Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street
Boston, MA  02111
www.mass.gov/dma	
	MassHealth
	Adult Foster Care Bulletin 6
	August 2002

	TO:	Adult Foster Care Providers Participating in MassHealth

	FROM:	Wendy E. Warring, Commissioner

	RE:	Changes in Clinical Assessment for Adult Foster Care Services  

Background	To be eligible for MassHealth, individuals must meet financial standards.  To be covered for certain MassHealth programs, members or applicants must meet clinical criteria.  The Division or its clinical screening agent, Coastline Elderly Services, Inc. (Coastline), determines clinical eligibility for coverage of adult foster care services based upon documentation submitted by the provider and the member’s physician.

New Forms	This bulletin provides you with copies of the following forms:
•	the Request for Services (formerly called the MassHealth Long 
	Term Care Assessment form);
•	the Minimum Data Set for Home Care (MDS-HC) version 2.0, 
			which replaces the current AFC participant assessment form; and 
•	the Physician’s Summary.

	These forms are the basis for determining clinical eligibility for adult foster 
care services.  

Begin using these forms as soon as you receive them.  As of September 1, 2002, the clinical screening agent will not accept the old forms.

Supplies of the Forms	You may photocopy the forms as needed.  To obtain supplies of the
forms, use the information below to mail or fax your request.  Include your provider number, address, telephone number, the exact title of the publication, and the date of issuance.

	MassHealth Forms Distribution
P.O. Box 9101
Somerville, MA 02145
Fax:  703-917-4937

	

Additional		In addition to the MDS-HC, the Request for Services, and the Physician’s
Documentation	Summary, AFC providers must supply the Division’s clinical assessment agent with any other additional information that the agent requests to determine clinical eligibility.

Clinical Screening	The provider must mail these forms to the Division’s clinical screening
Agency Address	agent for this program the following address.

Coastline Elderly Services, Inc.
Nursing Department
1646 Purchase Street
New Bedford, MA  02740-6819 

			As of September 1, 2002, Coastline Elderly Services will no longer issue verbal approvals for the AFC program.  All approvals will be in writing as of September 1, 2002.

Who May Complete	The program registered nurse is the assessment coordinator.  The 
 the MDS-HC 	assessment coordinator’s signature certifies the accuracy and
Assessment	completeness of the MDS-HC assessment.  
	
The program registered nurse must complete the MDS-HC; however, a licensed social worker (LSW, LCSW or LICSW) may complete the following sections of the MDS-HC: AA – Name and Identification Numbers, BB – Personal Items, CC – Referral Items, B – Cognitive Patterns, C – Communication/Hearing Patterns, E – Mood and Behavior Patterns, F – Social Functioning, G – Informal Support Services, and
O – Environmental Assessment.

Each individual who completes a portion of the MDS-HC should sign and certify the sections he or she completed in Section R.  (Assessment Information: signatures, title, sections, date).
				______________________________________________________________________

Annual Updates 	AFC providers must complete the MDS-HC annually for current participants.  The annual assessment must be completed within 15 days of the anniversary date of admission.  The AFC provider must maintain a copy of the annual MDS-HC in the member’s medical record.

ICD-9 Codes	The MDS-HC assessment requires the use of ICD-9-CM Codes for medical diagnoses.  ICD-9-CM code books are available at local medical supply stores and some local bookstores.  ICD-9-CM codes are also available on the Internet.

	

Future Trainings	Periodic trainings will be held for new providers.  Please contact the
	Division for dates and locations.

Questions	If you have any questions about this bulletin, please contact the MassHealth Provider Services Department at 617-628-4141 or 1‑800‑325-5231.