Community Supports (CS)
CS are optional services or settings offered through the CalAIM initiative to eligible Medi-Cal and CareAdvantage members in place of services or settings covered under Medi-Cal. Rather than a benefit, CS are medically appropriate and cost-effective alternative services.
The goal of CS is to improve members’ health outcomes and quality of life by addressing their social determinants of health (SDOH).
Eligibility and service options
A member may be eligible for Community Supports if they meet the following basic qualifications:
- Active HPSM Medi-Cal or CareAdvantage member.
- Engaged with a Care Manager.
- Willing to receive Community Supports services.
Members who are eligible for the Enhanced Care Management benefit will be eligible for Community Supports. Members may already be authorized to a Community Supports provider and may have received a letter notifying them of their qualification for these services. All HPSM members continue to have access to HPSM’s care coordination support care management team. For detailed information and service-specific eligibility criteria, please see DHCS' Community Supports Policy Guide.
Service options
HPSM offers ten CS service options to qualified members:
Asthma Remediation
Provides asthma self-management education to help explain asthma triggers and causes, symptom management, and more. Also provides an in-home environmental trigger assessment, home remediation and remediation supplies to help members live more comfortably in their homes.
Criteria
- Individuals with poorly controlled asthma (as determined by an emergency department visit or hospitalization or two sick or urgent care visits in the past 12 months or a score of 19 or lower on the Asthma Control Test) for whom a licensed health care provider has documented that the service will likely avoid asthma-related hospitalizations, emergency department visits, or other high-cost services.
Units per CS service option
| CPT Code | Service Option | Max Units Paid per Auth. | Days/Quantity |
|---|---|---|---|
| S5165, U5 | Asthma Remediation | Up to 1 unit | 1 unit = 3 months |
Community or Home Transition Services (formerly known as Community Transitions/Nursing Facility to Home)
Provides coordination of services to qualified members. Coverage includes (but is not limited to) nonrecurring home setup expenses for eligible members who are able to transition from a licensed facility into the community. This helps prevent further institutionalization based on each members’ individual needs.
Criteria
- Currently receiving medically necessary nursing facility Level of Care (LOC) services and in lieu of remaining in the nursing facility or Recuperative Care setting are choosing to transition home and continue to receive medically necessary nursing facility LOC services; and
- Have lived 60+ days in a nursing home and/or Recuperative Care setting; and
- Are interested in moving back to the community; and
- Are able to reside safely in the community with appropriate and cost-effective supports and services
Units per CS service option
| CPT Code | Service Option | Max Units Paid per Auth. | Days/Quantity |
|---|---|---|---|
| T2038 U5 | Community Transitions / Nursing Facility to Home | Up to 12 units | 1 unit = 1 month |
Environmental Accessibility Adaptations
Provides physical adaptations to members’ homes that are necessary to avoid institutionalization and increase independence or ensure health, welfare and safety.
Criteria
- Received PT/OT evaluation supporting medical necessity.
- Has PCP or other health professional Rx/order for medically necessary equipment or service.
Units per CS service option
| CPT Code | Service Option | Max Units Paid per Auth. | Days/Quantity |
|---|---|---|---|
| S5165 | Environmental Accessibility Adaptations | Up to 1 unit | 1 unit = $7,500 lifetime max |
Housing Deposits
Identify, coordinate, secure or fund one-time services and modifications to a person’s home that are necessary to enable them to establish a basic household (except room and board) based on their individualized needs.
Criteria
- Received Housing Transition Navigation Services.
- Prioritized for permanent supportive housing or rental subsidy resource through San Mateo CES or similar County system/resource.
or - Are experiencing or at risk of homelessness, including those at risk of losing housing.
Units per CS service option
| CPT Code | Service Option | Max Units Paid per Auth. | Days/Quantity |
|---|---|---|---|
| H0044 | Housing Deposits | Up to 1 unit | 1 unit = 3 months |
Housing Transition and Navigation Services
Provide supports that include (but are not limited to) advocacy, housing search and coordination of resources based on the member’s individualized needs.
Criteria
- Prioritized for permanent supportive housing or rental subsidy resource through San Mateo CES or similar County system/resource.
or - Are experiencing or at risk of homelessness, including those at risk of losing housing.
Units per CS service option
| CPT Code | Service Option | Max Units Paid per Auth. | Days/Quantity |
|---|---|---|---|
| H0043 | Housing Navigation / Transition Services | 1 unit per month, up to 6 units | 1 unit = 1 month |
Housing Tenancy and Sustaining Services – Available a single duration in a lifetime.
Provides tenancy and sustaining services including (but not limited to) advocacy, coordination, resource referrals, life-skills coaching and health/safety visits with a goal of maintaining stable tenancy once housing is secured based on the member’s individualized needs.
