CurrentmhnPolicy N/A

Assisted Living Facility (ALF) Transitions Referral Form — Coverage Criteria

Describes referral, eligibility, required documentation, allowable time-limited transition services, and itemized expense limits to support transitioning or remaining in community-based Assisted Living Facilities for Medi‑Cal members in North Carolina (document references CA program rules but policy instance applies to NC).

Policy Summary

Payermhn

PolicyAssisted Living Facility (ALF) Transitions Referral Form — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the ALF Transitions Referral Form with the Medi‑Cal Prior Authorization Request Form - Outpatient online or by fax for initial requests or extensions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60+ daysminimum nursing facility residency to qualify

$6,000maximum total allowance

$1,000movers allowance

Tier 1–5ALW service tiers

Coverage Criteria

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Eligibility for members residing in a nursing facility

Covered when ALL of the following are met

Nursing facility resident eligibility: Member has resided 60+ days in a nursing facility AND 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, in lieu of going into a facility, chooses to remain in the community and continue to receive medically necessary nursing facility level-of-care services at an ALF AND is willing to live in an assisted living setting as an alternative to a nursing facility AND can reside safely in an ALF.>= 60 days

Referenced in Eligibility criteria section

Members assigned to Tier 5 may have extensive care needs that exceed the scope of services an Assisted Living Facility (ALF) can provide. When a member is assessed as Tier 5, the ALF’s ability to safely meet those needs must be evaluated before placement is approved; if the ALF cannot meet the member’s needs, placement may be inappropriate. Document the requested tier on the Referral Form and include any explanation when a facility is not part of the ALW Program or cannot accept the member.

Key Coding & Thresholds

Minimum nursing facility residency

Minimum nursing facility residencyMember has resided 60+ days in a nursing facility.

Other residency-related criteriaMember is interested in remaining in the community and is willing and able to reside safely in an ALF.

LOC requirementMember must meet the minimum criteria to receive nursing facility level-of-care services.

Provider Actions & Submission Requirements

Prior Authorization

Referral and prior authorization submission

Complete and submit the Assisted Living Facility (ALF) Transitions Referral Form with the Medi‑Cal Prior Authorization Request Form - Outpatient. Submission methods: online (recommended) at provider.healthnetcalifornia.com or by fax at 800-743-1655. Indicate whether this is an initial or extension request and the type of transition (from nursing facility or remain in community).

Submit Referral Form together with Medi‑Cal Prior Authorization Request (Outpatient).
Online submission recommended: provider.healthnetcalifornia.com.
Fax: 800-743-1655.
Select request type: Initial or Extension.
Indicate transition type and member consent/financial responsibility where applicable.

Documentation Required

Required documentation for authorization

Submit all required supporting documents with the Referral Form to avoid delays or denial. For initial authorizations include admission face sheet, individual plan of care, ALW application copy (if applicable), and documentation of CBAS/IHSS/LTSS enrollment or medical provider order for NF level of care as applicable. For extension requests include reason for extension, individual plan of care, and status of ALW application (if applicable).

Initial authorization — Transition from nursing facility: Admission face sheet; Individual plan of care; Copy of Assisted Living Waiver (ALW) application (if applied).
Initial authorization — Remain in community: Documentation of authorization for CBAS or IHSS, or documentation of enrollment in LTSS or qualified waiver program; Medical provider order for nursing facility level of care.
Extension requests: Reason for authorization extension; Individual plan of care; Status of ALW application (if applied).

Documentation Required

DME denial required for adaptive aids requests

When requesting medically necessary adaptive aids (e.g., Hoyer lift, hospital bed, shower chair, bedside commode), provide the Medi‑Cal DME denial letter(s) from the member's Medi‑Cal health plan or delegated medical group as supporting documentation. Keep receipts in the member's records for audit purposes; receipts do not need to be submitted to the Plan.

Adaptive aids that require DME denial letter: Hoyer lift; Hospital bed; Shower chair; Bedside commode.
Include Medi‑Cal DME denial letter(s) with the Referral Form.
Receipts are not required to be submitted but must be retained in member records for auditing.

Denial Risk

Exceeding maximum allowance triggers denial

Approved items are subject to maximum allowances (including taxes, shipping and delivery). The total maximum allowance must not exceed $6,000. Any costs that exceed the applicable item maximums or the overall $6,000 maximum will be denied.

Item-level maximums examples include: Twin bed frame (Max $200); Mattress (Max $350); Dinning table and 2 chairs (Max $300); Mini refrigerator (Max $800); Microwave (Max $125); General home goods (Max $600 for all items); Television (Max 42 in.), TV stand (one max), Nightstand (one max), Lamps (limits apply).
Maximum allowance including taxes, shipping and delivery charges must not exceed $6,000.
Costs exceeding item maximums or the $6,000 overall maximum will be denied.

Background

The Assisted Living Facility Transitions program helps members move from institutional nursing facility settings to residence in an ALF when appropriate. The program uses the Assisted Living Waiver (ALW) tiering system — Tier 1 through Tier 5 — to reflect increasing levels of support need. Placement decisions rely on the member meeting the nursing facility level-of-care standard (referenced to Section 51124 of Title 22) and on the ALF’s capacity to deliver the level of care associated with the assigned tier.

Definitions

ALW tiers

Tier structureFive tiers (Tier 1 lowest support need through Tier 5 highest).

Tier 1Assigned to participants with the lowest level of support need.

Tiers 2–4Assigned to participants with progressively more significant support needs (Tier 2, Tier 3, Tier 4).

Tier 5Assigned to participants requiring intense, focused attention to ADLs/IADLs (e.g., severe TBI); may have needs beyond what an ALF can provide.

Nursing facility level of care (LOC) standard

Reference regulation for LOCNursing facility level of care as defined in Section 51124 of Title 22 of the California Code of Regulations.

Application in referral formFacility must indicate whether it is part of the ALW Program and specify the level-of-care requested (tier).

Use for eligibility determinationMember must meet nursing facility LOC criteria to be eligible to receive nursing facility LOC services at an ALF.

Admission Criteria

residential

Admission to ALF via transition program: Member meets nursing facility residency requirement (60+ days), meets nursing facility level-of-care criteria as defined in Section 51124 of Title 22, and is willing and able to reside safely in an ALF; facility must indicate Tier requested and whether part of the ALW Program.>= 60 days

Admission documented via referral form and required documents

Continued Stay Criteria

residential

Reauthorization/Extension: For extension requests submit reason for authorization extension, individual plan of care, and status of ALW application if applicable.

From Required documents - Extension request

Day Limits & Allowances

Transition assistance allowances

Movers allowanceMovers maximum allowance: $1,000.

Total maximum allowanceMaximum allowance including taxes, shipping and delivery charges must not exceed $6,000.

Receipts and documentationReceipts do not need to be submitted to the Plan but must be kept in the member's records for audit purposes.

Other moving itemsMoving supplies and quote/service costs may be requested subject to applicable limits.