MassHealth (Massachusetts Medicaid) Adult Foster Care (AFC) Program

Last updated: July 13, 2021

 

Overview of the Adult Foster Care Program

Through the Massachusetts’ Adult Foster Care (AFC) Program, program participants reside in a private home (an adult foster care home) with a caregiver who provides around-the-clock supervision, personal care assistance, and homemaker services. This program is intended for state residents who require assistance due to an inability to independently complete their activities of daily living (ADLs). ADLs include activities such as bathing, grooming, dressing, eating, mobility, and toiletry. While a program participant can be as young as 16, this program is particularly relevant to seniors, as physical limitations due to the natural process of aging, medical conditions, and cognitive issues, such as those commonly seen in persons with Alzheimer’s disease and related dementias, can be cause for needed assistance.

 Relatives, such as adult children, grandchildren, and siblings, can be paid to provide live-in care through the Adult Foster Care Program.

The live-in caregiver, who must be 18+ years old, may be a close friend or a family member. This includes an adult child, grandchild, niece / nephew, or sibling, but unfortunately, does not include a spouse or a person legally responsible for the care recipient. Caregivers are employed and paid by Adult Foster Care providers that are contracted by MassHealth. Up to three program participants can reside in an adult foster care home.

The home in which the program participant resides must be a private home. The live-in caregiver may move into the home of the program participant or the program participant can live in the caregiver’s home. An AFC program participant cannot reside in a rest home, an assisted living residence, or a group home. However, there is another MassHealth program, the Group Adult Foster Care (GAFC) Program, which allows program participants to reside in assisted living residences.

The AFC Program is an entitlement, which means meeting the state’s Medicaid eligibility requirements guarantees one will receive benefits. This means the state does not limit the number of persons who can receive adult foster care services.

The Adult Foster Care Program may also be called the Adult Family Care Program. It is a long-term service and support that is offered under Massachusetts’ regular Medicaid program. The Medicaid Program in MA is called MassHealth.

 HCBS Medicaid Waivers versus HCBS State Plan Medicaid?
While home and community based services (HCBS) can be provided via a Medicaid waiver or a state’s regular Medicaid plan, HCBS through Medicaid state plans are an entitlement. Put differently, meeting the program’s eligibility requirements guarantees an applicant will receive benefits. On the other hand, HCBS via Medicaid waivers are not an entitlement. Waivers have a limited number of participant enrollment slots, and once they have been filled, a waitlist for benefits begins. Furthermore, HCBS Medicaid waivers require a program participant require the level of care provided in a nursing home, while state plan HCBS do not always require this level of care.

 

Benefits of the Adult Foster Care Program

Benefits available via the AFC Program are as follows.

– 24-Hour Supervision
– Caregiver Training – initial and continuing
– Care Management
– Companionship
– Nursing Oversight – provided by a registered nurse
– Bathing – includes grooming and personal hygiene
– Dressing / Undressing
– Eating
– Housekeeping
– Laundry
– Meal Preparation / Clean Up
– Maintenance of Wheelchairs and Adaptive Equipment
– Medication Management – includes assistance with paperwork to receive prescribed medications
– Mobility
– Shopping for Essentials
– Toileting
– Transferring
– Transportation – to appointments

While MassHealth covers the cost of care services in adult foster care, MassHealth will not pay for room and board.

 

Eligibility Requirements for MassHealth Adult Foster Care Program

The AFC Program is for MA state residents who are 16+ years old who cannot live alone due to a condition that prohibits them from independently completing their activities of daily living. The condition may be medical or mental in nature. Additional eligibility criteria are as follows and is only relevant for seniors 65+ years of age.

 The American Council on Aging now offers provides a quick and easy MassHealth eligibility test for seniors

 

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 100% of the Federal Poverty Level (FPL), which increases on an annual basis in January. As of 2021, the income limit for a single applicant is $1,073 / month. Married couples, regardless of if one or both spouses are applicants, can have a monthly income up to $1,452.

 While many home and community based services Medicaid programs allow a non-applicant spouse to retain a larger portion of a couple’s income and assets, the Adult Foster Care Program does not. In contrast, MassHealth’s Frail Elder Waiver (FEW) does allow a non-applicant spouse a monthly maintenance needs allowance from his/her applicant spouse and a community spouse resource allowance.

