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    v1.0.28
    OpenPayerPolicy UpdatesHome Health & HospicePennsylvania Insurance Dept Adult Day Services Cov…
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    CurrentPennsylvania Insurance DepartmentPolicy N/A

    Adult Day Services — Coverage Criteria

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    Defines services, eligibility concepts, and service specifications for adult day services and related home- and community-based supports provided through Pennsylvania Area Agencies on Aging (AAAs). Affects providers, AAAs, and enrolled consumers receiving OPTIONS/Adult Day-related services.

    Policy Summary
    PayerPennsylvania Insurance Department
    PolicyAdult Day Services — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionAAAs must document approved care plans and retain proof of third‑party denials before purchasing DME and solicit multiple bids for home modifications up to the $5,000 lifetime cap.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    multipledistinct services described
    $5,000home modification lifetime cap
    24-72hemergent services duration
    NOT coveredDME exclusions (hearing/dentures/eyeglasses)

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Coverage Criteria

    Core Service Eligibility and Delivery

    Covered when services are provided to enrolled consumers with assessed needs and coordinated through AAAs:

    Adult Day Services Core Eligibility: Consumer is enrolled and has needs consistent with adult day services (older adult or adult with dementia-related disease, Parkinson's disease, or other organic brain syndrome) and services are provided through an adult day services center

    References Title 6, Chapter 11 regulations

    Care Management requires a comprehensive needs assessment, development of a written service plan, arrangement/coordination/follow-up of service delivery, and ongoing monitoring and reassessment

    Can be offered as a stand-alone service

    Personal Care Services: Personal care includes assistance with ADLs and IADLs (feeding, bathing, dressing, toileting, ambulation, transfers, grooming, mouth/skin care, meal preparation, and assistance with self-administration of medications); home support activities may be included when necessary and supplemental

    Must be provided through an agency meeting Department of Health requirements

    Meal Services

    Non-Congregate/In-Home Meals eligibility:

    Meal service eligibility: Individual must be at nutritional risk, physically or mentally unable to obtain or prepare food, and have no one willing or able to prepare meals as evidenced by a completed NATE; meals must meet PDA Nutrition Services APD requirements and may be provided hot, frozen, or combination

    Mandatory enrollment does not apply when meals are the only service required

    Extenuating provision: If consumer has no resources for food and is determined not to be nutritionally at risk, the AAA may provide meals after referral to community food resources; document circumstances in SAMS journal notes

    Home Modifications

    Home Modifications:

    Scope and limits: Modifications must improve safety or function and must not change or alter the dwelling footprint; multiple bids should be solicited and the AAA will fund up to the lowest bid amount (consumer responsible for difference); case record must document bid solicitation efforts if fewer than multiple bids obtained$5,000 lifetime

    There is a $5,000 lifetime cap per consumer; if $2,000 previously used, up to $3,000 additional may be authorized with documented need; AAA must explore other resources and be payer of last resort

    DME, Medical Supplies, Assistive Devices

    Durable Medical Equipment and Supplies:

    DME and supplies criteria: Durable medical equipment must be appropriate for home use, withstand repeated use, and be Medicare, Medicaid or third-party non-reimbursable; AAAs must ensure OPTIONS is payer of last resort and retain copies of insurer denials before purchasing DME; medical supplies and assistive devices must complement or, when appropriate and cost-effective, replace in-home services

    Hearing aids, dentures, and eyeglasses are excluded and not reimbursable as Medical Equipment, Supplies, or Assistive Devices

    PERS

    Personal Emergency Response System (PERS):

    PERS eligibility: Limited to consumers who live alone or are alone for significant parts of the day, have significant fall risk or an unstable medical condition, have no regular caretaker for extended periods, and are cognitively and functionally capable of using the device

    Hearing aids, dentures and eyeglasses are explicitly excluded from reimbursement as medical equipment, supplies, or assistive devices. These items are considered personal items and are NOT allowable purchases under Consumer Reimbursement or through OPTIONS, and therefore cannot be paid for by AAAs as Durable Medical Equipment, Medical Supplies, or Assistive Devices.

    When documenting services or consumer-directed purchases, providers and AAAs must not list hearing aids, dentures, or eyeglasses as reimbursable items and should direct consumers to alternative resources or third-party payers for these personal items.

