CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Adult Day Health Services — Coverage Criteria

Defines coverage, levels of care, billing, and eligibility requirements for adult day health services for Medicaid members of Neighborhood Health Plan of Rhode Island (excludes certain Medicaid subprograms and commercial plans).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAdult Day Health Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2013

Next Review DateN/A

Key ActionVerify eligibility, coverage, and authorization criteria and confirm services are medically necessary prior to rendering services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3levels of care defined

4-6minimum daily hours (Basic)

S5101/S5102primary billing HCPCS

U1,U3required modifiers

Coverage Criteria and Eligibility

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Basic Level: Minimum of four (4) hours per day up to six (6) days per week; transportation is included in the per diem or half day rate (total transportation not to exceed two (2) hours to and from home); physical, occupational, and speech therapy are not included in the per diem and must be billed separately.

Enhanced Level Non Skilled: Meets Basic Level criteria AND one of the following: daily assistance with at least 2 activities of daily living (ADLs); OR daily assistance with at least 1 skilled service by an RN or LPN; OR daily assistance with at least 1 ADL requiring two-person assist; OR diagnosis of Alzheimer’s disease or related dementia or a mental health diagnosis requiring staff intervention due to safety concerns.

Enhanced Level Skilled: Meets Enhanced Level Non Skilled criteria AND need for skilled services by a physician within the disciplines of nursing, physical, occupational, or speech therapy. Skilled services include, but are not limited to: administration of oxygen with skilled observation; insertion/sterile irrigation/replacement/care of catheters (including suprapubic or selected urethral catheter care when part of active treatment); pacemaker assessment; physician-ordered daily nurse monitoring related to the written care plan (for example measurement of output, unstable glucose or blood pressure, administration of oral or injectable medications requiring nurse monitoring); IV/IM/SC injections or intravenous feeding; nasogastric/gastrostomy/jejunostomy feeding; nasopharyngeal aspiration and tracheotomy care; treatment or sterile dressings of wounds when physician-prescribed irrigation or medication application is required; ostomy care; provision of maintenance therapy documented in the written plan of care.

Admission to adult day health services is ineligible when the services would duplicate or be substantially identical to other Medicaid‑funded services the member has elected. Residents of a residential health care facility are not eligible for adult day health. Individuals who are receiving 24‑hour inpatient care in a hospital or nursing home are excluded, as are those receiving partial care/partial hospitalization on the same day. Members enrolled in the Personal Choice Program are also not eligible for adult day health services.

Services must meet Neighborhood's medical necessity determination to qualify for reimbursement. Neighborhood may apply NCDs, LCDs, InterQual, EOHHS recommendations, and relevant Clinical Medical Policies when assessing medical necessity. It is the provider's responsibility to verify eligibility, coverage, and authorization criteria prior to rendering services and to consult Neighborhood's prior authorization resources or Provider Services for questions.

Billing Codes, Modifiers, and Service Frequencies

Covered HCPCS CodesHCPCSCovered

S5101	Day care services, adult; per half day
S5102	Day care services, adult; per diem

Required Modifiers for Enhanced LevelsModifierCovered

U1	Medicaid level of care 1, as defined by each state
U3	Medicaid level of care 3, as defined by each state

inv-06: Basic daily hours

Minimum daily hoursMinimum of 4 hours per day

Daily hours range (policy text)Minimum of four (4) hours per day

Therapies billing notePhysical, occupational, and speech therapy are not included in the per diem and must be billed separately

inv-07: Basic weekly frequency

Maximum days per weekUp to 6 days per week

Weekly frequency (policy text)Up to six (6) days per week

Per diem includes transportationTransportation is included in the per diem or half day rate

inv-08: Transportation time limit

Total transportation time limitTotal transportation not to exceed 2 hours to and from home

Transportation includedTransportation is included in the per diem or half day rate

ApplicabilityApplies to Basic Level per diem/half day rate

Provider Responsibilities, Documentation, and Denial Risks

Prior Authorization

Medical necessity and authorization verification

All services must be medically necessary to qualify for reimbursement. Providers are required to verify member eligibility, coverage, and any required authorizations prior to rendering services. Neighborhood may use NCDs, LCDs, industry-accepted criteria (e.g., InterQual), EOHHS recommendations, and Neighborhood Clinical Medical Policies to determine medical necessity. For questions, contact Provider Services at 1-800-963-1001 and refer to Neighborhood's Prior Authorization Reference page and Clinical Medical Policies.

Verify eligibility, coverage, and prior authorization before providing services.
Medical necessity may be assessed using NCD, LCD, InterQual, EOHHS guidance, and Neighborhood CMPs.

Documentation Required

Care plan and assessment documentation

Participant care plans must be completed, signed, and maintained in the record. Care plans must be signed by the participant or the participant’s legal guardian or representative. Required documentation includes progress notes and evidence of face-to-face assessments. Face-to-face assessment and reassessment with the member's Primary Care Provider (PCP) is required at least annually or any time the member's condition changes. Enhanced level skilled services require documentation that the services listed in the care plan are being provided and completion of required progress notes.

Care plan signed by participant or legal guardian/representative.
Progress notes documenting services and clinical status.
Annual (or as-needed for change in condition) face-to-face assessment with the PCP.

Denial Risk

Exclusion-based denial triggers

Admission and continued eligibility are denied when services would duplicate other Medicaid-funded services or when the member meets any exclusion criteria. Examples of exclusion-based denial triggers include: residence in a residential health care facility; receiving 24-hour inpatient care in a hospital or nursing home; receiving partial care/partial hospitalization on the same day; enrollment in the Personal Choice Program; or receipt of duplicative/substantially identical Medicaid-funded services.

Duplicate or substantially identical services funded by other Medicaid programs will render the member ineligible.
Residents of residential health care facilities are ineligible.
Adults receiving 24-hour inpatient care in a hospital or nursing home are ineligible.
Adults receiving partial care/partial hospitalization on a given day are not eligible for adult day health services that same day.
Members enrolled in the Personal Choice Program are not eligible.

Program Background

Adult day health programs provide supervised, nonresidential group care during daytime hours for adults who return home at the end of the day. Programs address the biological, psychological, and social needs of participants through individualized plans of health and deliver services such as supervision, nursing, therapies, personal care, social activities, and meals in a protective setting.

These programs operate as an alternative to continuous residential or inpatient care, and therefore are not appropriate for individuals who require 24‑hour inpatient care or who are residents of residential health care facilities. Admission is additionally ineligible when the member already receives duplicative Medicaid‑funded day services or is enrolled in programs (for example, the Personal Choice Program) that preclude adult day health participation.

Key Definitions

inv-14: Definition of Adult Day Health Program

DefinitionComprehensive, nonresidential program designed to address the biological, psychological, and social needs of adults through individual plans of health that incorporate health, social and related support services in a protective setting.

Services includedNursing care, therapies, personal care assistance, social and recreational activities, meals, supervision, health promotion, dietary services, counseling, therapeutic activities, and case management.

Setting and participant outcomeCommunity group setting for adults who return home at the end of the day; programs provide supervision and health services during daytime hours.