1010 The ALTCS Transitional Program

Policy

The ALTCS Transitional program is a program for customers who have improved medically, functionally or both to the point that they no longer need the level of care that is provided in a nursing facility (NF) or intermediate care facility institutionalization for individuals with intellectual disabilities (ICF-IID). These customers are determined through the PAS reassessment process to still need long-term care services, but at a lower level of care.

1) Who qualifies for ALTCS Transitional?

The ALTCS Transitional program is only available to customers who have been approved for ALTCS. It is not available to customer who fail the initial PAS and are not at risk of institutionalization.

The medical eligibility criteria for ALTCS Transitional are as follows:

·        DD customers - Receive a score of 30 or higher during the PAS reassessment, or must have a diagnosis of moderate, severe, or profound cognitive disability.

·        EPD customers, under age 12 - Must be found eligible for ALTCS Transitional through physician consultant review.

·        EPD customers, ages 12 and older - Receive a score of 40 or higher during the PAS reassessment.

The ALTCS Transitional effective date is the first of the month following the PAS decision date, allowing for advance notice of the change.

2) ALTCS Transitional - Covered Services

The ALTCS Transitional program allows customers who meet the lower level of care, to continue to receive all other medically necessary ALTCS covered services. Customers living in a NF or ICF-IID when determined eligible for the ALTCS Transitional Program may get continued NF or ICF-IID services for up to 90 days while being moved to an HCBS placement by the Program Contractor.

An ALTCS Transitional customer’s condition may worsen to the point that NF services are again medically necessary. The Program Contractor can place the customer in an NF temporarily, provided the stay is not more than 90 continuous days per admission.

NOTE          When an ALTCS Transitional customer may need NF care longer than 90 days, the Program Contractor must request a PAS reassessment. When the customer is determined to be at risk of institutionalization, the customer will be moved back to Full ALTCS effective the first day of the month following the PAS reassessment.

Definitions

Proof

The following information is used as proof of eligibility for ALTCS Transitional:

·        Current eligibility approved in the eligibility determination system, HEAplus; AND

·        PAS reassessment records showing a PAS score below the threshold for ALTCS but equal to or higher than the threshold score for ALTCS Transitional; or

·        Records of a Physician Review determination that the applicant or member meets the criteria for ALTCS Transitional.

Legal Authority