    Coding & Limits

    Home modification lifetime cap — $5,000
    Lifetime cap$5,000 total per consumer for home modifications (includes estimates, licenses, inspection fees)
    Bid solicitationMultiple bids should be solicited; AAA will fund only the lowest bid amount and consumer pays any difference
    Payer of last resortAAA must explore other resources and act as payer of last resort
    Partial prior fundingIf consumer previously received $2,000, up to $3,000 additional may be funded if documented need exists
    Emergent services short-term duration — 24-72 hours
    Typical durationShort-term (generally 24-72 hours)

    Provider Responsibilities & Billing Rules

    Prior Authorization

    Home modifications: $5,000 lifetime cap; AAA is payer of last resort

    Home modifications are subject to a lifetime cap of $5,000 per consumer; AAAs must solicit multiple bids (or document bid solicitation efforts if only one bid is obtained), fund up to the lowest bid amount, and explore all other funding resources because the AAA/OPTIONS must be the payer of last resort. If a consumer previously received $2,000, up to $3,000 additional may be authorized with documented need (not to exceed the $5,000 lifetime limit).

    • Do not change the dwelling footprint.
    • Solicit multiple bids; document solicitation efforts in the case record if unable to obtain more than one bid.
    • AAA funds only the lowest bid amount; consumer pays any difference if a higher bid is chosen.
    • Lifetime cap includes all charges (estimates, licenses, inspection fees).
    • Document need and approvals in SAMS; Quality and Compliance will monitor journal entries for compliance.

    Background

    Adult day services provide supervised, part-day care in a safe, interactive environment for older adults and adults with dementia-related disease, Parkinson's disease, or other organic brain syndromes. These centers operate as a community alternative to institutionalization and offer respite for caregivers while addressing a range of needs including personal care, nursing, social services, therapeutic activities, nutrition, and emergency care.

    Typical populations served include older adults and individuals with cognitive or functional impairments who require assistance with activities of daily living (ADLs/IADLs), supervision, social engagement, or medically related supports during daytime hours. Some centers also provide allied therapies (PT/OT/ST) and medical services when needed to meet client goals and the consumer's written service plan.

    Services are arranged and coordinated through Area Agencies on Aging (AAAs) and must be tied to a comprehensive needs assessment and written service plan; care management and ongoing monitoring ensure that the adult day program complements other home- and community-based supports.

    Definitions

    Adult day services center — definition
    DefinitionA part-day operation offering an interactive, safe, supervised environment for older adults and adults with dementia-related disease, Parkinson's disease, or other organic brain syndrome
    Services offeredProvides personal care, nursing, social services, therapeutic activities, nutrition/therapeutic diets, and emergency care
    RoleCommunity-based alternative to institutionalization and a source of caregiver respite
    Emergent Services — short-term services (generally 24-72 hours)
    DefinitionShort-term services (generally 24-72 hours) addressing immediate assistance due to a critical event posing imminent health and safety risk
    ScopeIncludes OPTIONS core services, overnight shelter, and emergency life-sustaining supplies
    Policy Summary
    PayerPennsylvania Insurance Department
    PolicyAdult Day Services — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionAAAs must document approved care plans and retain proof of third‑party denials before purchasing DME and solicit multiple bids for home modifications up to the $5,000 lifetime cap.
    SourceLink
    On This Page
    Coverage CriteriaCoding & LimitsProvider Responsibilities & Billing RulesBackgroundDefinitions
    Purpose
    Provides immediate assistance after a critical event posing imminent health and safety risk
    Continuation criteriaProvided until a permanent arrangement/payment solution is made or an alternate caregiver becomes available
    Assessment noteCan begin with a NAT-E; if needed beyond 72 hours the AAA must complete a LCD and NAT
    Documentation Required

    Approved care plan and documented bids required for reimbursement

    An approved care plan is required for consumer reimbursement under Consumer Reimbursement; case records must document bid solicitation efforts for home modifications and justify any additional funding up to the lifetime cap. Reimbursement requires submission of receipts, a service provision form with sign-offs, and a consumer attestation that submissions are true and reflect services in the care plan.

    • Maintain an approved care plan that specifies reimbursable items/services.
    • Retain submitted receipts and a completed service provision form (days/hours, service provided, by whom) with provider and consumer sign-offs.
    • Include consumer attestation that reimbursements are accurate.
    • Document all bid solicitation efforts and justification for additional home modification funding in the consumer record in SAMS.
    Denial Risk

    DME purchases only after third‑party denial; OPTIONS is payer of last resort

    Durable medical equipment may only be purchased when items are Medicare, Medicaid, or third‑party non‑reimbursable and OPTIONS/AAA has acted as the payer of last resort; AAAs must retain copies of Medicare or other insurance denials before purchasing DME.

    • Verify item is non-reimbursable by Medicare, Medicaid, or other third-party payer before AAA purchase.
    • Obtain and retain written denials from Medicare or other insurers in the consumer record.
    • Ensure DME purchases comply with OPTIONS being the payer of last resort.
    Exemption from cost shareIndividuals receiving Emergent services are not subject to OPTIONS cost share
    Assessment requirementMay initially use NAT-E; service beyond 72 hours requires AAA to complete LCD and NAT