MassHealth’s Adult Foster Care (AFC) program helps care recipients who need daily assistance with essential activities. This home‑based service allows members to live safely and comfortably with a dedicated caregiver, while receiving professional oversight from an AFC provider.

This program relies on the dedication of both care recipients and caregivers. Below are the eligibility requirements for each.

General Information

The MassHealth Adult Foster Care (AFC) program is designed to help members remain safely at home while receiving the daily assistance they need. To participate, both the care recipient and the caregiver must meet certain requirements.

Care Recipient Eligibility

To be eligible, the individual must:

  • Be 16 years or older
  • Have MassHealth coverage
  • Need help with at least one daily activity (bathing, dressing, eating, toileting, mobility, or transferring)
  • Live in a safe home environment

Caregiver Eligibility

To qualify as a caregiver, you must:

  • Be 18 or older
  • Live with the person you care for (not a spouse or legal guardian)
  • Pass a background check
  • Provide daily care and supervision

Clinical Eligibility Criteria

To qualify for AFC, members must:

  • Have an AFC order from their Primary Care Provider (PCP).
  • Have a medical or mental condition requiring daily hands‑on help or supervision with at least one ADL:

    • Bathing: Full‑body or partial sponge bath (personal grooming only does not qualify).

    • Dressing: Support for upper and lower body clothing.

    • Toileting: Assistance with incontinence care, cleansing, or routine catheter/colostomy care.

    • Transferring: Physical help moving between positions (e.g., bed to wheelchair).

    • Mobility: Help with walking or self‑propelling a wheelchair.

    • Eating: Supervision or physical assistance during meals.

Prior Authorization (PA) Requirements

Before starting AFC services, MassHealth requires Prior Authorization (PA).

How it works:

  • AFC providers submit requests electronically via the LTSS Provider Portal.
  • Documentation must include:
  • PA request form
  • MassHealth Clinical Assessment (within 90 days)
  • PCP order
  • Supporting clinical records

When PA is required:

  • Initial evaluation before admission
  • Annual evaluation (21 days before expiration)
  • Transfers from another AFC provider
  • Significant change in health status

Processing time: Up to 21 days, with expedited reviews in urgent cases such as hospital discharge or hospice care.

AFC Service Payment Levels

MassHealth determines payment levels based on member needs:

Level I:

  • Hands‑on help with 1–2 ADLs
  • Or supervision throughout one or more ADLs

Level II:

  • Hands‑on help with 3 or more ADLs
  • Or 2 ADLs plus management of challenging behaviors (wandering, resisting care, or disruptive symptoms)

Non‑Coverage Situations

AFC services are not covered when:

  • Clinical eligibility criteria are not met
  • Members receive overlapping home health aide or personal care services
  • Documentation is incomplete or inconsistent
  • Members live in ineligible facilities (e.g., hospitals, nursing homes, assisted living)
  • Members do not live with a qualified AFC caregiver

As a care recipient, the MassHealth Adult Foster Care program gives you the chance to receive the daily support you need while staying in the comfort of your home. Meeting the eligibility criteria and completing the Prior Authorization process ensures you receive the right care at the right level.

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