CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Assisted Living Services — Coverage and Medical Necessity Criteria

Defines Neighborhood Health Plan of Rhode Island coverage, medical necessity, billing, and documentation requirements for assisted living services across UNITY and INTEGRITY lines of business for services provided within licensed scope in Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAssisted Living Services — Coverage and Medical Necessity Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for all Assisted Living services using Neighborhood's Medical Management Request Forms.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4levels of care

6+ hrs/wkBase min hours

7-12 hrs/dayEnhanced hrs

>=13 hrs/dayDementia hrs

RequiredAuthorization

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Coverage Criteria

Level-Specific Medical Necessity Criteria

Covered when all specific level criteria are met for the applicable level of care

Base Level Assisted Living: Member must require medication administration and/or oversight; must require six or more hours of personal care per week; must require assistance with a minimum of two (2) activities of daily living;6+ hours/week

Enhanced Level Assisted Living: Member must require assistance with a minimum of two (2) activities of daily living; must require between seven and twelve (7-12) hours of any combination of personal care, limited health care services, care coordination (including behavioral health), and/or health and home stabilization services;7-12 hours/day

Dementia Care Assisted Living: Member must have a diagnosis of Alzheimer’s disease or another related dementia and be determined to need memory care; must require thirteen (13) hours or more of any combination of personal care, limited skilled nursing, and/or behavioral health or health and home stabilization services; must need assistance with a minimum of three (3) activities of daily living;>=13 hours/day

The following services are excluded from coverage under Neighborhood Health Plan of Rhode Island's Assisted Living policy: facility room and board, services that are similar or duplicative in nature, and assisted services for members enrolled in an Adult Day Health program. These exclusions apply regardless of setting and are not covered benefits.

Payment for Assisted Living services is not guaranteed. Reimbursement is subject to the member’s benefit coverage and eligibility, claims payment edit rules, applicable coding and documentation guidelines, authorization policies, provider contract terms, and state and federal regulations. All services billed to Neighborhood remain subject to audit and review and may be denied or adjusted if requirements are not met.

Providers must maintain complete medical records to support billed services. Treatment records must include member identification, diagnosis, physician orders (when skilled services are billed), admission and re-admission assessments as required by state regulations, the Individual Service Plan (ISP) with frequency/duration of services, and signatures. Records are subject to audit and must comply with state and federal privacy and documentation standards; failure to provide adequate documentation may affect payment.

Coding and Billing

Approved HCPCS Codes and ModifiersHCPCSCovered

T2031	Assisted Living, waiver; per diem, base level.
T2031 U1	Assisted Living, waiver; per diem, enhanced non-skilled.
T2031 U1/U3	Assisted Living, waiver; per diem, enhanced skilled.
T2031 U4	Assisted Living, waiver; per diem, dementia care.

Referenced coding/standards resourcesmixed

NUCC	NUCC referenced guidance
NUBC	NUBC referenced guidance
ANSLX42	ANSLX42 referenced
CMS 3.324	CMS Signature Requirements reference

Hourly thresholds for levels of care (inv-07)

Base Level thresholdRequires six or more hours of personal care per week (>=6 hours/week)

Enhanced Level thresholdRequires between seven and twelve (7-12) hours per day of any combination of personal care, limited health care services, care coordination (including behavioral health), and/or health and home stabilization services

Dementia Care thresholdRequires thirteen (13) hours or more per day of any combination of personal care, limited skilled nursing, and/or behavioral health or health and home stabilization services (>=13 hours/day)

Provider Actions & Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for all Assisted Living services. Please refer to Neighborhood's Medical Management Request Forms for details. Claims may be denied if prior authorization is not obtained.

Prior authorization required for all Assisted Living services
Refer to Neighborhood Medical Management Request Forms
Claims may be denied if prior authorization not obtained

Billing Rule

Reimbursement Subject to Eligibility and Rules

Claim payments are subject to Neighborhood Health Plan of Rhode Island benefit coverage and member eligibility. Reimbursement is also contingent on claims payment edit rules, correct coding and documentation, authorization policies, provider contract terms, and applicable state and federal regulations. All services billed to Neighborhood for reimbursement are subject to audit.

Background

Assisted living services provide supervision and personalized assistance with activities of daily living and limited health services in a residential setting. To qualify for reimbursement providers must create and maintain a treatment record for each member receiving services that documents the member’s needs, the ISP developed by an RN or certified assisted administrator within 7 days of move-in, ongoing assessments and ISP reviews at least every 12 months or upon change in condition, and any required physician orders to support skilled services.

Definitions

Activities of Daily Living (ADLs) (inv-17)

BathingDirect care or constant supervision during the entire activity of a shower, bath, or sponge bath to maintain adequate hygiene (includes cueing)

DressingDirect care or constant supervision and cueing for the entire activity of dressing and undressing; includes assistance with prostheses, braces, anti-embolism garments, or assisted devices

EatingDirect care or constant supervision, cueing, or physical assistance for portion or entirety of meals to consume food or drink by mouth, including ability to cut, chew, and swallow (may include adapted utensils)

MobilityAssistance when member must be steadied, assisted in ambulation, or is unable to self-propel a wheelchair

Personal hygiene / groomingDirect care or constant supervision and cueing during the entirety of hygiene/grooming activities

Toileting / Transferring

Admission Criteria

Assisted Living Facility — Admission Criteria

Admission to Assisted Living is covered when the member meets the applicable level-specific criteria and prior authorization is obtained.

Admission to Assisted Living: Member meets level-specific criteria: Base (medication oversight + >=6 hrs/week personal care + >=2 ADLs), Enhanced (>=2 ADLs + 7-12 hrs/day combined services), or Dementia (diagnosis of dementia + >=13 hrs/day combined services + >=3 ADLs).

Admission requires prior authorization per policy.

Continued Stay Criteria

Assisted Living Facility — Continued Stay Criteria

Continued stay is covered when required documentation and periodic reviews are maintained in the member record.

Continued Stay Documentation: Maintain regular member assessment documentation not to exceed 12 months or upon change in condition; Individual Service Plan (ISP) written by an RN or certified assisted administrator within seven (7) days of move-in and ISP nurse review/documentation as required by state regulations; re-admission assessment when applicable.

Records must be available for audit and meet CMS/EHR and state/federal privacy standards.

Discharge Criteria

Discharge from an Assisted Living Facility requires completion and retention of applicable assessments as required by state regulations, including re-admission or discharge assessments when applicable. These assessments must be documented in the member’s treatment record and maintained to support the reason for discharge and any subsequent billing or authorization actions.

Day Limits & Reimbursement

Assisted Living Facility — Per diem reimbursement details (inv-21)

Reimbursement basisPer diem reimbursement for Assisted Living services

Rate inclusionsRates are inclusive of all services as specified by the provider contract

No per-visit/day splitPayment is per diem only; services are not split into per-visit/day payments

Provider contract governs specificsExact per diem rates and inclusions determined by the provider contract