CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Assisted Living Residence (ALR) Medicaid Service Packages and Certification

Defines Medicaid-covered assisted living residence (ALR) service packages (Tier A, B, C), facility certification criteria, member eligibility requirements, and ALR operational requirements for Neighborhood Health Plan of Rhode Island members (Integrity Medicare Medicaid Plan). Applies to Medicaid/dual-eligible managed long-term services and supports.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAssisted Living Residence (ALR) Medicaid Service Packages and Certification

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2024

Next Review DateOct 9, 2024

Key ActionObtain ALR certification at the appropriate tier and submit required prior authorization using the payer's forms on the provider portal to receive payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3 tiersALR certification/service levels (A, B, C)

1 hr/wkTier A minimum CNA time

>=7 hrs/wkTier B intensity

>=16 hrs/wkTier C intensity

45 days

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Max skilled nursing days

Coverage Criteria and Service Tiers

inv-01: Tier A (Base-Level) Service Coverage

Covered when ALL of the following are met

Tier A coverage requirements: ALR provides the minimum HCBS service package including personal care/attendant services, chore services, housekeeping/homemaker services, companion services, meal preparation, medication administration and/or oversight, transportation or coordination of transportation, social and recreational programming, and 24-hour on‑site response staff; at least one (1) hour of certified nursing assistant (CNA) service is provided per week as determined by the ALR Assessment and person‑centered Service Plan; member requires assistance with at least two (2) activities of daily living (ADLs).

inv-02: Tier B (Enhanced-Level) Service Coverage

Covered when ANY of the following criteria are met (Tier A services are also included)

Tier B qualifying criteria: Extensive assistance with at least two (2) ADLs; OR complex medication management (enhanced number/complex delivery of medications or increased time delivering medications); OR seven (7) or more hours of ADL care as documented in the ALR Assessment and person‑centered Service Plan; OR coordination of behavioral and/or dementia care (therapeutic activities, cognitive assessments, redirection/behavior management, regular staff intervention for safety/elopement risk); OR coordination/provision of limited health services (simple wound care, stage I–II pressure ulcer care, ostomy appliance changes, urinary catheter care).

inv-03: Tier C (Specialized) Service Coverage

Covered when ALL of the following are met (Tier A & B services included)

Tier C qualifying criteria: ALR is certified as Facility Tier B and demonstrates ability to provide additional hours beyond Tier B; member requires extensive assistance with at least three (3) ADLs and/or sixteen (16) or more hours of ADL care as documented in the ALR Assessment and person‑centered Service Plan; facility provides specialized supports (e.g., single rooms/apartment‑like settings or designated dementia units, specially trained staff available 24/7, and intermittent skilled care or stabilization upon transition); and coordination of behavioral health/dementia care and limited health services as defined for Tier B/C.

inv-04: Member Eligibility for Admission

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

Member eligibility: Member requires assistance with a minimum of two (2) of six ADLs (bathing, toileting, ambulation, transfers, dressing, eating) for Tier A and at least one (1) hour/week of CNA personal care; for Tier B the member must need extensive assistance with at least two (2) ADLs OR seven (7) or more hours per week of combined personal care, limited health services, care coordination (including behavioral health or memory care); for Tier C the member must meet higher intensity requirements (extensive assistance with at least three (3) ADLs and/or sixteen (16) or more hours per week of ADL care or combined services).

inv-05: Coverage criteria for ALR Tier C / Memory Care

Covered when ALL of the following are met

Eligibility and clinical need: Member is a Medicaid beneficiary with a diagnosis of Alzheimer’s disease or related dementia and has been determined to need memory care.

Functional need — ADLs or weekly care hours: Member needs extensive assistance with a minimum of two (2) of six ADLs (Bathing, Eating, Toileting, Ambulation, Transfers, Dressing) OR requires seven (7) or more hours per week of combined personal care, limited health services, care coordination (including behavioral health or memory care) or complex services.2 ADLs OR >=7 hours/week

Memory care intensity requirement: For memory care beneficiaries: must need assistance totaling at least sixteen (16) hours per week of ADL care or a combination of personal care, limited skilled nursing, and/or behavioral health/home stabilization services.>=16 hours/week

Coverage for Assisted Living Residence (ALR) services is not universal across all Neighborhood Health Plan of Rhode Island lines of business. ALR services are excluded for: RItecare (MED), Substitute Care (SUB), Children with Special Needs (CSN), Rhody Health Partners (RHP), Extended Family Planning (EFP), ACA Adult Expansion (RHE), and Health Benefits Exchange (HBE).

