CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Assisted Living services coverage and reimbursement

Defines Neighborhood Health Plan of Rhode Island coverage, reimbursement, and documentation requirements for Assisted Living services for Integrity members (RI Medicaid program). Affects participating and nonparticipating providers delivering assisted living care.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAssisted Living services coverage and reimbursement

Policy CodePolicy N/A

Change TypeAnnual review / prior revisions

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility, coverage, and prior authorization before rendering assisted living services.

SourceLink

POLICY UPDATE CHANGES

03/29/23 Annual Review Date. No content changes.

03/16/22 Format changes and updates to include RI Assisted Living Rate Reform Tier A and Tier B language and coding effective 11/1/21 and Tier C effective 2/1/22.

Policy created and effective 03/01/18.

Tier A/B/CRate reform tiers defined

Per diemReimbursement basis

30 daysRecord entry time limit

MonthlyISP/assessment frequency

Assisted Living Coverage Criteria

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Tier A (Covered with criteria)

Covered when ALL of the following are met for Tier A

Tier A criteria: Daily assistance with at least two (2) ADLs AND at least one (1) hour of personal care per day.2 ADLs; 1 hour/day

Tier B (Covered with criteria)

Covered when ONE of the following applies for Tier B

Tier B criteria: Extensive assistance with a minimum of two (2) ADLs OR seven (7) or more hours per week of any combination of personal care, limited health care services, care coordination (including behavioral health or memory care) or complex medication management.2 ADLs OR >=7 hours/week

Tier C (Covered with criteria)

Covered when ALL of the following are met for Tier C

Tier C criteria: Extensive assistance with a minimum of three (3) ADLs AND sixteen (16) hours or more per week of any combination of personal care, limited health care services, care coordination (including behavioral health or memory care) or complex medication management.3 ADLs; >=16 hours/week

The following services are excluded from coverage under the Assisted Living benefit: facility room and board; assisted living services for a member enrolled in an Adult Day Health program; and other services that are similar or duplicative in nature. Providers should not bill these items under the Assisted Living benefit and must document alternative coverage sources when applicable.

Billing and Code Guidance

Assisted Living HCPCS codes by tierHCPCSCovered

T2031	Assisted living, Tier A Facility; Beneficiary A or B Member.
T2031-UB	Assisted living, Tier B Facility; Tier B Member.
T2031-UC	Assisted living, Tier C Facility, Tier C Member.

Tier C hours threshold

Tier C hours threshold>= 16 hours per week

Applies toTier C admission and continued-stay criteria

Included services countedPersonal care, limited health care services, care coordination (including behavioral health or memory care), complex medication management

Tier B hours threshold

Tier B hours threshold>= 7 hours per week

Applies toTier B admission and continued-stay criteria

Included services countedPersonal care, limited health care services, care coordination (including behavioral health or memory care), complex medication management

Tier A personal care minimum

Tier A personal care minimum>= 1 hour per day

Additional requirementDaily assistance with at least two (2) ADLs

Applies toTier A admission criteria and reimbursement

Provider Requirements and Actions

Prior Authorization

Verify eligibility and prior authorization

It is the provider's responsibility to verify eligibility, coverage and authorization criteria prior to rendering services. For plan-specific prior authorization requirements, refer to Neighborhood's Prior Authorization Reference page and Clinical Medical Policies. Contact Provider Services at 1-800-963-1001 with questions.

Verify member eligibility and coverage before providing services
Check plan-specific prior authorization requirements on Neighborhood's Prior Authorization Reference page
Contact Provider Services: 1-800-963-1001

Note

Provider action: documentation and orders required

Providers must take all required actions to support billing and reimbursement, including obtaining orders, creating and maintaining required records, and complying with state and federal regulations.

