Community-Based LTSS Services Clinical Coverage Criteria
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Defines Fallon Community Health Plan's clinical coverage criteria, prior authorization requirements, provider qualifications, service limits, and documentation standards for a range of community-based long-term services and supports (LTSS) for NaviCare HMO SNP members.
No material clinical or coverage changes in this revision.
Service-Specific Coverage Criteria
General Medical Necessity Criteria
Covered when ALL of the following are met
Based on Clinical Coverage Criteria section
Alzheimer's/Dementia Coaching Eligibility
Alzheimer's/Dementia Coaching is covered when ALL of the following are met
From Alzheimer's/Dementia Coaching eligibility and description
Alzheimer's/Dementia Coaching (Habilitation Therapy)
Alzheimer's/Dementia Coaching covered when ALL of the following are met
From Description and Eligibility Criteria.
Comfort Animals (Assistive Technology)
Assistive Technology - Comfort Animals covered when ALL of the following are met
Coverage limited to two animals every three years with a maximum benefit of $600; internet fees not covered.
Assistive Technology for Telehealth
Assistive Technology for Telehealth covered when ALL of the following are met
Benefit capped at $500 per five-year period; evaluation will consider existing technology and avoid duplicate device funding.
Chore Services
Chore Services covered when ALL of the following are met
Exclusions: routine cleaning, ongoing/regular chores, duplication of homemaker services, tasks benefiting others, landlord responsibility, and tasks that are home accessibility adaptations are not covered.
Companion Services
Companion Services covered when ALL of the following are met
Companion services must not duplicate other IADL-support services unless unique needs exist and are inappropriate for members who require constant supervision.
Companion Services — Covered when ALL of the following are met (supervision/duplication exclusions highlighted)
Companion services are permissible where they do not duplicate personal care or medication administration and meet supervision-related suitability.
Based on exclusions/limitations and guidance in chunk 36.
Complex Care Training and Oversight
Specialized training and supervision provided by qualified nursing staff for members with complex medical needs.
Eligibility criteria from chunk 39.
Exclusions/denial triggers described in chunk 40.
ET/CPERS & VCAM Emergency Response Systems — Covered when ALL of the following are met
Technology-enabled emergency response devices and services for members who are at risk and can use devices responsibly.
Core eligibility from chunk 45 and device features in chunks 43/44.
VCAM-specific criteria from chunk 46 and VCAM features in chunk 44.
Exclusions listed in chunk 47.
Environmental Accessibility Adaptations / Home Modifications — Covered when ALL of the following are met
Physical home modifications to improve safety and independence when necessary, cost-effective, and supported by required documentation.
Eligibility criteria from chunk 49.
Documentation list from chunk 49.
Exclusions from chunk 50.
Evidence-Based Education Program — Covered when ALL of the following are met
Structured, validated education programs to improve member self-management and health outcomes when aligned with care plan and delivered by trained providers.
Eligibility criteria from chunk 53.
Service delivery standards from chunk 53.
Exclusions from chunk 54.
Grocery Shopping and Delivery Eligibility
Grocery Shopping and Delivery: Covered when ALL of the following are met
From eligibility criteria list
Home-Delivered Meals Eligibility
Home-Delivered Meals: Covered when ALL of the following are met
7 meals/week or fewer do not require prior authorization; 8+ meals/week require prior authorization.
Home Health Aide Eligibility
Home Health Aide Services: Covered when ALL of the following are met
From Home Health Aide eligibility.
Home Safety/Independence Evaluation Eligibility
Home Safety/Independence Evaluation: Covered when ALL of the following are met
From Home Safety/Independence Evaluation eligibility and documentation requirements.
Homemaker Services — Covered with criteria
Covered when ALL of the following are met
From Homemaker Services eligibility and limitations.
Laundry Services — Covered with criteria
Covered when ALL of the following are met
Exclusions include services where member or household member can perform the task or where another service already includes laundry assistance.
Medication Dispensing System — Covered with criteria
Covered when ALL of the following are met
Not covered if member already has MedMinder or sufficient caregiver support; prior authorization expected to confirm criteria.
Orientation and Mobility — Covered with criteria
Covered when ALL of the following are met
Provider qualifications and exclusions from chunks 84-85.
Peer Support — Covered with criteria
Covered when ALL of the following are met
Peer support limited to 16 hours per week.
