CurrentMass General Brigham Health PlanPolicy N/A

Adult Foster Care (AFC) — Coverage Criteria

Defines medical necessity criteria, exclusions, and authorization requirements Mass General Brigham Health Plan uses to determine coverage of adult foster care for plan members, with specific variations for One Care and SCO members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyAdult Foster Care (AFC) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain and maintain clinical documentation and a plan of care to support eligibility and prior authorization for AFC services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

One Care & SCOPlans with explicit AFC eligibility criteria

Multiple rulesAuthorization varies by product

2 codesInformational codes

6 activitiesADL/IADL definitions

Coverage criteria for Adult Foster Care (AFC)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

OneCare_SCO_Eligibility: A representative from the member's Individualized Care Team ordered AFC; AND the member has a medical or mental condition that requires daily hands-on (physical) assistance or cueing and supervision throughout the entire activity for the member to successfully complete at least one activity of daily living.at least one ADL requires full hands-on assistance or continuous cueing/supervision

Applies to One Care and SCO members only

Coverage for Adult Foster Care (AFC) is not provided when the member does not meet the policy’s eligibility requirements. Specific exclusionary situations include when the member is currently receiving home health aide services from a home health agency or other personal care services, when required clinical documentation (including assessments and the plan of care) is missing, insufficient, or inconsistent, for days of service without prior authorization, when the member is an inpatient or resident of another licensed residential facility (except allowable MLOA days), and when the member does not reside in a qualified setting with a qualified AFC caregiver (except for defined Alternative Caregiver or NMLOA days).

Provision of AFC will be denied as not medically necessary when the documentation needed to show that the member meets eligibility or ongoing need is missing, insufficient, or inconsistent. The policy requires clinical documentation, including assessments and a plan of care, to support the need for initiation or continuation of AFC; absence or inadequacy of these records is a valid rationale for denial.

Coding and Eligibility Details

Informational codesHCPCS

S5140	Foster care, adult; per diem.
T1028	Assessment of home, physical, and family environment; to determine suitability to meet patient's medical needs.

Eligibility requirement

Eligibility requirementMember must require daily hands-on (physical) assistance or cueing and supervision throughout the entire activity to successfully complete at least one activity of daily living (applies to One Care and SCO members only).

Ordering requirementA representative from the member's Individualized Care Team must order adult foster care (AFC).

Applicable plansOne Care and SCO members only as specified in policy.

Provider requirements, authorizations, and denial triggers

Prior Authorization

Prior Authorization Required

Authorization requirements vary by product. Some products require prior authorization; services for which the AFC provider has not received prior authorization may be denied.

Authorization Required: One Care; Senior Care Options (SCO).
Not Covered: Commercial and Qualified Health Plans; Mass General Brigham ACO; Medicare Advantage.

Step Therapy

Step therapy

Step therapy requirements are not specified for Adult Foster Care in this policy. Check product-specific guides for any step therapy or sequencing rules.

Documentation Required

Required documentation

Clinical documentation is required to support the need for, or continuation of, Adult Foster Care (AFC). Insufficient, missing, or inconsistent documentation may result in denial or delay of services.

Required documentation includes comprehensive clinical assessments and an individualized plan of care.
Documentation must demonstrate eligibility criteria are met and justify the level of services requested.
Providers should supply prior authorization documentation when applicable and retain records for audit.

Denial Risk

Triggers for denial

Services may be denied when the member does not meet eligibility criteria or when exclusion conditions apply. Common denial triggers include concurrent personal care/home health aide services, inpatient/resident status in other licensed facilities, lack of a qualified AFC caregiver, and unauthorized days of service.

Member does not meet eligibility criteria.
Member is receiving any home health aide services from a home health agency or any other personal care services.
Clinical documentation (assessments and plan of care) is missing, insufficient, or inconsistent.
Days of service for which the AFC provider has not received prior authorization.
Member is an inpatient or resident of a hospital, nursing facility (except Medical Leave of Absence days), rest home, intermediate care facility for individuals with intellectual or developmental disability, assisted living residence, or any other residential facility subject to state licensure or certification.
Member does not live in a qualified setting with a qualified AFC caregiver (except for Alternative Caregiver days or Non-Medical Leave of Absence days).

Background on Adult Foster Care

Adult Foster Care provides daily hands-on assistance, cueing, and supervision to support members who cannot complete at least one activity of daily living independently. The service is intended to meet ongoing functional needs such as bathing, dressing, toileting, transferring, mobility, or eating by providing continuous cueing/supervision or hands‑on physical assistance throughout the activity.

