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Does Medicaid Pay for Adult Day Care?

In most all cases, Medicare Part B DOES NOT cover any type of adult day care. It will, however, cover some of the services the adult day care provides, though normally in limited circumstances. Medicare Part B covers mental health treatments that have been prescribed by a physician and provided by an outpatient mental health facility. If that place also happens to be an adult day care center, the patient will have the added benefit of those types of services while also receiving mental health treatments. You should be aware that Medicare will only cover care if said care involves actual medical treatment—like administration and monitoring of medication, treatment to recover from a medical crisis, or either individual or group psychotherapy.

Medicare Part C Medicare Advantage plans cover everything that’s included in Parts A and B. Though, sometimes a part C plan will cover more than that, with any extra services or an expanded amount of coverage. Co-payments for Part C plans may also be different from those for Part A or B. Contact your plan directly to see if your plan provides this extra coverage or requires different co-payments.

If Medicare Part B covers some adult day care as a part of mental health care, it only covers around 50% of the approved amount that they have allotted to perform the service. In some states, Medicare partners up with Medicaid to sponsor what’s known as the PACE program, or the Program of All-Inclusive Care for the Elderly. This program provides comprehensive in-home and community care—including adult day care—for any elders who may otherwise need to be put into nursing home care. In those states that have the PACE program, only those with low income and few assets, who are also eligible for both Medicare and Medicaid can participate in the program.

No matter the rules regarding any specific type of care, in order for any Medicare plans to provide coverage (whether Parts A, B, or C), the care has to meet the following requirements:

  • The care has to be “medically necessary.” This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or Medicare Part C) agrees that it is both necessary and proper.
  • The care must be performed or delivered by a healthcare provider that participates in Medicare.

If you or someone you love needs assistance with Elder Care law issues, call 856-281-3131. Let us help ease your stress and give you a plan.