ModifiedNeighborhood Health Plan of Rhode IslandPolicy N/A

Adult Day Health Payment Policy – Archive 4

Defines Medicaid payment and billing rules for Adult Day Health programs in Rhode Island, including levels of care, eligibility/exclusions, billing modifiers, and claim submission requirements. Applies to Medicaid products (excludes certain Medicaid subprograms and commercial plans).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAdult Day Health Payment Policy – Archive 4

Policy CodePolicy N/A

Change TypeModified (2022 content reduction for Enhanced Level Skilled)

Effective DateSep 1, 2013

Next Review Date

Key ActionBill Basic Level with no modifier; bill Enhanced Level Non Skilled with modifier U1; bill Enhanced Level Skilled with modifiers U1 and U3.

SourceLink

POLICY UPDATE CHANGES

10/01/2022 Annual Policy Review Date. Removed additional criteria from policy for Enhanced Level Skilled.

09/29/2021 Annual Policy Review Date. No Content Changes.

09/14/2020 Policy Review Date. Format Change.

09/01/2013 Policy Effective Date.

3Defined Levels of Care

2Billable HCPCS Codes

5Named Exclusion Conditions

Policy Summary & Scope

Adult Day Health programs are comprehensive, nonresidential daytime programs for adults who return home at the end of the day and provide supervision plus health services such as nursing care, therapies, personal care assistance, social and recreational activities, meals, and related supports in a protective setting in accordance with Rhode Island EOHHS definitions and long-term services and supports levels of care. Programs must meet Rhode Island EOHHS minimums (members must meet at least the preventive level of care) and require an annual or change‑of‑condition face-to-face assessment with the member's primary care provider.

This policy defines three billable levels of Adult Day Health services: Basic Level (minimum of 4 hours per day up to 6 days per week; transportation included in the rate with total travel not to exceed 2 hours; therapies billed separately), Enhanced Level Non Skilled (Basic Level plus criteria such as daily assistance with ≥2 ADLs OR daily assistance with ≥1 skilled nursing service OR an ADL requiring two‑person assist OR diagnosis of dementia/mental health requiring staff intervention), and Enhanced Level Skilled (Enhanced Non‑Skilled plus need for skilled services within nursing, PT, OT, or ST disciplines; documentation in a signed care plan and required progress notes are required to bill).

The policy applies to Medicaid products only (excludes Extended Family Planning, Children with Special Health Care Needs <18, Substitute Care <18, and excludes commercial plans). Billing uses HCPCS codes S5101 (per half day) and S5102 (per diem); Basic Level is billed with no modifier, Enhanced Level Non Skilled requires modifier U1, and Enhanced Level Skilled requires modifiers U1 and U3. Claim submission must follow contractual timely‑filing, eligibility, coding and authorization requirements. (Policy effective 09/01/2013; most recent review 10/01/2022 — removed additional criteria for Enhanced Level Skilled.)

Effective date2013-09-01

Last review2022-10-01

Next review

Policy TitleAdult Day Health Payment Policy

Policy NumberN/A

StatusMODIFIED

Defined Levels of Care3

Billable HCPCS Codes2

Named Exclusion Conditions5

Medical Necessity & Eligibility Criteria

General Medical Necessity

All services must be medically necessary. Neighborhood may use the listed sources to determine medical necessity:

ALL of the following

Services are medically necessary as determined by Neighborhood using NCD, LCD, InterQual, EOHHS recommendations, and Neighborhood Clinical Medical Policies
Provider verifies eligibility, coverage and authorization prior to rendering services

Member Eligibility / Minimum Care Level

Member must meet all of the following

ALL of the following

Enrollment: Member is enrolled in Medicaid (excludes Extended Family Planning (EFP); Children with Special Health Care Needs (CSN) < 18 years; Substitute Care (SUB) < 18 years)
Minimum preventive level: Member meets, at minimum, the preventive level of care as determined by the EOHHS Office of Long Term Service Supports
PCP face-to-face assessment: Face-to-face assessment and reassessment with the member’s Primary Care Provider (PCP) is completed annually or if the member’s condition changes

