Medicaid-funded Group Adult Foster Care (GAFC) in Assisted Living Residences in Massachusetts

Last updated: July 23, 2021

 

Overview of the Group Adult Foster Care Program

The Massachusetts’ Group Adult Foster Care (GAFC) Program provides care assistance in a congregate (group) setting, commonly an assisted living residence, for persons 22+ years old who are at risk of nursing home placement. Program participants require assistance to complete their activities of daily living (ADLs). ADLs include bathing, personal hygiene, dressing/undressing, eating, mobility, and toiletry. In addition to help with these tasks, nursing oversight and assistance with homemaker tasks, such as laundry and housecleaning is provided.

While the GAFC program isn’t solely intended for the elderly, it is extremely relevant for this age group. Many seniors require assistance with daily living activities as a result of the natural process of aging. Additionally, Alzheimer’s disease and related dementias are more prevalent with the elderly. Cognitive limitations, commonly seen in persons with dementia, often results in the need or assistance with daily living activities.

Program participants must live in a congregate setting that is contracted by MassHealth to provide GAFC. This may be an assisted living facility or subsidized group housing. While the cost of care assistance is covered by the program, room and board is not. This means program participants must pay this cost. That said, there is a Social Security Administration program called SSI-G (Supplemental Security Income – Category G), which provides supplemental income to help cover the costs of GAFC room and board for low-income persons living in assisted living residences.

 Another MassHealth program that provides adult foster care, but in a private home, is MassHealth’s Adult Foster Care (AFC) Program. Unlike with Group Adult Foster Care, via AFC, the program participant lives with their caregiver. Furthermore, a family member can be paid to be the live-in caregiver.

GAFC is an entitlement program. This means meeting the state’s Medicaid eligibility requirements enables one to receive benefits without being put on a waitlist. However, there must be an available bed in a GAFC-approved assisted living residence or group home. If there is no bed, one will have to wait for a bed to become available.

The Group Adult Foster Care Program is a long-term service and support available through Massachusetts’ regular Medicaid program. The Medicaid Program in MA is called MassHealth, and the program specific to the elderly (65+) is MassHealth Standard.

 Medicaid Waivers versus Regular 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 Group Adult Foster Care Program

The GAFC Program provides the following benefits.

– 24-7 On-Call Access
– Care Management
– Nursing Oversight
– Bathing / Grooming / Personal Hygiene
– Dressing / Undressing
– Eating
– Housecleaning
– Laundry
– Meal Preparation / Clean Up
– Medication Management / Reminders
– Mobility
– Shopping for Essentials / Errands
– Supervision
– Toileting
– Transferring
– Transportation

 

Eligibility Requirements for MassHealth Group Adult Foster Care

The GAFC Program is for MA state residents who are 22+ years old. They must have a physical, medical, mental, or cognitive issue that prevents them from living independently due to a need for assistance with daily living activities. Additional eligibility criteria follows and is relevant for seniors 65+ years of age.

 The American Council on Aging provides a quick and easy MassHealth eligibility test for seniors that require long term care. 
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, it is thought that the Group 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 Group Adult Foster Care Program. In other words, the look back period is not applicable for this MassHealth program.

 To determine if you might have assets over MassHealth’s countable limit, and if so, receive an estimate of the amount, use our MassHealth 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, an applicant cannot require skilled nursing care on a full time basis. Instead, applicants must require hands on assistance or continued prompting and supervision with a minimum of one of their activities of daily living (ADLs). This includes mobility in bed (i.e., turning over), transferring (i.e., moving from bed to a chair), walking, dressing, personal hygiene, using the toilet, and eating. A functional (clinical) needs assessment is completed to determine if one meets this criteria. For GAFC, the Minimum Data Set (MDS) Version 2.0 form is used. Relevant to persons with dementia, cognitive deficits, such as short-term memory loss and difficulty making decisions, are a consideration. A diagnosis of dementia in and of itself does not mean one will meet the functional criteria. The functional need for group adult foster care must be authorized by one’s doctor.

 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” can be thought of as a recurring deductible. Once one’s “deductible” has been met for the spend down period, which is 6-months in MA, the Group Adult Foster Care Program will pay for care services. Persons who qualify via this avenue must have access to additional resources, such as VA Aid and Attendance benefits, which do not count towards MassHealth eligibility.

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 “spend down” assets on home improvements (i.e., updating plumbing, replacing a water heater), home modifications (i.e., adding a first floor bedroom, addition of grab bars), and replacing an older car with a newer one. 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. While the MassHealth 60-month look back rule does not apply to the Group Adult Foster Care Program, it does apply to nursing home Medicaid and the Frail Elder Waiver, either of which might become necessary for an individual in the future. Commonly, over time, persons require more extensive care, and therefore, it is critical to avoid violating the look back rule. Many of the available planning strategies should 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 the Group Adult Foster Care Program

Before You Apply

Prior to submitting an application for the Group 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 Group 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 can be found on the application.

A functional needs assessment is required as part of the application process for GAFC. Persons who are enrolled in MassHealth can contact Coastline Elderly Services at 508-999-6400 or 866-274-1643 to initiate the assessment.

Additional information about MassHealth’s Group Adult Foster Care Program, although very limited and 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 their local Aging Services Access Point (ASAP). Contact information for ASAPs can be found here.

For more information about Massachusetts’ SSI-G benefit, or to apply, one should contact their local Social Security office. Contact information can be found here.

Massachusetts’ Executive Office of Health and Human Services (EOHHS) administers the Group Adult Foster Care Program.

 

Approval Process & Timing

The Medicaid / MassHealth 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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