Personal Care Services — Covered with criteria
Covered when ALL of the following are met
From PCS eligibility and documentation requirements.
Personal Care Services (PCS) — Eligibility
PCS may be approved when ALL of the following are met:
Assistance may be direct hands-on help or ongoing cueing/supervision; documentation must show limitations.
Informal supports and adaptive equipment should be considered first.
Respite Services — Eligibility
Respite care may be approved when ALL of the following are true:
From Respite Services eligibility.
Provider qualifications described in chunk 94.
Supportive Day Program — Eligibility
Supportive Day Program may be approved when ALL of the following are met:
Eligibility criteria from chunks 96-97.
Exclusions from chunk 98.
Supportive Home Care Aide (SHCA) — Eligibility
SHCA may be approved when ALL of the following are met:
From SHCA eligibility documentation requirements.
From SHCA eligibility and exclusions.
Transitional Services — Eligibility
Transitional assistance expenses may be eligible when ALL of the following are met:
From Transitional Services eligibility.
From Transitional Services eligibility.
Limitations/Exclusions — Noted under each service above
Limitations/Exclusions are noted under each service above.
See service-level exclusions and the Universal Exclusions section for details.
Members may not receive duplicate services that address the same functional, physical, cognitive, or behavioral health need. Services delivered while a member is residing in or admitted to a licensed medical facility (hospital, nursing facility, ICF/IID, or similar) are not eligible. Where a legally responsible household member (for example, a spouse) can safely perform the task, or an existing service already provides the same support, requests may be denied. Combined weekly hours across select personal and home services are capped at 84 hours per week (see service-level sections for how this is applied and for short-term exceptions).
Exclusions at the service level include clinical, provider, and benefit-limit conditions. Examples: Alzheimer’s/dementia coaching requires a physician-documented diagnosis and will be denied without it; comfort animals exclude internet installation or ongoing service fees and are limited to 2 animals every three years with a maximum benefit of $600; telehealth assistive technology is subject to a $500 per five-year cap and duplicate device funding is prohibited; chore services that are routine, benefit others, are landlord responsibility, or duplicate homemaker services are excluded; providers must meet specified qualifications or services will be denied.
Companion services are explicitly excluded from providing personal care or medication reminders/administration and must not duplicate other IADL supports unless a unique unmet need is documented. They cannot be provided in Adult Day Health or Day Habilitation centers or alongside other supervisory services, and they are not appropriate for members who require constant supervision. Purely recreational or diversionary companion activities are not covered.
Complex Care Training is not covered when delivered by an agency that lacks the required license or when provided by staff without required nursing supervision. Training must be provided by an RN or an LPN under RN supervision and both must hold a current, unrestricted Massachusetts nursing license per state law; failure to meet these provider/licensure requirements is a basis for denial.
ET/CPERS and VCAM devices are excluded when the member cannot use the device independently or does not understand safe use; coverage is denied for members in facilities that already provide 24-hour monitoring or for members who already have a working device of the same type. VCAM also requires a certified provider and a documented backup plan for system failure; devices used for telehealth may be excluded if duplicative of Transitional Assistance or other Assistive Technology funding.
Home modifications are excluded when they are general home improvements or maintenance (for example, carpeting, roof or HVAC upgrades, paving, decks, fences, plumbing remediation), when they are the legal responsibility of a landlord or third party, or when a less expensive viable solution exists (for example, using a raised toilet seat rather than installing a new toilet). Requests for provider-owned or group-home settings, items not in an approved Home Modification Plan, extended service/maintenance contracts, or modifications requested outside the care plan are also not payable.
Education programs are excluded when they are not based on validated, peer-reviewed research, lack a structured curriculum with measurable outcomes, or duplicate education the member already receives through another service. Providers must be trained in validated models and align programs with the member’s individualized care plan to avoid denial.
Programs lacking a structured, evidence-based curriculum or that duplicate existing member education (for example, overlap with disease management programs) will not be approved.
Grocery shopping and delivery do not cover the cost of groceries themselves—only the shopping and delivery service. Requests are excluded when services do not directly benefit the member, when shopping at requested stores is not linked to the provider, when prior authorization is not obtained, when a legally responsible relative/spouse can shop, or when free local/third‑party delivery options exist.
