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 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.
Old Colony Elder Services (OCES) is a private nonprofit organization in Brockton. It is 1 of 26 Aging Services Access Points (ASAPs) in Massachusetts. According to the website of the Executive Office of Elder Affairs (EOEA), ASAPs are “private non-profit agencies with governing boards that serve and represent 51% of people age 60 and older.” OCES has been a MassHealth provider since 1985 and offers adult foster care (AFC) and home health services for older adults, and people with disabilities, in southeastern Massachusetts.
During the audit period, January 1, 2016 through December 31, 2018, MassHealth paid approximately $1.03 billion for AFC and group adult foster care (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 AFC and GAFC programs’ cost almost doubled (as shown below in millions of dollars).
AFC and GAFC Programs
The AFC and GAFC 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. AFC caregivers are compensated at a daily rate based on the level of care. During the audit period, the rate was between $40 and $80 per day.
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 GAFC 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 Care
Home care consists of skilled and supported care provided to eligible MassHealth members in an attempt to reduce more costly hospitalization and institutionalization and to help members maintain their independence and quality of life in their own homes. It is provided through contracts with home health agencies (HHAs) and includes skilled nursing; home health aide services; and physical, occupational, and speech therapies that are medically necessary for members who are under the care of physicians. During our audit period, MassHealth processed approximately 17.4 million claims for home care and paid approximately $1.65 billion to HHAs for the care of approximately 61,500 MassHealth members.
Frail Elder Waiver
The Frail Elder Waiver program (FEW) is a MassHealth program that went into effect in January 1990. It provides home- and community-based services (HCBS) to Massachusetts residents who require a nursing-home level of care, allowing them to receive healthcare and ongoing support services in their homes or community-living residences instead of in nursing homes. Examples of available services include Alzheimer’s- and dementia-related coaching, companion services, grocery shopping and delivery, home-delivered meals, housework and chores, home health aide services, occupational therapy, and skilled nursing. To qualify for FEW, an individual must do the following:
- be 60–64 years old and have a disability, or be 65 or older
- meet clinical requirements and require the level of care provided in nursing homes, but be willing to receive the care at home
- be able to be safely served in the community within the terms of FEW
- meet the financial requirements to qualify for MassHealth Standard2 in the community.
Before May 5, 2017, MassHealth regulations stated that the agency would not pay for AFC for a member on the same day s/he received other services such as home care. However, in July 2014, it issued MassHealth Provider Bulletin No. 10, stating that providers could bill for AFC and home care provided on the same day to members who were participating in FEW. Subsequently, on May 5, 2017, Section 408.437 of Title 130 of the Code of Massachusetts Regulations was amended to allow home care for all members receiving AFC.
FEW is operated by EOEA, which contracts with ASAPs such as OCES to provide regionally based services. During the audit period, MassHealth paid approximately $505,982,127 for 17,745 members to receive HCBS under FEW.
| Date published: | June 29, 2020 |
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