Massachusetts Medicaid / MassHealth Adult Day Health (ADH) Program

Last updated: August 03, 2021

 

Overview of the Adult Day Health Program

The Massachusetts’ Adult Day Health (ADH) Program provides daytime supervision and care in a community group setting for persons 18+ years old who have a cognitive, medical, or mental health condition. Intended to delay nursing home admissions, attendees are provided nursing services, medication reminders, and assistance with activities of daily living (ADLs), such as taking a bath, getting dressed, using the toilet, and feeding oneself. Particularly relevant to the aging population, some adult day health facilities provide Alzheimer’s / dementia care with staff specifically trained to handle the needs of persons with dementia. For many families, the Adult Day Health Program serves as respite care, allowing informal caregivers to work during the day.

ADH program participants must live at home. However, “homes” may include an adult foster care home or an assisted living residence, given the individual is not receiving Medicaid-funded (MassHealth) services in these settings.

 MassHealth offers several additional long-term care programs in which MA seniors might be interested. These include the Personal Care Attendant Program, the Adult Foster Care Program, and the Group Adult Foster Care Program.

The ADH Program is an entitlement, which means meeting the state’s Medicaid eligibility requirements guarantees one will receive benefits. This means the state does not limit the number of persons who can receive adult day health services.

The “Adult Day Health Program” is a long-term service and support that is offered under Massachusetts’ regular Medicaid program. The Medicaid Program in MA is called MassHealth and the program specific to persons 65+ years old is called MassHealth Standard. The adult day health facilities that provide MassHealth adult day health services are licensed by the Department of Public Health (DPH) and regulated by the MassHealth Office of Long-Term Services and Supports. Each facility site is essentially an “adult day health program”.

 HCBS Medicaid Waivers versus HCBS State Plan Medicaid?
While home and community based services (HCBS) can be provided via a Medicaid waiver or a state’s regular Medicaid plan, HCBS through Medicaid state plans are an entitlement. Put differently, meeting the program’s eligibility requirements guarantees an applicant will receive benefits. On the other hand, HCBS via Medicaid waivers are not an entitlement. Waivers have a limited number of participant enrollment slots, and once they have been filled, a waitlist for benefits begins. Furthermore, HCBS Medicaid waivers require a program participant require the level of care provided in a nursing home, while state plan HCBS do not always require this level of care.

 

Benefits of the Adult Day Health Program

Adult Day Health facilities must be open Monday – Friday for a minimum of 8 hours each day. While benefits may vary slightly based on the facility, they generally include the following services and supports.

– Activities – i.e., social, recreational, educational, therapeutic
– Case Management
– Dementia care – limited to specific adult day health facilities
– Health Monitoring
– Medication Reminders / Administration
– Nutrition Services – meals and snacks
– Personal Care Assistance – i.e., mobility, transferring bathing, dressing, toileting, eating
– Supervision
– Socialization
– Skilled Nursing
– Therapies (physical, occupational, speech)
– Transportation – between one’s home and adult day health facility

 

Eligibility Requirements for MassHealth Adult Day Health Program

The ADH Program is for MA state residents who are 18+ years old who have a medical, cognitive, or mental health illness that will likely get worse without nursing oversight or care. Additional eligibility criteria are as follows and is relevant for seniors 65+ years of age:

 

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 100% of the Federal Poverty Level (FPL), which increases on an annual basis in January. As of 2021, the income limit for a single applicant is $1,073 / month. Married couples, regardless of if one or both spouses are applicants, can have a monthly income up to $1,452.

 While many home and community based services Medicaid programs allow a non-applicant spouse to retain a larger portion of a couple’s income and assets, it is thought that the Adult Day Health Program does not. In contrast, MassHealth’s Frail Elder Waiver (FEW) does allow a non-applicant spouse a monthly maintenance needs allowance from his/her applicant spouse and a community spouse resource allowance.

Assets
In 2021, the asset limit is $2,000 for a single applicant. For married couples, the asset limit is slightly higher at $3,000. This hold true whether one or both spouses are applicants.