Home-delivered meals are not paid if the member does not meet medical necessity criteria, if the service duplicates other nutrition supports (including meals provided by a facility), if meals are intended for other household members, or if community meal resources or family support are available. Note: prior authorization is required for 8 or more meals per week; 7 meals per week or fewer do not require prior authorization.
Home health aide services are not approved when the member’s needs are non‑medical, can be met in another setting or with a lower level of care, duplicate other covered services, lack supporting clinical documentation, or are considered experimental. Monitoring for unpredictable needs, incidental household tasks as the primary purpose, or when a MedMinder/other medication system already meets needs are examples of exclusions; provider qualifications and required RN oversight apply.
Home safety and independence evaluations must be performed in the member’s own residence; assessments conducted in institutions, community centers, or other non‑residence settings are ineligible. Evaluations intended for general home improvement, convenience, or duplication of existing supports may be denied.
Assessment services are excluded when they occur outside the member’s home, are intended for general home improvement or convenience rather than health and safety, duplicate existing supports, or when a legally responsible household member can safely perform the tasks. Services already provided in the member’s setting (for example, facility‑managed safety) are also excluded.
Personal Care Services are excluded for anticipatory needs or supervision outside of ADLs/IADLs, when provided for the benefit of other household members, in institutional or group settings, when duplicative of other covered ADL-support services, before an authorized service plan exists, or when a household member can provide the IADL support. For chronic conditions, authorizations follow time limits (up to one year) and combined hours remain subject to the 84 hours/week cap.
Supportive Home Care Aide (SHCA) and similar personal support services are excluded when they duplicate other personal care supports or overlap with IADL services unless specific, documented unique needs exist. SHCA cannot be provided in Adult Day Health, Day Habilitation, group homes, or alongside other ADL assistance and will be denied if a family member or caregiver already meets the member’s needs.
Respite services are excluded when requested as relief for paid staff or substitute staffing for paid providers, or when other independent living assistance is available. Respite has an annual limit of 360 hours per member and must meet provider qualification and documentation requirements to be payable.
Supportive Day Program services are not approved for members residing in assisted living, hospital, or nursing home settings, or for members already participating in Day Habilitation/Adult Day Health. Exceptions are possible for longstanding program attendance tightly tied to the care plan and safe participation.
SHCA exclusions emphasize duplication and setting-based limits: requests that overlap existing personal care supports or other IADL services will be denied unless unique needs are documented. SHCA authorizations must comply with time standards and are subject to the combined 84 hours per week cap across related services.
Transitional assistance excludes costs not essential for a safe move (for example, rent/mortgage, food, utilities, or non‑essential household items), items already the provider’s responsibility under HCBS waivers, equipment already supplied through Assistive Technology, and requests not tied to the individualized care plan or outside the 180‑day authorization window around discharge.
Limitations and exclusions are defined at the service level and noted under each service heading. Providers must consult the specific service sections for the detailed exclusions, documentation expectations, and examples of duplications or legally responsible party responsibilities that would preclude coverage.
Routine cleaning and ongoing/regular chores are not covered under chore or homemaker benefits. Services that simply maintain household cleanliness, provide regular domestic housekeeping, or duplicate homemaker services will be denied. Combined authorization rules and the distinction between light chore, heavy chore, and homemaker tasks must be applied when reviewing requests.
Non‑necessity examples for companion services include requests for constant supervision (which indicate a higher level of care is needed), purely recreational or diversion activities, or tasks that duplicate other IADL services already in place. Companion services do not cover personal care or medication administration.
Home‑delivered meals that are non‑medically necessary include meals provided when the member does not meet the medical necessity criteria, meals that duplicate other nutrition supports, meals intended for other household members, or services used as a form of financial support. Prior authorization is required when requests exceed 7 meals per week (i.e., 8+ meals/week requires authorization).
Non‑necessity examples for home health aide requests include situations where the member’s condition is not medical/cognitive/behavioral, needs can be met in a lower level of care or different setting, the request is duplicative of other covered services, there is no supporting clinical documentation, or the required provider qualifications and RN oversight are not met.
Authorization, Documentation, and Denial Triggers
Prior authorization and in‑home face-to-face assessment required
Prior authorization is required for all services in this policy. Authorization decisions must be based on a face-to-face, in‑home evaluation conducted by a member of the Interdisciplinary Care Team and approved services must be documented in the service assessment and the member's Individualized Care Plan (ICP).