As a condition of admission or continued stay, a certified ALR must not require a Medicaid beneficiary to request any item or service. The ALR is prohibited from charging a Medicaid beneficiary or the managed care plan for Medicaid services that have not been properly authorized and must not demand or accept supplemental payments from family or friends except for permissible amenities. The ALR also may not require private payment for a defined number of months as a prerequisite for accepting Medicaid beneficiaries.

Bed-holds are not a Medicaid-funded service. A certified ALR may accept private payment for a bed-hold, but any private bed-hold charge must not exceed the daily Medicaid payment for the period of absence. For social leave in excess of 18 calendar days per year, the ALR must obtain contractual managed care approval for payment. Additionally, a certified ALR is not required to discharge a Medicaid beneficiary receiving enhanced or specialized services who is absent for fewer than 21 consecutive days.

Residents who require daily professional medical or skilled nursing care equivalent to that provided in a health care facility, individuals who are bedbound, or those who require assistance from more than one person for ambulation are not appropriate for ALR residency except in limited circumstances (for example, if the individual is an established resident receiving licensed hospice care or receiving temporary skilled services for up to 45 days as permitted by policy).

Admission Criteria

inv-24: ALR — admission criteria top-level node

Admission is allowed when ALL of the following are met

Admission criteria: Resident meets the RI DOH definition of 'resident' (does not require 24‑hour skilled nursing), requires assistance with at least two (2) ADLs for Tier A, is capable of self‑preservation in emergencies unless the facility meets a more stringent Life Safety Code, and the ALR demonstrates appropriate licensure and capacity for the requested tier.

inv-25: ALR (Tier C / Memory Care) — admission criteria top-level node

Admission allowed when ALL of the following are met for Tier C (memory care)

Admission clinical criteria: Medicaid beneficiary with Alzheimer’s disease or related dementia who needs extensive assistance with two (2) or more ADLs OR seven (7) or more hours/week of combined personal care/limited skilled services; for memory care specifically, requires sixteen (16) or more hours/week of ADL assistance or combined services as documented in the ALR Assessment and person‑centered Service Plan; ALR must hold appropriate Tier C licensure/capacity and dementia‑specific program elements.

Continued Stay Requirements

inv-26: ALR — continued stay criteria top-level node

Continued stay is allowed when ALL of the following are met

Continued stay: Ongoing documentation in the person‑centered service plan and ALR Assessment demonstrates continued need for the tiered services (hours of ADL care, behavioral interventions, limited health services) and the facility maintains required licensure and capacity to provide those services.

inv-27: ALR (Tier C / Memory Care) — continued stay criteria top-level node

Continued stay for memory care is allowed when ALL of the following are met

Continued stay: Ongoing need for memory‑care level services is documented (dementia‑specific assessments/therapies, therapeutic activities, enhanced staffing, assistance with ADLs consistent with initial criteria) and the ALR adheres to policies for wandering management and behavioral health coordination; facility retains necessary licensure/capacity for the service level.

Discharge Criteria

Discharge from ALR is indicated when the resident requires care beyond the ALR scope — specifically, when the individual needs daily professional medical or skilled nursing care provided in a health care facility, becomes bedbound, or requires assistance from more than one person for ambulation without an applicable hospice or temporary-skilled exception.

When a resident is absent due to hospitalization or temporary nursing facility placement, the ALR and managed care plan should review likely return status. If, at the end of a 20-day hold period both parties concur the beneficiary will not return, unit-hold payment terminates and the ALR may re-rent the unit (with Medicaid beneficiaries given first preference). Throughout the hold period, bed-hold and social leave policies described in the managed care contract apply.

