Why Might My Loved One Not Qualify for Adult Foster Care in Massachusetts?

By Mass Care Link Editorial Team

Adult Foster Care eligibility in Massachusetts depends on more than a diagnosis. A parent, adult child, sibling, relative, or friend may need meaningful help at home and still face an eligibility problem involving MassHealth coverage, daily care needs, the caregiver relationship, the living arrangement, safety, or missing documentation.

If you were told that your loved one may not qualify, do not assume that the answer explains the whole situation. First, identify the specific requirement that is not met. That will help your family determine whether more information is needed, whether the proposed caregiver arrangement must change, or whether another MassHealth service may be a better fit.

What Does Adult Foster Care Eligibility Depend On?

MassHealth Adult Foster Care supports eligible members who need daily help with personal care and can safely live in a qualified home setting with a live-in caregiver. Under the MassHealth Adult Foster Care regulations, eligibility generally depends on several requirements working together.

• The potential member must have qualifying MassHealth coverage.
• The potential member must be at least 16 years old.
• The person must need daily physical assistance or cueing and supervision with at least one qualifying activity of daily living.
• The member and caregiver must live together in the same qualified home setting.
• The caregiver and home must meet applicable program requirements.
• MassHealth must determine that the service is medically necessary and authorize it.

A diagnosis, disability, or need for general supervision does not automatically establish eligibility. The assessment focuses on what the person needs help doing each day and whether Adult Foster Care is the appropriate way to provide that support.

For a broader overview, read our guide to Adult Foster Care in Massachusetts.

1. Your Loved One May Not Have Qualifying MassHealth Coverage

One of the first Adult Foster Care eligibility checks is the person’s current MassHealth coverage. MassHealth Standard and CommonHealth are generally qualifying coverage types. Certain integrated care plans may also cover the service, depending on the person’s enrollment.

Medicare, a commercial health plan, or another form of insurance by itself does not qualify someone for MassHealth Adult Foster Care. A person who has Medicare may still qualify if they also have an eligible MassHealth benefit.

If you are unsure about the coverage listed on the member’s account, verify it before concluding that the program is unavailable. Our MassHealth frequently asked questions explain several common coverage issues.

2. The Person May Not Need Daily Help With a Qualifying Activity

A medical diagnosis and a qualifying functional need are not the same thing. Adult Foster Care focuses on the person’s need for daily physical assistance or cueing and supervision with an activity of daily living, commonly called an ADL.

Qualifying ADLs may include:

• Bathing
• Personal hygiene or grooming
• Dressing
• Eating
• Toileting
• Walking or mobility
• Transferring, such as getting into or out of a bed or chair

For example, someone may live with diabetes, arthritis, or another chronic condition but still complete all personal-care activities independently. The diagnosis may be serious, but it may not establish the type of daily assistance required for Adult Foster Care.

Families should explain both the task and the type of help required. “She has difficulty dressing” is less useful than “She needs hands-on help putting on pants and fastening clothing every morning.” Specific examples help the clinical team understand the person’s actual functional needs.

3. The Proposed Caregiver May Not Meet the Rules

A qualified family member, friend, or other adult may serve as the live-in caregiver, but MassHealth excludes certain relationships. A spouse or court-appointed legal guardian cannot receive payment as the Adult Foster Care caregiver. A parent also cannot serve as the paid caregiver for their child who is under age 18.

This does not always mean the potential member is ineligible for services. In some situations, the family may be able to identify another qualified caregiver who lives with the member and can provide the required daily care.

The caregiver must also meet the program’s applicable screening, training, availability, and care requirements. Learn more about how to qualify for Adult Foster Care.

4. The Member and Caregiver May Not Live Together

Adult Foster Care is a live-in caregiver program. The member and caregiver must share the same qualified home setting. A caregiver who visits during the day but lives somewhere else does not meet the program’s live-in requirement.

Families sometimes plan for a caregiver to move in later. The admissions team can explain the requirement, but the living arrangement must satisfy program rules before placement can occur.

