Section 408.419 - Conditions for Payment(A) The MassHealth agency pays an AFC provider for AFC in accordance with the applicable payment methodology and rate schedule established by the EOHHS. Rates of payment for AFC do not cover or include any amount for room and board.(B) Payment for AFC is subject to the conditions, exclusions, and limitations set forth in 130 CMR 408.000 and 130 CMR 450.000: Administrative and Billing Regulations.(C) The MassHealth agency pays an AFC provider for AFC only if (1) the person receiving AFC is eligible under 130 CMR 408.403;(2) the member meets the clinical eligibility criteria for AFC in accordance with 130 CMR 408.416;(3) the AFC provider has obtained prior authorization for AFC in accordance with130 CMR 408.417.(4) the member resides in an AFC-qualified setting in accordance with 130 CMR 408.435;(5) the AFC provider bills at the payment level authorized by the MassHealth agency or its designee; and(6) the AFC provider is not billing for days that are non-covered days under 130 CMR 408.437.(D) AFC Payments are made as follows. (1)AFC Level I Service Payment. The MassHealth agency will pay the level I service payment rate if a member requires hands-on (physical) assistance with one or two of the activities described in 130 CMR 408.416 or requires cueing and supervision throughout one or more of the activities listed in 130 CMR 408.416 in order for the member to complete the activity.(2)AFC Level II Service Payment. The MassHealth agency will pay the level II service payment rate for members who require (a) hands-on (physical) assistance with at least three of the activities described in 130 CMR 408.416; or(b) hands-on (physical) assistance with at least two of the activities described in 130 CMR 408.416 and management of behaviors that require frequent caregiver intervention as described in 130 CMR 408.419(D)(2)(b)1. through 5.1. wandering: moving with no rational purpose, seemingly oblivious to needs or safety;2. verbally abusive behavioral symptoms: threatening, screaming, or cursing at others;3. physically abusive behavioral symptoms: hitting, shoving, or scratching;4. socially inappropriate or disruptive behavioral symptoms: disruptive sounds, noisiness, screaming, self-abusive acts, disrobing in public, smearing or throwing food or feces, rummaging, repetitive behavior, or causing general disruption; or(3)Intake and Assessment Services. The MassHealth agency will pay the intake and assessment rate for preadmission intake and assessment services as outlined in 130 CMR 408.431(A). In order to bill for the intake and assessment rate, an AFC provider must complete the tasks described in 130 CMR 408.431(A).(E) If a member changes from one AFC provider to another AFC provider, a new assessment is required and the new AFC provider must obtain prior authorization. The previous AFC provider must continue to provide AFC to the member while the new AFC provider is obtaining prior authorization and until the member is admitted and receiving services from the new AFC provider. The previous AFC provider must discharge the member from its AFC program before the new AFC provider may bill the MassHealth agency for AFC. The MassHealth agency will pay only one AFC provider per day for the provision of AFC to a member.(F) The AFC provider must review each member in its care to ensure that clinical eligibility criteria for AFC continue to be met. An AFC provider must not bill and the MassHealth agency will not pay for any member who does not meet the clinical criteria for AFC.(G) MassHealth payment to AFC providers begins on the later of (1) the effective date of the prior authorization from the MassHealth agency; or(2) the first date on which AFC is provided to the member.(H) MassHealth payment to an AFC provider ends on the date on which a member no longer meets the clinical criteria for AFC described in 130 CMR 408.416, is no longer receiving AFC, or no longer has a prior authorization in effect, whichever comes first.(I) The MassHealth agency pays an AFC provider for days that an eligible member receives AFC. An AFC provider may not bill for non-service days and the MassHealth agency does not pay for any period during which an eligible member does not receive AFC, with the exception of a medical leave of absence or nonmedical leave of absence. The MassHealth agency does not pay an AFC provider for non-covered days, which includes days when the AFC caregiver or setting has become unqualified for any reason, or a member has exhausted alternative caregiver days, MLOA days, or NMLOA days.(J) The MassHealth agency pays for a maximum of 40 days per member per calendar year for MLOA and up to 15 days per member per calendar year for NMLOA. Any unused leave-of-absence days follow the member when changing from one AFC provider to another AFC provider. MLOA and NMLOA days cannot be used interchangeably.(K) An AFC provider may bill for up to 14 alternative-caregiver days per member per calendar year. Any unused alternative caregiver days follow the member when changing from one AFC provider to another AFC provider.Amended by Mass Register Issue 1338, eff. 5/5/2017.Amended by Mass Register Issue 1472, eff. 7/1/2022.Amended by Mass Register Issue 1520, eff. 4/26/2024.