Day Limits and Leave Policies

ALR — maximum 45 days skilled nursing in assessment period and related limits

Maximum skilled nursing daysUp to 45 days of daily skilled nursing or therapy services for an established or new resident for a condition resulting from temporary illness or injury (subject to Department-approved extension or if under licensed hospice care)

Scope of temporary skilled servicesLimited skilled nursing and therapy services permitted temporarily (e.g., simple wound care, pressure ulcer treatment stage I-II, ostomy/catheter care) as part of the 45-day allowance

Condition for provisionALR must assume responsibility for ensuring required care is received when providing temporary skilled nursing or hospice services during the 45-day period

ALR — unit retention / bed-hold maximums and social leave payment notes

Unit retention (hospital/nursing placement)ALR must retain a unit for a Medicaid beneficiary receiving enhanced (Tier B) or specialized services for up to 20 days when the managed care entity indicates in writing the beneficiary is likely to return

Coding and Authorization Quick Reference

Covered Codes / Authorization Quick Referencemixed

No codes listed

Provider Actions, Documentation, and Authorization

Prior Authorization

Certification and resident appropriateness

ALR certification is required for payment. The ALR must be certified at the appropriate Facility Tier (A, B, or C) to bill for the corresponding service package; beneficiaries who require skilled nursing or daily professional nursing care (e.g., are bedbound or require more than one staff person for ambulation) are not appropriate for ALR placement and ALR payment will not apply. Certification demonstrates the ALR can meet Medicaid beneficiaries' long-term services and supports needs while promoting choice, dignity, and independence. Services furnished by other individuals or agencies under arrangement with the beneficiary's plan must supplement, not supplant, state plan or waiver services provided by the ALR.

Certification is a condition of payment — ensure the ALR holds the correct Tier certification for billed services.
Beneficiaries requiring daily skilled nursing, professional observation, or assistance of more than one person for ambulation are excluded from ALR payment.
Services from outside providers must supplement, not replace, ALR-covered state plan or waiver services.

Definitions

ADLs — activities of daily living

BathingDirect care or constant supervision/cueing for full shower, bath, or sponge bath to maintain hygiene

DressingDirect care or constant supervision/cueing to dress/undress and manage prostheses, braces, or assistive devices

EatingDirect care or constant supervision/cueing to consume food or drink orally using routine or adapted utensils

Mobility (Ambulation)Requires physical steadying, assistance, or wheelchair self-propulsion without another person's help

ToiletingNeeds assistance due to incontinence or scheduled catheter/colostomy care, including transfers and cleansing

TransferringAssistance or lifting to move between surfaces (bed/chair/wheelchair) including position changes for pressure relief

Background

Assisted Living Residences (ALRs) are community-based, licensure-regulated residences that provide personal care, supervision, and limited health services without 24-hour skilled nursing. ALRs deliver services focused on activities of daily living (ADLs) and supportive services in a homelike environment; they do not function as medical facilities and must meet state licensure and fire/medication classification requirements to be certified for Medicaid payment.

Revision History

2016-02-18created

Policy originally created (CMP Cross Reference created).

2017-08-29revision

Policy revised (listed among revision dates).

2018-02-27revision

Policy revised (listed among revision dates).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAssisted Living Residence (ALR) Medicaid Service Packages and Certification

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2024

Next Review DateOct 9, 2024

Key ActionObtain ALR certification at the appropriate tier and submit required prior authorization using the payer's forms on the provider portal to receive payment.

SourceLink

On This Page

Provider capability and setting: ALR must hold appropriate licensure and provide an enhanced dementia service package (cognitive assessments, enhanced staffing, dementia‑focused care planning and therapeutic activities), have policies/procedures to manage wandering/elopement, and be organized as dementia‑dedicated or have designated separate units/neighborhoods for dementia care.

Staffing and behavioral health coordination: Staffing must be adequate to respond to assessed sleeping/waking patterns and needs; behavioral health and home stabilization services must be provided in coordination with the beneficiary’s plan by licensed professionals experienced in dementia care.

