Adult Day Care Program Manual


General Information – Overview of Departments

Adult Day Care Program Licensure

Regulated by the Department Of Health & Senior Services (DHSS), Division of Regulation & Licensure-Section for Long-Term Care Regulation (SLCR):

19 CSR 30-90.010 (1): An adult day care program is a group program designed to provide care and supervision to meet the needs of five (5) or more functionally impaired adults for periods of less than twenty-four (24) hours but more than two (2) hours per day in a place other than the adult's own home.

A licensed adult day care (ADC) program must comply with all state, county, and city requirements. Occupancy and business permits must be obtained, if required by the county or city in which the center will conduct business in. These permits must be obtained prior to an initial inspection being conducted by the DHSS for licensure.

After approval of an application to operate an ADC program, an initial inspection will be conducted at the ADC program. If the program is in compliance with all licensure regulations during that inspection, the center will receive a license to begin operating.

If you are an ADC provider who does not receive any Medicaid reimbursement you are required to adhere to the regulations outlined in 19 CSR 30-90 and the statutory laws outlined in Chapter 192, RSMo.

  • If you have an Alzheimer’s special care unit or program which provides a designated separated unit or program for participants with a diagnosis of probable Alzheimer’s disease or related disorder, to prevent or limit access by a participant outside the designated or separated area; or that advertises, markets or promotes the adult day care program as providing Alzheimer’s or dementia care services, providers are required to comply with 198.515, RSMo – Alzheimer’s Special Care Services Disclosure.

Weblinks

Medicaid Reimbursement

Adult Day Care Services – Overview

DHSS Division of Senior & Disability Services, Missouri Department of Social Services - MO HealthNet Division, and Missouri Medicaid Audit and Compliance.

ADC services provide the continuous care and supervision of disabled adults in a licensed ADC setting for up to ten (10) hours per day for a maximum of five (5) days per week. These services include, but are not limited to, assistance with activities of daily living, planned group activities, food services, client observation, skilled nursing services as specified in the individual’s plan of care, and transportation. ADC services are provided by licensed ADC programs enrolled as a MO HealthNet provider.

ADC services are available to Medicaid eligible participants who meet the nursing facility level of care and have been approved to participate in the ADC Waiver or the Aged and Disabled Waiver by the Department of Health and Senior Services, Division of Senior and Disability Services (DSDS). The ADC Waiver and the Aged and Disabled Waiver are Home and Community Based (HCB) Medicaid Waivers operated by the DSDS. In order for ADC providers to be reimbursed by MO HealthNet, all ADC services must be prior authorized by DSDS.

Enrollment as a MO HealthNet Adult Day Care Provider

ADC programs must enroll with the Department of Social Services (DSS), Missouri Medicaid Audit and Compliance Unit (MMAC) in order to be reimbursed for services provided to MO HealthNet Waiver participants. Each location providing ADC services to MO HealthNet participants must enroll with MMAC separately.

In order to enroll as a MO HealthNet Provider you must apply for a National Provider Identifier (NPI). The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) required the adoption of standard unique identifiers for health care providers and health plans. The purpose of these provisions was to improve the efficiency and effectiveness of the electronic transmission of health information.

The Centers for Medicare & Medicaid Services (CMS) has developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers. Adult Day Care programs may apply for an NPI at the following link: https://nppes.cms.hhs.gov/login

Information regarding MO HealthNet enrollment forms and required information that must be submitted to MMAC is located at the following link: https://mmac.mo.gov/providers/provider-enrollment/home-and-community-based-services/

Completed enrollment packets are submitted to MMAC at:
MMAC Provider Contracts
P.O. Box 6500
Jefferson City, MO 65102-6500
Fax: (573) 751-5065

Upon receipt of the required documents MMAC will review and make a determination. On average, it is approximately six (6) months from the time a proposal is submitted and the provider can begin serving participants. This timeframe can take much longer depending on the quality of the submitted information, the amount of additional or revised information that must be submitted and the current workload of MMAC staff. The ADC will be notified via email if additional information is needed or the application is finalized and approved.

If you have questions or need assistance completing the enrollment forms, please contact Provider Contracts via email at: mmac.ihscontracts@dss.mo.gov

Once an ADC program has been enrolled as a MO HealthNet ADC provider, the provider information will be added to the MO HealthNet provider list. This provider will then be available for selection by waiver participants who are determined eligible and authorized for ADC services offered through the ADC Waiver or Aged and Disabled Waiver.

Prior Authorization of Adult Day Care Services

All ADC services must be prior authorized by the DSDS before services are provided in order to be paid by MO HealthNet. The DSDS is responsible for the following activities: intake of referrals, conducting assessments of nursing facility level of care and authorization of services through person centered care planning.

In order to make an initial referral for ADC Services, contact DSDS by phone at: (866) 835-3505. Initial referrals will be processed with fifteen (15) business days.

Requests for changes in a participant’s care plan for those participants already receiving adult day care services must be made by contacting the appropriate Regional Evaluation (REV) Team.

Information regarding prior authorized services may be found on the Home and Community Based Services (HCBS) Web Tool. The HCBS Web Tool provides a web portal that gives HCB providers access to a participants’ screening, assessment(s), and prior authorization(s) for Medicaid funded HCBS. More information about the HCBS Web Tool may be found at the MDHSS website.

ADC services are authorized and billed in units. Each unit represents a fifteen (15) minute block of provided service. ADC services may be authorized up to ten (10) hours per day for a maximum of five (5) days per week. No more than 8 units (two (2) hours) daily, of the authorized units, will be reimbursed for transporting the participant to and from the facility.