Criteria
- Received Housing Transitions Navigation Services.
or - Prioritized for permanent supportive housing or rental subsidy resource through San Mateo CES or similar County system/resource.
or - Are experiencing or at risk of homelessness, including those at risk of losing housing.
Units per CS service option
| CPT Code | Service Option | Max Units Paid per Auth. | Days/Quantity |
|---|---|---|---|
| T2050, U6 | Housing Tenancy – Financial Management (per diem) | 1 unit per month, up to 12 units | 1 unit = 1 month |
Medically Tailored Meals
Provides medically tailored home-delivered meals for members with chronic conditions to help achieve their nutrition goals at critical times and help them regain and maintain their health. Starting July 1st, 2025 members will be required to have one nutritional assessment conducted by the Community Supports Service Provider in order to receive Medically Tailored Meals.
Criteria
- Individuals who have chronic or other serious health conditions that are nutrition sensitive.
Units per CS service option
| CPT Code | Service Option | Max Units Paid per Auth. | Days/Quantity |
|---|---|---|---|
| S5170 | Medically Tailored Meals | Up to 168 units | 1 unit = 1 meal |
| S9470 | Nutritional Counseling | 3 sessions total | 1 unit= 1 session |
Assisted Living Facility (ALF) Transitions (formerly known as Nursing Facility Transition / Diversion to Assisted Living Facilities)
Provides coordination of services to facilitate nursing facility transition back into a home-like, community setting and/or prevent skilled nursing admissions for members with an imminent need for nursing facility level of care (LOC). Members have the choice of residing in an ALF as an alternative to long-term placement in a nursing facility when they meet eligibility requirements.
Criteria for SNF transition
- Residing in SNF for more than 60 days, and
- Willing and able to reside safely in an Assisted Living Facility (ALF) or Residential Care Facility for the Elderly (RCFE) in lieu of a SNF with appropriate supports in place.
Criteria for SNF diversion
- Wants to remain in the community; and
- Meets minimum criteria for SNF level of care, and, in lieu of going into a facility, choose to remain in the community and continue to receive medically necessary nursing facility LOC services at an Assisted Living Facility; and
- Willing and able to reside safely in an ALF/RCFE in lieu of SNF with appropriate supports in place.
Units per CS service option
| CPT Code | Service Option | Max Units Paid per Auth. | Days/Quantity |
|---|---|---|---|
| T2038 | Nursing Facility Transition / Diversion to Assisted Living Facilities | Up to 12 units | 1 unit = 1 month |
Personal Care and Homemaker Services
Provides assistance to members who could not otherwise remain in their homes. Helps with activities of daily living (ADLs) such as ambulation, bathing, dressing, toileting, grocery shopping, meal preparation, feeding and money management. Includes services provided through in-home supportive services (IHSS).
Criteria
- Approved for IHSS but needs additional hours. IHSS benefits are exhausted
- Currently in IHSS waiting period. Includes services prior to and through the IHSS application date for an IHSS-referred member during IHSS waiting period
- If not eligible for IHSS, to help avoid a short-term skilled nursing facility stay (not to exceed 60 days)
- Has functional deficits and no other adequate support system.
Units per CS service option
| CPT Code | Service Option | Max Units Paid per Auth. | Days/Quantity |
|---|---|---|---|
| S5130, U6 | Personal Care and Homemaker Services | N/A | 1 unit = 15 minutes |
Respite Services
Provides non-medical, short-term services to members due to the absence of or need to relieve their caregivers to prevent burnout.
Criteria
- Lives in the community and is compromised in their ADLs and are therefore dependent upon a qualified caregiver who provides most of their support.
- Requires caregiver relief to avoid institutional placement.
Units per CS service option
| CPT Code | Service Option | Max Units Paid per Auth. | Days/Quantity |
|---|---|---|---|
| S5151, U6 | Respite Care | Up to 336 units | 1 unit = 1 hour |
Community Supports Provider List
This CS provider list should be used as a reference for referring patients. Before starting referrals, review capacity and eligibility.
NPI: 1376797035
Phone: 888-324-6225
Fax: 888-522-6796
200 N. Pacific Coast Hwy
Suite 300
El Segundo, CA 90245
- Service option: Personal Care and Homemaker Services
- CPT Code: S5130, U6
- Capacity: Download the CS Provider List for current capacity
- Service option: Respite Care
- CPT Code: S5151, U6
- Capacity: Download the CS Provider List for current capacity
NPI: 1609290030
Phone: 650-573-3900
Fax: 833-522-0986
801 Gateway Blvd.
Suite #400
South San Francisco, CA 94080
- Service option: Personal Care and Homemaker Services
- CPT Code: S5130, U6
- Capacity: Download the CS Provider List for current capacity
- Service option: Respite Care
- CPT Code: S5151, U6
- Capacity: Download the CS Provider List for current capacity
- Service option: Community Transition Services / Nursing Facility Transition to a Home
