Nursing Facility Transition Services in Kentucky help Medicaid participants who reside in nursing homes or other institutional settings transition to community-based living. These services are part of Kentucky’s commitment to rebalancing long-term care, promoting home and community-based options, and supporting the rights of individuals to live in the least restrictive environment. Transition services are typically authorized through Medicaid waiver programs and must align with the participant’s Person-Centered Service Plan (PCSP).

1. GOVERNING AGENCIES

Agency: Kentucky Cabinet for Health and Family Services (CHFS) — Department for Medicaid Services (DMS)
Role: Oversees transition initiatives, Medicaid billing, and provider enrollment

Agency: Kentucky Department for Aging and Independent Living (DAIL)
Role: Manages oversight for waiver-based transitions, ensures participant rights, and monitors outcomes

Agency: Centers for Medicare & Medicaid Services (CMS)
Role: Enforces federal HCBS transition compliance and supports deinstitutionalization efforts through programs like Money Follows the Person (MFP)

Agency: Managed Care Organizations (MCOs)
Role: Approve transition service plans, coordinate case management, and oversee reimbursement and service quality

2. SERVICE OVERVIEW

Nursing Facility Transition Services support eligible participants with planning, preparation, and move-in assistance to return to a home or community-based setting.

Authorized transition supports may include:

• Pre-discharge planning and readiness assessments
• Community housing identification and application assistance
• Coordination of services such as personal care, CLS, and home modifications
• Purchase of household items (in coordination with Community Transition Services)
• Advocacy with discharge planners and facility staff
• Linking participants to natural and formal community supports
• Follow-up visits to ensure stabilization
• Coordination with programs like Money Follows the Person (MFP)

Eligibility: Participant must have resided in a nursing facility or ICF/IID for a minimum period (typically 90 days) and have an approved PCSP supporting transition.

3. LICENSING & PROVIDER APPROVAL REQUIREMENTS

Prerequisites:

• Register business with the Kentucky Secretary of State
• Obtain IRS EIN and Type 2 NPI
• Enroll as a Transition Services provider through the Medicaid Partner Portal Application (MPPA)
• Maintain general liability and professional insurance
• Employ or contract Transition Coordinators with background in housing, HCBS, or case management
• Develop a Nursing Facility Transition Policy & Procedure Manual
• Implement HIPAA-compliant documentation systems and participant safeguards

4. KENTUCKY PROVIDER ENROLLMENT PROCESS

Step 1: Medicaid Enrollment via MPPA

• Apply as a provider of Nursing Facility Transition or Transition Coordination Services
• Credential with all participating MCOs in your intended service region

Step 2: Documentation Submission

• Submit operational policies, staffing model, insurance, and sample transition plans

Step 3: Service Authorization & Implementation

• Collaborate with MCO case managers and waiver teams to build a transition plan
• Support the participant’s move, ensure housing setup, and coordinate post-transition stabilization
• Submit claims for authorized services using approved codes

5. REQUIRED DOCUMENTATION

• Articles of Incorporation or business license
• IRS EIN and NPI verification
• Liability and worker’s compensation insurance

Nursing Facility Transition Services Policy & Procedure Manual, including:

• Transition assessment and intake forms
• Service coordination checklist and housing timeline
• Communication log with nursing facility and housing partners
• Participant rights, informed consent, and HIPAA forms
• Critical incident protocols and follow-up documentation
• Quality assurance monitoring and satisfaction surveys
• Medicaid billing templates and audit documentation systems

6. STAFFING REQUIREMENTS

Role: Transition Coordinator / Community Integration Specialist
Requirements: Experience in housing navigation, case management, or disability services; background check; familiarity with Medicaid waivers and discharge planning

Role (optional): Peer Support Worker or Community Navigator
Requirements: Trained in recovery-oriented care and person-centered planning

All staff must complete:

• HCBS waiver orientation and HIPAA compliance
• Housing and benefits coordination training
• Abuse, neglect, and exploitation prevention protocols
• Emergency preparedness and post-transition follow-up planning

7. MEDICAID PROGRAMS & HCBS WAIVERS

Nursing Facility Transition Services are authorized under:

• Home and Community Based (HCB) Waiver
• Michelle P. Waiver (MPW)
• Supports for Community Living (SCL) Waiver
• Acquired Brain Injury (ABI & ABI-LTC) Waivers
• Money Follows the Person (MFP) Demonstration Program

Service delivery settings include:

• Nursing facilities (for discharge planning only)
• Community-based residences (after transition)
• Participant’s new home or apartment

8. TIMELINE TO LAUNCH

Phase: Business Formation and Policy Development
Timeline: 1–2 months

Phase: MPPA Medicaid Enrollment and MCO Credentialing
Timeline: 60–90 days

Phase: Staff Hiring and Transition Tool Setup
Timeline: 30–45 days

Phase: Service Coordination and Participant Referrals
Timeline: Rolling, based on waiver team and discharge planner referrals

9. CONTACT INFORMATION

Kentucky Department for Medicaid Services (DMS)
Website: https://chfs.ky.gov/agencies/dms

Medicaid Provider Enrollment (MPPA): https://mppa.ky.gov

Kentucky Department for Aging and Independent Living (DAIL)
Website: https://chfs.ky.gov/agencies/dail

Money Follows the Person Program (KY MFP): https://chfs.ky.gov/agencies/dms/dca

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10. SCOPE OF WORK

• MPPA enrollment and MCO credentialing
• Policy & Procedure Manual tailored for transition services
• Intake, discharge planning, and stabilization templates
• Staff orientation materials and training logs
• Housing and resource coordination workflow tools
• HIPAA, consent, and billing documentation support
• Outreach tools for partnerships with nursing facilities, housing agencies, and waiver teams