District of Columbia Medicaid Adult Day Health Program (ADHP)

Last updated: March 18, 2023

 

Overview of DC’s Adult Day Health Program

The District of Columbia’s Adult Day Health Program Services, or ADHP, provides adult day health care for persons 55+ years of age with chronic medical conditions. Intended to assist these persons in continuing to live in their own homes rather than require nursing home admission, program participants receive daytime care and supervision in adult day care centers. This includes meals, medical care, and assistance with daily living activities, such as mobility, toileting, and eating.

Program participants can live in their own home or that of a loved one. ADHP Services are not available to persons residing in assisted living residences or adult foster care homes.

While many home and community based services (HCBS) Medicaid programs allow program participants to self-direct their own care, specifically allowing them to hire their own caregiver, this is not an option for the Adult Day Health Program. However, program participants are able to select which Medicaid-enrolled adult day health care center they attend.

The District of Columbia’s Adult Day Health Program (ADHP) Services are available through the Regular State Plan Medicaid program. It is a 1915(i) State Plan Home and Community Based Services (HCBS) benefit. State Plan ADHP Services is an entitlement. This means meeting the state’s Medicaid eligibility requirements guarantees one will receive assistance; there is never a waiting list for program participation.

 Medicaid Waivers vs. 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. This means 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 are filled, a waitlist for benefits forms. 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

Program participants may attend adult day health care as many as five days per week and up to 8 hours per day. Services and supports may include the following.

– Meals / Snacks
– Medical / Nursing Consultation Services
– Medication Administration
– Personal Care Assistance
– Social Service Supports – i.e., consultations to determine one’s service needs, counseling
– Socialization
– Therapeutic Activities (Social, Recreational, Educational) – individual and group
– Transportation to Off-Site Activities

 Adult day care is also available through DC’s Elderly and Persons with Physical Disabilities Medicaid Waiver. This program allows applicants a higher income limit, but also requires one to have a higher level of care need.

 

Eligibility Requirements for DC’s Adult Day Health Program

ADHP Services is for DC residents who are 55+ years old and have a chronic medical condition that has been diagnosed by a doctor. Additional eligibility criteria follows.

 The American Council on Aging provides a quick and easy Medicaid Eligibility Test for DC seniors

 

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 150% of the Federal Poverty Level (FPL). These figures increase annually in January. In 2023, the individual applicant income limit is $1,823 / month. For married applicants, regardless of if one or both spouses are applicants, the income limit is $2,465 / month.

 Higher Limits: Some Medicaid programs allow a non-applicant spouse to retain a larger portion of a couple’s income and assets. DC’s State Plan Adult Day Health Program does not but DC’s Elderly and Persons with Physical Disabilities Waiver allows a non-applicant spouse a Monthly Maintenance Needs Allowance from their applicant spouse, as well as a Community Spouse Resource Allowance.

Assets
In 2023, the asset limit is $4,000 for an individual applicant. For married couples, it is $6,000, regardless of if one spouse or both are applying.

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 does not apply to the Adult Day Health Program.

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

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that DC Medicaid will take it. Applicants for the State Plan Adult Day Health Program need not worry. As long as they live in their home, the home is exempt (non-countable). However, if they live in a relative’s home, they must have “Intent to Return” home in order for it to remain exempt. It is important to note that other DC Medicaid programs, such as the EPD Waiver and nursing home Medicaid, have additional requirements for home exemption. Learn more about when Medicaid can and cannot take the home here.

 

Medical Criteria: Functional Need

While many Medicaid long-term care programs require an applicant to need a Nursing Facility Level of Care (NFLOC), this is not true for State Plan Adult Day Health Program Services. However, assistance must be medically necessary. To make this determination, an in-person functional needs assessment is completed, and based on the results, a functional assessment score is generated. If one’s score is at least a 4, the functional need criteria is met.

One’s ability / inability to complete Activities of Daily Living (ADLs), such as bathing, dressing, mobility, eating, and toiletry, is assessed, as well as a need for skilled care, such as wound care and infusions. Cognition and behavior is another area of assessment. This is relevant to many persons with Alzheimer’s disease or a related dementia, as cognitive decline and certain behaviors, such as wandering, is common. To be clear, a diagnosis of dementia in and of itself does not mean one will automatically meet the level of care need.

 Learn more about long-term care Medicaid in Washington DC.

 

Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for Medicaid in Washington DC. 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.

Persons who have income over the limit, but have high medical bills, can become income eligible via DC’s Medically Needy Spenddown program. This program permits applicants to spend their “excess” income on medical expenses in order to meet the Medically Needy income limit. The amount that must be paid each month can be thought of as a deductible. Once one’s “deductible” has been met for the month, DC Medicaid will pay for Adult Day Health Services. More about the Medically Needy pathway to eligibility.

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 may also “spend down” countable assets on ones that Medicaid considers to be exempt (non-countable). Examples include making home reparations and modifications, purchasing home furnishings, and even taking a vacation. Medicaid-Compliant Annuities, in which a lump sum of cash is converted into a monthly income stream, is another option. There are many other planning strategies available 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 Medicaid benefits. Professional Medicaid Planners are educated in the planning strategies available in Washington DC to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, while Medicaid’s 60-month Look Back Rule does not apply for the State Plan Adult Day Health Program, it does apply to Nursing Home Medicaid and the EPD Medicaid 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 Medicaid when over the income and / or asset limit(s). Find a Medicaid Planner.

 

How to Apply for DC’s Adult Day Health Program

Before You Apply

Prior to submitting an application for State Plan ADHP Services, applicants need to ensure they meet the eligibility criteria. 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, previous bank statements, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are delayed is required documentation is missing or not submitted in a timely manner.

 

Application Process

To be eligible for State Plan Adult Day Health Program Services, one must be eligible for Medicaid in the District of Columbia. Persons can apply in person at an ESA Service Center, by completing and submitting an Integrated Application for Public Assistance Benefits (found halfway down the webpage), or by calling the ESA Public Benefits Call Center at 202-727-5355.

To initiate the functional needs assessment, a Prescription Order Form (POF) must be completed by a doctor or advanced practice registered nurse who is enrolled as a DC Medicaid Provider. The POF must be submitted to Liberty Healthcare per instructions on the form.

Although not intended for a consumer audience, additional information about the State Plan Adult Day Health Program can be found here. Persons can also call the Department of Aging and Community Living (DACL) at 202-724-5626 or the Department of Health Care Finance Long Term Care Administration at 202-442-5988 to learn more. The Adult Day Health Services Program is administered by the Washington DC Department of Health Care Finance (DHCF).

 

Approval Process & Timing

The DC Medicaid 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. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even further.

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