or IHSS, enrollment in LTSS or a qualified waiver, or a medical provider order indicating nursing facility level of care per Section 51124 of Title 22, California Code of Regulations.

Admission face sheet
Individual plan of care
Copy of ALW application (if applied)
For community-to-ALF transitions: documentation of CBAS or IHSS authorization, LTSS or waiver enrollment, or medical provider order for nursing facility LOC (Title 22 §51124)

Denial Risk

Duplicate Program Participation & Concurrent Service Rules

Members may participate in complementary programs but may not receive duplicative program services. A member cannot receive both the Assisted Living Waiver (ALW)/California Community Transitions (CCT) program and the Plan's ALF Transition program simultaneously. Time-limited transition services may run concurrently with Housing Transition Navigation Services and are designed to complement Enhanced Care Management (ECM). Room and board are not covered by this service.

Prohibition on duplicate participation: cannot receive both ALW/CCT and the Plan's ALF Transition program
Concurrent allowed programs: Housing Transition Navigation Services; complementary to ECM
Exclusions: room and board not included; avoid duplication with skilled nursing, inpatient hospital, and psychiatric inpatient services

Background and Program Purpose

ALF Transitions are community support services intended to help members move from nursing facilities into assisted living facilities or to prevent nursing facility admission by enabling eligible members to live in ALFs. The service has two components: (1) time-limited transition services and expenses that enable a member to establish residence in an ALF (for example, housing needs assessment, securing facility applications and required documents, moving expenses, and coordination with facility administration), and (2) ongoing assisted living services provided after transition to maintain community residence (including ADL/IADL support, meal preparation, transportation, medication administration/oversight, companion services, and other onsite supports).

Key Definitions

inv-09: ALF — Assisted Living Facility (definition entry)

TermAssisted Living Facility (ALF)

IncludesResidential care facility for the elderly (RCFE) or an adult residential care facility (ARF)

PurposeAssists individuals to live in the community and avoid institutionalization by facilitating transition from nursing facilities to a home-like assisted living setting or preventing nursing facility admissions.

ScopeCommunity Support for members needing nursing facility level of care who choose ALF as an alternative to long-term nursing facility placement.

inv-10: Nursing facility level of care (LOC) — defined in Section 51124 of Title 22 of the California Code of Regulations

TermNursing facility level of care (LOC)

Defined bySection 51124 of Title 22 of the California Code of Regulations

ApplicationMembers must meet the minimum criteria to receive nursing facility LOC to be eligible to receive medically necessary LOC services in an ALF (community‑resident pathway).

IncludesMembers in private residences, subsidized housing, or already in an ALF who are at risk of institutionalization; may include those receiving acute or post‑acute facility care if other eligibility criteria met.

Admission Criteria

Admission criteria (residential)

Admission for residential (ALF) transitions requires submission of the following documentation:

NF to ALF admission documents: Submit admission face sheet AND individual plan of care AND copy of Assisted Living Waiver (ALW) application if member has applied for the ALW.

NF-to-ALF documentation

Community to ALF admission documents: Provide 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 a medical provider order for nursing facility level of care.

Community-to-ALF documentation

Authorization Durations and Transitional Limits

inv-14: residential — Up to 6 months (initial authorization duration)

Applies toInitial authorization for residential ALF transition services after receipt of all required documentation.

Maximum durationUp to 6 months

Use caseIssued following completion of required admission documentation to support establishment of ALF residency and transition supports.

inv-15: residential — 7 days (presumptive authorization for acute-to-ALF transitions)

Applies toTransitions from an acute setting to an Assisted Living Facility (ALF).

Presumptive authorization period7 days

PurposeProvides immediate, time-limited authorization to allow placement and initial supports while full documentation is obtained.

Requirement after presumptive periodFull initial authorization depends on receipt of all required documentation; presumptive authorization is temporary until documentation is received.

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

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

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