You Cannot Bill Medicare Directly for Adult Day Care The question comes up, sometimes multiple times after we answer it.
There is no direct bill to Medicare specifically for adult day services.
Several years ago, California Representative Linda Sanchez did sponsor a bill that, if signed by the U.S. President at the time would have created a billing code and protocol for adult day care direct billing to Medicare.
This was July 25, 2009. Among the articles written about it at the time included the following:
“In a move sure that would further shift the focus of long-term care away from nursing homes and toward other home- and community-based services, Rep. Linda Sanchez (D-CA) Thursday introduced a bill that would allow Medicare to pay for adult day care services.
Under the Medicare Adult Day Care Services Act of 2009, seniors and those with disabilities who qualify for home-care services would be able to choose whether they would like to receive care at home or at an adult day care center. Currently, adult day care is not covered under Medicare, which would pay adult day care providers 98% of the home-health rate, according to a statement made by Sanchez.
Adult day care centers typically provide skilled nursing, physical therapy, social services and personal care for adults who require assistance, but not 24-hour care, Sanchez says.
In early 2008, reports began to emerge that showed demand for adult day care services rising between 5% and 15% every year. (McKnight’s, 1/11/08) Sanchez’s bill has been referred to the House Committee on Ways and Means, where it awaits deliberation and voting.” —-
In 2019, Representative Sanchez was back at it again with some limited bipartisan support for legislation that would also add to the expansion of adult day services and allow them to be paid by Medicare. Here is the initial press release:
Reps. Sánchez, Kelly, and Schrader Introduce Bipartisan Legislation to Help
Seniors Stay in Their Homes
June 25, 2019
Washington, DC – U.S. Representative Linda Sánchez (D-CA), along with Reps. Mike Kelly (R-PA) and Kurt Schrader (D-OR), today introduced the Community-Based Independence for Seniors Act to create a new Community-Based Institutional Special Needs Plan (CBI-SNP) demonstration program. This program would target home and community-based services to low-income Medicare beneficiaries who need help with activities of daily living.
Statement by Rep. Linda Sánchez (D-CA):
“Seniors and their families have to make difficult decisions when it comes to deciding whether or not to stay in the comfort of their home or move into a nursing home. I know this reality firsthand. That is why I am proud to introduce the common sense, bipartisan Community-Based Independence for Seniors Act. This bill would enable seniors to maintain their independence by providing them with the home and community-based services they need to thrive. Without community-based long-term services and supports, which are not typically covered by Medicare, seniors frequently experience negative health outcomes, lose their ability to live independently, and often turn to Medicaid for coverage of long-term care expenses. I am proud to lead this effort to help seniors stay in their homes.”
Statement by Rep. Mike Kelly (R-PA):
“A house is a person’s castle, and it can be a burden for American seniors to leave them for medical or other services. That’s why we need to improve home-based care options for Medicare beneficiaries, who right now aren’t always getting what they need where they need it. I am a proud co-author of the Community-Based Independence for Seniors Act, which will create a program to help us determine the best way to provide such benefits, including delivered meals, adult day care, and housekeeping services, to name a few. America’s seniors have paid into Medicare their entire lives and have earned and deserve the best care we can offer.
This bill moves us closer to that goal!”
2019 Press Release continued from U.S. Representative Linda Sanchez
Statement by Rep. Kurt Schrader (D-OR):
“Seniors shouldn’t be forced to spend down their life savings to access the care they need. Too often, we rely on nursing home care as a one-size-fits-all solution while it’s often ineffective and inefficient. I’m proud that we are tackling this problem at a federal level in a way that aligns with evidence-based practices to promote what we have long known, that helping folks live at home provides benefits for everyone. Oregon has been a longtime leader in this area through what we call Project Independence, which does what this bill does, broadens services available to seniors to include vital day-to-day services like home-delivered meals and transportation assistance, bringing down the costs of care and helping seniors stay in their own homes.”
The Community-Based Independence for Seniors Act establishes a demonstration program that targets home and community-based care to eligible seniors who need help with two or more activities of daily living. Seniors would receive services specific to their needs, such as home-delivered meals, transportation services, adult day care services, and homemaker services. By targeting services to at-risk seniors, the Community-Based
Independence for Seniors Act helps seniors stay in their homes and communities, rather than moving to a nursing home, which can be very expensive and is often not the older adult’s preferred care setting. This bill also helps keep federal and state governments’ costs down as seniors under this program would not need to deplete their resources to be eligible for Medicaid in order to receive home and community-based services.
This proposed bill is not scheduled for any action in the U.S. House of Representatives.
Those looking to utilize public funding for adult day care pursue contracts with Medicaid Waiver Agents in your jurisdiction. These are often Area Agencies on Aging. They publish state approved guidelines for participation and are allowed to add vendor enrollment requirements, including how you train and continually develop your staff, safety requirements and client engagement. Of course, states where adult day care programs are licensed create another set of rules.
Other ADC providers create the kind of program that can also attract those families who do not want an assisted living solution and pay privately for adult day services.
Let’s face it, $65.00 per day x 20 people is $1300.00 per day or $26,600.00 for a 22-day month. Even after expenses in a moderate facility, a life can be made for an owner and a quality program can serve its community well.
Others decide to push the clinical end to its max by adding specific rehabilitative and other clinical services Medicare can reimburse. Adding a CORF to an ADC Program (Comprehensive Outpatient Rehabilitation Facility), gives the community a program of consistent clinical and rehabilitative attention and includes the services of a respiratory therapist.
Services are guided by a physician signed Treatment Plan (CMS Form 700) which is updated about every 60 days.
Its care along the continuum and can be a real contribution to medical stability for vulnerable adults in your community. It must be approached and treated with that in mind.
Of course, when operating in states where adult day care is licensed, you need to make sure you can run both business models in the same location. And if you can, find out any population separation, lavatory and other special requirements that might apply.
Hopefully this answers some important questions about the ever-evolving adult day care and its relationship to Medicare.