ModifiedFallon Community Health Plan IncPolicy N/A

Adult Foster Care

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This policy governs medical necessity, authorization, documentation, service levels, exclusions, and coding for Adult Foster Care services provided in qualified Massachusetts settings to eligible NaviCare HMO SNP members and PACE participants.

Policy Summary

PayerFallon Community Health Plan Inc

PolicyAdult Foster Care

Policy CodePolicy N/A

Change TypeModified

Effective DateJanuary 27, 2027

Last ReviewSep 15, 2026

Next Review DateN/A

Key ActionSubmit complete AFC authorization and reauthorization requests directly to Fallon Health and monitor authorization expiration dates.

SourceLink

POLICY UPDATE CHANGES

Adult Foster Care requirements were updated and aligned with current MassHealth guidance.

Provider documentation, authorization pathways, and coding references were clarified or corrected.

Prior authorizationAuthorization requirement

2AFC service levels

6Qualifying activities of daily living

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ModifiedFallon Community Health Plan IncPolicy N/A

Adult Foster Care

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Sign up for all fallon_community_health_plan_inc policy alerts

Know when fallon_community_health_plan_inc releases new policies or updates existing guidance.

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Policy Summary

PayerFallon Community Health Plan Inc

PolicyAdult Foster Care

Policy CodePolicy N/A

Change TypeModified

Effective DateJanuary 27, 2027

Last ReviewSep 15, 2026

Next Review DateN/A

Key ActionSubmit complete AFC authorization and reauthorization requests directly to Fallon Health and monitor authorization expiration dates.

SourceLink

POLICY UPDATE CHANGES

Adult Foster Care requirements were updated and aligned with current MassHealth guidance.

Provider documentation, authorization pathways, and coding references were clarified or corrected.

Prior authorizationAuthorization requirement

2AFC service levels

6Qualifying activities of daily living

Caregiver supervision model

MassachusettsQualified setting

Adult Foster Care Coverage Criteria

General AFC Medical Necessity

AFC is medically necessary when ALL of the following criteria are met:

ALL of the following

The member has a medical, physical, cognitive, or behavioral health condition requiring daily hands-on assistance or cueing and supervision throughout at least one qualifying ADL.
The member and qualified live-in AFC caregiver reside in a qualified Massachusetts setting.
A current PCP order supports AFC services.
The clinical assessment supports the requested Level I or Level II service.
AFC does not duplicate another personal-care service.

AFC Level I

The member qualifies for AFC Level I when ANY of the following criteria are met:

ANY of the following

Requires hands-on assistance with at least one ADL.
Requires cueing and supervision throughout one ADL.

AFC Level II

The member qualifies for AFC Level II when ANY of the following criteria are met:

ANY of the following

Requires hands-on assistance with three or more ADLs.
ALL of the following
- Requires hands-on assistance with two ADLs.
- Behavioral management for ANY of the following
  - Wandering: Aimless movement without regard for safety.
  - Verbal abuse: Threatening, screaming, or cursing.

Fallon Health does not pay for AFC when the AFC provider has not received prior authorization from Fallon Health; when the AFC caregiver is a Family Member*; or when services are duplicative of other personal-care or IADL support services.

Fallon Health does not pay for AFC when the member is a resident or inpatient of a hospital, nursing facility (except during authorized Medical Leave of Absence days), ICF/IID, Assisted Living Facility, or another licensed or state-funded residential setting that provides the member's medically necessary personal care services.

CPT and HCPCS Coding

CPT/HCPCS CodesHCPCS

S5140	Foster care, adult; per diem (adult foster care personal care and administration; per diem, Level I).
S5140 TG	Foster care, adult; per diem (adult foster care personal care and administration; per diem, Level II).
S5140 TF	Foster care, adult; alternate caregiver day (Level I)
S5140 U5	Foster care, adult; alternate caregiver day (Level II)
S5140 U6	Foster care, adult; medical leave of absence day (Level I)
S5140 TG U6	Foster care, adult; medical leave of absence day (Level II)
S5140 U7	Foster care, adult; non-medical leave of absence day (Level I)
S5140 TG U7	Foster care, adult; non-medical leave of absence day (Level II)

CPT/HCPCS Codes — informational onlyHCPCS

S5140	Foster care, adult; per diem (adult foster care personal care and administration; per diem, Level I)
S5140 TG	Foster care, adult; per diem (adult foster care personal care and administration; per diem, Level II)
S5140 TF	Foster care, adult; alternate caregiver day (Level I)
S5140 U5	Foster care, adult; alternate caregiver day (Level II)
S5140 U6	Foster care, adult; medical leave of absence day (Level I)
S5140 TG U6	Foster care, adult; medical leave of absence day (Level II)
S5140 U7	Foster care, adult; non-medical leave of absence day (Level I)
S5140 TG U7	Foster care, adult; non-medical leave of absence day (Level II)

AFC Level I

Service levelAFC Level I

Hands-on assistanceRequires hands-on assistance with at least one activity of daily living (ADL).

Cueing and supervisionAlternatively, requires cueing and supervision throughout one ADL.

AFC Level II

Service levelAFC Level II

Three-ADL pathwayRequires hands-on assistance with three or more ADLs.

Two-ADL pathway

Authorization and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. For NaviCare members, effective January 1, 2027, the AFC provider must submit complete authorization and reauthorization requests directly to Fallon Health and monitor authorization expiration dates.

Prior authorization is required before AFC services are provided.
For NaviCare members, submit complete authorization and reauthorization requests directly to Fallon Health beginning January 1, 2027.
Monitor authorization expiration dates.