Levels of Adult Day Health Services and Required Conditions to Bill

Service level definitions and required conditions for billing

One of the following levels

Basic Level
- Daily time requirement: Minimum of four (4) hours per day>= 4 hours/day
- Days per week: Up to six (6) days per week<= 6 days/week
- Transportation is included in the per diem or half day rate; total transportation not to exceed two (2) hours to and from home<= 2 hours total to and from home

Exclusions (Not Eligible)

Services are not eligible when the following conditions apply:

ANY of the following

Duplicative services: Admission would result in duplicative or substantially identical services as those provided by any other Medicaid funded service the individual has chosen
Residential facility resident: Resident of a residential health care facility
24-hour inpatient care: Receiving 24-hour inpatient care in a hospital or nursing home
Partial hospitalization same day: Receiving partial care/partial hospitalization program services on the same day

Billing, Documentation & Authorization Requirements

Billing Rule

Modifier Use by Level

Bill Basic Level with no modifier; bill Enhanced Level Non Skilled with modifier U1; bill Enhanced Level Skilled with modifiers U1 and U3.

Basic: S5101 or S5102 — no modifier
Enhanced Non Skilled: S5101 or S5102 — modifier U1
Enhanced Skilled: S5101 or S5102 — modifiers U1 and U3

Documentation Required

Care Plan and Progress Notes for Enhanced Levels

To bill Enhanced Levels, the adult day care must document the services required for that level in the care plan. The care plan must be signed by the participant or the participant's legal guardian or representative. Required progress notes must be completed and maintained to support Enhanced Level billing.

Care plan documenting services required for Enhanced Level
Care plan signed by participant or legal guardian/representative
Completion and retention of required progress notes

Prior Authorization

Verify Authorization and Eligibility

Verify member eligibility, coverage and authorization prior to rendering services. Refer to the plan-specific Prior Authorization Reference page and Neighborhood Clinical Medical Policies for authorization requirements.

Confirm Medicaid eligibility and that member meets required level of care
Check for required prior authorization per plan-specific Prior Authorization Reference page
Consult Neighborhood Clinical Medical Policies for clinical and authorization criteria

Billing Rule

Timely Filing

Submit complete claims for payment within the contractually determined timely filing guidelines. Claim payments are subject to member eligibility, contractual agreements, payer edits, coding and documentation rules, authorization policies, and audit.

Submit complete claims within contractually determined timely filing deadlines
Payments subject to eligibility verification, claims edit rules, coding/documentation guidelines, authorization policies, provider contract terms, and audit

Billing operational thresholds

Daily minimum hours for Basic Level>= 4 hours/day

Basic Level maximum days/week<= 6 days/week

Transportation maximum time<= 2 hours total to and from home

NoteThresholds apply to billing operations and inclusion in per diem/half-day rate

Key Terms

Adult Day Health programA comprehensive, nonresidential program addressing biological, psychological, and social needs via individual plans of health incorporating health, social and related support services in a protective setting (RI EOHHS definition).

Basic LevelMinimum of 4 hours per day up to 6 days per week; transportation included in rate; PT/OT/ST billed separately.

Enhanced Level Non SkilledBasic Level plus daily assistance with ≥2 ADLs OR ≥1 skilled nursing service daily (RN/LPN) OR an ADL requiring 2-person assist OR diagnosis of Alzheimer’s/related dementia or mental health diagnosis requiring staff intervention for safety.

Enhanced Level SkilledEnhanced Non Skilled plus need for skilled services by a physician within nursing, physical, occupational, or speech therapy disciplines; care plan must document services and be signed with required progress notes.

Policy Change Timeline

10/01/2022Removed additional criteria from policy for Enhanced Level Skilled.Latest