Mass General Brigham LTSS Coverage & Prior Auth

Coverage Criteria

General Eligibility

Covered when ALL of the following general eligibility criteria are met (applies to services unless otherwise stated):

General eligibility: 1. The member has a documented medical, cognitive, or physical condition that impairs their ability to undertake activities of daily living (ADLs), instrumental activities of daily living (IADLs), or other tasks independently; 2. The member has completed a comprehensive in-home assessment within 90 days of requesting the service; 3. The member needs assistance with two or more IADLs; 4. The requested service is included in the member's individualized plan of care.

Chore Services

Chore services are covered when ALL of the following are met (one-time basis; authorized up to 6 months):

Chore eligibility: 1. An unusual household task is required to make the member's home clean, sanitary, and safe or to permit safe ingress/egress (examples: moving furniture, remediating severely unsanitary conditions, minor home maintenance, preparing for pest extermination); 2. The member does not have a spouse or legally responsible individual residing in the home who can perform the necessary tasks; 3. The tasks are not the responsibility of the member's property management, housing authority, homeowners' association, or landlord (housing agreement examined for rentals); 4. The number of hours approved is appropriate for the task(s) required and does not exceed 20 hours per authorization.

Companion Services

Companion services are covered when ALL of the following are met (authorized up to 6 months):

Companion eligibility: 1. The member's individualized plan of care includes specific therapeutic goals for which the companion is provided (e.g., assistance with or supervision of ADLs, IADLs, or other tasks necessary for independent living); 2. A skilled therapist or clinician has determined the member cannot complete ADLs, IADLs, or other tasks without supervision or assistance of a companion; 3. Documentation supports the hours requested.

Complex Care Training and Oversight

Complex Care Training and Oversight covered when medical necessity is determined using InterQual 'Home Care Services, Adult' subset:

Complex Care Training: Service performed by a skilled nurse that includes medication management, filling medication cassettes, and development/ongoing management and evaluation of the member's Home Health Aide Plan of Care to monitor underlying conditions and ensure unskilled care is addressing the member's needs. Medical necessity is determined using the InterQual 'Home Care Services, Adult' subset.

Grocery Services

Grocery services are covered when ALL of the following are met (authorized up to 6 months):

Grocery eligibility: 1. The member is homebound due to their documented medical, cognitive, or physical condition, or requires assistance with IADLs such as meal preparation, laundry, or light housework; 2. The member does not have a spouse or other legally responsible adult who can assist with shopping for groceries; 3. The member must utilize the grocery store linked to the contracted grocery shopping service and may not have access to their preferred stores.

Home Delivered Meals and Medically Tailored Meals

Home delivered meals and medically tailored meals coverage logic:

Standard meals eligibility: Member meets general eligibility AND either A or B: A) No access to adequate kitchen facilities; OR B) Unable to prepare own meals due to documented condition and no spouse/responsible adult to assist. Eligible up to 14 home delivered meals per week; services authorized up to 1 year.

Increased meals for malnutrition: Member meets general eligibility AND (A or B) AND C, where C = GLIM malnutrition criteria (both 1 and 2 as defined). Eligible up to 21 home delivered meals per week. Services authorized up to 1 year for chronic/irreversible conditions or up to 3 months for acute conditions.

Medically tailored meals: Member meets general eligibility AND (A or B) AND D, where D requires an advanced chronic disease/condition with specific nutritional requirements AND a specific therapeutic diet recommended by a nutritionist, PCP, or other clinician. Services authorized up to 1 year. When access to other community nutrition resources exists, the number of meals must be adjusted accordingly.

Homemaker Services

Homemaker services are covered when ALL of the following are met (authorized up to one year):

Homemaker eligibility: 1. The member does not have support or someone residing in the home who can undertake or is responsible for housekeeping duties (including meal preparation, grocery shopping, laundry, and light housekeeping of primary living areas); 2. The service is provided in accordance with the member's goals in their individualized care plan; 3. The member will be present in the home while services are delivered; 4. The service supports the member's health and ability to maintain integrated community living; 5. No assistive/adaptive device or home modification would allow the member to perform these services independently; 6. Documentation supports the hours requested.

Laundry Services

Laundry services are covered when ALL of the following are met (authorized up to six months):

Laundry eligibility: 1. The member has a documented medical, cognitive, or physical condition that impairs their ability to do their own laundry; 2. The member does not have support or someone residing in the home who can do the laundry; 3. If the member requires more frequent services or more than one bag/20 pounds, documentation must support the request. Laundry services are provided once per week for one bag up to 20 pounds.

