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Overview of the Office of Medicaid (MassHealth)—City Home Care, LLC

This section describes the makeup and responsibilities of the Office of Medicaid (MassHealth)—Review of Claims Paid for Services by City Home Care, LLC.

Table of Contents

Overview

City Home Care, LLC is a private organization in Worcester. It has been a MassHealth provider since 2013 and offers adult foster care (AFC), group adult foster care (GAFC), and home health services for older adults, and people with disabilities, in Massachusetts.

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 provides access to healthcare for approximately 1.9 million low- and moderate-income children, families, seniors, and people with disabilities annually. In fiscal year 2018, MassHealth paid healthcare providers more than $15 billion, of which approximately 50% was funded by the Commonwealth. Medicaid expenditures represented approximately 39% of the Commonwealth’s total fiscal year 2018 budget of approximately $40 billion.

During the audit period, January 1, 2016 through December 31, 2018, MassHealth paid approximately $1.03 billion for AFC and GAFC for 28,287 members, as detailed below.

Amounts Paid for AFC and GAFC

Calendar Year

Amount Paid

Members Served

Number of Claims

2016

$336,542,916

19,993

1,783,922

2017

347,052,674

20,989

1,867,651

2018

351,035,446

21,009

2,247,302

Total

$1,034,631,036

61,991*

5,898,875

*     Of these 61,991 members, the unduplicated count is 28,287.

 

From 2010 through 2018, the Adult Foster Care and Group Adult Foster Care Programs’ cost almost doubled, as shown below.

MassHealth Spending on AFC and GAFC

A line graph showing that the spending on AFC and GAFC services by MassHealth has increased from approximately 175 million in 2010 to approximately 350 million in 2018.

Adult Foster Care and Group Adult Foster Care Programs

The Adult Foster Care and Group Adult Foster Care Programs provide MassHealth members who are elderly or have disabilities with assistance performing activities of daily living (ADLs) and instrumental activities of daily living (IADLs). ADLs include activities such as eating, toileting, bathing, walking, and dressing. 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. Members are eligible to receive either AFC or GAFC 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 high cost of a long-term-care facility.

Members who receive AFC live in the private residences of caregivers employed by MassHealth-contracted AFC providers and receive 24-hour supervision and assistance with ADLs and IADLs. Each AFC residence may house up to three members. AFC providers must provide nursing and case management for each member.

Members enrolled in the Group Adult Foster Care Program typically live in assisted-living residences or subsidized group housing. Members receive assistance with ADLs and IADLs from GAFC aides for one to two hours each day. GAFC providers also employ nurses and case managers who meet with members at least once every two months to develop and revise member-specific care plans.

Home Health Services Program

The Home Health Services Program pays for home health services, including skilled nursing, home health aide services (for ADLs and IADLs), and therapeutic services (physical, occupational, and speech and language therapy), that are medically necessary for eligible MassHealth members who are under the care of physicians and who live in non-institutional settings. These settings may include their homes, homeless shelters, or other temporary residences in community settings. The program provides home health services through contracts with home health agencies (HHAs) and independent nurses.

During our audit period, MassHealth processed approximately 17.4 million claims for home health services and paid approximately $1.65 billion to HHAs for the care of approximately 61,500 MassHealth members.

Date published: September 21, 2020
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