Absence without dischargeCertified ALR may allow absence of less than 21 consecutive days without discharging a Medicaid beneficiary receiving Tier B or specialized services

Social leave payment approvalManaged care approval is required for payment of social leave in excess of 18 calendar days per year

Bed-hold private payment noteBed-holds are not Medicaid-funded; ALRs may accept private payment for bed-holds not to exceed the daily Medicaid payment amount

ALR — prohibition on >45 consecutive days of skilled nursing in assessment period

Prohibition on consecutive skilled nursing daysA beneficiary is prohibited from receiving more than 45 consecutive days of skilled nursing in any assisted living assessment period

Context of prohibitionThis 45-day limit applies to any assessment living period and supports the temporary nature of limited skilled nursing in ALRs

Exception noteExtensions may be approved by the Department or when the resident is under licensed hospice care (see ALR temporary skilled nursing allowance)

Denial Risk

Certification termination and immediate payment stoppage

EOHHS may terminate an ALR's certification with at least 30 days' notice. However, payment must stop immediately if EOHHS determines that a beneficiary's health, safety, or general welfare is in imminent jeopardy. Providers must cease billing for ALR services upon receipt of a termination notice or an imminent jeopardy determination and coordinate with the beneficiary's plan regarding transitions and continuity of care.

EOHHS termination requires >= 30 days' notice except when imminent jeopardy is found.
Immediate payment cessation occurs when a beneficiary's health, safety, or general welfare is in imminent jeopardy.
Providers must coordinate with the beneficiary's plan to manage transitions and ensure required care is maintained.

Documentation Required

Supplement, not supplant

Services provided by other entities under arrangement with the beneficiary's plan must supplement, not supplant, ALR-provided state plan or waiver services. The ALR must document the role of external providers in the person-centered service plan and ensure the ALR remains responsible for oversight of the beneficiary's covered services.

Document in the person-centered service plan when other providers deliver services and how these services supplement ALR care.
Do not shift primary responsibility for covered services to external providers in a way that supplants ALR obligations.

Prior Authorization

Authorization and prior authorization forms

Authorization is required for Tier C and Tier B services; refer to the Authorization Quick Reference Guide for coding and prior authorization forms. Prior authorization request forms are available via the provider portal: Providers > Provider Resources > Forms > 'Click here for a list of prior authorization request forms'. For coding questions, consult the Authorization Quick Reference Guide. For assistance with requests or inquiries call 1-800-963-1001.

ALR Tier B and Tier C require prior authorization — follow payer-specific prior authorization process.
Access prior authorization forms: Providers > Provider Resources > Forms > 'Click here for a list of prior authorization request forms'.
For coding guidance, see the Authorization Quick Reference Guide.
Provider assistance: 1-800-963-1001.

Billing Rule

Coding reference and documentation responsibilities

For code-specific billing questions, always reference the Authorization Quick Reference Guide and the payer's prior authorization forms. Proper authorization and documentation are required to support payment.

Use the Authorization Quick Reference Guide for covered codes.
Submit required prior authorization documentation with requests to avoid denials.

Assisted living residence (ALR) — definition and licensure/regulatory note

DefinitionA residence licensed by the state and regulated by the Department of Health (DOH) that is a community setting (not a medical facility) and does not provide 24-hour skilled nursing

Services providedPersonal care, supervision, limited health services as ordered by a physician, medication administration, and assistance with ADLs

Regulatory noteLicensed pursuant to RI G.L. 23-17.4 and subject to Certification Standards to participate in the Community Supportive Living Program

Person-centered care plan — definition and purpose

DefinitionAn individualized approach to planning that places the person at the center of decisions, documenting their desires, goals, supports, and needed services

PurposeTo guide service delivery and ensure care reflects the resident's preferences, including delegation of decision-making to legal representatives when applicable

Documentation usePerson-centered service plan is used to document hours of ADL care, behavioral interventions, cognitive assessments, and to support tiered service authorizations

ALR Tier C (Enhanced/Memory Care) — definition and distinguishing features

DefinitionAn ALR certified and organized to provide an enhanced service package specifically for dementia care, including cognitive assessments, enhanced staffing, care planning, therapeutic activities, and wandering/elopement policies

Intensity and staffingStaffing adequate to respond to assessed sleeping/waking patterns and needs with behavioral health and home stabilization services coordinated by licensed professionals familiar with dementia care

Setting requirementsMay be dedicated solely to dementia care or organized into designated separate units/neighborhoods for individuals with dementia

Memory care hours requirementMemory care beneficiaries must need assistance with at least sixteen (16) hours of ADL-related personal care and/or combined services

2022-08-17revision

Policy revised (listed among revision dates).

2023-08-16revision

Policy revised (listed among revision dates).

2024-06-01effective

Effective date recorded for the policy document version in this file.

2024-10-09last_review_and_revisionLatest

Policy last reviewed and revised (clinical medical policy review noted).