Medicaid Benefits in Adult Day Care: Programs, Locations & How Coverage Works

Summary
Every state offers Medicaid programs that pay for, or at least help pay for, the cost of Adult Day Care (ADC). In most states, there are two types of Medicaid programs that provide this benefit: HCBS Waiver and Regular (ABD) Medicaid. Unfortunately, the eligibility criteria for recipients as well as the rules for who can be a provider vary dramatically from state to state. In short, recipients must qualify functionally (demonstrate a medical need) and financially (be considered low-income) to receive Medicaid-funded adult day care.

 

 

Understanding the Three Types of Adult Day Care

Adult day care is a location where someone—usually with health problems related to chronic illness or old age—can be left for several hours, even up to eight hours, during which time all their care needs are looked after including personal care, medication management and sometimes minor nursing services. Not all ADCs offer the same level of service, however. There are three types of Adult Day Care, though you may find Adult Day Care that offers one, two, or all three of these care types in different areas of the same facility.

1) Social Adult Day Care, SADC or Adult Day Services, is for seniors who need supervision, activities, and meals, but not medical care. If someone has a chronic illness, SADC would not be appropriate, but for seniors looking for supervision and socialization it might be exactly what they need.

2) Adult Day Health Care, ADHC or Adult Day Medical Care, offers services similar to SADC (like activities and socialization), but staff includes trained nurses or other healthcare professionals who can provide medical care. ADHC provides medical equipment, physical and occupational therapy, and help with Activities of Daily Living (ADLs). ADHC has a higher level of services than SADC.

3) Specialized Adult Day Care is usually for people with dementia who require help from specially trained staff. It also might be called Alzheimer’s Day Treatment in your state. These are very high-level ADCs that would offer medical care and help with ADLs. Also, the designs for Specialized ADC will have distinct features, like brighter lighting and special locks on doors to prevent wandering.

Adult day cares are licensed and/or regulated by states. Administrators and staff must be qualified, and there is often an enforced staff-to-resident ratio to ensure adequate care. (A good ratio is 1 staff member for every 6 residents, though the number could be between 1-to-4 and 1-to-10.)

 

Services Paid for by Medicaid in Adult Day Care

In most ADCs, the costs covered by Medicaid are for supervision, activities that are often either educational or social, and nutritious meals. Generally speaking, you will find some or all of these services in adult day care:
– Counseling
– Education
– Exercise
– Meals
– Recreation
– Respite care
– Socialization
– Supervision
– Transportation
– Medication management

Costs and services, however, will vary depending on the type of ADC (see Three Types above). Adult Day Health Care is more expensive than Social Adult Day Care because while offering some of the same services common for ADCs—supervision, activities, and meals—ADHCs also provide medical care. This means someone who is frail or has a chronic illness can receive physical therapy in an ADHC, as well as help with Activities of Daily Living like eating and going to the bathroom.

In Specialized ADCs, or Alzheimer’s ADCs, guests usually require an extra level of care because they have Alzheimer’s disease or a related dementia. Caring for people with dementia requires specialized skills, especially when it comes to communication.

Medicaid pays for the cost of Adult Day Care because it saves money by keeping people in their homes longer, rather than moving into more-expensive nursing homes. Also, for families who can provide a level of care at home but must leave the home to work, ADC can provide a preferably living arrangement for the beneficiary. The cost of ADC is much lower than a nursing home—usually about $70 per day in the United States, compared to more than $200 per day for a nursing home. Adult Day Cares usually bill in half-day or 4-hour increments.

 Medicare does NOT cover adult day care. However, Medicare Advantage (Medicare Part C) offers additional benefits from private insurers and might include ADCs.

 

Eligibility Requirements for Medicaid to Pay for Adult Day Care

 Eligibility criteria vary dramatically. An easy way to find your specific requirements is to use our Medicaid Eligibility Requirements Finder tool.

There are two types of Medicaid Long Term Care that might cover Adult Day Care: Regular Medicaid (also known as Aged, Blind and Disabled or ABD Medicaid) and Home and Community Benefit Services (HCBS) waivers. Recipients must meet financial criteria, meaning their income is below a certain amount, and demonstrate a physical need for the services covered by Medicaid. Eligibility criteria will change depending on the program and the recipient’s state of residence.

 

Regular / ABD Medicaid Eligibility

Regular Medicaid, or Aged, Blind, and Disabled (ABD) Medicaid, will cover adult day care in some (about 15) states. Because regular Medicaid is an entitlement, those who apply and are qualified must receive the benefits without being put on a waiting list. Regular Medicaid has stricter eligibility criteria than HCBS Waiver, including a lower monthly income limit.

Single ABD Medicaid applicants, in the majority of states, must earn less than either the income limit for Supplemental Security Income or the Federal Poverty Level. These figures for 2022 are $841 and $1,133 respectively. Asset limits for ABD Medicaid are usually the same as for HCBS waivers. Homes are exempt. Married couples have slightly higher limits.

 

HCBS Waiver Eligibility

Every state has a program under the Medicaid umbrella to cover adult day care. Usually, the Medicaid program that covers ADC is a waiver. By far the most commonly used waiver to pay for ADC is the Home and Community Benefits Services (HCBS) waiver. There are many types of HCBS waivers, but every state has at least one version; other names for these waivers include “1915(c)” and “1115 Demonstration” waivers.

One good thing about Medicaid waivers is that the eligibility criteria is usually not as strict as regular Medicaid, so your loved one might be more likely to qualify. Unfortunately, the downside of waivers is that there are often waiting lists that can last years because waivers are not considered entitlements like regular Medicaid, so enrollment can be capped and not everyone who qualifies will receive the benefits right away.

Single waiver applicants in 2022 in most states, must earn less than $2,523 per month and have countable financial assets valued at $2,000 or less. Most homes are exempt. Married applicants have higher limits.

 

Understanding Consumer Direction & How It Helps Finding Adult Day Care

Even if an adult day care does not accept Medicaid, it might still be possible to use your Medicaid benefits to pay for ADC. In many states, Home and Community Based Services waivers offer an option called Consumer Directed Care (CDC), which gives recipients more control over which services are provided through Medicaid. Care providers, which would include ADC, are managed by the recipient, and payments are made out of a predetermined budget.

CDC allows for more options and control because recipients may look outside lists of Medicaid-approved providers. Someone under Consumer Directed Care, therefore, could use the funds provided by Medicaid to pay for services in a non-Medicaid care provider, including adult day care.

 

How to Find Medicaid Adult Day Care Providers in Your Area

Unfortunately, most states do not offer publicly accessible databases of Medicaid-certified adult day cares. This means that finding adult day care is yet another job for you as a caregiver. Contacting your local Area Agency on Aging is a good idea if you don’t know how to begin.

For persons who are already eligible or enrolled in a Medicaid program, the first step in finding adult day care is to write down a detailed list of your loved one’s care requirements. You should also have a schedule in mind for how often and on which days you’ll use adult day care. Having this information handy when you begin your search will save time and effort later.

Next, contact centers in your area by phone and ask whether they can meet your loved one’s needs generally and inquire whether they accept Medicaid as a payer.

Then visit. It’s usually best to visit a prospective adult day care twice. First, visit alone to get a sense of the home and make sure you’re comfortable. If you think it would provide a nurturing and stimulating environment, visit a second time with your loved one.

Try a one-week trial, where you use the services there for a week and see how well your loved one is taken care of, and whether they like it there.

Finally, enter into a contractual agreement with the ADC to receive services there. You’ll probably set a schedule, and services and costs will be finalized.