CurrentFallon Community Health Plan IncPolicy N/A

Group Adult Foster Care Clinical Coverage Criteria

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This policy governs medical necessity, prior authorization, documentation, and coverage criteria for Group Adult Foster Care (GAFC), a MassHealth-covered personal care service delivered in a member's residence by qualified non-live-in staff. It applies to NaviCare HMO SNP members and addresses daily ADL assistance, nursing oversight, care management, provider requirements, and nonduplication of services.

Policy Summary

PayerFallon Community Health Plan Inc

PolicyGroup Adult Foster Care Clinical Coverage Criteria

Policy CodePolicy N/A

Change TypeRevised

Effective DateJanuary 1, 2027

Last ReviewSep 15, 2026

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

The policy was revised effective January 1, 2027 to align with the GAFC Payment Policy and current MassHealth GAFC requirements.

6Qualifying activities of daily living

RequiredAuthorization requirement

≥1 ADLMedical-necessity threshold

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CurrentFallon Community Health Plan IncPolicy N/A

Group Adult Foster Care Clinical Coverage Criteria

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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

PolicyGroup Adult Foster Care Clinical Coverage Criteria

Policy CodePolicy N/A

Change TypeRevised

Effective DateJanuary 1, 2027

Last ReviewSep 15, 2026

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

The policy was revised effective January 1, 2027 to align with the GAFC Payment Policy and current MassHealth GAFC requirements.

6Qualifying activities of daily living

RequiredAuthorization requirement

≥1 ADLMedical-necessity threshold

Explicit exclusion conditions

H0043Informational HCPCS code

Coverage Criteria

Initial GAFC Medical Necessity

GAFC is medically necessary when ALL of the following are met:

ALL of the following

The member has a medical, cognitive, or behavioral health condition requiring daily hands-on assistance or cueing and supervision throughout at least one qualifying ADL.
The member resides in an eligible GAFC setting.
The provider's clinical assessment supports the required assistance and planned interventions.
The services are included in the member's person-centered plan of care.
GAFC does not duplicate another personal-care service.

Concurrent Related Services

Members may receive GAFC concurrently with related services when ALL of the following are met:

ALL of the following

The member is independently eligible for one of the following services
- Adult Day Health services.
- Day Habilitation services.
The GAFC and related services are coordinated and nonduplicative.

GAFC is not covered when the member does not require daily assistance with at least one qualifying ADL or when the request is based only on instrumental activities of daily living (IADL) needs.

GAFC is also not covered when prior authorization was not obtained; the provider, direct-care worker, or setting does not meet applicable requirements; the member resides in an excluded institutional or provider-operated setting; or the requested amount represents rent, room and board, housing charges, or personal-care supplies.

CPT/HCPCS Coding

CPT/HCPCS CodesHCPCS

H0043

Supported Housing, per diem

Provider Requirements and Actions

Prior Authorization

Prior Authorization and NaviCare Submission

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. PACE members do not require prior authorization for GAFC services.

Documentation Required

Required Authorization Documentation

Submit complete and current documentation with each authorization request, reauthorization, provider transfer, or service change. Fallon Health may request additional clinical information reasonably necessary to determine medical necessity.

Completed authorization request.
Current PCP order or other acceptable clinical documentation supporting the need for GAFC.
Current GAFC clinical assessment identifying qualifying ADL needs, required assistance, relevant conditions, interventions, service frequency, and living setting.

GAFC Service Overview

Group Adult Foster Care (GAFC) is a MassHealth-covered personal care service provided in the member’s residence by qualified, non-live-in staff. The service includes daily assistance with activities of daily living and related instrumental activities of daily living, along with nursing oversight and care management based on the member’s assessed needs and plan of care. Medical necessity is based on a medical, cognitive, or behavioral health condition requiring daily hands-on assistance or cueing and supervision with at least one qualifying ADL.

Key Definitions

Clinical Assessment

Assessment scopeA comprehensive GAFC provider assessment documenting the member's medical, cognitive, behavioral, and functional status.

Functional requirementsDocuments each qualifying ADL and the assistance or supervision required.

Planning detailsDocuments proposed interventions and frequency, the living setting, and the basis for the plan of care and prior authorization request.

Family Member

SpouseThe member's spouse.

ParentA parent of a minor child who is the member.

Legal guardian

Policy Summary

PayerFallon Community Health Plan Inc

PolicyGroup Adult Foster Care Clinical Coverage Criteria

Policy CodePolicy N/A

Change TypeRevised

Effective DateJanuary 1, 2027

Last ReviewSep 15, 2026

Next Review DateN/A

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

SourceLink

On This Page

Current plan of care and planned service schedule.

Documentation of the eligible GAFC living setting.

For reauthorization, updated information supporting continued eligibility and any relevant changes.

For provider transfers or service changes, applicable transition and member-notification documentation.

Denial Risk

GAFC Exclusions and Denial Conditions

GAFC is not covered when eligibility, authorization, provider, setting, duplication, or requested-service requirements are not met. Claims or requests may be denied when any of the following exclusion conditions apply.

The member does not require daily assistance with at least one qualifying ADL.
The request is based only on IADL needs.
Prior authorization was not obtained.
The provider, direct-care worker, or setting does not meet applicable requirements.
The service duplicates another personal-care program.
The member resides in an excluded institutional or provider-operated setting.
The requested amount represents rent, room and board, housing charges, or personal-care supplies.

The member's legal guardian.

Uniform Core Assessment (UCA)

PurposeA standardized assessment used to evaluate a member's functional status, support needs, and community-based service requirements.

Medical necessity reviewInformation from the UCA may be considered during medical necessity review.

Required documentationThe UCA does not replace the provider's current service-specific assessment, plan of care, or required supporting documentation.

Bathing

Qualifying assistanceAssistance with full-body bathing or personal hygiene qualifies as bathing assistance.

Non-qualifying limitationAssistance limited to grooming, oral care, shaving, or similar hygiene tasks alone does not qualify.

ADL focusThe qualifying need must involve bathing or personal hygiene assistance rather than hygiene-only tasks.

Dressing

Qualifying assistanceAssistance with upper- and lower-body dressing qualifies as dressing assistance.

Upper-body dressingQualifying assistance may include help with dressing the upper body.

Non-qualifying limitationAssistance limited to shoes, socks, buttons, or zippers alone does not qualify.

Toileting

ToiletingAssistance with toileting qualifies.

Related careQualifying related activities include incontinence care, catheter care, and colostomy care.

Toileting routinesAssistance with related toileting routines is included.

Transferring

DefinitionTransferring is physical assistance to move between positions.

Bed transfersExamples include physical assistance moving between a bed and another position.

Chair or wheelchair transfersExamples include physical assistance moving between a chair or wheelchair and another position.

Mobility (Ambulation)

Mobility assistanceMobility assistance includes physical assistance, steadying, or guidance during mobility.

Steadying or guidanceSteadying or guidance during ambulation is included.

Wheelchair mobilityAssistance with wheelchair mobility qualifies when the member cannot self-propel independently.

Eating

Supervision and cueingEating assistance includes ongoing supervision or cueing during meals.

Physical assistancePhysical assistance during meals is included.

Non-qualifying limitationAssistance limited to meal preparation or setup does not qualify.