CurrentNeighborhood Health Plan of Rhode IslandPolicy Adult Health- # 058 Day

Adult Day Health / Adult Day Care services

Defines coverage criteria, levels of service (Basic, Enhanced Non-Skilled, Enhanced Skilled), provider and member eligibility, and coding/authorization instructions for Neighborhood Health Plan of Rhode Island lines of business listed in the document.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAdult Day Health / Adult Day Care services

Policy CodePolicy Adult Health- # 058 Day

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization for Skilled Enhanced Level claims and ensure Enhanced-level care plans and progress notes are completed, signed, and retained.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Service levels described (Basic, Enhanced Non-Skilled, Enhanced Skilled)

S5101,S5102Primary HCPCS codes listed for billing

AuthFor Skilled Enhanced Level

Eligibility and Service Levels

General Eligibility / Minimum Criteria

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ALL of the following

Member has a medical or mental dysfunction involving one or more physiological systems indicating need for nursing care, supervision, therapeutic or support services, and/or socialization.
Member requires services in a structured adult health (day) setting.
Adult day health service provider completes health assessment for admission, establishes oversight and monitoring involving a licensed nurse, and provides standard and ad hoc reporting.
Member has a personal physician who can attest to the member's need.
Member meets Preventive Level of Care as defined by RI EOHHS LTSS (minimum level to attend).
Specific RI EOHHS criteria referenced (Attachment D Level of Care Criteria).

Basic Level Coverage

Basic level adult day services (no prior authorization required) - member is entitled if minimum criteria are met and at least one of the following:

ANY of the following

Daily assistance on site with at least two (2) Activities of Daily Living (ADLs) as defined.
Daily assistance on site with at least one skilled service (from Skilled Services list) provided by an RN or LPN.
Daily assistance on site with at least one ADL that requires a two-person assist to complete.

Enhanced Level Coverage (Non-Skilled Enhanced)

Enhanced (Non-Skilled) level — documentation and care plan requirements to bill the Enhanced level:

ALL of the following

Adult care must document provision of services required for Enhanced level in the care plan.
Care plan must be signed by participant, legal guardian, or representative.
Completion of required progress notes must be documented.

Clinical triggers for Enhanced level (non-skilled)

Daily assistance on site with at least three (3) ADLs where supervision and cueing are needed to complete the ADLs.
Diagnosis of Alzheimer's disease, related dementia, or a mental health diagnosis with documented staff interventions for safety (e.g., elopement risk, inappropriate behaviors) documented in care plan and progress notes.

Enhanced Level - Skilled (Authorization Required)

Skilled Enhanced level requires prior authorization and both clinical criteria:

ALL of the following

Member meets criteria for Non-Skilled Enhanced level.
Member requires skilled services ordered by a physician within disciplines of physical, occupational, or speech therapy (even if assistance is not provided by the adult center).

Excluded / Not Eligible Situations

Members are ineligible for adult day health services in the following situations:

ANY of the following

Admission would result in duplicative or substantially identical services covered by another Medicaid-funded service the individual has chosen (e.g., home personal care attendant, physician office, hospital outpatient, partial hospitalization program, adult training program).
Resident of an assisted living or residential health care facility.
Receiving 24-hour inpatient care in a hospital or nursing home.
Receiving partial hospitalization program services on the same day as adult day health services.
Members enrolled in excluded lines of business: Extended Family Planning (EFP) and Health Benefit Exchange (HBE), Substitute Care (SUB) <19 years old, Children with Special Needs (CSN) <19 years old.

Specialty / Program Eligibility Notes

Additional program-specific eligibility:

ANY of the following

Members enrolled in specified waivers (Preventive, Core Community HCBS-LTSS, DEA or OHA Community, Habilitation Community, Shared Personal Choice, Intellectual Disabilities) may qualify to receive the service.
For HIV Medical Care services: member must be at least 18 years old with HIV infection (documented).

HCPCS / Billing Codes

Covered HCPCS / Billing CodesHCPCSCovered

S5101	Adult Day Care - Basic level (per document listing)
S5102	Adult Day Care - Basic level (per document listing)
S5101 U1	Adult Health Services - Enhanced Level Non-Skilled (modifier/usage indicated in document)
S5102 U1	Adult Health Services - Enhanced Level Non-Skilled (modifier/usage indicated in document)
S5101 U1 U3	Adult Day Health Services - Enhanced Level Skilled (per document listing)
S5102 U1 U3	Adult Day Health Services - Enhanced Level Skilled (per document listing)
S5101 UL	Listed in document as Non-Skilled Day billing variant (UL modifier usage listed for Enhanced Level Non-Skilled)

Prior Authorization, Documentation, and Denial Risks

Prior Authorization

Authorization for Skilled Enhanced Level

Prior authorization is required to bill the Skilled Enhanced Level; the member must meet Non‑Skilled Enhanced criteria and require physician‑ordered skilled therapy services. Billed HCPCS codes for Skilled Enhanced are S5101 U1 U3 and S5102 U1 U3.