- CPT Code: T2038, U5
- Capacity: Download the CS Provider List for current capacity
NPI: 1396400891
Phone: 408-998-5865
Fax: 408-998-0578
1469 Park Ave.
San Jose, CA 95126
- Service option: Asthma Remediation
- CPT Code: S5165, U5
- Capacity: Download the CS Provider List for current capacity
NPI: 1356687354
Phone: 415-618-0012
Fax: 877-320-8164
1390 Market St.
San Francisco, CA 94102
- Service option: Housing Transition Navigation Services
- CPT Code: H0043
- Capacity: Download the CS Provider List for current capacity
- Service option: Housing Deposits
- CPT Code: H0044
- Capacity: Download the CS Provider List for current capacity
- Service option: Housing Tenancy – Financial Management
- CPT Code: T2050, U6 (per diem)
- Capacity: Download the CS Provider List for current capacity
- Service option: Environmental Accessibility Adaptations
- CPT Code: S5165
- Capacity: Download the CS Provider List for current capacity
NPI: 1285478164
Phone: 925-924-7288
Fax: 925-414-4102
310 Miller Ave.
South San Francisco, CA 94080
- Service option: Housing Tenancy and Sustaining Services
- CPT Code: T2050, U6 (per diem)
- Capacity: Download the CS Provider List for current capacity
NPI: 1255730222
Phone: 628-239-3565
Fax: 650-963-4699
3575 Geary Blvd.
San Francisco, CA 94118
- Service option: Environmental Accessibility Adaptations
- CPT Code: S5165
- Capacity: Download the CS Provider List for current capacity
- Service option: Nursing Facility Transition / Diversion to Assisted Living Facilities
- CPT Code: T2038, U4
- Capacity: Download the CS Provider List for current capacity
- Service option: Community Transition Services / Nursing Facility Transition to a Home
- CPT Code: T2038, U5
- Capacity: Download the CS Provider List for current capacity
NPI: 1073678793
Phone: 650-257-8816
Fax: 650-507-4071
2686 Spring St.
Redwood City, CA 94063
- Service option: Housing Transition Navigation Services
- CPT Code: H0043
- Capacity: Download the CS Provider List for current capacity
- Service option: Housing Tenancy – Financial Management
- CPT Code: T2050, U6 (per diem)
- Capacity: Download the CS Provider List for current capacity
- Service option: Housing Deposits
- CPT Code: H0044
- Capacity: Download the CS Provider List for current capacity
NPI: 1114674546
Phone: 650-218-0555
Fax: 650-281-0012
303 Vintage Park Dr.
Suite 250
Foster City, CA 94404
- Service option: Housing Tenancy – Financial Management
- CPT Code: T2050, U6 (per diem)
- Capacity: Download the CS Provider List for current capacity
NPI: 1093834020
Phone: 888-701-5279
Fax: 866-942-7873
3210 SE Corporate Woods Dr.
Ankeny, IA 50021
- Service option: Medically Tailored Meals
- CPT Code: S5170
- Capacity: Download the CS Provider List for current capacity
Refer a member for Community Supports
To refer a member for CS services, please complete the CS Referral Form typed (hand-written forms will not be accepted) and ensure it is completed accurately and completely. If you are interested in re-referring the member for the same service, please work with the Rendering Provider directly.
After completing the form, please see instructions below to determine where to send the form
- If you are interested in referring the member to Brilliant Corners for any of the following (Housing Tenancy Services, Housing Navigation Services, Housing Deposits, or Environmental Accessibility Modifications), please securely email the completed form to Brilliant Corners at [email protected].
- If you are interested in referring the member to Mental Health Association for any of the following services (Housing Tenancy Services or Housing Deposits), please fax the completed form to Mental Health Association at 650-507-4071; Attention: Tiffany Bailey.
- If you are interested in referring the member to Mom’s Meals for Medically Tailored Meals and Nutritional Counseling Services, please securely email the completed form to Mom’s Meals at [email protected].
- If you are interested in referring the member to Breathe California for Asthma Remediation, please fax the completed form to Breathe California at 408-998-0578; Attention: Asthma Team; or securely email the completed form to [email protected] and [email protected].
- If you are interested in referring the member to Institute on Aging for Assisted Living Facility Transitions or Community/Home Transition Services, please securely email the completed form to Institute on Aging at [email protected] and [email protected].
- If you are interested in referring the member to Aging and Disability Services (formerly known as Aging and Adult Services) for Personal Care and Homemaker Services or Respite Care, please email the completed form to Aging and Disability Services at [email protected] and [email protected].
- If you are interested in referring the member to 24 Hour Home Care for Personal Care and Homemaker Services or Respite Care, please securely email the completed form to 24 Hour Home Care at [email protected].
After you have sent the completed form as outlined above, the Rendering CS Provider will process the referral in collaboration with the Health Plan of San Mateo. HPSM will notify referents with the outcome of the referral after it is processed.