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Who is eligible?

ACO and MCOs refer individuals with complex LTSS needs to Community Partners. ACOs and MCOs will identify members with complex LTSS needs through a number of mechanisms including:

  • Care Needs Screening
  • Member self-referrals
  • Referrals from CPs, providers, or other individuals familiar with the member

The LTSS CP Focus population of individuals with complex LTSS needs are MassHealth Members with $300 plus spend on LTSS over 3 consecutive months. Examples of eligible participants will include those who receive the following services:

  • PCA Services
  • Home Health
  • Independent Nurse
  • Adult Foster Care
  • Group Adult Foster Care
  • Adult Day Health
  • Day Habilitation

Other criteria include:

  • Individuals with complex LTSS needs
  • Individuals with brain injury or cognitive impairments
  • Individuals with physical disabilities
  • Individuals with Intellectual Disabilities and Developmental Disabilities (I/DD), including Autism
  • Older adults (up to age 64) with LTSS needs
  • Children and youth (ages 3 - 21) with LTSS needs

​Eligible Clients must live in any of these regions

Referrals for MCCN Care Coordination services can be made for individuals living in any of the Massachusetts northern, central, and southern regions where we operate:


Regional Network

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