Assets
In 2021, the asset limit is $2,000 for a single applicant. For married couples, the asset limit is slightly higher at $3,000. This hold true whether one or both spouses are applicants.

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

While there is a 60-month look back rule in which Medicaid checks past asset transfers of those applying for nursing home Medicaid or home and community based services via a Medicaid waiver, this is not relevant for the Adult Foster Care Program. In other words, the look back period is not applicable.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our spend down calculator.  

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take their home. Fortunately, for eligibility purposes, Massachusetts Medicaid considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $906,000. Home equity interest is the current value of the home minus any outstanding mortgage.
– A spouse lives in the home.
– The applicant has a child under 21 years old living in the home.
– The applicant has a blind or permanently and totally disabled child living in the home.

To learn more about the potential of Medicaid taking the home, click here.

 

Medical Criteria: Functional Need

Unlike with many Medicaid long-term care programs, a nursing facility level of care (NFLOC) is not required. In fact, applicants cannot require around the clock skilled nursing care. For AFC, applicants must need hands on assistance or continuing supervision and prompting with at least one of their activities of daily living (ADLs). Areas of consideration are mobility, toileting, bathing/personal hygiene, dressing, transferring (moving to another position), and eating. Behaviors, such as wandering, resisting care, and being disruptive, which are seen in persons with Alzheimer’s disease or another related dementia, are also taken into consideration. A diagnosis of dementia in and of itself does not mean one will meet the functional criteria.

 For more information about long-term care Medicaid in Massachusetts, click here.

 

Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for MA Medicaid / MassHealth. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

Massachusetts has a Medically Needy Medicaid Program for Medicaid applicants who have high medical expenses relative to their income. Also known as a spend-down program, applicants are permitted to spend “excess” income on medical expenses and health care premiums, such as Medicare Part B, in order to meet Medicaid’s income limit. The amount that must be “spent down” each month can be thought of as a deductible. Once one’s “deductible” has been met for the spend down period, which is 6-months in MA, the Adult Foster Care Program will pay for care services.

When persons have assets over the limits, Irrevocable Funeral Trusts (IFTs) are an option. IFTs are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Persons can also purchase an annuity, which converts a lump sum of cash (countable assets) into a stream of income. There are many other options when the applicant has assets exceeding the limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of MassHealth benefits. Professional Medicaid planners are educated in the planning strategies available in Massachusetts to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, while Medicaid’s 60-month look back rule does not apply to the Adult Foster Care Program, it does apply to nursing home Medicaid and other long-term care Medicaid programs. As more extensive Medicaid-funded care might be required in the future, it is vital that one not violate the look back rule. Medicaid planning strategies should ideally only be implemented with careful planning and well in advance of the need for long-term care. However, there are some workarounds, and Medicaid planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.

 

How to Apply for MassHealth Adult Foster Care Program

Before You Apply

Prior to submitting an application for the Adult Foster Care Program, applicants need to ensure they meet the eligibility criteria for MA Medicaid. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid eligibility test.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, proof of income, previous bank statements, copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.

 

Application Process

To apply for the Adult Foster Care Program, applicants must be eligible for MA Medicaid / MassHealth. To apply for MassHealth, seniors must complete the Application for Health Coverage for Seniors and People Needing Long-Term Care Services, which can be found here. The completed application can be mailed, faxed, or dropped off at the MassHealth Enrollment Center. The fax number and addresses are on the application.

Persons already enrolled in Medicaid should contact an adult foster care provider agency to complete and submit the MassHealth Adult Foster Care Primary Care Provider Order Form. This form must be signed by one’s primary doctor, indicating that foster care services are needed. Contact information for AFC agencies can be found here. AFC providers can also assist with the MassHealth application process.

Additional information about the MassHealth Adult Foster Care Program, although not intended for a consumer audience, can be found here. Persons can also contact the MassHealth Customer Service Center at 1-800-841-2900 or MassOptions at 1-800-243-4636.

The Massachusetts’ Executive Office of Health and Human Services (EOHHS) administers the Adult Foster Care Program in conjunction with adult foster care provider agencies contracted by MassHealth.

 

Approval Process & Timing

The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further.

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