- Face-to-face, in-home evaluation required
- Assessment must be by a member of the Interdisciplinary Care Team
- Approved services documented in assessment and ICP
Care team approval and benefit limits required for comfort animals and telehealth AT
Comfort animals and telehealth assistive technology require care team approval and documented authorization; behavioral health consultation and a purchase estimate are required for comfort animals, and telehealth devices are subject to the $500 per five‑year benefit cap.
- Comfort animals: care team approval, behavioral health consultation, purchase estimate, limited to 2 animals/3 years and $600 maximum
- Telehealth AT: care team approval, device evaluation against existing technology, capped at $500 per five years
Prior authorization and detailed documentation required for home modifications
Home modification requests require prior authorization with comprehensive supporting documentation, including a physician order, a signed medical necessity letter from an in‑home PT/OT evaluation, detailed modification drawings, and a provider quote with labor breakdown and manufacturer invoice for HCPCS S5165.
- Physician order or written prescription
- Signed PT/OT medical necessity letter based on in‑home evaluation
- Comprehensive plan with detailed drawings
- Provider quote with labor breakdown and manufacturer invoice for items billed under HCPCS S5165
- Proof of ownership and signed homeowner agreement
HDM prior authorization threshold: 8+ meals/week requires PA
Home‑Delivered Meals do not require prior authorization for 7 meals per week or fewer; requests for 8 or more meals per week require prior authorization with documentation of medical necessity.
- ≤7 meals/week — no prior authorization required
- ≥8 meals/week — prior authorization required
Prior authorization required for grocery shopping and delivery
Grocery shopping and delivery services require prior authorization as a condition of coverage; services provided without prior authorization may be denied.
- Cost of groceries is not covered (only shopping/delivery)
- Providers must obtain prior authorization before providing services
Authorization timeframes and service limits (homemaker, laundry)
Authorizations must align with organizational assessment time standards; homemaker services for chronic conditions may be authorized for up to one year (acute conditions typically 3–6 months), and standard laundry authorization is one bag/week (up to 20 lbs) with limited extra allowances.
- Homemaker chronic authorization up to 1 year; acute 3–6 months
- Authorizations must follow assessment tool time standards
- Laundry: standard authorization one bag/week (up to 20 lbs); two extra bags per year allowed with documentation
Authorization criteria for medication dispensing systems (≥9 maintenance meds)
Medication dispensing systems require prior authorization documentation showing documented medication adherence issues and that the member is prescribed at least nine maintenance medications per month; the member or caregiver must be able to operate the system and it must not duplicate existing systems (e.g., MedMinder).
- Documented adherence issues due to cognitive impairment or lack of caregiver support
- ≥9 maintenance medications monthly required
- Member/caregiver capable of operating the system
- Not covered if MedMinder or adequate caregiver support exists
Prior authorization and required evidence for PCS, SHCA, and related services
Prior authorization is required for Personal Care Services (PCS), Supportive Home Care Aide (SHCA), and similar services; requests must document functional limitations, time‑for‑task for each ADL/IADL, duties, and how the member's diagnosis affects care strategies and inclusion in the ICP.
- Documentation of functional limitations and time needed per ADL/IADL (Time‑for‑Task/Functional Assessment)
- Clinician detail of SHCA duties and diagnosis‑related care strategies
- Inclusion of authorized duties/services in the member's Individualized Care Plan
Prior authorization for Supportive Day Program with documented need
Supportive Day Program requires prior authorization with documentation demonstrating the member needs a structured, non‑medical supportive environment to maintain community functioning; the member must be independent with ADLs and able to self‑administer medication.
- Documentation must show need for non‑medical structured activities to maintain functioning
- Member must be ADL‑independent per MDS and able to self‑administer medication
- Provider must obtain prior authorization before providing services
PACE interdisciplinary team authorization and product‑specific authorization rules
For PACE members, all care and services (except emergency and out‑of‑area urgent care) must be authorized by the PACE interdisciplinary team; authorization practices for other products follow Medicare/MassHealth rules and the member's benefit plan.
- PACE: interdisciplinary team authorization required for all non‑emergency care
- When Medicare NCDs/LCDs do not establish coverage, Fallon may apply internal criteria; MassHealth guidelines used where applicable
(No requirement provided in source to populate this placeholder.)