Codes: S5101 U1 U3; S5102 U1 U3

Documentation Required

Care plan and progress notes for Enhanced Levels

To bill the Enhanced level, the care plan must document the services required for Enhanced level, be signed by the participant, legal guardian, or representative, and the required progress notes must be completed and retained. Applicable billing codes include both Enhanced Non‑Skilled and Enhanced Skilled variants.

Codes: S5101 U1; S5102 U1; S5101 U1 U3; S5102 U1 U3
Care plan must be signed by participant, legal guardian, or representative
Required progress notes must be completed and retained

Documentation Required

Health assessment and nursing oversight

The provider must complete a health assessment for admission and establish an oversight and monitoring process that involves a licensed nurse, including standard and ad hoc reporting.

Complete nursing/health assessment at admission
Establish licensed nurse oversight and monitoring processes
Provide standard and ad hoc reporting as required

Denial Risk

Duplicative services exclusion

Claims may be denied when admission would result in duplicative or substantially identical services covered by another Medicaid‑funded service the member has chosen; ambulatory settings that may cause ineligibility are listed as examples.

Examples of potentially duplicative services: home personal care attendant services, a physician's office visits, hospital outpatient department services, partial hospitalization programs, and adult training programs
Admission that results in duplicative coverage will render the individual ineligible for adult day health services and may result in denied claims

Operational / Authorization Contacts

Authorization request formsProviders instructed to access Prior Authorization forms via Provider Resources -> Forms on the payer website (see Providers -> Provider Resources -> Forms).

Phone supportPhone messaging available for requests/inquiries; providers may call 1-800-963-1001 for assistance (including outside business hours).

Lines of business coveredRite Care (MED); Rhody Health Partners (RHP); Rhody Health Expansion (RHE); Children with Special Health Care Needs (CSN) (19 and over); Substitute Care (SUB) (19 years and over); Medicare-Medicaid Plan (MMP) Integrity years.

Lines of business excludedExtended Family Planning (EFP); Health Benefit Exchange (HBE); Substitute Care (SUB) <19 years old; Children with Special Needs (CSN) <19 years old.

Clinical and Program Context

Adult day health programs provide community-based, nonresidential daytime services that address the biological, psychological, and social needs of adults through individualized plans of care. These programs offer a combination of nursing care, therapies, personal care assistance, social and recreational activities, meals, and other supports in a supervised group setting for adults who return home at the end of the day (adult returns to home/caregiver after the day) and require regular oversight and services [[3]].

Services are intended to meet both health and functional needs: staff deliver daily assistance with Activities of Daily Living (ADLs) — such as bathing, dressing, eating, grooming, mobility/ambulation, toileting, and transferring — which may include direct care, constant supervision, cueing, physical assistance, or two-person assist as defined in policy [[4]]. Programs must provide nursing assessment and oversight performed by a program registered nurse, medication administration according to law, and an organized program of supervision, health promotion, and health prevention (including nutritional and therapeutic activities) [[5],[8]].

Skilled services that may be provided or ordered within the adult day setting include physician-ordered nursing and therapy interventions (nursing, physical, occupational, and speech) such as oxygen administration, catheter care, pacemaker assessment, injections, tube feedings, tracheotomy and sterile dressing care, ostomy care, and maintenance therapy when part of a written plan of care. Documentation of these clinical services and of the member’s functional needs is required to determine level of service and any authorization requirements [[6],[7]].

Defined Terms

ADL / ADLsActivities of Daily Living including bathing, dressing, eating, grooming, mobility (ambulation), toileting, and transferring; documented need includes direct care, constant supervision, cueing, physical assistance, or two-person assist as defined in policy.

Preventive Level of CareThe minimum level of care required (as outlined in the RI 1115 Waiver Attachment D Level of Care Criteria) for attendance at adult day care.

Skilled ServicesServices ordered by a physician within nursing, physical, occupational, and speech therapy disciplines; examples include oxygen administration, catheter insertion/maintenance when indicated, pacemaker assessment, RN/LPN monitoring, injections, tube feedings, tracheotomy care, sterile dressing changes, ostomy care, and maintenance therapy as part of a written plan of care.

Policy Dates

Policy review history shows routine annual review. The policy lists the most recent review date as 2/12/25 and the same date recorded under Medical Director approval and CMC review logs [[15],[17]].

No explicit effective or next review date is specified in the brief. The policy’s historical effective dates are recorded in the source (earliest 12/13/13 with multiple subsequent effective dates), and the payer notes that clinical medical policies are reviewed on an annual basis for future updates [[15]].

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAdult Day Health / Adult Day Care services

Policy CodePolicy Adult Health- # 058 Day

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization for Skilled Enhanced Level claims and ensure Enhanced-level care plans and progress notes are completed, signed, and retained.

SourceLink

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