These Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information that MassHealth uses to determine medical necessity for adult foster care (AFC). These Guidelines are based on generally accepted standards of practice, review of the medical literature, and federal and state policies and laws applicable to Medicaid programs.
MassHealth AFC providers should consult MassHealth regulations at 130 CMR 408.000 and 101 CMR 351.000 and the MassHealth Adult Foster Care Provider Manual for information about coverage, limitations, service conditions, and prior-authorization (PA) requirements. Providers serving members enrolled in a MassHealth-contracted accountable care partnership plan (ACPP), managed care organization (MCO), integrated care organization (ICO), senior care organization (SCO), or program of all-inclusive care for the elderly (PACE) should refer to the ACPP’s, MCO’s, ICO’s, SCO’s or PACE’s medical policies for covered services.
MassHealth requires PA (see Section III) for AFC. MassHealth reviews requests for PA on the basis of medical necessity. If MassHealth approves the request, payment is still subject to all general conditions of MassHealth, including member eligibility, other insurance, MassHealth’s administrative and billing regulations and guidance, and MassHealth’s AFC program regulations and guidance.