CurrentMass General Brigham Health PlanPolicy 092

Medical Necessity Guidelines — Day Habilitation

Guidelines governing medical necessity determinations for day habilitation services for Mass General Brigham Health Plan members, with specific coverage rules for One Care and SCO; other products (Medicare Advantage, ACO, Commercial) are not covered.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Necessity Guidelines — Day Habilitation

Policy CodePolicy 092

Change TypeOperational (reformat and clarifying paragraph)

Effective DateJan 1, 2026

Next Review DateJun 1, 2026

Key ActionObtain prior authorization for One Care and SCO members and document PCP certification of intellectual/developmental disability and need for day habilitation.

SourceLink

POLICY UPDATE CHANGES

Reformatted policy and added paragraph to clarify criteria; updated list of related policies.

coveredOne Care & SCO

not coveredMedicare Advantage

not coveredCommercial/QHP

≤5 days/wk, 6 hrs/dayService limits

S5100–S5102Example codes

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Coverage Criteria for Day Habilitation

One Care and SCO Medical Necessity Criteria

Covered when ALL of the following are met for One Care and SCO members:

Non–nursing-facility residents: Member has an intellectual or developmental disability as certified by the member's primary care provider (PCP) AND the member needs day habilitation to acquire, improve, or retain their maximum skill level and independent functioning.

PCP certification required; aligns with MassHealth Day Habilitation Manual

Nursing facility residents: Department of Developmental Services (DDS) Level II Preadmission Screening and Resident Review (PASRR) must determine the member requires specialized services.

Applies when member is in a nursing facility

Members receiving hospice: Day habilitation provider must obtain written confirmation from the hospice provider that day habilitation services are not related to the member's terminal illness and are not equivalent to or duplicative of hospice services.

Documentation requirement to avoid duplication with hospice care

Exclusions and partial-coverage rules for day habilitation align with MassHealth rate and site requirements. Services are excluded when they occur during any portion of a day that is outside the approved rate structure and the member is not receiving scheduled services from the day habilitation provider unless the provider documents that staff were delivering services in a community setting. Coverage does not apply when the member’s needs can no longer be met by day habilitation as determined by the PCP and the interdisciplinary team or by a qualified representative of MassHealth, DDS, or DPH. Days or portions of days outside the rate structure that consist of vocational/prevocational training, work-related services, educational services, or social/vocational/recreational services not administered through the DH provider are excluded. Services provided to members residing in intermediate care facilities for individuals with intellectual disabilities are excluded. Claims billed above the approved census are excluded.

Day habilitation is not a covered service for the following product lines: Medicare Advantage, Mass General Brigham ACO, and Commercial and Qualified Health Plans.

Coding and Service Limits

Informational HCPCS/Service CodesHCPCS

S5100	Skills training and development, quarter per diem.
S5101	Half per diem - Skills training and development, half per diem.
S5102	Skills training and development, per diem

Service frequency/duration limits

Maximum days per weekNo more than 5 days per week

Maximum hours per dayNo more than 6 hours per day

ApplicabilityLimit applies per member to day habilitation services

Provider Actions, Authorization, and Documentation

Prior Authorization

Prior Authorization — One Care & SCO

Prior authorization is required for One Care and Senior Care Options (SCO) members. Mass General Brigham Health Plan follows CMS guidance (NCDs, LCDs, LCAs, Medicare manuals) for medical necessity determinations; when CMS guidance is absent, Mass General Brigham Health Plan follows MassHealth criteria. CMS does not provide guidance for day habilitation; MassHealth Day Habilitation Manual and 130 CMR 419.000 inform reviews.

One Care & SCO: prior authorization required
Mass General Brigham Health Plan uses CMS guidance when available; otherwise MassHealth criteria apply

Note

Provider Note — Documentation and Clinical Rationale

Actionable provider note: ensure the member meets plan-specific eligibility and documentation requirements before submitting authorization requests. If a regulation or guidance is unclear, include supporting clinical rationale and references to MassHealth Day Habilitation Manual or relevant state regulations.

Include clinical rationale when regulations lack specificity

Key Definitions

Developmental Disability — definition

Core definitionA severe, chronic disability attributable to conditions closely related to intellectual disability that requires similar treatment or services

Onset ageManifested before 22 years of age

ChronicityLikely to continue indefinitely

Severity/functional impactResults in substantial functional limitations in three or more major areas (self-care; language; learning; mobility; self-direction; capacity for independent living)

Intellectual Disability — definition

Core definitionSignificant limitations in both intellectual functioning and adaptive behavior expressed in conceptual, social, and practical skills

Background

Day habilitation services are intended to support individuals with an intellectual or developmental disability to acquire, improve, or retain skills and promote maximum independent functioning. For non–nursing-facility members, the PCP must certify that the member has an intellectual or developmental disability and that day habilitation is needed to achieve or maintain their maximum skill level. For members in nursing facilities, a DDS Level II PASRR determination is required to establish the need for specialized services. If a member is receiving hospice, written confirmation from hospice is required to show services are not related to the terminal illness and are not duplicative of hospice care.

Revision History

2026-06annual_reviewLatest

Annual review completed; policy reformatted, a clarifying paragraph was added to the criteria section, and the list of related policies was updated.

2026-01-01effective_date

Policy effective date established.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Necessity Guidelines — Day Habilitation

Policy CodePolicy 092

Change TypeOperational (reformat and clarifying paragraph)

Effective DateJan 1, 2026

Next Review DateJun 1, 2026

Key ActionObtain prior authorization for One Care and SCO members and document PCP certification of intellectual/developmental disability and need for day habilitation.

SourceLink

On This Page

Reference MassHealth Day Habilitation Manual when applicable

Documentation Required

Required Documentation

Required documentation must include: primary care provider (PCP) certification that the member has an intellectual or developmental disability, and documentation that day habilitation is needed to acquire, improve, or retain the member's maximum skill level and independent functioning. For nursing facility residents, include DDS Level II PASRR determination that specialized services are required. If the member is receiving hospice, include written confirmation from hospice that day habilitation services are not related to terminal illness and are not duplicative of hospice.

PCP certification of intellectual/developmental disability
Documentation that day habilitation is needed to acquire, improve, or retain skills and independent functioning
DDS Level II PASRR for nursing facility residents
Written confirmation from hospice when applicable

Denial Risk

Triggers for Denial

Requests may be denied when required documentation is missing or when members do not meet MassHealth-aligned eligibility criteria. Examples of denial triggers include: absence of PCP certification of intellectual/developmental disability; lack of documentation that day habilitation is needed to acquire, improve, or retain skills; no DDS Level II PASRR for nursing facility residents requiring specialized services; or services that meet exclusion criteria (e.g., services outside approved rate structure, vocational/educational/work services, care in unapproved sites, more than five days/week or six hours/day, services after discharge effective date, claims billed above approved census).

Missing PCP certification of intellectual/developmental disability
No documentation that day habilitation is needed to acquire/improve/retain skills
Missing DDS Level II PASRR when member is a nursing facility resident
Services meeting exclusion criteria listed by MassHealth (see exclusions)

Onset ageOriginates before 22 years of age

Standards referencedConsistent with AAIDD 12th edition definition (2021) or subsequent publication

Level II PASRR — definition

Regulatory basisDDS-conducted evaluation per 42 CFR 483.100

PurposeDetermine whether an individual seeking admission or continued stay in a Medicaid nursing facility has an intellectual or other developmental disability

Outcome assessedWhether the individual requires the level of services provided by a nursing facility and whether specialized services are required