Respite Services

Respite services are covered when ALL of the following are met (authorized up to one year):

Respite eligibility: 1. The member does not have support or someone residing in the home who can temporarily relieve their regular non-paid caregiver; 2. Respite services will be provided by a qualified individual or organization that meets 130 CMR 630.000, provides waiver services to participants, and has a signed provider agreement; 3. The respite provider meets Massachusetts Rehabilitation Commission (MRC) and site-based requirements (licensed hospital, certified assisted living, licensed nursing facility, licensed respite care facility, licensed rest home, enrolled adult foster care provider, or meets DDS 115 CMR 7.00 site-based requirements); 4. Comprehensive in-home assessment requirement is within the past year (exception noted). Services authorized up to one year.

Respite Services (Covered when all criteria met)

Respite services are covered when ALL of the following are met:

Respite eligibility: (1) Member requires assistance with activities related to independent living and non-paid caregiver requires temporary relief; (2) No support or someone residing in the home who can temporarily relieve the regular non-paid caregiver; (3) Respite services provided by a qualified individual or organization meeting 130 CMR 630.000 and having a provider agreement and meeting MRC/MassHealth standards; (4) Comprehensive in-home assessment completed within past year for laundry services exception; services authorized up to one year.

Provider must meet listed licensure/enrollment/site-based requirements (hospital, assisted living, nursing facility, licensed respite facility, rest home, adult foster care enrollment, or meet DDS 115 CMR 7.00 site-based requirements).

Supportive Home Care Aide (Covered when all criteria met)

Supportive home care aide services are covered when ALL of the following are met:

Supportive home care aide eligibility: (1) The member has a diagnosis of Alzheimer's disease or other dementia-related condition or a documented emotional or behavioral health condition; (2) The member would benefit from emotional support, socialization, and/or accompaniment to community locations and needs assistance with ADLs and IADLs; (3) The member meets all criteria for authorization of Personal Care Assistant, Home Health Aide, or Homemaker; (4) Documentation supports the hours requested; services authorized up to six months.

Supportive home care aide has completed coursework in dementia or serious mental illness care. Excluded when member is admitted to a hospital, skilled nursing facility, or resides in assisted living, group home, or other supervised setting; service duplicates PCA, HHA, or homemaker services.

Chore services are not covered when the work requested is routine or ongoing household cleaning, when it constitutes a home modification or improvement, or when it requires a skilled tradesperson (for example, plumbing, electrical, carpentry, or masonry). Coverage is also excluded if the member receives adult foster care, if the tasks duplicate homemaker or other covered services, if the tasks primarily benefit other household members, if they involve maintenance/modifications of group homes or therapeutic residential settings, if they are related to moving, or if the services would be provided while the member is in a hospital, nursing facility, or other supervised/therapeutic setting.

Companion services are excluded when the activity is purely recreational or diversionary, when provided while the member is in a hospital, nursing facility, Day Habilitation center, Adult Day Health center, or other supervised/therapeutic setting, when the companion assistance would duplicate tasks already covered by a Personal Care Assistant or Homemaker (or any other covered service), or when the member requires constant supervision rather than the type of companion support envisioned by this benefit.

Grocery services are not covered when they duplicate other services the member already has access to (including home delivered meals, adult foster care, PCA, homemaker, assisted living, or group home services). Coverage is also excluded if the member is admitted to a skilled nursing facility, hospital inpatient, or other therapeutic environment where food is provided, if a free grocery shopping or delivery service is reasonably available from a local supermarket or app, or if the member is capable of shopping independently but only lacks transportation (in which case the nonmedical transportation benefit should be used).

Home delivered meals and medically tailored meal services are excluded when they would duplicate other covered nutrition supports (for example grocery shopping services or homemaker meal preparation), when meals are requested for individuals other than the eligible member, or when a spouse or other legally responsible person is capable of obtaining and preparing adequate meals for the member.

Homemaker services are excluded when they duplicate other covered services (such as grocery, laundry, PCA, adult foster care, or home delivered meals), when the services primarily benefit other household members (for example cleaning common areas or preparing meals for other residents), or when the member is admitted to a hospital, skilled nursing facility, assisted living, group home, or other supervised setting.

Laundry services are excluded when they duplicate services already covered by a homemaker, PCA, or other benefit, when the work benefits other household members, or when the member is admitted to a hospital, skilled nursing facility, assisted living, group home, or other supervised setting. Laundry is also not covered for members who are capable of performing this IADL independently but lack access to facilities; in those cases the nonmedical transportation benefit may be used to access a laundromat.

Respite services are excluded when the request is to temporarily relieve a paid caregiver, when the requested hours would exceed 360 hours in one calendar year, when respite began before the member's service plan was developed, when services would be provided to someone other than the eligible member, when the services are duplicative of those paid for by MassHealth or a third party, or when the member has already reached their maximum allowable hours without approval.

Requests for respite that are intended to relieve a paid caregiver are not eligible for coverage. Respite beyond the policy cap of 360 hours per calendar year is excluded, and services that commenced prior to development of the member’s service plan are not covered.

