CurrentMass General Brigham Health PlanPolicy N/A

Day Habilitation Services Reimbursement

Governs reimbursement and billing rules for day habilitation services for Mass General Brigham Health Plan members, including prior authorization requirements for dual-eligible (Medicare & Medicaid) members and provider payment guidelines.

Policy Summary

PayerMass General Brigham Health Plan

PolicyDay Habilitation Services Reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJanuary 1, 2026

Next Review DateN/A

Key ActionA day habilitation provider must request prior authorization for all medically necessary, reimbursable services (applies to dual-eligible members).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

S5102/S5101/S5100Primary codes referenced

1 unitMax units per DOS

one-timeS5105 payment

requiredPrior auth

auditedClaims edits

Coverage Criteria

Coverage is available when services are medically necessary, consistent with the member's benefit plan, billed using the specified codes/units, and prior authorization and billing rules are followed.

ALL of the following

Member is dual-eligible (Medicare & Medicaid) or otherwise eligible for day habilitation under the member's benefit plan.
Per Mass General Brigham Health Plan eligibility and benefit definitions.
Services are provided to individuals with an intellectual disability (ID) or developmental disability (DD) and are supported by a Day Habilitation Service Plan (DHSP) that documents measurable goals, objectives, and an integrated program of activities/therapies necessary to achieve those goals.
See Definitions: Day Habilitation (codes S5102, S5101, S5100).
Services are billed using the appropriate day habilitation codes (S5102, S5101, S5100) with correct per diem/half per diem/quarter per diem unit selection: per diem for >3 hours, half per diem for 1.5–3 hours, quarter per diem for <1.5 hours; maximum one unit per claim date of service.
Provider must follow CPT/HCPCS/ICD-10 and modifier guidance; CMS/AMA coding updates apply.
Day Habilitation Admission Services (S5105) are billed as a one-time lifetime payment for members enrolling in day habilitation services for the first time, and Day Habilitation Re-engagement Services (S5105 with appropriate modifier/usage) are billed as a one-time claim for returning members meeting the specified re-engagement period criteria.
Admission and re-engagement payments are paid on or after the 45th day of service; one-time-only per MassHealth ID.
Any associated transportation is billed separately using T2003 with the appropriate modifier for nonemergency, wheelchair, or monitor transportation; transport services must be billed as one-way trips (round trips billed as two one-way trips) and units follow T2003 rules.
See Provider Payment Guidelines for T2003 mapping and unit rules.
Prior authorization is obtained when required: a day habilitation provider must request prior authorization for all medically necessary, reimbursable services as specified by the plan and network/contract rules.
Failure to obtain required prior authorization may result in denial or payment reduction.
Reimbursement follows the plan's network provider reimbursement or contracted rates; claims are subject to payment edits, member liability (copay, deductible, coinsurance) per the member's benefit plan, and services considered incidental, mutually exclusive, integral, or part of a global allowance are not separately reimbursable.
Providers must follow General Coding and Billing guidelines and payer-specific payment policies.

Coding and Billing Rules

Day habilitation and related transportation/admission codesHCPCSCovered

S5102	Day care services, adult, per diem - day habilitation, community based, levels 1-4
S5101	Day care services, adult, half per diem - day habilitation, community based, levels 1-3
S5100	Day care services, adult, quarter per diem - day habilitation, community based, levels 1-4
S5105	Admission services / re-engagement services - one-time payment per member
T2003	Nonemergency transportation (one-way trips billed separately)

Maximum units per date of service

Maximum units per date of serviceOne unit per claim date of service for day habilitation codes (S5102, S5101, S5100). Per diem = >3 hours; half per diem = 1.5–3 hours; quarter per diem = <1.5 hours.

Applies to day habilitation codes onlyThe maximum allowable units apply only to day habilitation service codes S5102, S5101, and S5100.

Unit definitions by hours attendedPer diem unit used for service greater than three hours per day; half per diem for 1.5–3 hours; quarter per diem for under 1.5 hours.

Transportation billing rule

One-way trip billingAll transportation services must be billed as one-way trips; round trips should be billed as two one-way trips.

Applicable codeUse T2003 for nonemergency transportation; include appropriate encounter/trip modifiers for ambulatory, wheelchair, or monitor transport.

Service timingT2003 is used for transportation furnished on a single date or on consecutive dates.

S5105 timing

Timing of paymentS5105 is payable on or after the 45th day of service.

One-time-only claimS5105 is a one-time lifetime payment; one-time-only claim per MassHealth ID.

Use casesUse S5105 for admission services and for re-engagement when member meets re-engagement criteria (returning members who lacked center-based services between March 24, 2020 and June 30, 2023).

Provider Actions and Authorization

Prior Authorization

Prior authorization required for dual-eligible members

A day habilitation provider must request prior authorization for all medically necessary, reimbursable services for dual-eligible (Medicare & Medicaid) members.

Note

Where to find referral and prior authorization requirements

Various services and procedures require referral and/or prior authorization; providers should consult the plan resources linked in the policy for referral and prior authorization requirement details.

Referral and prior authorization requirement information can be located via the plan resources referenced in the policy.
Follow current CPT, HCPCS Level II, and ICD-10-CM code guidance and CMS/CPT modifier rules when submitting authorization requests.

Definitions

Day Habilitation

DefinitionService for individuals with an intellectual disability (ID) or a developmental disability (DD) that is based on a day habilitation service plan (DHSP) with measurable goals and an integrated program of activities and therapies.

Plan requirementMust be based on a DHSP that sets forth measurable goals and objectives.

Service componentsPrescribes an integrated program of activities and therapies necessary to reach stated goals and objectives.

Day Habilitation Admission Services

DefinitionServices provided to ensure safe and appropriate care planning for members enrolling in day habilitation services for the first time.

PurposeUsed to establish care plans and ensure safe initiation of day habilitation services.

Associated codeAdmission services are billed using S5105 as a one-time lifetime payment per member enrolling for the first time.

Day Habilitation Re-engagement Services

DefinitionServices provided to ensure successful re-engagement of members who have not received site-based services during March 24, 2020 through June 30, 2023.

PaymentRe-engagement services may be billed using S5105 as a one-time-only claim per MassHealth ID, paid on or after the 45th day of service with sustainable re-engagement in center-based services.

Eligibility windowSpecifically applies to members who did not receive center-based services between March 24, 2020 and June 30, 2023.