Behavioral health consult for comfort animals and chore assessment requirements
Behavioral health consultation is required to confirm benefit for comfort animals; chore service authorization must include an assessment confirming the task exceeds homemaker scope and that family/landlord responsibility has been considered.
- Behavioral health consultation to confirm benefit for comfort animals
- Comfort animal documentation must include purchase estimate and provider qualifications
- Chore services require assessment showing health/safety risk, task exceeds homemaker scope, and family/landlord are not responsible
Document consideration of lower‑cost alternatives and choose when viable
Before authorizing modifications or adaptations, less costly alternatives must be considered and documented (for example, raised toilet seat instead of new toilet, ramp instead of vertical lift).
- Document consideration of lower‑cost alternatives and favor when viable
- Examples: raised toilet seat vs new toilet; ramp vs vertical lift
Step therapy: not specified
Step therapy is not specified for these services in this section of the policy.
- No step therapy sequence described in the policy excerpt
Consider and document less costly alternatives and assistive devices before authorization
Prior to authorizing services, less costly alternatives and assistive devices (e.g., adaptive equipment) should be considered and documented in the request to demonstrate cost‑effectiveness and avoid duplication.
- Evaluate and document adaptive equipment or informal supports before authorizing services
- Demonstrate PCS/homemaker is the most cost‑effective option
Sequence for coverage determinations when Medicare guidance is absent
When Medicare NCDs/LCDs do not establish coverage, Fallon Health may apply internal coverage criteria; Fallon follows MassHealth Medical Necessity Guidelines for MassHealth members and product Evidence of Coverage governs benefit applicability.
- Apply Medicare NCDs/LCDs first for Medicare Advantage determinations
- If not established, apply MassHealth guidelines or internal criteria as described
Required documentation checklist for prior authorization
Required documentation for prior authorization includes a PCP/provider order for new services or significant changes, recent assessments (MDS/Health Risk Assessment/GSSC within 3 months), and an in‑person Functional Assessment within 3 months when assistance or supervision is needed; documentation must support requested services and hours.
- PCP/provider order required for new services or significant changes
- MDS, Health Risk Assessment, or GSSC completed within 3 months of PA request
- In‑person Functional Assessment within 3 months when assistance/supervision is needed
- Documentation must support requested services and hours
Formal diagnosis, caregiver participation, and ICP inclusion required
A formal physician diagnosis is required for Alzheimer's/Dementia Coaching; caregiver participation must be documented, and evidence of caregiver involvement and care plan inclusion (ICP) is required for services like dementia coaching and SHCA.
- Formal diagnosis of Alzheimer's or related dementia by a qualified physician for dementia coaching
- Documentation of caregiver willingness/participation
- Inclusion of services and duties in the member's ICP
Home modification documentation and provider qualifications required
Home modification documentation must include a physician order or written prescription, a signed medical necessity letter from an in‑home PT/OT evaluation, comprehensive modification drawings and provider quote, and provider qualifications and homeowner agreement with proof of ownership.
- Physician order or written prescription
- Signed PT/OT medical necessity letter from in‑home evaluation
- Detailed drawings and provider quote with labor breakdown and manufacturer invoice for HCPCS S5165
- Signed homeowner agreement and proof of ownership
Complex care training provider licensure and supervision requirements
Complex care training must be delivered by an RN or LPN under RN supervision and must comply with the Massachusetts Nurse Practice Act; the RN/LPN must hold a current, unrestricted Massachusetts nursing license and the agency must hold required licensure.
- Provided by RN or LPN under RN supervision
- Must comply with Massachusetts Nurse Practice Act
- RN/LPN must have current, unrestricted MA nursing license
- Agency must hold required license
VCAM provider certification and backup plan documentation
VCAM providers must be certified and have a documented backup plan in case of system failure to meet VCAM eligibility and support requirements.
- VCAM provider certification required
- Documented backup plan for system failure
Education program documentation and evidence‑based provider requirements
Evidence‑based education program providers must be trained in validated models, use goal‑driven measurable outcomes, align services with the member's care plan, include ongoing support and monitoring, and document review in reassessments.
- Providers trained in validated evidence‑based models
- Programs must be goal‑driven with measurable outcomes
- Services must align with ICP and be included in reassessments
- Telehealth delivery permitted when appropriate
HDM prior authorization documentation requirements (8+ meals/week)
For HDM prior authorization (8+ meals/week), document the member's diagnosis, functional limitations, barriers to food access, and evidence of three or more nutritional risk factors or lack of adequate kitchen facilities.
