Clinical Eligibility Criteria for AFC

A member must meet the following clinical eligibility criteria for receipt of AFC. (A) AFC must be ordered by the member’s PCP. (B) The member has a medical or mental condition that requires daily hands-on (physical) assistance or cueing and supervision throughout the entire activity in order for the member to successfully complete at least one of the following activities: (1) Bathing: a full-body bath or shower or a sponge (partial) bath that may include washing and drying of face, chest, axillae (underarms), arms, hands, abdomen, back and peri-area that may include personal hygiene such as: combing or brushing of hair, oral care (including denture care and brushing of teeth), shaving, and, when applicable, applying make-up; (2) Dressing: upper and lower body, including street clothes and undergarments, but not solely help with shoes, socks, buttons, snaps, or zippers; (3) Toileting: member is incontinent (bladder or bowel) or requires assistance or routine catheter or colostomy care; (4) Transferring: member must be assisted or lifted to another position; (5) Mobility: (ambulation) - member must be physically steadied, assisted, or guided during ambulation indoors and outdoors, or is unable to self-propel a wheelchair appropriately without the assistance of another person; and (6) Eating: if the member requires constant supervision and cueing during the entire meal, or physical assistance with consuming a portion or all of the meal.