CalAIM Pre-Referral Package
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, San Bernardino and Riverside counties. This CS allows participating Managed Care Plans (MCPs) to pay for the “assisted living” portion of a RCFE/ARF based on care level assessment. The member is responsible for paying the “room and board” portion (see Additional Eligibility Requirements below).
For the CS, we’ve developed a CS Pre-Referral Package (see the instructions below) which will be submitted to the MCP member services. If the member is authorized, Connections will start the process of providing information and referral to RCFEs/ARFs for member placement. Additional information at: DHCS CalAIM Website and Articles about CalAIM.
Call us (800-330-5993) with any questions about the process.
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 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 meet the minimum 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 for “room and board” and the MCP will pay the RCFE the “assisted living” portion.
The 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. The MCP will pay the “assisted living” portion and both the “room and board” and “assisted living” contribution pays for the RCFE/ARF.
Community support (CS) PRE-referral PACKAGE INSTRUCTIONS
For us to compile the CS Pre-Referral Package, please follow the instructions below:
1) Read the above eligibility and additional eligibility requirements.
2) Does the member’s MCP have this CS (refer to MCPs CS Member Services page)? If not, they might need to switch to a MCP that offers the CS. Converting from one CalAIM MCP to another takes effect at the beginning of the following month.
3) Fill out CS Declaration of Eligibility to specify the reason for the CS request from the current licensed primary care provider (PCP), designated health care provider, or government agencies (APS, Public Guardian, etc.) including a brief written evaluation specific to the participant describing how and why the CS meets the needs of the individual.
4) Fill out RCFE Physician’s report (602).
5) Fill out HIPAA Form to give us permission to receive information about the applicant.
6) Email all forms above to calaim@carehomefinders.com with the subject line: CS Pre-Referral Package for Mr./Mrs. (name of member, CalAIM MCP and Member Number. For example: CS Pre-Referral Package for Mr. Johnson/Health Net/ Member Number: 10000241233.
7) Fill out and submit the Community Support Referral Form (see below).
8) Once we receive all the forms we’ll submit the Pre-Referral Form and Documents to the MCP.
9) Once the MCP has determined CS approval or denial we’ll inform the member and/or family about the determination.
10) If authorized for the CS, we will provide information and referral to RCFEs/ARFs for the member and/or authorized health representative to visit and evaluate for possible placement options.