- Diagnosis and functional limitations
- Barriers to food access
- Evidence of three or more nutritional risk factors (e.g., low body weight, significant weight change, reduced intake)
- Lack of adequate kitchen facilities
Time‑for‑Task/functional assessment and OT documentation required for home health aide and safety evaluations
Home health aide and home safety evaluations require a clinical functional assessment (Time‑for‑Task Tool or Functional Assessment within 6 months), a Fallon Service Plan, RN/LPN‑developed Plan of Care, and OT documentation tying observed risks to recommended interventions.
- Time‑for‑Task Tool or Functional Assessment within 6 months
- Fallon Service Plan and RN/LPN Plan of Care from the home health agency
- OT documentation of observed risks and recommended interventions tied to care plan goals
Document changes in condition, ADL/IADL impact, and time‑for‑task in authorization requests
Authorization requests must document any change in medical condition or living situation, the impact on ADL/IADL performance, whether the change is temporary or permanent, and specify the time needed for each ADL/IADL to justify the requested services.
- Document change in medical condition or living situation and impact on ADL/IADL performance
- Indicate whether change is temporary or permanent
- Specify time needed for each ADL/IADL to support duration and hours requested
- Demonstrate that services are necessary and cost‑effective
Provide proof of provider licensure and qualifications with PA requests
Providers must be appropriately licensed and qualified; prior authorization documentation must include proof of provider qualifications (e.g., Home Health Agency license under 130 CMR 403.000, OT credentials, orientation & mobility degrees/certificates) as applicable.
- Home Health Agency license under 130 CMR 403.000 where applicable
- Licensed OT or certified OT assistant documentation
- Orientation & Mobility provider academic/certification credentials
Documentation standards for Personal Care Services (PCS)
Personal Care Services documentation must show how the member's condition limits ADLs and IADLs, specify the need for prompting/supervision or hands‑on help with at least one ADL, demonstrate impact on at least two IADLs, and identify time needed for each task.
- Show limitations in ADLs and IADLs caused by the member's condition
- Specify need for prompting/supervision or hands‑on help with at least one ADL
- Demonstrate impact on at least two IADLs
- Identify time needed for each ADL/IADL
SHCA duties and transitional assistance documentation and timing requirements
For SHCA and Transitional services, clinicians must detail SHCA duties, explain how diagnosis affects care needs and strategies, include SHCA tasks in the individualized care plan, and ensure transitional expenses are authorized in the ICP and incurred within the 180‑day discharge window.
- Clinician description of SHCA duties and diagnosis‑linked care strategies
- Inclusion of SHCA tasks in ICP
- Transitional expenses must be authorized in ICP and incurred within 180 days of discharge
Coding informational note: codes do not imply coverage
Codes listed in the policy are for informational purposes only; inclusion does not constitute or imply coverage — providers must follow plan‑specific coverage and billing rules and submit appropriate documentation per the product Evidence of Coverage.
- Codes are informational only and do not guarantee coverage
- Follow the member's benefit plan/Evidence of Coverage for coverage and billing rules
Common denial triggers: missing documentation, duplication, or ineligible setting
Denial may be triggered by failure to submit required documentation (provider order, recent assessments), provision of duplicate services, or provision of services while the member is admitted to a licensed medical facility; requests may also be denied when a legally responsible household member can perform the task or when services duplicate existing supports.
- Missing PCP/provider order, MDS/HRA/GSSC or in‑person Functional Assessment within required timeframes may trigger denial
- Duplicate services or services provided while member is ineligible setting may be denied
- Services performable by a legally responsible household member risk denial
Denial risks: missing diagnosis, exceeded benefit limits, or unqualified providers
Services will not be approved if the member lacks a physician‑documented diagnosis where required (e.g., Alzheimer's/dementia coaching), if comfort animal or telehealth AT requests exceed coverage limits, or if the provider does not meet specified qualifications.
- Physician‑documented diagnosis required for dementia coaching
- Comfort animal limits ($600/3 years) and documentation requirements must be met
- Telehealth AT limited to $500 every five years and evaluated against existing devices
- Provider must meet service‑specific qualifications
Companion services denial triggers: duplication, recreational use, or constant supervision needs
Companion services may be denied when they duplicate other IADL support services, are purely recreational/diversional, are provided alongside excluded facility services, or when the member requires constant supervision (in which case alternative settings should be considered).
