Anthem Blue Cross

Providers - California

Managed long-term services and supports (MLTSS)


Managed long-term services and supports (MLTSS) consists of a variety of the state of California programs that provide services to help individuals remain living independently in the community or the most appropriate setting of their choice. MLTSS are provided over an extended period, predominantly in the member’s home or community, but also in facility-based settings such as nursing facilities.

MLTSS consists of:

  • Long-term care (LTC).
  • Community-based adult services (CBAS).

Note: Medi-Cal beneficiaries, including dual-eligible individuals must join a managed care organization, like Anthem Blue Cross (Anthem) to receive MLTSS benefits.



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MLTSS program benefits

Members have a voice in how eligible MLTSS services are provided, who provides the services, and what goals they want prioritized within their MLTSS plans of care.  Anthem’s LTSS team works to support member choice and independence by providing access to and coordination of services and supports. This allows members to live with dignity in their community or LTC facility, improving their quality of life.

To ensure members’ needs are being met, LTSS staff work closely with our Case Management and Behavioral Health teams, PCPs, and MLTSS providers to identify and connect with members who could benefit from MLTSS services. This includes:

  • Coordination of community-based adult services (CBAS).
  • Referrals to in-home supportive services (IHSS).
  • Referrals to Multipurpose Senior Services Program (MSSP).
  • Identification of needs through the review of health risk assessments and other member assessments.
  • Review and processing of referrals from PCP, specialists, and MLTSS providers.
  • Coordination with members, family, providers, and case managers as needed to implement a plan of care.
  • Review of MLTSS provider care plans and coordination with providers on additional support.
  • Assistance in determining the right combination of MLTSS supports.
  • Assistance in accessing MLTSS and other home- and community-based services.
  • Assistance with caregiver issues, community resource referrals, emergency needs, financial assistance, housing arrangements, long-term care planning, and nursing home placement discussions.
  • Assistance with transitions from skilled nursing facilities back to the community.

Refer to your provider manual for more information on LTSS requirements and covered benefits.

Long-term care

Long-term care (LTC) is the provision of care in a facility, such as a skilled nursing facility or subacute facility for an extended period (in other words, longer than the month of admission plus one month). Long-term subacute care outside of Los Angeles and Santa Clara counties is the responsibility of fee-for-service Medi-Cal until July 1, 2023.

LTC services are for the purpose of assisting the member with their activities of daily living or in meeting personal needs. LTC does not include specific therapy for an illness or injury, is not skilled care, and does not require the continuing attention or supervision of trained medical or paramedical personnel.

LTC eligibility and referral process

LTC services are available to Medi-Cal Managed Care (Medi-Cal) recipients who require 24-hour long or short-term care and have a written order from their PCP requesting the services.

Requests for LTC authorizations should be submitted prior to the first day of service and no later than 30 days past the first day of service. General guidelines for obtaining prior authorization for LTC services are as follows:

  • Requests for authorizations must include a completed LTC authorization request form, face sheet, medication administration record (MAR), and the most recent minimum data set (MDS) for the member.
  • Requests for authorizations may be made through Availity or via fax.
  • Facilities who have multiple members needing authorization for LTC services should submit each request separately.
     

PA requests may be faxed to:

An LTSS clinician will review the request and determine if the member qualifies for LTC placement following clinical guidelines for medical necessity.

Refer a member

Please contact the Medi-Cal Customer Care Center  to verify eligibility or refer a member for LTC services.

Authorized LTC absences 

LTC facilities are allowed to request a bed hold for up to seven days when an LTC member leaves a facility and is admitted to an acute care facility or hospital. To ensure accurate payment, the facility must bill hospital leave days consecutively beginning with the date of admission. If a member goes to a hospital for observation purposes and is not admitted, the LTC facility should bill for this as a normal day of service.

In the event of a nonmedical leave of absence from an LTC facility, providers must obtain an authorization and bill utilizing the appropriate leave of absence revenue code and accommodation code. A maximum of 18 leave days for LTC are allowed per calendar year (certain exceptions may apply). Leave of absence qualifications are followed in accordance with DHCS.

