CurrentmhnPolicy N/A

Recuperative Care (Medical Respite) Referral - Coverage Criteria

This document governs referral, eligibility, required documentation, and authorization submission for recuperative (medical respite) care for Medi-Cal members in North Carolina (NC). It applies to community supports providers and referring entities submitting prior authorization for short-term residential recovery services for individuals experiencing or at risk of homelessness.

Policy Summary

Payermhn

PolicyRecuperative Care (Medical Respite) Referral - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the referral form with the Medi-Cal Prior Authorization Request Form - Outpatient online or by fax and include required clinical attachments.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsmax duration per rolling 12 months

30 daysdischarge summary recency

2required eligibility elements

Coverage Criteria

Initial eligibility criteria

Covered when ALL of the following are met:

Eligibility: 1) Individual requires a period of recovery to heal from an injury or illness.

Checkbox item on referral form; see chunk 4

Housing status: 2) Individual is experiencing or at risk of homelessness (meets HUD-modified definition).

Checkbox item on referral form; see chunk 4 and HUD modifications in chunk 7

Global cap check: Member has not already used their six-month global cap for room and board services in the rolling 12-month period.<= 6 months used

If member has used the cap they are not eligible; see chunk 5

Policy Summary

Payermhn

PolicyRecuperative Care (Medical Respite) Referral - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the referral form with the Medi-Cal Prior Authorization Request Form - Outpatient online or by fax and include required clinical attachments.

SourceLink

On This Page

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Members who have already used the six-month global cap for room-and-board services within any rolling 12-month period are not eligible for recuperative care. The referral form asks explicitly: Has the member already used their six-month global cap per rolling 12-month period? If the answer is Yes, the member is not eligible for authorization of recuperative care.

Coding and Limits

Recuperative care duration cap

Recuperative care duration cap<= 6 months per rolling 12-month period (global cap across Room and Board services)

Authorization lengthMay be authorized for a shorter period based on individual needs

Applies toCombined Short-Term Post-Hospitalization Housing, Recuperative Care, and Transitional Rent

Discharge summary recency requirement

Discharge summary recency requirementDischarge summary must be dated within 30 days of submission

Required attachmentDischarge summary from medical or behavioral health facility must be included with referral

Related documentHistory and physical must also be attached

Provider Actions and Authorization

Prior Authorization

Prior Authorization Submission

Complete and submit the Recuperative Care Referral Form with the Medi‑Cal Prior Authorization Request Form - Outpatient online (recommended) at provider.healthnetcalifornia.com or by fax to 800-743-1655. The Prior Authorization Request Form is available at https://bit.ly/HN-prior-auth. Select Initial authorization or Authorization extension on the referral.

Submit referral + Medi‑Cal Prior Authorization Request Form - Outpatient (online recommended)
Fax option: 800-743-1655
Authorization type: Initial authorization or Authorization extension

Denial Risk

Global Cap Exceeded

If the member has already exhausted the six‑month global cap for room and board services within a rolling 12‑month period, the member is not eligible for recuperative care. Confirm whether the member has used their six‑month global cap before submitting the referral.

Has the member already used their six‑month global cap per rolling 12‑month period? ☐ Yes ☐ No
If yes, member is not eligible for recuperative care

Documentation Required

Required Clinical Documents

Attach required clinical documents with the referral. For recovery from physical illness/injury: include History and Physical, AND discharge summary from the medical facility (ED, mental health facility, SNF). For recovery from behavioral health conditions: include History and Physical (with diagnoses, high‑risk diagnoses, medications, comorbidities, psychosocial risk factors), AND discharge summary from the behavioral health treatment facility. Discharge summary must be dated within 30 days of submission.

Physical illness/injury: History and physical; Discharge summary from medical facility (ED, mental health facility, SNF)
Behavioral health: History and physical (include diagnoses, high‑risk diagnoses, medications, comorbidities, substance use issues, psychosocial risk factors); Discharge summary from behavioral health treatment facility
Discharge summary requirement: must be dated within 30 days of submission

Documentation Required

Missing or Outdated Discharge Summary

Ensure the discharge summary is present and dated within 30 days of submission for members recovering from physical illness/injury or behavioral health conditions. Missing or outdated discharge summaries will render the referral incomplete and may result in denial or delayed authorization.

Verify discharge summary is attached and dated within 30 days
If missing or older than 30 days, obtain updated discharge summary before submission

Admission Criteria

Residential admission criteria

Admission prerequisites: Member requires recovery from injury, illness, or behavioral health condition AND is experiencing or at risk of homelessness per HUD-modified definition; required clinical documentation must be attached.

Required documents: History & Physical and discharge summary (discharge summary must be dated within 30 days of submission); see chunks 6 and 7

Continued Stay Criteria

Residential continued stay criteria

Continued stay limitation: Total duration of recuperative care must not exceed six months combined with other room and board services within any rolling 12-month period.<= 6 months per rolling 12 months

See global cap description in chunk 5

Discharge Criteria

Admission to residential recuperative care requires that the individual both needs a period of recovery to heal from an injury, illness, or behavioral health condition and is experiencing or at risk of homelessness (HUD-modified definition). Required clinical documentation must accompany the referral, including a history and physical and a discharge summary from the most recent medical or behavioral health facility; the discharge summary must be dated within 30 days of submission.

Definitions

HUD-modified homelessness definition

DefinitionHomeless or at risk of homelessness as per HUD Section 91.5 of 24 CFR with local modifications

Modification — institutional exitIndividuals exiting an institution are considered homeless if they were homeless immediately prior to entry or became homeless during the stay, regardless of length

Modification — imminent loss timeframeExtended timeframe for imminent loss from 14/21 days to 30 days

Modification — income requirementWaives the <30% area median income requirement for the at-risk definition

Background

Recuperative care (medical respite) provides short-term residential recovery for individuals experiencing or at risk of homelessness who require a safe place to heal from injury, illness, or behavioral health conditions. The service is intended for members whose medical needs are significant enough to have led to emergency department visits, hospital admissions, or other institutional care and who need supportive, non-acute residential services during recovery.