CurrentmhnPolicy N/A

Assisted Living Facility (ALF) Transitions — Authorization and Coverage Criteria

Governs authorization requirements, coverage scope, and documentation for Assisted Living Facility transition services for Medi‑Cal members in Imperial County (CHPIV) served by Health Net Community Solutions. Affects providers arranging ALF transitions and ongoing assisted living services.

Policy Summary

Payermhn

PolicyAssisted Living Facility (ALF) Transitions — Authorization and Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit required documentation (referral form, individual plan of care, and ALW status when 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 auth max

7 daysPresumptive auth

T2038 U4, H2022 U5Billing codes

Imperial County (CHPIV)Coverage area

Coverage and Eligibility Criteria

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General coverage criteria

Covered when ALL of the following are met

Eligibility from nursing facility: Members residing in a nursing facility who have resided for 60+ days, 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.

Eligibility from community: Members residing in the community who 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 and choose to receive those services in an ALF.

Community supports included: Service includes time-limited transition services to establish ALF residency (excluding room and board) and ongoing assisted living services such as ADL/IADL assistance, meal preparation, transportation, medication administration/oversight, companion services, therapeutic programming, and 24-hour direct care.

The ALF Transitions service excludes room and board expenses from covered benefits. In addition, the service may not be provided concurrently with certain duplicative state-funded transition programs: a member who is enrolled in the Assisted Living Waiver (ALW) or California Community Transitions (CCT) program cannot receive the Plan's ALF Transition program at the same time. Providers should verify beneficiary participation in other state, local, or federally funded programs before requesting authorization to avoid duplication and denial risks.

Discharge Criteria

Discharge from the time-limited ALF transition component occurs once the member successfully establishes residency in the assisted living facility; ongoing assisted living services continue while the member maintains residency. The transition component is deliberately short-term and concludes when placement is secured and the member is settled into the ALF. Ongoing services (ADL/IADL assistance, medication oversight, meals, transportation, companion and therapeutic programming, and 24-hour direct care) continue beyond discharge from the transitional supports as long as the member maintains residency in the facility.

Authorization, Documentation, and Coordination Requirements

Prior Authorization

Prior Authorization Required

Initial authorizations 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. If an extension is needed, providers must submit a new referral form that includes: (1) reason for authorization extension; (2) individual plan of care; and (3) status of Assisted Living Waiver (ALW) application, if the member has applied.

Initial authorization: up to 6 months after all required documentation received
Acute-to-ALF transition: 7-day presumptive authorization
Reauthorization requires new referral form with: reason for extension; individual plan of care; ALW application status (if applied)

Documentation Required

Required Documentation for Authorization

Required documentation varies by referral type. For members transitioning from a nursing facility, submit: admission face sheet; individual plan of care; and a copy of the Assisted Living Waiver (ALW) application if the member has applied. For members remaining in the community prior to ALF admission, submit 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 demonstrating nursing facility level of care as defined in Section 51124 of Title 22 of the California Code of Regulations.

Nursing facility → ALF: admission face sheet; individual plan of care; ALW application copy (if applied)
Community → ALF: one of CBAS authorization, IHSS authorization, LTSS/waiver enrollment, or medical provider order for nursing facility LOC (per Title 22 §51124)

Note

Overlap and Program Coordination

The ALF Transition service is intended to complement, not duplicate, other funded programs. Members may concurrently receive Housing Transition Navigation Services and Enhanced Care Management (ECM) alongside time-limited transition services. However, a member may not receive the Plan's ALF Transition program at the same time they are receiving the Assisted Living Waiver (ALW) or California Community Transitions (CCT) program. Room and board expenses are excluded from this service; members may obtain assistance for room and board from other sources simultaneously. Providers must avoid enrolling members in duplicative state, local, or federally funded programs (examples to avoid include skilled nursing facility services, inpatient hospital services, and psychiatric inpatient stays).

Housing Transition Navigation Services may run concurrently with time-limited transition services
ALF Transition complements Enhanced Care Management (ECM)
Members cannot receive both the Plan's ALF Transition program and ALW or CCT simultaneously
Room and board are not covered by this service
Avoid duplicate enrollment in state/local/federally funded programs (e.g., SNF, inpatient hospital, psychiatric inpatient)

Billing Codes and Coverage Status

Covered procedure codesHCPCSCovered

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

Covered procedure codes (duplicate listing)HCPCSCovered

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

Billing Rule

Billing overlap and exclusion coordination

Coordinate billing when members are receiving other funded supports: room and board are excluded from ALF Transitions and should not be billed under ALF Transition codes; if a member receives ALW/CCT, the Plan's ALF Transition program cannot be billed concurrently.

Do not bill ALF Transition for room and board — these are excluded from the service.
Do not bill Plan ALF Transition services concurrently for members enrolled in ALW/CCT.

Key Definitions

ALF definition

ALF definitionAssisted Living Facility (ALF) includes a residential care facility for the elderly (RCFE) or an adult residential care facility (ARF).

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

Context of ALF serviceALF Transitions are Community Support services for members needing nursing facility LOC to transition to or remain in an assisted living setting.

Nursing facility level of care (LOC) reference

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

Use of LOC for eligibilityMembers must meet nursing facility LOC criteria (CA Title 22 §51124) or have a medical provider order for nursing facility LOC when pursuing ALF Transitions from the community.

Role in service intentThe ALF Transitions service is intended for members with a need for nursing facility LOC to provide an assisted living alternative to nursing facility placement.

Background

ALF Transitions are Community Support services that help members who meet or would meet nursing-facility level of care either move from a nursing facility into an assisted living facility or avoid nursing facility admission by receiving care in an ALF. The program includes two components: (1) time-limited transition services and related allowable expenses to establish residency in an ALF (for example, housing assessments, assistance completing facility applications, moving assistance, and coordination with facility administration — excluding room and board), and (2) ongoing assisted living services provided after transition to support continued residency (ADL/IADL assistance, meal preparation, transportation, medication administration/oversight, companion services, therapeutic programming, and 24-hour direct care). The ALF Transitions service is designed to complement Enhanced Care Management and may be provided alongside Housing Transition Navigation Services when activities are distinct; however, it must not duplicate ALW/CCT programs.