Home care billing in Massachusetts

Key facts for Massachusetts home care billing

Programs that pay for home care in Massachusetts¹

• Frail Elder Waiver (0059.R08.00)

  Home health aide, homemaker, personal care, respite, supportive home care aide, chore, companion, laundry, grocery shopping and delivery, home delivered meals, Alzheimer's and dementia coaching, complex care training and oversight, personal emergency response systems, environmental accessibility adaptations, assistive technology, medication dispensing, transitional assistance, transportation and virtual communication and monitoring, for people with physical disabilities ages 60 to 64 and people 65 and older who meet a nursing facility level of care.

  Senior Care Options plans cover all MassHealth long-term services and supports and all Frail Elder Waiver services for their enrollees, so a waiver participant in SCO is the plan's member for home care claims.

• Moving Forward Plan Community Living Waiver (MFP-CL, 1027.R02.00) and Acquired Brain Injury Non-Residential Habilitation Waiver (ABI-N, 40702.R03.00)

  Home health aide, homemaker, personal care, skilled nursing, supportive home care aide, respite, adult companion, chore, laundry, physical, occupational and speech therapy, individual support and community habilitation, home accessibility adaptations, home delivered meals, specialized medical equipment, transitional assistance and transportation. MFP-CL serves people 65 and older, people with physical disabilities ages 18 to 64 and people with mental illness 18 and older who meet a hospital or nursing facility level of care; ABI-N serves people with brain injury 22 and older at the same level of care.

  Participants in the ABI and MFP waivers may self-direct adult companion, chore, homemaker, personal care and peer support with direct care workers they hire, paid through the state's fiscal intermediary against the frequency and duration in the waiver plan of care; HCBS Waiver Provider Bulletin 27 sets a 60-hour weekly limit per worker from July 3, 2026 and EVV timesheets for self-directed services beginning in fall 2026.

• Department of Developmental Services waivers (Community Living 0826.R03.00, Adult Supports 0828.R03.00, Intensive Supports 0827.R03.00)

  Individualized home supports, live-in caregiver (Community Living and Intensive Supports), residential habilitation and 24-hour supports (Intensive Supports), respite, adult companion, chore, individualized and community based day supports, supported employment, behavioral supports, family training, home modifications, specialized medical equipment and supplies, remote supports and monitoring, transportation and vehicle modifications, for people with intellectual disabilities 22 and older who meet an ICF/IID level of care.

• MassHealth Personal Care Attendant program (130 CMR 422.000)

  PCA services for members with a permanent or chronic disability who need physical assistance with two or more activities of daily living. A personal care management agency the member selects performs the evaluation and requests prior authorization, and a fiscal intermediary under contract with MassHealth performs the employer tasks for the PCAs the member hires.

  Transmittal Letter PCA-27 amends the regulations effective July 3, 2026 with a seven-hour weekly cap on authorized meal preparation time and a 60-hour weekly maximum per PCA. The initial PA request is due within 45 days of the PCP Summary Form, and a continuation request must reach MassHealth at least 21 days before the current authorization expires or payment may stop at the expiration date.

• MassHealth home health agency services (130 CMR 403.000)

  Intermittent skilled nursing visits, medication administration visits, physical, occupational and speech-language therapy and home health aide services in the member's home, with prior authorization after a set number of visits in a calendar year.

  Home Health Agency Bulletin 96 reiterates 130 CMR 403.416(A): aide services are payable only when medically necessary to directly support concurrent nursing or therapy or to give hands-on assistance through an activity of daily living, and only at the direction of an RN or therapist.

Common rejections in Massachusetts, and the fix

• Claim received after the 90-day deadline

  The fixMassHealth must receive the claim within 90 days of the date of service or of the other insurer's EOB. The biller files each visit as soon as it is verified, measures consecutive-day services from the latest date, and files an electronic 90-day waiver request only for the listed exceptions, such as a member enrolled retroactively for the date of service.

• Paper claim rejected

  The fixEvery claim goes to MassHealth electronically unless the agency holds an electronic claim submission waiver, which runs 12 months and must be renewed 30 days before it ends. The biller submits 837I transactions or direct data entry and keeps paper for nothing but a waived agency.

• Home health visits beyond the threshold without prior authorization

  The fixSkilled nursing and medication administration visits need PA after 30 combined in a calendar year, aide services after 240 units, physical and occupational therapy after 20 visits and speech-language therapy after 35. The biller counts visits per member per calendar year and files in the LTSS Provider Portal at least 21 days before the trigger with the plan of care, assessment note and three visit notes.

• Renewal filed after the authorization expired

  The fixMassHealth does not approve services retroactively when the request comes in after the PA expires, and renewals are due 21 days before the authorized end date. The biller calendars every PA end date at approval and uses the expedited path only for the post-acute discharges Bulletin 93 covers.

• Dual-eligible claim denied for third-party liability

  The fixMedicare must be demand billed at the start of services and every 12 months, and again after a qualifying event, unless the member is not homebound or receives only medication administration visits. When Medicare or a commercial carrier finds the service not covered, the biller files the 837I with claim filing indicator MA or CI, the A8 total noncovered amount equal to the billed amount and the MassHealth carrier code, and keeps the remittance or EOB on file.

• Home health aide visits without a concurrent skilled need

  The fixUnder 130 CMR 403.416(A) aide services are payable only to directly support concurrent nursing or therapy or to give hands-on help through an ADL task, at an RN's or therapist's direction. The biller checks that the aide's plan of care is tied to an active skilled service before the visit is billed.

• Visit missing in Sandata or recorded in an unregistered system

  The fixFee-for-service agencies must be registered with Sandata directly or through a registered alternate EVV system, meet the auto-approved verified visit threshold, and, once claims edits are live, have a correctly entered visit behind every claim. The biller watches the share of visits that need manual correction and clears them before billing rather than after a notice of non-compliance.

• PCA continuation request filed inside the 21-day window

  The fixMassHealth keeps paying PCA services during review only when the personal care management agency's continuation request arrived at least 21 days before the current authorization expires. The biller tracks the expiration date for each consumer and confirms the PCM agency's submission date against it.