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

While there is a 60-month look back rule in which Medicaid checks past asset transfers of those applying for nursing home Medicaid or home and community based services via a Medicaid waiver, it is thought that this is not relevant for the Adult Day Health Program. In other words, the look back period is not applicable.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our spend down calculator.  

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take their home. Fortunately, for eligibility purposes, Massachusetts Medicaid considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $906,000. Home equity interest is the current value of the home minus any outstanding mortgage.
– A spouse lives in the home.
– The applicant has a child under 21 years old living in the home.
– The applicant has a blind or permanently and totally disabled child living in the home.

To learn more about the potential of Medicaid taking the home, click here.

 

Medical Criteria: Functional Need

Unlike with many Medicaid long-term care programs, a nursing facility level of care (NFLOC) is not required for the ADH Program. In addition to a doctor’s authorization for adult day health services, applicants must have a need for a skilled service AND/OR require regular assistance with at least one activity of daily living, such as bathing, toileting, transferring, mobility, and eating. Skilled services may include a variety of services, such as intravenous feeding, jejunostomy feeding, and regular oxygen administration for medical conditions that require close monitoring, such as chronic obstructive pulmonary disease. Troublesome behaviors, such as wandering, verbal / physical abuse, and socially inappropriate sounds / actions, which are sometimes seen in persons with Alzheimer’s disease or another related dementia, may meet the need of requiring a skilled service. A diagnosis of dementia in and of itself does not mean one will meet the functional criteria.

 For more information about long-term care Medicaid in Massachusetts, click here.

 

Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for MA Medicaid / MassHealth. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

Massachusetts has a Medically Needy Medicaid Program for Medicaid applicants who have high medical expenses relative to their income. Also known as a spend-down program, applicants are permitted to spend “excess” income on medical expenses and health care premiums, such as Medicare Part B, in order to meet Medicaid’s income limit. The amount that must be “spent down” each month can be thought of as a deductible. Once one’s “deductible” has been met for the spend down period, which is 6-months in MA, the Adult Day Health Program will pay for care services.

When persons have assets over the limits, Irrevocable Funeral Trusts (IFTs) are an option. IFTs are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Persons can also “spend down” assets on ones that are not counted towards eligibility purposes, such as making home modifications, purchasing new household appliances, or even taking a vacation. There are many other options when the applicant has assets exceeding the limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of MassHealth benefits. Professional Medicaid planners are educated in the planning strategies available in Massachusetts to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, while it is thought that Medicaid’s 60-month look back rule does not apply to the Adult Day Health Program, it does apply to nursing home Medicaid and other long-term care Medicaid programs (i.e., the MassHealth Frail Elder Waiver). As more extensive Medicaid-funded care might be required in the future, it is vital that one not violate the look back rule. Medicaid planning strategies should ideally only be implemented with careful planning and well in advance of the need for long-term care. However, there are some workarounds, and Medicaid planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for MassHealth when over the income and / or asset limit(s). Find a Medicaid planner.

 

How to Apply for the Adult Day Health Program

Before You Apply

Prior to submitting an application for the Adult Day Health Program, applicants need to ensure they meet the eligibility criteria for MA Medicaid. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid eligibility test.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, proof of income, previous bank statements, copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.

 

Application Process

To apply for the Adult Day Health Program, applicants must be eligible for MA Medicaid / MassHealth. To apply for MassHealth, seniors must complete the Application for Health Coverage for Seniors and People Needing Long-Term Care Services, which can be found here. The completed application can be mailed, faxed, or dropped off at the MassHealth Enrollment Center. The fax number and addresses are on the application.

A functional needs assessment will be completed by an Aging Services Access Point (ASAP) as part of the application process.

Additional information about the MassHealth Adult Day Health Program, although not intended for a consumer audience, can be found here. Persons can also contact the MassHealth Customer Service Center at 1-800-841-2900.

The Massachusetts’ Office of Long-Term Services and Supports within the Executive Office of Health and Human Services (EOHHS) administers the Adult Day Health Care Program in conjunction with adult day health service providers contracted by MassHealth.

 

Approval Process & Timing

The MassHealth application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. In most cases, it takes between 45 and 90 days for the Medicaid / MassHealth agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further.

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