Overview
Under Chapter 118E of the Massachusetts General Laws, the Executive Office of Health and Human Services, through the Division of Medical Assistance, administers the state’s Medicaid program, known as MassHealth. MassHealth annually provides access to healthcare services for approximately 2.3 million eligible children, families, people over 65, and people with disabilities, all of whom have low or moderate incomes. In fiscal year 2023, MassHealth paid healthcare providers more than $17.1 billion, of which approximately 35% was funded by the Commonwealth. Medicaid expenditures represented approximately 33% of the Commonwealth’s total fiscal year 2023 budget.
Adult Day Health
Adult day health (ADH) is a community-based, nonresidential service that delivers nursing, supervision, and assistance with daily activities to MassHealth members in an organized group setting. MassHealth covers ADH for eligible members who need assistance with activities of daily living (e.g., eating, toileting, bathing, or walking) or skilled nursing services. MassHealth requires prior authorization for ADH. ADH providers can also bill MassHealth for transportation that they provide for members to and from the ADH center.
Telehealth
Following the Governor’s Declaration of Emergency on March 10, 2020, which was in response to the COVID-19 pandemic, MassHealth issued All Provider Bulletin 289, which permitted qualified providers to deliver clinically appropriate and medically necessary services to MassHealth members through telehealth. During this time, ADH providers were allowed to bill MassHealth on a retainer basis at the frequency that their members were attending ADH before the COVID-19 pandemic. That is, if a member attended ADH five days per week before the COVID-19 pandemic, then MassHealth would still pay claims for up to five days per week for that member, even though the member did not receive any ADH between April 1, 2020 and July 31, 2020.
During the audit period, MassHealth paid ADH providers $136,134,425, of which $41,809,653.67 (31%) was for telehealth ADH, as detailed in the graph below.
Amount Paid for ADH by Year
In August 2020, MassHealth issued ADH Bulletin 18, which provided guidance to ADH providers regarding MassHealth’s telehealth policies. ADH providers were allowed to bill MassHealth using a partial per diem service code for providing telehealth ADH for up to three hours per day. Some examples of ADH-related services that could be provided through telehealth, according to MassHealth’s bulletin, included coordination of care, wellness checks, medication management, and group activities with specific goals for members. Services that could not be provided through telehealth, according to MassHealth’s bulletin, included meal delivery, COVID-19 symptom checks, and arrangement of a member’s on-site attendance at their ADH center (e.g., calls from the ADH provider to confirm a pickup time). Additionally, ADH providers could not bill for transportation to an ADH center on days when a member received telehealth ADH.
Levels of Care
ADH is provided at the basic level of care if a MassHealth member needs either one of the following: (1) skilled services ordered by a physician, such as nursing or physical therapy, or (2) assistance with daily activities such as eating, bathing, or toileting. ADH is provided at the complex level of care for MassHealth members who need both of the aforementioned services and assistance.
| Date published: | October 1, 2024 |
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