- No personal care or medication administration included in companion services
- Companion services inappropriate if member needs constant supervision
- Coverage denied when service is purely recreational or duplicates other IADL supports
Complex Care Training denial triggers: licensure and supervision deficiencies
Complex care training will be denied if delivered by an unlicensed home health agency, not provided by an RN or LPN under RN supervision, or if the RN/LPN lacks a current, unrestricted Massachusetts nursing license.
- Agency must hold required license
- RN/LPN must provide care under RN supervision and hold current, unrestricted MA license
ET/CPERS & VCAM denial triggers: inability to use, existing monitoring, or low risk
Emergency response devices (ET/CPERS & VCAM) will be denied if the member cannot use the device independently or does not understand safe use, lives in a facility with 24‑hour monitoring, already has a working device of the same type, or lacks significant risk of falls or medical emergencies.
- Member must be able to use device independently and understand its use
- Not covered if member resides in facility providing 24‑hour monitoring
- Not covered if an equivalent working device is already in place
- Member must have significant risk of falls/medical emergencies
Home modification denial triggers: non‑medical improvements, landlord responsibility, or cost‑ineffective requests
Home modification requests may be denied if the request is for general home improvements, landlord/third‑party responsibility, if less expensive alternatives exist, if modifications are not in the care plan, or if requested for group/provider‑owned settings or maintenance/repairs.
- Requests for general improvements, maintenance, or landlord responsibility will be denied
- Less expensive alternatives must be considered prior to approval
- Modifications not included in the approved Home Modification Plan are not covered
Education program denial triggers: non‑evidence‑based or duplicative programs
Education programs will be denied if they are not based on validated, peer‑reviewed research, lack a structured curriculum, or duplicate education the member already receives through another service.
- Providers must use validated evidence‑based models
- Programs duplicative of other education will be denied
Grocery shopping and delivery denial triggers
Grocery shopping and delivery services are subject to denial if provided without prior authorization, if they duplicate other supports, or if a legally responsible relative or spouse can perform the task.
- Provider must have obtained prior authorization
- Service duplicates or can be provided by a legally responsible person — risk of denial
- Cost of groceries not covered
Home‑Delivered Meals denial triggers: lack of medical necessity or duplication
Home‑Delivered Meals will not be paid if the member does not meet medical necessity criteria, if the service duplicates other nutrition supports, if meals are provided by a facility, intended for other household members, or if the member has access to community meal resources.
- Member must meet medical necessity criteria for HDM
- Meals provided by facility or intended for other household members not covered
- Duplication with other nutrition supports or community resources will result in denial
Home Health Aide denial triggers: duplication, non‑medical conditions, or missing clinical support
Home health aide services will be denied if the service duplicates care provided in other settings, the member's condition is not medical/cognitive/behavioral, the needs can be met in a lower level of care, or if there is no supporting clinical documentation or treatment plan.
- Not approved when duplicative of other settings or supports
- Member condition must be medical/cognitive/behavioral to qualify
- Supporting clinical documentation and Plan of Care required
Home safety evaluation denial triggers: assessments outside residence or for general improvement
Home safety/independence evaluations must occur in the member's residence; assessments performed outside the residence (institutions or community centers), or intended for general home improvement/convenience, duplicative of existing supports, or where a legally responsible household member can perform the tasks, are not eligible and may be denied.
- Evaluations must take place in the member's own residence
- Assessments outside the residence are not eligible
- Coverage denied for evaluations intended for general home improvement or duplicative supports
Assessment location restriction: in‑residence required
Assessments performed outside the member's residence (e.g., in institutions or community centers) are specifically not eligible and may be denied.
- Ineligible settings include institutions and community centers
- Assessments must be performed in the member's residence
Denial risk for duplication, household‑responsibility, or existing supports
Requests may be denied if services duplicate existing supports, a legally responsible household member can perform tasks, the member already receives similar services (e.g., MedMinder), or the service is otherwise inappropriate, unsafe, or unnecessary.
