Mass Health AFC Level I vs Level II: What Families Need to Know

When a loved one needs daily help, Adult Foster Care (AFC) can keep them safe at home with a live-in caregiver and professional oversight—often avoiding a nursing facility. In Massachusetts (including Boston, Massachusetts), MassHealth recognizes two AFC service levels: Level I and Level II. This guide explains how they differ, how eligibility is determined, what visits to expect each month, and practical steps families can take to choose the right level and enroll.

What is MassHealth AFC?

MassHealth’s AFC program pays approved provider agencies to coordinate care for members who need daily help with personal care in a qualified home setting. Payment is for services only—it does not include room and board.

AFC helps people stay safely at home rather than moving to facilities. Eligibility is based on daily need for hands-on assistance or cueing with essential activities (ADLs) and on medical necessity documented by clinicians (explained below).

First, a quick refresher on ADLs

ADLs are the basic tasks required to live safely each day: bathing, dressing, toileting, transferring, walking, and eating. MassHealth uses ADLs to measure functional need for AFC.

Read: ADLs and IADLs Explained: Why They Matter for Senior Care

The core difference: Level I vs Level II

MassHealth pays at Level I or Level II based on how much hands-on help or continuous cueing a member needs with ADLs, and whether significant behavioral support is required.

Level I (when Level I service payment applies)

MassHealth pays Level I when the member requires hands-on assistance with one or two ADLs, or requires cueing and supervision throughout one or more ADLs in order to complete the activity.

Level II (when Level II service payment applies)

MassHealth pays Level II for members who require either:

Hands-on assistance with at least three ADLs, or
Hands-on assistance with at least two ADLs and management of behaviors that need frequent caregiver intervention (for example: wandering, verbal or physical aggression, disruptive behaviors, or resisting care).

Bottom line: Level II reflects higher daily personal-care needs and/or significant behavior management; Level I reflects moderate personal-care needs or continuous cueing.

How often does the care team visit at each level?

MassHealth sets different visit frequencies for the nurse and care manager at Level I vs Level II.

Level I:
- Care manager: on-site every other month (alternating with nurse visits) so the member gets one visit each month from either the nurse or the care manager. A community support specialist may replace the care manager for up to three non-consecutive visits per year if the multidisciplinary team (MDT) approves.
- Nurse: on-site every other month (alternating with care manager) so the member receives one visit each month from nurse or care manager. A community support specialist may replace the nurse for up to three non-consecutive visits per year if the MDT approves.
Level II:
- Care manager: monthly on-site visits (member must receive one nurse and one care manager visit every month). A community support specialist may replace the care manager for up to six non-consecutive visits per year if the MDT approves.
- Nurse: monthly on-site visits (member must receive one nurse and one care manager visit every month). A community support specialist may replace the nurse for up to six non-consecutive visits per year if the MDT approves.

These cadence rules ensure consistent clinical oversight that matches the member’s level of need.

What the nurse and care manager actually do

At either level, the registered nurse monitors health status, documents findings at each visit, educates the member on hygiene/health concerns, coordinates the PCP order, and maintains emergency backup plans—while overseeing, supporting, training, and evaluating caregivers.

The care manager performs psychosocial evaluations, supports and trains caregivers, helps develop and implement the plan of care, coordinates services, completes progress notes for each visit, and reports changes in condition to the nurse.

How MassHealth determines the level (assessment & PA)

AFC level is authorized through Prior Authorization (PA). The PA must include:

The MassHealth-designated clinical assessment (MDS).
A PCP Order.
Clinical documentation supporting medical necessity and the member’s need for AFC.
If the MDS and PCP Order clearly show the need, extra documentation may not be required.

Validity windows & timing:

The PCP Order and clinical assessment must be completed within 90 days of the PA request.
Initial PAs cannot be submitted more than 90 days before, or less than 21 days before, the requested effective date. Re-evaluations can be submitted up to 60 days before expiration and must be submitted at least 21 days before expiry.
If you can’t submit a full re-evaluation on time after a deferral, you may submit an extension; MassHealth recommends submitting no later than 21 days prior to the PA expiration.

Uploading required attachments: The LTSS Provider Portal specifies attachments by PA type (Initial, Re-evaluation, Significant Change, Transfer) and allows uploading both the MDS and PCP Order.

Can a member’s level change?

Yes. Providers must continuously confirm that members still meet clinical criteria; if not, billing must stop. Payment begins on the later of the PA effective date or the first date AFC is delivered and ends when the member no longer meets criteria, AFC stops, or PA lapses. MassHealth does not pay for non-service days (except allowed leaves).

When needs rise (e.g., new behaviors or more ADLs), providers submit a Significant Change PA with updated documentation; when needs lessen, level may decrease at re-evaluation in line with regulations and medical necessity guidance.

Transfers between AFC providers

If a member switches providers, the new provider must complete a new assessment and obtain a new PA; the previous provider must continue services until the transition is complete, and only one provider can bill per day. The portal’s transfer workflow clarifies steps for both agencies so payment is coordinated.

Level I vs Level II: quick comparison for families

Care need

Level I: Hands-on help with 1–2 ADLs or continuous cueing/supervision.
Level II: Hands-on help with ≥3 ADLs, or with 2 ADLs + frequent behavior management (wandering, aggression, disruptive behaviors, resisting care).

Visit cadence

Level I: One visit per month total (alternating nurse and care manager; each on-site every other month).
Level II: Monthly nurse visit and monthly care manager visit (two visits/month).

Who typically fits

Level I: Needs prompting and some hands-on help (e.g., dressing, showers, meals), generally stable behavior.
Level II: Needs extensive hands-on care across the day and/or behaviors needing close supervision and intervention.

What families should prepare for the assessment

To streamline your PA and get the right level from the start, make sure your provider collects and submits:

The MassHealth-designated clinical assessment (MDS)
A PCP Order (signed within 90 days)
Any clinical notes/evaluations that clarify medical necessity and ADL/behavior needs
Correct timing: initial PA within allowed 90-to-21-day submission window; re-evaluation 60-to-21-day window before expiration; submit extension if needed after a deferral.

Coverage notes families often miss

Service vs. housing: MassHealth pays for AFC services, not room/board.
Only service days are billable: Non-service days aren’t paid (with limited leave exceptions); billing stops if criteria are not met.
Ongoing review is required: Providers must verify members continue to meet criteria; otherwise, payment cannot continue.

How to choose the right level

Ask these questions with your nurse/care manager during intake:

How many ADLs need hands-on help daily? If three or more, Level II is likely; if one or two, Level I may fit.
Are there frequent behaviors requiring intervention (wandering, aggression, resisting care)? If yes plus two ADLs, Level II is often appropriate.
What visit cadence will best keep your loved one safe? Level II provides two clinical visits each month (nurse + care manager).

For families in Boston, Massachusetts—your next step

If your loved one needs daily help, the right AFC level can keep them safe at home with predictable clinical support. Clare Senior Care’s team in Boston, Massachusetts can review ADLs/behaviors, coordinate the MDS and PCP Order, and submit the PA within MassHealth timelines so you receive the correct level from day one. (Service coverage excludes room/board per MassHealth rules.)

Ready to check eligibility or discuss Level I vs Level II? Book a consultation—we’ll walk you through documents, timing, and the visit cadence that fits your family best.