5. The Home Setting or Level of Care May Not Be Appropriate

The program is designed for people who can safely receive care in a home setting with caregiver support and professional oversight. The assessment considers the member’s health, behavior, mobility, supervision needs, emergency risks, and the suitability of the home.

If the person’s needs cannot be safely managed through the Adult Foster Care model, a different service or care arrangement may be appropriate. Needing more care does not necessarily make someone more eligible. The service must match the person’s needs and allow care to be delivered safely at home.

6. The Documentation May Not Clearly Establish Medical Necessity

Sometimes a family has described real care needs, but the available records do not document them clearly enough. MassHealth requires prior authorization and reviews clinical information to determine medical necessity.

The application process may require a recent physical examination, a written order from the primary care provider, clinical assessments, information about the caregiver and home, and other supporting records. Missing, outdated, inconsistent, or vague documentation can delay the review or prevent approval.

When describing a typical day, include details such as:

• Which personal-care activities require help
• Whether the person needs hands-on assistance, cueing, or supervision
• How often the help is needed
• What may happen if the assistance is not provided
• Whether the need is consistent with the medical record

Our guide to what to expect after applying explains the general review process.

What Should You Do After an Eligibility Concern or Denial?

Start by asking for the exact reason. Do not settle for a general statement that the person “does not qualify.” Determine whether the issue concerns coverage, age, an ADL need, the caregiver relationship, the living arrangement, home safety, medical necessity, or missing documentation.

Next, review the information that was submitted. If the records do not accurately describe the person’s daily needs, ask the appropriate health care professional or program representative what additional information may be required. If MassHealth issued a formal denial, review the written notice carefully because it may contain appeal rights and deadlines.

Finally, consider whether another program better matches the person’s needs. A family should not assume that ineligibility for Adult Foster Care means that no home-care assistance is available.

Could Another MassHealth Program Be a Better Fit?

Adult Foster Care is only one MassHealth home and community-based service. The Personal Care Attendant Program uses a self-directed model in which the member generally recruits, hires, trains, schedules, and manages personal care attendants. Group Adult Foster Care uses a different service structure for eligible members living in qualifying settings.

These services have different eligibility standards and caregiver arrangements. They generally cannot be used at the same time as Adult Foster Care when the services would duplicate one another. MassHealth or an appropriate provider can help the family explore which option may fit the member’s circumstances.

Get Help Reviewing Adult Foster Care Eligibility

Mass Care Link helps Massachusetts families understand Adult Foster Care eligibility, gather the required information, complete clinical assessments, and navigate the MassHealth authorization process. We cannot guarantee approval, but we can help your family understand the requirements and identify the appropriate next step.

Ready to find out whether your loved one may qualify? Complete our short prequalification form or call 866-880-8889, Monday through Friday from 8:30 a.m. to 4:30 p.m.

Frequently Asked Questions

Does having a disability automatically qualify someone for Adult Foster Care?

No. A disability or medical diagnosis alone does not establish eligibility. MassHealth also considers qualifying coverage, daily functional needs, medical necessity, the caregiver and living arrangement, the home setting, and supporting documentation.

Does someone have to need help with bathing?

No. Bathing is one qualifying activity of daily living, but others include personal hygiene or grooming, dressing, eating, toileting, walking or mobility, and transferring. The person must need daily physical assistance or cueing and supervision with at least one qualifying ADL.

Can a family member be the caregiver?

In many circumstances, yes. However, a spouse or court-appointed legal guardian cannot serve as the paid caregiver, and a parent cannot serve as the paid caregiver for a child under age 18. The caregiver must also meet all other program requirements.

Does the caregiver have to live with the member?

Yes. Adult Foster Care requires the member and caregiver to live together in the same qualified home setting.

Can someone receive PCA and Adult Foster Care at the same time?

Generally, no. MassHealth does not allow duplicative personal-care services. If the person already receives PCA services, the family should discuss the timing and transition requirements before enrolling in Adult Foster Care.

What if my loved one does not qualify?

Identify the specific reason first. Depending on the circumstances, the family may need to provide additional documentation, consider a different qualified caregiver or living arrangement, review any appeal rights, or explore another MassHealth service.