Adult Foster Care (AFC) payment and coverage policy
Customize your policy alerts
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.
Monitor payer policy activity
Governs eligibility, prior authorization, billing, and reimbursement for Adult Foster Care services for NaviCare HMO SNP members living in qualified AFC settings; outlines service definitions, visit requirements, leave/alternative caregiver rules, and telehealth allowances per MassHealth guidance.
Added a new section summarizing Scope of Adult Foster Care (AFC) Services and incorporated guidance from MassHealth Adult Foster Care Bulletin 34 on admission and monthly visit requirements.
Added reimbursement sections for Intake and Assessment Services and clarified AFC Level I and Level II service payments.
Clarified reimbursement for Medical Leave of Absence (MLOA), Nonmedical Leave of Absence (NMLOA), and Alternative-Caregiver Days including annual day limits and portability between providers.
Added telehealth guidance permitting limited telehealth use under extraordinary circumstances per MassHealth Bulletin 34, with documentation and time limits.
Adult Foster Care (AFC) Coverage Criteria
AFC coverage criteria and rules
Conditions required for Plan reimbursement of AFC per diem:
ALL of the following
ALL of the following
- Member must be eligible under 130 CMR 408.403 (member deemed nursing-home certifiable and eligibility determined by the NaviCare Nurse Case Manager).
- Member must meet clinical eligibility criteria for AFC in accordance with 130 CMR 408.416.
ALL of the following
- AFC Provider must have obtained prior authorization for AFC in accordance with 130 CMR 408.417 before billing for AFC per diem; failure to obtain prior authorization renders days non-reimbursable.
- Payment to an AFC Provider ends when the member no longer meets clinical criteria, is no longer receiving AFC, or no prior authorization is in effect.
ALL of the following
- Member must reside in an AFC-qualified setting that meets the requirements of 130 CMR 408.435.
- AFC Provider is responsible for compliance with the MassHealth AFC Manual (130 CMR 408.000) and related guidance, and must bill at the payment level authorized by the Plan (Level I or Level II).
ALL of the following
- An AFC Provider may not bill for non-service days; the Plan does not pay for any day on which an eligible member does not receive AFC except for authorized MLOA or NMLOA days.
- The Plan will pay only one AFC provider per day for provision of AFC to a member.
ALL of the following
ALL of the following
- Medical Leave of Absence (MLOA) reimbursed up to 40 days per calendar year; Nonmedical Leave of Absence (NMLOA) reimbursed up to 15 days per calendar year; unused leave days follow the member between providers.
- Up to 14 alternative-caregiver days per member per calendar year; Plan reimburses both primary and alternative per diem for the same date up to the limit.
ALL of the following
- Telehealth permitted only for visits/services that can be delivered via telehealth under extraordinary circumstances; telehealth cannot be used for direct caregiver assistance with ADLs/IADLs.
- AFC Program Director must document the extraordinary circumstance, timeframe, permitted visit types, and tailoring; if telehealth use extends beyond three months the AFC provider must contact the Plan for approval and provide a deadline for conclusion.
ALL of the following
- Initial admission visit must be by RN, LPN, or care manager; if RN/LPN do not make the initial visit, RN/LPN must do so within the first five working days.
- RN/LPN must conduct on-site visits every other month alternating with care manager visits as determined by the multidisciplinary team; community support specialist may conduct up to three nonconsecutive on-site visits per year.
Service Codes and Limits
| S5140 | Foster care, adult; per diem (AFC Level I) |
| S5140 | Foster care, adult; per diem (AFC Level II) |
| S5140 | Foster care, adult; per diem (AFC Level I alternativecaregiver day) |
| S5140 | Foster care, adult; per diem (AFC Level II alternative caregiver Day) |
| S5140 | Foster care, adult: per diem (AFC Level I MLOA day) |
| S5140 | Foster care, adult: per diem (AFC Level II MLOA day) |
| S5140 | Foster care, adult: per diem (AFC Level I NMLOA day) |
| S5140 | Foster care, adult: per diem (AFC Level II NMLOA day) |
| T1028 | Assessment of home, physical, and family environment, to determine suitability to meet patient's medical needs (adult foster care intake and assessment services rate; one- time payment per member per provider) |
Provider Requirements, Prior Auth, and Telehealth
Obtain prior authorization for all AFC services and intake/assessment
Prior authorization is required from the Plan before delivering any AFC services, including intake and assessment; prior authorization determines medical necessity and the authorized payment level (Level I or Level II). When a member changes AFC providers, the new provider must obtain prior authorization for the required new assessment; intake and assessment are reimbursable only once per member per AFC provider.
- Obtain prior authorization from the Plan before providing any AFC services.
- Secure prior authorization and NaviCare Care Team approval prior to performing intake and assessment.
- If a member changes providers, perform a new assessment and obtain prior authorization before admission and billing.
Risk of denied payment for non‑authorized days; one provider paid per day
Failure to obtain prior authorization renders days non-reimbursable; the Plan will pay only one AFC provider per day for provision of AFC to a member.
- Do not expect payment for AFC days provided without prior authorization.
- Ensure discharge by the previous AFC provider only after the new provider has obtained prior authorization and the member is admitted; otherwise only one provider may be paid per day.
Obtain Plan approval and document telehealth if use exceeds 3 months
Telehealth may be used only under extraordinary circumstances and must be documented by the AFC Program Director; if telehealth use for extraordinary circumstances extends beyond three months, the AFC provider must contact the Plan for approval and provide a deadline for conclusion.
- Document the extraordinary circumstance, timeframe, permitted visit types for telehealth, and how telehealth is narrowly tailored; make documentation available to the Plan.
- Record each telehealth visit in the member’s record.
- Contact the Plan for approval and provide a conclusion deadline if telehealth use will extend beyond three months.
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.