Providers will not be reimbursed for days a bed is held for a resident beyond the day limit and will not be reimbursed for any absences without prior authorization.

LTC claims and reimbursement

Prior authorizations are required for all LTC services. Providers rendering LTC services should submit claims to Anthem using the appropriate revenue and accommodation codes.

There are several nuances specific to LTC that should be taken into consideration when navigating the LTC billing and payment process. This includes retroactive eligibility, authorizations for LTC absences, member share of cost, and the relationship between LTC and hospice.

Referral face sheet located in prior authorization forms in provider resources.

For more information on long-term care, please visit the California Department of Aging site.

Community-based adult services (CBAS)

Community-based adult services (CBAS) is a facility-based outpatient program serving individuals 18 years of age or older who have a functional impairment that puts them at risk for institutional care.  The primary objective of CBAS is to prevent inappropriate institutionalization in long-term care facilities. CBAS stresses partnership with the member, the family and/or caregiver, and the PCP in working toward maintaining personal independence.

Each CBAS center has a multidisciplinary team of health professionals who conduct a comprehensive assessment of potential participants and work with the member to meet their specific health and social needs.

Enrolled members attend an Anthem-contracted adult healthcare center several times a week where they can receive:

  • Skilled nursing.
  • Social services.
  • Physical, occupational, and speech therapies.
  • Personal care.
  • Family/caregiver training and support.
  • Hot meals and nutritional counseling.
  • Behavioral health services.
  • Transportation (to and from the healthcare center to residence).

CBAS eligibility & referrals process

CBAS services may be provided to members over 18 years of age who:

  • Meet nursing facility A or B requirements (reference your provider manual for nursing facility requirements).
  • Have organic/acquired or traumatic brain injury and/or chronic mental health conditions.
  • Have Alzheimer’s disease or other dementia.
  • Have mild cognitive impairment.
  • Have a developmental disability.

To determine whether the member meets nursing facility A or B requirements, refer to your provider manual or refer to the CBAS Eligibility Determination Tool

Referrals and requests for CBAS can be made by the member, caregiver, family member, or provider A prior authorization is required for all CBAS services. Referrals should be faxed to Anthem at:

Referral face sheet located in prior authorization forms in provider resources.

Once a referral is received by Anthem:

  1. An LTSS clinician will conduct an eligibility assessment of the member and assist in locating a CBAS facility if needed.
  2. Using an evaluation tool developed and provided by the state, Anthem will approve or deny the request for services.
  3. If approved, the member’s selected CBAS center will conduct a needs assessment, develop a plan of care for the member, and determine the level of service that will be provided at the center.

Refer a member

Please contact the Medi-Cal Customer Care Center to verify eligibility or refer a member for CBAS services.

For more information on CBAS, please visit the California Department of Aging site.

Learn more about CBAS

Emergency remote services (ERS)

Emergency remote services is the temporary provision and reimbursement of CBAS in alternative settings (outside of a CBAS center) such as in the community, the participant’s home, or via telehealth to allow for immediate response to address the continuity of care needs when an emergency restricts or prevents the participants from receiving services at their respective CBAS center. For more information regarding ERS, please visit the California Department of Aging site.

Learn more about ERS

Anthem members must be a CBAS participant to receive ERS services. ERS services will be reviewed in accordance with guidelines set by DHCS and Anthem.

ERS requests

To make an ERS request, use the referral/request for CBAS and include the completed CBAS ERS Initiation Form (CEIF). For more information and instructions on ERS requests, use the California Department of Aging’s Emergency Remote Services Portal Instructions .

LTSS liaisons

Members and providers may request assistance from an LTSS liaison. Liaisons are trained Anthem associates who understand the full spectrum of LTSS, home- and community-based services, and long-term institutional care, including payment and coverage rules. Liaisons can help facilitate member care transitions and be engaged in the Interdisciplinary Care Team meetings as appropriate. Provider and members may request an LTSS liaison by contacting the LTSS at 855-871-4899.

Phone:

855-871-4899

Related information

 
 

Provider tools & resources

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