Procedure code and Description
S5100 Day care services, adult; per 15 minutes
S5110 Home care training, family; per 15 minutes
S5102 Day care services, adult; per diem
S5105 Day care services, center-based; services not included in program fee per diem
S5115 Home care training, nonfamily; per 15 minutes
DEFINITIONS
Please check the definitions within the member benefit plan document that supersede the definitions below.
Custodial Care: Services that are any of the following non-Skilled Care services:
• Non-health-related services, such as help with daily living activities. Examples include eating, dressing, bathing, transferring and ambulating.
• Health-related services that can safely and effectively be performed by trained non-medical personnel and are provided for the primary purpose of meeting the personal needs of the patient or maintaining a level of function as opposed to improving that function to an extent that might allow for a more independent existence.
Place of Residence: Wherever the member makes his/her home. This may include his/her dwelling, an apartment, a relative’s home, home for the aged, or a Custodial Care facility. Skilled Care: Skilled nursing, skilled teaching, skilled habilitation, and skilled rehabilitation services when all of the following are true:
• Must be delivered or supervised by licensed technical or professional medical personnel in order to obtain the specified medical outcome, and provide for the safety of the patient
• Ordered by a Physician
• Not delivered for the purpose of helping with activities of daily living, including dressing, feeding, bathing or transferring from a bed to a chair
• Requires clinical training in order to be delivered safely and effectively
• Not Custodial Care, which can safely and effectively be performed by trained non-medical personnel
Indications for Coverage
• Skilled Care in the member’s Place of Residence. Skilled Care includes:
o Skilled nursing
o Skilled teaching
o Skilled rehabilitation (physical therapy, occupational therapy and speech therapy)
• For Skilled Care to be covered in the member’s Place of Residence, the following criteria must be met:
o A plan of care must be established and periodically reviewed and updated by the treating practitioner or specialist
o Be ordered and directed by a licensed practitioner or specialist (M.D., D.O., P.A. or N.P)
o It must not be Custodial Care
o The care must be delivered or supervised by a licensed nurse, technical or professional medical personnel in order to obtain a specified medical outcome
o The care requires clinical training in order to be delivered safely and effectively
o The member’s condition must be documented to be such that they cannot receive the Skilled Care in a setting other than the member’s Place of Residence
OVERVIEW
Adult medical day care services in community-based facilities provide structured, individualized programs to meet the physical and/or cognitive health needs of adults with disabilities, living at home, who are unable to care for themselves for long periods of time. Adult day programs provide a variety of care management, including nursing, nutritional, therapeutic, personal care, educational and family support services in a protective, medically supervised setting during daytime hours. Members return to their home and caregiver(s) at the end of the day. Nursing, functional and social supports are tailored to meet the unique needs of program participants and their family caregivers. Members need to meet, at a minimum, a preventive level of care, as determined by the RI Executive Office of Health and Human Services (EOHHS) Office of Long Term Service Supports, in order to receive adult day care services:
• Member has a chronic illness or disability that requires, at a minimum:
– Supervision with 2 or more activities of daily living (ADLs) such as, bathing, eating, dressing, toileting, and ambulation/transfers
OR
– Extensive or greater assistance with at least 3 instrumental activities of daily living (IADLs) such as meal preparation, laundry, shopping, and cleaning.
• There must be no other person or agency available to perform these services.
• The criteria will be based on (1) a physician or other licensed practitioner’s assessment and (2) a DHS caseworker or EOHHS nurse’s assessment.
Providers will need to check Member Eligibility on the Healthcare Portal to determine if the recipient is entitled to Adult Day Care Services. If the recipient is enrolled in one of the following waivers then the person qualifies to receive the service: Preventive, Core Community, DEA Community, Habilitation Community, Shared Living and Intellectual Disabilities
CLINICAL COVERAGE CRITERIA
1. The Member must have a medical or mental dysfunction that involves one or more physiological systems and indicates a need for nursing care, supervision, therapeutic services, support services, and/or socialization.
2. The Member must require services in a structured adult day health setting.
3. The Member must have personal physician that can attest to the Member’s need.
4. Adult day health service provider must complete a health assessment for admission; establish an oversight and monitoring process for the program that involves a licensed nurse; and provide standard and ad hoc reporting on this project.
There are two levels of adult day care, basic and enhanced.
– Basic is the provision of services by the ADC provider of an organized program of supervision, health promotion, and health prevention services that include the availability of nursing services and health oversight, nutritional dietary services, counseling, therapeutic activities and case management.
Enhanced is the provision of services by the ADC provider when the participant meets at least one of the five requirements:
• Daily assistance, on site in center, with at least two activities of daily living
• Daily assistance, on site in center, with at least one skilled service, by registered professional nurse (RN) or licensed practical nurse (LPN)
• Daily assistance, on site in center, with at least one ADL which requires a two-person assist to complete the ADL
• Daily assistance, on site in center, with at least 3 ADL’s when supervision and cueing are needed to complete the ADL’s identified
• An individual who has been diagnosed with Alzheimer’s disease or other related dementia, or mental health diagnosis, as determined by a physician, and, requires regular staff interventions due to safety concerns related to elopement risk or other behaviors and inappropriate behaviors that adversely impact themselves or others. Such behaviors and interventions must be documented in the participant’s care plan and in the required progress notes.
Definitions:
Activities of daily living (ADL’s) are defined as basic tasks of everyday life, such as eating, bathing, dressing, toileting, and transferring. Instrumental activities of daily living (IADL’s) are defined as a range of activities that are more complex than those needed for ADLs, including meal preparation, shopping, housework, using the telephone, and taking medications.
*Daily assistance= every day of attendance
Exclusions:
• Individuals who reside in a facility-based setting
• Days or portion of day(s) not attended by Member
• If admission of the individual to adult day health services would result in the individual receiving duplicative or substantially identical services as those provided by any other Medicaid funded service that the individual has chosen, then the individual will not be eligible for adult day health services. Ambulatory care settings include but are not limited to, the home, personal care attendant services, a physician’s office, a hospital outpatient department, a partial care/partial
hospitalization program, and an adult day training program.
• An adult who has partial care/partial hospitalization program services on a particular day is not eligible for adult day health services on the same day.
