Audit of the Office of Medicaid (MassHealth)—Review of Payment for Telehealth Adult Foster Care and Group Adult Foster Care Overview of Audited Entity

This section describes the makeup and responsibilities of the Office of Medicaid (MassHealth)—Review of Payment for Telehealth Adult Foster Care and Group Adult Foster Care.

Overview

Under Chapter 118E of the Massachusetts General Laws, the Executive Office of Health and Human Services, through the Division of Medical Assistance, administers the state’s Medicaid program, known as MassHealth. MassHealth annually provides access to healthcare services for approximately 2.3 million eligible children, families, people over 65, and people with disabilities, all of whom have low or moderate incomes. Below is a chart of MassHealth’s 2023 income standards and federal poverty guidelines.

2023 MassHealth Income Standard and Federal Poverty Guidelines

Family Size	MassHealth Income Limit (Annually)	100% Federal Poverty Level	133% Federal Poverty Level	150% Federal Poverty Level
1	$6,264	$14,580	$19,392	$21,876
2	$7,800	$19,728	$26,232	$29,580
3	$9,300	$24,864	$33,072	$37,296
4	$10,692	$30,000	$39,900	$45,000
5	$12,192	$35,148	$46,740	$52,716
6	$13,692	$40,284	$53,580	$60,420
7	$15,192	$45,420	$60,420	$68,136
8	$16,596	$50,568	$67,248	$75,840

In fiscal year 2023, MassHealth paid healthcare providers more than $17.1 billion, of which approximately 35% was funded by the Commonwealth. Medicaid expenditures represent approximately 33% of the Commonwealth’s total fiscal year 2023 budget.

Adult Foster Care and Group Adult Foster Care Programs

The MassHealth adult foster care (AFC) and group adult foster care (GAFC) programs provide adult members over 65 and adult members with disabilities with assistance performing activities of daily living (ADLs) and instrumental activities of daily living (IADLs). ADLs include activities such as eating, toileting, dressing, bathing, and walking. IADLs are activities related to independent living that are incidental to a member’s care, such as laundry, shopping, housekeeping, meal preparation and cleanup, transportation, and medication management.

MassHealth members are eligible to receive AFC or GAFC services if they require assistance or supervision with at least one ADL or IADL. Both programs are designed to provide sufficient assistance to allow members to continue to live independently and avoid the much higher cost of a long-term healthcare facility. MassHealth requires all AFC and GAFC services to have an approved prior authorization from MassHealth before the first date of service and annually thereafter.

MassHealth’s contracted AFC providers employ caregivers¹ who provide AFC services to MassHealth members who require them. Members live in caregivers’ private residences and receive 24-hour supervision and assistance with both ADLs and IADLs. Each caregiver may house up to three members in their private residence.

Members enrolled in the GAFC program typically live in assisted living or subsidized group housing. Members receive assistance with ADLs and IADLs from GAFC direct care aides² for one to two hours each day.

AFC and GAFC providers are responsible for providing nursing oversight from a registered nurse / licensed practical nurse in conjunction with AFC and GAFC care managers,³ AFC caregivers, and GAFC direct care aides. AFC providers are required to visit monthly or bimonthly, depending on the level of care.

For AFC Level I and the GAFC level of service, the care manager and registered nurse / licensed practical nurse must conduct required oversight visits every other month. For AFC Level II service, the care manager and registered nurse / licensed practical nurse must conduct required oversight visits monthly.

Sections 408.505(B) and 408.415(B) of Title 130 of the Code of Massachusetts Regulations require AFC and GAFC nursing oversight to be individualized to each member’s needs. Examples of AFC and GAFC nursing oversight and care management responsibilities include, but are not limited to, the following:

• performing all clinical assessments, evaluations, and semiannual health status reports;
• performing required oversight visits at least every other month;
• coordinating all services with the care manager;
• making sure the plans of care are implemented;
• providing support and training to caregivers / direct care aides; and
• reporting changes to a member’s health.

Telehealth

Following the Governor’s Declaration of Emergency on March 10, 2020, which was in response to the COVID-19 pandemic, MassHealth issued All Provider Bulletin 289, which permitted qualified providers to deliver clinically appropriate and medically necessary services to MassHealth members through telehealth. According to data from the Medicaid Management Information System, during the audit period, MassHealth paid AFC and GAFC providers $771,112,638; $22,979,654 of this amount was paid for telehealth AFC and GAFC services delivered by five providers.

According to MassHealth Adult Foster Care Bulletin 18, dated May 2021, AFC and GAFC caregivers / direct care aides could not provide services through telehealth. However, the bulletin also stated that AFC and GAFC providers could use telehealth services for initial evaluations, reassessments, and care management and nursing oversight. In addition, AFC and GAFC providers could not bill MassHealth for care management services or nursing oversight services because these services were included in the AFC and GAFC payment rate schedule established by the Executive Office of Health and Human Services.

1.    Section 408.402 of Title 130 of the Code of Massachusetts Regulations defines an AFC caregiver as “a person who lives with the AFC member and [is] paid by the AFC provider for the provision of direct care.”

2.    GAFC direct care aides provide daily assistance with ADLs and IADLS and are supervised by the GAFC provider.

3.    AFC and GAFC care managers work with registered nurses / licensed practical nurses to coordinate and monitor services for members receiving AFC and GAFC.

Date published:	September 4, 2024