California Advancing and Innovating Medi-Cal (CalAIM) Referral Package for Authorization Request

For Community Support (CS) for Skilled Nursing Facility Diversion/Transition to Residential Care Facility for the Elderly or Adult Residential Facility.

Connections Care Home Consultants is a CalAIM Community Support (CS) Provider for Skilled Nursing Facility (SNF) Diversion/Transition to Residential Care Facilities for the Elderly (RCFE) and Adult Residential Facilities (ARF) in Los Angeles, Ventura, Sacramento, San Diego, Orange, San Bernardino and Riverside counties for various Managed Care Plans (MCPs). Call us for the list. Read more about CalAIM here.

For eligible members, MCPs pay for the “assisted living” portion of a RCFE/ARF based on a tiered care level assessment. The member is responsible for paying the “room and board” portion usually from SSI/SSD income (see Additional Eligibility Requirements below).

For the CS, we’ve developed a CalAIM CS Referral Package which will be submitted to the MCP authorization request department. If the member is authorized, Connections will start the process of providing information and referral to RCFEs/ARFs for member placement.

Call us (800-330-5993) with any questions about the program instructions.

CS Eligibility Requirements

SNF Transition to RCFE or ARF (Enables a current SNF resident to transfer to a RCFE or ARF).
1) Has resided in a SNF for at least 60 consecutive days (which can include a combination of Medicare and Medi-Cal days); and
2) Is willing to live in RCFE as an alternative to a SNF; and
3) Is able to safely reside in RCFE with appropriate and cost-effective supports and services.

SNF Diversion to RCFE or ARF (Transition a member who, without this support, would need to reside in a SNF and instead transitions him/her to RCFE or ARF).
1) Interested in remaining in the community; and
2) Is able to safely reside in RCFE with appropriate and cost-effective supports and services; and
3) Must be currently at medically necessary SNF level of care: e.g., require substantial help with activities of daily living (help with dressing, bathing, incontinence, etc.) or at risk of premature institutionalization; and meet the criteria to receive those services in RCFE or ARF.

Additional eligibility requirements for the CS for SNF Diversion/Transition to RCFE/ARF:

The MCP member is responsible for paying the RCFE the “room and board” and the MCP is responsible for paying the RCFE the “assisted living” portion.

For members eligible for SSI/SSP and the 2025 Non-Medical Out of Home Care payment (NMOHC), SSI/SSP is bumped up to $1,599.07. The member usually retains $179 for personal needs expenses and the RCFE receives the $1,420.07 balance as payment for “room and board”.

For example, Mr. Johnson is eligible for NMOHC and receives $500/month. He will receive the NMOHC RCFE bump-up of $1,099.07 ($500 + $1,099.07 = $1,599.07), pay $1,420.07 for “room and board” and retain $179 for personal needs expenses.

Members not eligible for the NMOHC will still have a “room and board” obligation but the amount could be flexible depending on the RCFE and the assessed tiered level.

Members who cannot pay any “room and board” portion or who do not have families who could pay this portion are not eligible for the CS since program requirements mandate a "room and board” payment from the member (or their family). See DHCS CalAIM CS Policy Guidelines p. 24 here.

Medi-Cal Share of Cost

When you apply for Medi-Cal and are over the income limit for free Medi-Cal, you may still qualify for Medi-Cal with a shared monthly cost (formerly known as “Share of Cost”). A shared monthly cost (SMC) is the amount of money you must pay each month towards medical related services, supplies, or equipment before your Medi-Cal insurance pays anything. Think of it like a monthly “deductible.” Oftentimes, applicants cannot apply for a Managed Medi-Cal plan that offers CalAIM unless they eliminate their SOC. The California Association for Nursing Home Reform (CANHR) has two useful factsheets: https://canhr.org/understanding-the-shared-monthly-cost-for-medi-cal/ and https://canhr.org/board-care-medi-cal-deduction/ about how to eliminate the SMC in order to enroll with a Managed Medi-Cal plan to access the CalAIM program.

Authorization Request

For standard authorization requests, the MCP typically has five to seven business days to determine CS approval or denial. Once we receive the determination we’ll inform the member/responsible party and, if authorized, begin the next steps in providing information and referral to the family of RCFEs/ARFs to visit and evaluate as possible placement options. We will also send out a RN (virtual visit) to do a tiered level assessment to determine the tiered level (the amount Medi-Cal will pay to the RCFE) for the “assisted living” portion.

Community support (CS) referral PACKAGE

For us to compile the CS Referral Package, please follow the instructions below. Once we receive the CS Member Referral Form and required signed documents the CS Referral Package is complete and we’ll submit the documents to the MCP as an authorization request.

1. The member must be on Medi-Cal with a participating CS MCP that offers SNF Diversion/Transition to RCFEs. We are a CS Provider for a few MCPs that offer the CS for SNF Diversion/Transition to Assisted Living. Call us for the list.

2. If the member’s MCP does not offer the CS they might need to switch to a MCP that offers this program. Converting Medi-Cal coverage from one CalAIM MCP to another usually takes effect at the beginning of the following month. For instance, Mr. Johnson wants to switch from one Medi-Cal MCP to another on the 15th of January. The change takes affect on February 1st.

3. Does the member have capacity to make his/her own health care and financial decisions? If not, a responsible party must have a Power of Attorney (POA) for Health, also known as Advanced Health Care Directive, to make health care decisions and a POA for Financial Decisions. Both forms need to be notarized. A POA for Health can be found here and a POA for Finance here.

4. Read the above eligibility and additional eligibility instructions for “room and board” payment.

Referral Package Submission Instructions

1) Complete Forms 1-6: (for SNF Transition Form 3 is not required and for SNF Diversion Form 6 is not required). See the email and subject title instructions below.

Should you have general questions call us at 800-330-5993 or email us at calaiminfo@carehomefinders.com.

Required Forms

FORMS #1-6

Form 1: Member Summary Referral Form (which is directly submitted to our database and gives us all the essential information we need to check eligibility).

Form 2: Freedom of Choice Waiver, HIPAA Form, CalAIM Participant Liability Waiver and RCFE “Room and Board” Obligation Statement Forms Adobe Sign Version. The PDF version is here. All individual forms can be found here.

Form 3: Declaration of Eligibility for SNF Diversion Adobe Sign Version or PDF: To be signed by the primary care provider (PCP), medical health care provider, or government agency (APS, Public Guardian, etc.) with an explanation as to why the member is considered at risk of premature institutionalization. Please note this form is only required for SNF Diversion not SNF Transition.

Form 4: RCFE Physician’s report (602): To be filled out by the member’s primary care provider (PCP). This form includes a declaration that the TB test or chest x-ray is negative.

Form 5: Diagnostic Codes and Medicine List (usually obtained from the SNF, doctor’s office or hospital).

Form 6: SNF Facesheet (for SNF Transition) showing at the bottom a length of stay of more than 60 days.

Final Instructions:

Send Forms 2-6 in one email to calaimreferralpackage@carehomefinders.com with the subject title CalAIM Referral Package for Name of Member: Medi-Cal Number: (e.g., CalAIM Referral Package for Mr. Johnson: Medi-Cal Number: 44445335C). We receive a high volume of email and this subject title helps us track incoming referral packages. Please only use this email when submitting referral package components.