101 CMR 351.00 — Rates for Certain Adult Foster Care Services

Final Adoption Date Appears in Mass Register: October 24, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 351.00: RATES FOR CERTAIN ADULT FOSTER CARE SERVICES

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Section

351.01: General Provisions 351.02: Definitions 351.03: Rate Provisions 351.04: Filing and Reporting Requirements 351.05: Severability

101 CMR 351.00 Rates for Certain Adult Foster Care Services

351.01 General Provisions

351.01: General Provisions

(1) Scope and Purpose. 101 CMR 351.00 governs the MassHealth payment rates for adult foster care services and group adult foster care services described in 130 CMR 408.000: Adult Foster Care that are provided by participating providers to eligible publicly aided individuals.

(2) Applicable Dates of Service. The rates contained in 101 CMR 351.00 apply for dates of service provided on or after November 1, 2025.

(3) Administrative Bulletins. EOHHS may issue administrative bulletins to clarify provisions of 101 CMR 351.00.

(4) Coding Updates and Corrections. EOHHS may publish service code updates and corrections in the form of an administrative bulletin if the coding system adds, deletes, or changes relevant codes.

(5) Disclaimer of Authorization of Services. 101 CMR 351.00 is neither authorization for nor approval of the services for which rates are determined pursuant to 101 CMR 351.00. Governmental units that purchase services described in 101 CMR 351.00 are responsible for the definition, authorization, and approval of services provided to publicly aided individuals.

351.02 Definitions

351.02: Definitions

As used in 101 CMR 351.00, unless the context requires otherwise, terms have the meanings in 101 CMR 351.02.

Activities of Daily Living (ADLs). Fundamental personal care tasks as defined in 130 CMR 408.402: Activities of Daily Living (ADLs) performed as part of an individual's routine of self- care. ADLs include, but are not limited to, eating, toileting, dressing, bathing, transferring, and ambulation.

Adult Foster Care (AFC). Services as defined in 130 CMR 408.402: Adult Foster Care.

Adult Foster Care (AFC) Caregiver. A person selected, supervised, and paid by the provider for the provision of direct care in accordance with 130 CMR 408.415(A): Direct Care.

AFC Level I. A level of payment for adult foster care services provided to a member who meets the clinical criteria of 130 CMR 408.419(D)(1): AFC Level I Service Payment.

Final Adoption Date Appears in Mass Register: October 24, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 351.00: RATES FOR CERTAIN ADULT FOSTER CARE SERVICES

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AFC Level II. A level of payment for adult foster care services provided to a member who meets the clinical criteria of 130 CMR 408.419(D)(2): AFC Level II Service Payment.

Alternative Caregiver Days. A short-term placement during which a member receives adult foster care from an alternative care provider when the AFC caregiver is temporarily unavailable or unable to provide care.

EOHHS. The Executive Office of Health and Human Services established under M.G.L. c. 6A.

Governmental Unit. The Commonwealth, any board, commission, department, division, or agency of the Commonwealth, and any political subdivision of the Commonwealth.

Group Adult Foster Care (GAFC). Services as defined in 130 CMR 408.402: Adult Foster Care.

Intake and Assessment Services. Services as defined in 130 CMR 408.402: AFC Intake and Assessment Services and outlined in 130 CMR 408.431(A): Preadmission Procedures and Activities provided to a MassHealth member referred to a provider for AFC services.

MassHealth. A program of medical care and assistance that includes, but is not limited to, payment for certain health care services to eligible residents of the Commonwealth established under M.G.L. c. 118E and administered by the Executive Office of Health and Human Services through its Office of Medicaid.

Medical Leave of Absence (MLOA). A short-term absence during which a member does not receive AFC from the AFC caregiver because the member is temporarily admitted to a hospital or nursing facility.

Member. A MassHealth eligible member who has received clinical authorization by either MassHealth or its designated screening agent for payment of adult foster care.

Nonmedical Leave of Absence (NMLOA). A short-term absence during which a member does not receive AFC from the AFC caregiver because the member is away from the AFC-qualified setting for nonmedical reasons.

Provider. An organization that meets the requirements of 130 CMR 408.000: Adult Foster Care and that contracts with MassHealth to provide adult foster care or group adult foster care to eligible MassHealth members.

Publicly Aided Individual. A person who receives health care and other services for which a governmental unit is in whole or in part liable under a statutory program of public assistance.

Service Code. The standardized code from the Healthcare Common Procedure Coding System (HCPCS).

Final Adoption Date Appears in Mass Register: October 24, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 351.00: RATES FOR CERTAIN ADULT FOSTER CARE SERVICES

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351.03 Rate Provisions

351.03: Rate Provisions

(1) Reimbursement as Full Payment. The payment rates in 101 CMR 351.00 are full compensation for all adult foster care services or group adult foster care services rendered to members, including any related administrative or supervisory duties in connection with the provision of AFC services or GAFC services outlined in 130 CMR 408.000: Adult Foster Care.

(2) Payment Rates. The rates for AFC services, including GAFC services, are set forth in 101 CMR 351.03(2).

Service Code- Modifier Rate Unit Service Description S5140 $54.37 Per Diem AFC Level I S5140-TG $91.31 Per Diem AFC Level II S5140-TF $54.37 Per Diem AFC Level I Alternative Caregiver Day S5140-U5 $91.31 Per Diem AFC Level II Alternative Caregiver Day S5140-U6 $54.37 Per Diem AFC Level I MLOA Day S5140-TG-U6 $91.31 Per Diem AFC Level II MLOA Day S5140-U7 $54.37 Per Diem AFC Level I NMLOA Day S5140-TG-U7 $91.31 Per Diem AFC Level II NMLOA Day T1028 $266.62 Per Admission AFC Intake and Assessment Services H0043 $50.00 Per Diem GAFC

351.04 Filing and Reporting Requirements

351.04: Filing and Reporting Requirements

(1) Required Reports. Reporting requirements are governed by 957 CMR 6.00: Cost Reporting Requirements.

(2) Penalty for Noncompliance. A purchasing governmental unit may impose a penalty in the amount of up to 15% of its payments to any provider that fails to submit required information. The purchasing governmental unit will notify the provider in advance of its intention to impose a penalty under 101 CMR 351.04(2).

351.05 Severability

351.05: Severability

The provisions of 101 CMR 351.00 are severable. If any provision of 101 CMR 351.00 or application of any provision to an applicable individual, entity, or circumstance is held invalid or unconstitutional, that holding will not be construed to affect the validity or constitutionality of any remaining provisions of 101 CMR 351.00 or application of those provisions to applicable individuals, entities, or circumstances.

REGULATORY AUTHORITY

101 CMR 351.00: M.G.L. c. 118E.