- Duplicate services or services performable by household member risk denial
- Existing similar services (e.g., MedMinder) preclude coverage for duplicative equipment
- Requests must demonstrate necessity and safety
Denial triggers: anticipatory or household‑benefit services and ineligible settings
Requests may be denied when services are anticipatory, for the benefit of other household members, delivered in institutional/group settings, or provided before a service plan is authorized.
- Anticipatory services or those benefiting other household members are not covered
- Not covered before development/authorization of a service plan
- Not covered in institutional or group settings
SHCA denial triggers: duplication, overlap, or family already meeting needs
SHCA requests may be denied if they duplicate other personal care supports or overlap with other IADL supports (unless unique needs are documented), if provided in excluded settings, or if a family/caregiver already meets the member's needs.
- SHCA cannot duplicate PCA, personal care, AFC, group AFC, assisted living, home health aide, or another SHCA service
- Not authorized if family/caregiver already meets needs or in excluded settings
PACE authorization requirement and denial risk if not authorized
Services not authorized by the PACE interdisciplinary team (except emergency care and out‑of‑area urgently needed care) risk denial for PACE members.
- PACE members: interdisciplinary team must authorize services (except emergencies and out‑of‑area urgent care)
- Failure to obtain team authorization risks denial
Codes, Limits, and Quantitative Rules
| S5165 | HCPCS code referenced for manufacturer invoice for items billed under home modifications |
| S5120 | Light Chore Services; per 15 minutes |
| S5121 | Heavy Chore Services; per diem; Grocery Shopping and Delivery (Chore Services uses same code) |
| S5135 | Companion care for adults, per 15 minutes |
| S5136 | Companion care for adults, per-diem |
| S5165 | Home modifications, per service |
| G0156 | Services of home health/hospice aide in home health or hospice settings, each 15 minutes |
| G0156 UD | minutes Services of home health aide in the home health setting for ADL support |
| G0493 | Skilled services of a registered nurse (RN) for the observation and assessment of the patient's condition provided every 60 days |
| S5130 | services for ADL support Homemaker service, NOS; per 15 minutes |
| S5131 | Homemaker service, NOS; per diem |
| T1004 | Attendant care services; per diem |
| G0299 | Direct skilled nursing services of registered nurse (RN) in the home health or hospice setting, each 15 minutes (use for Complex) |
| G0300 | Direct skilled nursing services of a licensed practical nurse (LPN) in the home health setting |
| G0299 UD | Direct skilled nursing services of a registered nurse (RN) in the home health setting (31+ calendar days) |
| G0300 UD | Direct skilled nursing services of a licensed practical nurse (LPN) in the home health setting (31+ calendar days) |
| T1502 | Administration of oral, intramuscular, and/or subcutaneous medication by health care agency/professional per visit (RN or LPN) |
| T1503 | Administration of medication other than oral, intramuscular, and/or subcutaneous medication by health care agency/professional per visit (RN or LPN) |
| G0151 | Services performed by a qualified physical therapist in the home health setting |
| G0152 | Services performed by a qualified occupational therapist in the home health setting |
| G0153 | Service performed by a qualified speech/language pathologist in the home |
| T2038 | Transitional Assistance Respite Services |
| H0045 | Transitional Assistance Respite Services (listed alongside T2038) |
| S9125 | Respite care services provided outside of the home, on a per diem |
| S5150 | Unskilled respite care, not hospice, per 15 minutes |
| S5151 | Unskilled respite care, not hospice; per minutes |
| T1005 | Respite care services, up to 15 minutes |
| T2025 | Waiver Services; not otherwise specified (use for Evidence Based Education) |
| H2021 | Community-based wrap around services; per 15 minutes (orientation and mobility services) |
| S5111 | Home care training, family; per session- Alzheimer's/Dementia Coaching |
| S5160 | Cellular Network Emergency Response System; installation and testing |
Key Terms and Service Definitions
Policy Scope and Intent
This policy governs Fallon Community Health Plan’s coverage of community‑based long‑term services and supports (LTSS) intended to help members with functional, cognitive, or physical limitations remain safely in the community. Covered services span habilitation therapies, assistive technology, personal care, homemaker and chore services, home modifications, and transitional supports; all services require interdisciplinary assessment, individualized care planning, and prior authorization with documentation to demonstrate medical necessity.
Document Revision History
Policy effective date for the Community-Based LTSS Services Clinical Coverage Criteria.
Policy last reviewed on 2025-10-21.
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