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, 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 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 by the MCP, 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; and
2) Willing to live in RCFE as an alternative to a SNF; and
3) 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) 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 services 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.
The 2024 member’s expected “room and board” payment is $1,324.82. For member eligible for SSI/SSP who receive less than this amount, SSI/SSP bumps up the payment to the 2024 Non-Medical Out of Home Care payment (NMOHC) which is $1,575.07. The member retains $177 for personal needs expenses and the RCFE receives the $1,398.07 balance as payment for “room and board”.
For example, Mr. Johnson has an income of $600/month and is eligible for SSI/SSP. He will receive an additional $975 from the SSI/SSP NMOHC ($1,575.07-$600) and pay $1,398.07 to the RCFE/ARF for “room and board” and retain $177 for his personal needs allowance.
Members who cannot pay the “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 the "room and board” payment from the member (or their family). See DHCS CalAIM CS Policy Guidelines p. 24 here.
Authorization Request
For standard authorization requests, the MCP has five business days to determine CS approval or denial. Once we receive the determination we’ll inform the member and, if authorized, begin the next steps in providing information and referral to RCFEs/ARFs for the member and/or authorized health representative to visit and evaluate as possible placement options.
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.
Community support (CS) referral PACKAGE INSTRUCTIONS
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 from one CalAIM MCP to another usually takes effect at the beginning of the following month.
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.
5. Fill out and submit the required forms below. The pdf print version for all the forms can be found here.
REQUIRED FORMS
For efficient processing of the referral package, please send us only one email with all the forms. Email Forms 1-5 to calaim@carehomefinders.com with the subject title CalAIM Package for Name of Member, (e.g., Re: CalAIM Referral Package for Mr. Johnson). If using the Adobe Sign Version for Form 5, only send Forms 1-4, since Form 5, once submitted, will e-mail a copy to all parties.
Form 1: The CS Referral Package Check List
Form 2: Declaration of Eligibility: Have the primary care provider (PCP), designated health care provider, or government agencies (APS, Public Guardian, etc.) fill out the with a brief evaluation specific to the participant describing how and why the CS meets the needs of the individual.
Form 3: 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 4: Diagnostic Codes for Member and Medicine List: Usually obtained from doctor’s office, hospital, SNF, etc. This is needed for submitting the claim for Medi-Cal reimbursement.
Form 5: Combined Adobe Sign Waiver Package for: Freedom of Choice Waiver, HIPAA Form, CalAIM Participant Liability Waiver and RCFE “Room and Board” Obligation Statement forms or use the pdf print versions.
Form 6: The Member Summary Referral Form (below).