GAFC Conditions for Payment

(A) The MassHealth agency pays a GAFC provider for GAFC in accordance with the applicable payment methodology and rate schedule established by the EOHHS. Rates of payment for GAFC do not cover or include any amount for room and board. (B) Payment for GAFC 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 a GAFC provider for GAFC only if (1) the member receiving GAFC is eligible under 130 CMR 408.503; (2) the member meets the clinical eligibility criteria for GAFC in accordance with 130 CMR 408.506; (3) the GAFC provider has obtained prior authorization for GAFC in accordance with 130 CMR 408.507; (4) the GAFC provider bills for GAFC provided by direct care aides with the use of electronic visit verification (EVV) in the form and format as required by EOHHS; and (5) the GAFC provider is not billing for days that are non-covered days under 130 CMR 408.526. (D) If a member changes from one GAFC provider to another GAFC provider, a new assessment is required and the new GAFC provider must obtain prior authorization. The previous GAFC provider must continue to provide GAFC to the member while the new GAFC provider is obtaining prior authorization and until the member is admitted and receiving services from the new GAFC provider. The previous GAFC provider must discharge the member from its GAFC program before the new GAFC provider may bill the MassHealth agency for GAFC. The MassHealth agency will pay only one GAFC provider per day for the provision of GAFC to a member. (E) The GAFC provider must review each member in its care to ensure that clinical eligibility criteria for GAFC continue to be met. A GAFC provider must not bill and the MassHealth agency will not pay for any member who does not meet the clinical criteria for GAFC. (F) MassHealth payment to GAFC 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 GAFC is provided to the member. (G) MassHealth payment to a GAFC provider ends on the date on which a member no longer meets the clinical criteria for GAFC described in 130 CMR 408.456, is no longer receiving GAFC, or no longer has a prior authorization in effect, whichever comes first. (H) The MassHealth agency pays a GAFC provider for days that an eligible member receives GAFC services. A GAFC 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 GAFC. (130 CMR 408.510 through 408.520 Reserved)