Supportive home care aide services are excluded when the member is admitted to a hospital or skilled nursing facility, or when residing in an assisted living, group home, or other supervised setting. Coverage is also excluded when the service would duplicate care provided by a Personal Care Assistant, Home Health Aide, or Homemaker.

General exclusions include requests for services when the member does not meet the policy’s general eligibility criteria, when services began before the member’s service plan was developed, when services are provided to someone other than the eligible member, when the member is a resident or inpatient of a licensed medical facility (except for specified exceptions such as certain respite and transitional assistance), when services duplicate those paid by MassHealth or a third party, or when the member has reached maximum allowable hours and additional hours have not been approved.

If a request falls into any of the listed exclusions — for example, it duplicates another covered service, began prior to the member’s service plan, is intended to relieve a paid caregiver, or would exceed the 360-hour per calendar year respite limit — the request should be denied as not covered/not medically necessary under this policy.

Coding and Clinical Markers

Informational service codesmixed

99509	Home visit for assistance with activities of daily living and personal care.
H0045	Respite care services, not in the home; per diem.
S5101	Day care services, adult; per half day.
S5102	Day care services, adult; per diem.
S5120	Chore services; per 15 minutes.
S5121	Chore services; per diem.
S5125	Supportive home care aide; per 15 minutes.
S5130	Homemaker service, not otherwise specified; per 15 minutes.
S5131	Homemaker service, not otherwise specified; per diem.
S5135	Companion care, adult; per 15 minutes.

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GLIM malnutrition criteria — key thresholds

GLIM diagnostic thresholdsLow BMI (<20 if <70 y; <22 if ≥70 y) OR >5% weight loss in 6 months OR >10% beyond 6 months OR reduced muscle mass by validated technique

Associated clinical conditions (GLIM criterion 2)Chronic inflammatory disease (e.g., cancer, COPD, CHF, chronic renal disease) OR acute injury/disease (e.g., major infection, burns, trauma) OR reduced food intake (≤50% energy >1 week or any reduced intake >2 weeks) OR chronic GI condition affecting absorption (e.g., short gut, IBD, strictures, pancreatic insufficiency, chronic diarrhea)

Combined requirement for malnutritionDiagnosis requires BOTH an etiologic criterion (criterion 2) and one phenotypic criterion (criterion 1) per GLIM

Respite annual hours limit

Annual limit for respite servicesMaximum 360 hours per calendar year

Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required

Authorization is required for Senior Care Options (SCO) members and per product-specific rules. Providers must confirm member eligibility and product coverage before delivering services.

Authorization required for Senior Care Options (SCO).
Check product-specific prior authorization rules for Commercial, QHP, ACO, Medicare Advantage, One Care, and other lines.

Prior Authorization

Authorization Time Limits and Quantity Caps

Respite and supportive home care aide services require prior authorization and are limited to specified authorization periods. Requests that exceed defined time limits or exceed hourly caps risk denial.

Respite services: authorized up to one year; maximum 360 hours per calendar year — requests beyond 360 hours will be denied.
Supportive home care aide services: authorized up to six months.
Chore services: authorized for up to six months; Homemaker, Companion, Grocery, Laundry, and Home Delivered Meals have service-specific authorization durations as noted in the policy.

Definitions

ADLs / IADLs as clinical basis

Clinical basisEligibility based on documented impairment in ADLs or IADLs that limits independent function

Assessment requirementComprehensive in‑home assessment required (within 90 days for most services) to document ADL/IADL deficits

Plan of care linkageRequested service must be included in the member's individualized plan of care

Activities of Daily Living (ADLs)

ADLs definedBathing, grooming, dressing, toileting/continence, transferring/ambulation, and eating

Role in eligibilityDocumented impairment in one or more ADLs supports need for LTSS services

Admission Criteria

home/community

Admission exclusions for supportive services: Supportive home care aide not available if member is admitted to a hospital or skilled nursing facility, or resides in assisted living, group home, or other supervised setting.

Limits and Maximums

home / community — respite limit

Respite hours cap (home/community)360 hours per calendar year

Consequence of exceeding capRequests beyond 360 hours/year are excluded/not covered unless approved

Setting applicabilityLimit applies to respite provided in home/community settings

home/community — maximum hours per year

Maximum annual hoursMaximum 360 hours per calendar year

Exclusion summaryRespite requests beyond this annual maximum are not covered; services begun before service plan are excluded

Authorization period note

Background

Long-term services and supports (LTSS) assist members with deficits in activities of daily living (ADLs) and instrumental activities of daily living (IADLs) to maintain safe, independent community living. LTSS include non‑skilled supports such as homemaker, companion, chore, and laundry services, as well as skilled functions like complex care training and oversight performed by a nurse; services may be time‑limited or ongoing depending on documented need and the individualized plan of care.

OpenPayer

Long-Term Services and Supports (LTSS) Coverage Criteria