CurrentMass General Brigham Health PlanPolicy 107

Transitional Assistance Services (SCO)

Defines medical necessity and coverage criteria for transitional assistance services for Mass General Brigham Health Plan members, specifically governing Senior Care Options (SCO) members; notes noncoverage for other product lines.

Policy Summary

PayerMass General Brigham Health Plan

PolicyTransitional Assistance Services (SCO)

Policy CodePolicy 107

Change TypeReformattedclarified SCO-only benefit

Effective DateJan 1, 2026

Next Review Date

Key ActionObtain prior authorization for SCO members; services are authorized for up to 6 months when criteria are met.

SourceLink

POLICY UPDATE CHANGES

Reformatted policy and added paragraph clarifying creation of criteria; clarified that this is a SCO only benefit.

Updated list of related policies.

SCO onlyBenefit limited to

6 monthsMax authorization

180 daysExpense timing window

T2038Informational code

Coverage Criteria — SCO Transitional Assistance

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SCO Transitional Assistance Eligibility

Covered when ALL of the following are met

SCO eligibility: Member is a Senior Care Options (SCO) member; service is non-recurring setup expense for the member's primary residence; the member would otherwise be responsible for these expenses; services are authorized for up to 6 months.

Reference policy overview and SCO section.

Clinical and assessment requirements: 1) Member has a documented medical, cognitive, or physical condition that impairs ability to undertake tasks to increase independence; 2) Comprehensive in‑home assessment completed within the past year; 3) Member needs assistance with two or more Instrumental Activities of Daily Living (IADLs); 4) Requested service is included in the member's individualized plan of care.

From SCO criteria items 1–4.

Discharge and transition requirements: Member is currently in a nursing facility, hospital, or other provider‑operated living arrangement and will be discharged to a community living arrangement; member needs support with at least one enumerated transition task required for safe transition (a–i); expenses were incurred during the 180 days prior to discharge or during establishment of the living arrangement.180 days

From SCO criteria items 5–6 and 8.

Support and contracting: No available support or person residing in the home who can be responsible for these expenses; the organization providing services is under contract with the Massachusetts Rehabilitation Commission or the Department of Developmental Services in accordance with their standards and requirements.

From SCO criteria items 7 and 9.

Covered items are one-time, non-recurring setup expenses that are necessary for a safe transition from an institutional or provider-operated living arrangement to community living, such as expenses to establish a primary residence, obtain essential furnishings, set up utilities, or moving support when these are directly required for the member’s safe discharge and are included in the individualized plan of care. Requests are only considered when they meet all eligibility criteria and documentation requirements (see policy coverage criteria).

Not covered are routine ongoing obligations and non-essential items. Specifically excluded are: monthly rent or mortgage payments, food, regular utility payments, items that are purely for diversion or recreation, and any services that are not necessary for the member’s safe transition. Also excluded are requests for home accessibility adaptations made outside the 180 days prior to discharge, services that began before the member’s service plan was developed, services provided to someone other than the eligible member, duplicative services paid by MassHealth or a third party, and requests where the member has already reached their maximum allowable hours without approved additional hours.

This service is not covered for the following product lines: Medicare Advantage, Mass General Brigham ACO, One Care, and Commercial and Qualified Health Plans. For members in these product lines, requests will be denied as not covered under this policy.

Additional circumstances that will result in exclusion or denial are listed in the policy: services that began before the member’s service plan was developed; services provided to an individual other than the eligible member; duplicative services covered by MassHealth or a third party; and situations where the member has reached the maximum allowable hours for the requested service without approval.

Coding and Authorization Details

Informational codeHCPCS

T2038

Community transition waiver; per service

Authorization duration — up to 6 months

Authorization durationServices authorized for up to 6 months when criteria are met

ScopeApplies to Senior Care Options (SCO) members only

BasisPrior authorization is required for SCO members (see coding and prior auth requirements)

IADL requirement — needs assistance with two or more IADLs

IADL assistance requirementMember needs assistance with two or more Instrumental Activities of Daily Living (IADLs)

Assessment timingAssistance requirement must be documented via a comprehensive in‑home assessment completed within the past year

Inclusion in planRequested service must be included in the member's individualized plan of care

Expense timing — incurred during 180 days prior to discharge or during establishment of living arrangement

Eligible expense windowExpenses must be incurred during the 180 days prior to discharge or during establishment of the living arrangement

Triggering settingMember must be transitioning from a nursing facility, hospital, or other provider‑operated living arrangement to community living

Examples of covered transition tasksCovered tasks include paying deposits, acquiring essential furnishings, arranging moves, setting up utilities, pest extermination/one‑time cleaning, and home accessibility adaptations

Provider Actions, Documentation, and Authorization

Prior Authorization

Prior Authorization Required (SCO)

Prior authorization is required for SCO members; services are authorized for up to 6 months when criteria are met.

Applies to Senior Care Options (SCO) members only
Services authorized for up to 6 months when criteria are met

Step Therapy

No Step Therapy Specified

No step therapy requirements apply for this service.

Documentation Required

Documentation Requirements

Provider must document a comprehensive in-home assessment completed within the past year and include the requested service in the member's individualized plan of care.

Comprehensive in-home assessment within the past 12 months required
Requested service must be included in the member's individualized plan of care

Denial Risk

Exclusion / Denial Triggers

Requests will be excluded or denied if any of the following apply: services began before the member's service plan was developed; services are provided to someone other than the eligible member; member does not meet all eligibility criteria; services are duplicative of those paid by MassHealth or a third-party; member has reached maximum allowable hours without approved additional hours; or exclusions listed in policy apply (e.g., monthly rent/mortgage, food, regular utility payments, purely recreational items).

Services that began before the member's service plan was developed
Services provided to an individual other than the eligible member
Member does not meet all eligibility criteria
Duplicative services already paid for by MassHealth or a third party
Member has reached maximum allowable hours for the requested service without approved additional hours
Exclusions include: monthly rent or mortgage payments; food; regular utility payments; items purely for diversion or recreation; services not necessary for safe transition; transitional assistance requests for home accessibility adaptations made outside 180 days prior to discharge

Denial Risk

Product-Line Exclusions

This service is not a covered benefit for Medicare Advantage, Mass General Brigham ACO, One Care, Commercial, or Qualified Health Plan (QHP) members.

Not covered for Medicare Advantage members
Not covered for Mass General Brigham ACO members
Not covered for One Care members
Not covered for Commercial members
Not covered for Qualified Health Plan (QHP) members

OpenPayer

Transitional Assistance Services (SCO)

Coverage Criteria — SCO Transitional Assistance

Coding and Authorization Details

Provider Actions, Documentation, and Authorization

Key Definitions

Background

Revision History and Policy Changes