Prior Authorization

Coordinate AFC Services Through PACE

For PACE participants, the PACE interdisciplinary team determines and coordinates AFC services through the applicable PACE site.

Coordinate AFC services through the applicable PACE site.
Follow the authorization decisions and processes of the member's PACE interdisciplinary team.

Adult Foster Care Overview

Adult Foster Care (AFC) is a MassHealth-covered personal care service provided in the member’s residence or in the home of a qualified live-in caregiver. The caregiver provides 24-hour supervision and daily assistance with activities of daily living, instrumental activities of daily living, and other care identified in the plan of care under the oversight of the AFC provider’s multidisciplinary team. Members may receive both AFC and Adult Day Health when independently eligible and when the services are coordinated and nonduplicative.

Key Definitions

AFC Caregiver

Residence arrangementA live-in individual who resides with the member.

Care providedProvides direct care to the member.

CompensationIs compensated by the AFC provider.

Clinical Assessment

Assessment typeThe comprehensive assessment performed by the AFC provider.

Member needs and eligibilityDocuments the member's functional needs and clinical eligibility.

Service planningDocuments the requested service level, caregiver arrangement, and qualified setting.

Policy Summary

PayerFallon Community Health Plan Inc

PolicyAdult Foster Care

Policy CodePolicy N/A

Change TypeModified

Effective DateJanuary 27, 2027

Last ReviewSep 15, 2026

Next Review DateN/A

Key ActionSubmit complete AFC authorization and reauthorization requests directly to Fallon Health and monitor authorization expiration dates.

SourceLink

On This Page

Physical abuse: Hitting, shoving, or scratching.

Socially disruptive behavior, including screaming, self-harm, public disrobing, smearing, throwing objects, or repetitive disruptive actions.

Resisting care: Refusal or interference with care, either verbally or physically.

Alternatively, requires hands-on assistance with two ADLs plus behavioral management for wandering, verbal abuse, physical abuse, socially disruptive behavior, or resisting care.

Prior Authorization

PACE IDT Authorization Required

Each PACE plan member is assigned to an interdisciplinary team (IDT). Except for emergency care and out-of-area urgently needed care, all care and services provided to PACE plan members must be authorized by the IDT.

PACE provides Medicare- and Medicaid-covered care and services as authorized by the IDT, as well as additional medically necessary care and services not covered by Medicare or Medicaid.
Emergency care and out-of-area urgently needed care are exceptions to the IDT authorization requirement.

Documentation Required

Initial Authorization Documentation

Submit a completed authorization request with the documentation needed to establish AFC eligibility, medical necessity, caregiver arrangements, setting, and requested service level.

Completed authorization request.
Current PCP order or PCP Summary Form.
Current AFC clinical assessment identifying each qualifying ADL, required assistance, relevant condition, caregiver arrangement, qualified setting, and requested level.
Current plan of care.
Documentation that the member resides with the caregiver in a qualified setting.

Documentation Required

Reauthorization Documentation

For reauthorization, submit updated documentation supporting the member's continued eligibility, medical necessity, required oversight, and requested AFC service level.

Updated documentation supporting continued eligibility.
Updated documentation supporting medical necessity and oversight.
Updated documentation supporting the requested level of AFC services.

Documentation Required

Provider Transfer and Additional Information

For a provider transfer, submit a new assessment and transition documentation. Fallon Health may request additional clinical information reasonably necessary to determine eligibility or the appropriate AFC level.

Provider transfer: new assessment and transition documentation.
Provide additional clinical information reasonably necessary for eligibility or AFC-level determination when requested by Fallon Health.

Denial Risk

Non-Duplication Attestation

Providers must attest that AFC services are not duplicative of other personal care, supportive care, or substantially similar ADL or IADL assistance services.

Attest that AFC is not duplicative of PCA, GAFC, agency-delivered personal care, home health aide, supportive home care aide, another AFC provider, or other programs providing substantially similar ADL or IADL assistance.

Denial Risk

Excluded Settings, Caregivers, and Duplicative Services

Fallon Health does not pay for AFC when required authorization has not been obtained, the caregiver is a Family Member*, or services duplicate other personal care or IADL support. AFC is also not covered while the member is in a setting that provides medically necessary personal care services.

No Fallon Health payment if the AFC provider has not received prior authorization.
No coverage when the AFC caregiver is a Family Member*.
No coverage for services duplicative of other personal care or IADL support services.
No coverage while the member is a resident or inpatient of a hospital, nursing facility (except during authorized Medical Leave of Absence days), ICF/IID, Assisted Living Facility, or another licensed or state-funded residential setting that provides medically necessary personal care services.

Denial Risk

Benefit-Plan Exclusions and Limitations

Coverage is subject to the member's particular benefit plan, which may contain specific provisions for coverage, exclusions, or other limitations regardless of medical necessity. If this policy conflicts with the benefit plan, the benefit plan governs; consult the product's Evidence of Coverage.

Not all services in this policy are covered for all products or employer groups.
Review the applicable Evidence of Coverage for exclusions and benefit limitations.
Applicable state mandates take precedence for fully insured and self-funded non-ERISA plans; unless specifically excluded, federal mandates apply to all plans.

Family Member

SpouseA spouse of the member.

Parent of a minor childThe parent of the member's minor child.

Legal guardianA legal guardian of the member.

Caregiver eligibilityFamily Members are not eligible to serve as AFC caregivers.

Qualified Setting

Regulatory standardA location that meets all standards outlined in 130 CMR 408.435.

SafetyMeets applicable safety standards.

AccessibilityMeets applicable accessibility standards.

Care deliveryIs appropriate for care delivery.