Obtain physician's order supporting need for skilled services before billing
Create an Individual Service Plan (ISP) within 7 days of move-in
Ensure ISP includes services, frequency/duration, responsible parties, dates and required signatures

Documentation Required

Required documentation and record timelines

Maintain a treatment record for each member receiving Assisted Living services that includes identification, physician orders, diagnoses, admission assessments, ISP and required reviews. Records must be accurate, legible, and completed with signature within 30 days of the date of service.

Member identification (Neighborhood ID, name)
Physician's order supporting need for skilled services
Member diagnosis and initial admission assessment
Individual Service Plan (ISP) completed by RN or certified assisted living administrator within 7 days of move-in
ISP must document services/interventions, frequency/duration, responsible parties, date and signature
ISP nurse review and regular member assessment at least every 12 months or as condition changes
Re-admission assessment when applicable
All record changes must comply with CMS Medicare Program Integrity Manual Chapter 3

Denial Risk

Documentation supports medical necessity — provide records on request

Neighborhood may request medical records for any billed service. Documentation must support the services billed and the medical necessity of those services; failure to provide adequate documentation may result in claim denial.

Neighborhood follows CMS standards for documentation and may request records at any time
Documentation must demonstrate medical necessity and support billed services
Electronic Health Records must meet state and federal privacy and documentation standards

Definitions of ADLs and Related Terms

Bathing

DefinitionDirect care or constant supervision during the entire activity of a shower, bath, or sponge bath to maintain hygiene.

ExamplesShower assistance, sponge bath with cueing, supervision to ensure safety during bathing

PurposeMaintain adequate personal hygiene and prevent complications related to poor hygiene

Dressing

DefinitionDirect care or constant supervision during the entire activity of dressing and undressing, including taking prostheses, braces, anti-embolism garments, or assisted devices on or off.

ExamplesAssistance with putting on clothes, managing prostheses or braces, cueing during dressing

PurposeSupport safe and independent clothing management and device handling

Eating

DefinitionDirect care, constant supervision, or physical assistance during meals to consume food or drink through the mouth, including cutting, chewing, and swallowing.

ExamplesFeeding assistance, supervision to prevent aspiration, cutting food, adaptive utensils support

PurposeEnsure safe nutrition intake and reduce risk of choking or aspiration

Mobility

DefinitionAssistance provided when a member must be steadied, assisted, or guided in ambulation, or is unable to self-propel a wheelchair.

ExamplesHand‑over‑hand support during walking, guidance with gait belt, wheelchair propulsion by staff

PurposeMaintain safe mobility and prevent falls or injury during ambulation or transfers involving wheelchair use

Toileting

DefinitionAssistance due to incontinence or for scheduled catheter/colostomy care, including transfers on/off the toilet, self‑cleansing, and changing of pads/briefs.

ExamplesHelp with toileting transfers, catheter care, changing incontinence briefs, hygiene after toileting

PurposeMaintain continence care, prevent skin breakdown, and ensure hygienic toileting practices

Transferring

DefinitionAssisting or lifting the member to another position between surfaces (e.g., bed to chair) and performing position changes for pressure relief or due to poor sitting tolerance.

ExamplesTransfers from bed to chair, repositioning in wheelchair or bed for pressure relief, assisted standing transfers

PurposePrevent falls, maintain skin integrity, and support safe repositioning and transfers

Continued Stay Criteria

Assisted Living facility continued stay criteria

Continued stay documentation: Ongoing eligibility requires regular member assessments and ISP review not to exceed 12 months or sooner if condition changes; documentation must support continued need for services.<=12 months between reviews

Neighborhood may request records to verify. ISP must be written within 7 days after move-in by RN or certified assisted living administrator; entries completed no later than 30 days from date of service.

OpenPayer

Assisted Living services coverage and reimbursement

Assisted Living Coverage Criteria

Billing and Code Guidance

Provider Requirements and Actions

Background and Scope

Definitions of ADLs and Related Terms

Admission Criteria for Assisted Living

Continued Stay Criteria

Discharge Criteria