Definitions of Activities of Daily Living (ADLs)

Bathing — Definition and qualification

DefinitionBathing: a full-body bath or shower (front, back, upper, lower) or a partial (sponge) bath and peri-area; may include personal hygiene such as hair care, oral/denture care, shaving, and applying makeup.

Qualification for AFCNeed for support with a full-body bath/shower or partial (sponge) bath alone meets clinical eligibility for AFC.

Personal hygiene onlyNeed for support with personal hygiene alone does not meet clinical eligibility for AFC.

Dressing — Definition and qualification

DefinitionDressing: assistance with both upper- and lower-body items of clothing, including street clothes and undergarments.

Non-qualifying needSupport only with shoes/socks, buttons, snaps, or zippers does not qualify for AFC dressing assistance.

Level II dressingDeemed Level II when member requires hands-on assistance with lower-body dressing and cueing/supervision throughout the entire activity for upper-body dressing, or vice versa.

Toileting — Definition and qualification

DefinitionToileting: includes incontinence (bladder and/or bowel), routine catheter or colostomy/urostomy care, cueing/supervision, or physical assistance with toileting and cleansing after elimination.

Scheduled toiletingNeed for scheduled toileting care to prevent incontinence qualifies as toileting support for AFC.

Non-qualifying tranfer-onlySupport only with transferring on/off the commode does not qualify as toileting; that is classified as transferring only.

Transferring — Definition

DefinitionTransferring: member must need assistance or must be lifted to move from one position to another (e.g., from wheelchair to commode).

ExamplesIncludes assistance to move between positions such as bed, chair, wheelchair, commode, or toilet.

DistinctionIf need is transfer-only (e.g., on/off commode) it is transferring rather than toileting.

Mobility — Ambulation and wheelchair criteria

DefinitionMobility (ambulation): member must be physically steadied, assisted, or guided during ambulation, or unable to self-propel a wheelchair appropriately without another person's assistance in all environments (indoors and outdoors).

Level II mobilityDeemed Level II when member requires hands-on physical assistance with ambulation outdoors and cueing/supervision indoors, or vice versa.

Wheelchair self-propulsionInability to self-propel appropriately without assistance qualifies as a mobility support need.

Eating — Supervision and feeding criteria

DefinitionEating: member requires constant supervision and cueing during the entire meal or needs physical assistance (fed) for all or a portion of the meal.

Cognitive impairment exampleMembers physically capable of eating but who need constant cueing/supervision due to cognitive impairment are deemed to require assistance with eating.

Non-qualifying needsHelp only with cutting food or meal setup does not qualify as assistance with eating.

Admission criteria for Adult Foster Home placement

Adult Foster Home — Admission criteria

Admission criteria for Adult Foster Home:

AFC_Admission: A representative from the member's Individualized Care Team orders AFC AND the member requires daily hands-on assistance or continuous cueing and supervision with at least one activity of daily living (bathing, dressing, toileting, transferring, mobility, or eating).at least one ADL requires hands-on assistance or continuous cueing/supervision

Applies to One Care and SCO members per policy

Continued stay / ongoing authorization criteria

Adult Foster Home — Continued stay criteria

Continued stay criteria for Adult Foster Home:

AFC_ContinuedStay: Ongoing clinical documentation, including assessments and a plan of care, that supports the continued need for AFC; absence, insufficiency, or inconsistency of required documentation can result in denial.documented plan of care present and supports ongoing need

Clinical documentation required for continued coverage

Discharge criteria

Discharge from an Adult Foster Home is appropriate when the member no longer meets the policy’s AFC eligibility criteria, when clinical documentation (including assessments and plan of care) no longer supports ongoing need, when the member becomes an inpatient or resident of another licensed facility (except allowable MLOA/NMLOA/Alternative Caregiver days), or when other exclusions in the policy apply (for example, if the member begins receiving home health aide or other personal care services).

Day limits and excluded days

Adult Foster Home — Day limits and exclusions

Day limitsDays of service for which the AFC provider has not received prior authorization are excluded from coverage.

Documentation requirementServices without required clinical documentation or plan of care may be excluded or denied.

Inpatient/resident exclusionsDays when the member is an inpatient or resident of another licensed facility (except allowable MLOA days) are excluded.