MO HealthNet Adult Day Care Services - Program Manuals

If you are an ADC provider who receives Medicaid reimbursement you are required to comply with all regulations contained in 19 CSR 30-90 Adult Day Care Program Licensure and the standards outlined in the applicable MO HealthNet ADC Waiver or Aged and Disabled Waiver Manual.

MO HealthNet enrolled ADC providers must be aware of program requirements as provided in the program manuals. These manuals may be found as follows:

Participant Eligibility for MO HealthNet

The Department of Social Services, Family Support Division, determines eligibility for MO HealthNet benefits. Information regarding eligibility and the application for MO HealthNet for the Aged, Blind and Disabled is available at the following link.

Information regarding local Family Support Division offices is available under the drop down for Food, Health Care and Family Care at the following link.

The Division may be reached at (855) 373-4636 (7am to 6pm) or (800) 392-1261 for the automated line.

Education for New MO HealthNet Providers

Valuable information for MO HealthNet providers can be found at the Provider Participation page of the MO HealthNet website. You may browse this site to view Provider Frequently Asked Questions (FAQs), Education and Training, Manuals, Bulletins and Hot Tips at the following link.

Provider representatives are available to train providers and other groups on proper billing practices as well as educating them on MO HealthNet programs and policies. In order to discuss training options, contact the provider education unit at (573) 751-6683, or email at mhd.provtrain@dss.mo.gov. Scheduled training webinars and workshops are also available.

The following link provides dates, times, and locations of upcoming workshops: https://mydss.mo.gov/mhd/providers

Billing MO HealthNet

Prior authorized ADC services provided for MO HealthNet eligible participants may be billed to MO HealthNet. These claims are billed through the EMOMED system. EMOMED is accessible at the following link: https://www.emomed.com/

You must register for EMOMED access to bill electronically. For electronic billing assistance you may contact Wipro Infocrossing Healthcare Services, Inc. Help Desk at (573) 635-3559 or email address: internethelpdesk@momed.com. Providers may call or send an e-mail for help in establishing the required electronic claims format, network communication, or assistance with the MO HealthNet billing web site and other simple help tips.

Providers billing MO HealthNet for services are paid depending upon the financial cycle when the claim was processed. The Claims Processing Schedule is located on the MoHealthNet Portal.

MO HealthNet Provider Communication

MO HealthNet providers may call the Interactive Active Voice Response System (IVR) at (573) 751-2896. The IVR provides answers to such questions as participant eligibility, last two check amounts, and claim status using a touch-tone telephone. Anytime during the IVR options, you may select “0” to speak to the next available specialist. Your call will be put into a queue and will be answered in the order it was received. Providers should utilize Provider Communication as their first point of contact for inquiries, concerns, and questions regarding proper claim filing, claims resolution and disposition, and participant eligibility questions and verifications.

Providers may send and receive secure e-mail inquiries through the MO HealthNet web portal at EMOMED.com. Once you have logged on to the e-provider page, click on Provider Communications Management to send inquiries, or questions regarding proper claim filing instructions, claims resolution and disposition, and participant eligibility file problems. Providers may send one inquiry per e-mail.

Written inquiries are also handled by the Provider Communications Unit and can be mailed to the following address:
Provider Communications Unit
PO Box 5500
Jefferson City, MO 65102-5500

MO HealthNet Provider Review

MMAC, Provider Review Group is responsible for reviewing and monitoring statewide utilization and program compliance of MO HealthNet providers. The Provider Review Group conducts post payment reviews and investigates complaints regarding MO HealthNet Providers. These reviews may be either at the providers’ facility or may be through desk review (where records are requested through the mail).

Information regarding this process may be found at: http://mmac.mo.gov/providers/provider-reviews/

Developmental Disabilities (DD) Medicaid Waiver Program (Independent Living Skills Development (ILSD))

Regulated by the Department of Mental Health (DMH), Licensure and Certification Unit.

Independent living skills development focuses on skill acquisition/development, retention/maintenance to assist the individual in achieving maximum self-sufficiency. This service assists the individual to acquire, improve and retain the self-help, socialization and adaptive skills necessary to reside successfully in home and community-based settings. A provider is not required to make services available in a stand-alone facility to provide this service, but may choose only to provide the Home Skills Development and Community Integration components of this service.

Day services are provided at a stand-alone licensed or certified day program facility, which is not physically connected to the individual’s residence. Day services assist the individual to acquire, improve and retain the self-help, socialization, adaptive, and life skills necessary at home or in the community. Costs for transporting the individual from their place of residence to the day program site are not included in the day service rate, and waiver transportation may be provided and separately billed.

If you are a provider dually licensed by both DMH and DHSS you are required to adhere to all regulations contained in DMH regulations at 9 CSR 45-5 Certification* or 9 CSR 40-9 or 9 CSR 40-10 Licensing*, and DHSS regulations at 19 CSR 30-90 Adult Day Care Program Licensure. When the regulation(s) conflict, the provider is required to comply with the more stringent regulation(s).

In addition, you must comply with the standards outlined in the MO HealthNet Developmental Disabilities (DD) Waivers Manual.

*Clarification: A provider can apply for either certification of a waiver service such as ILSD or a license for a business such as a Day Program. Since the ILSD is a certified waiver service, providers must comply with the standards in 9 CSR 45-5. If a business opens a Day Program for either the developmentally disabled or mentally ill the business is required to apply for a DMH license and comply with the standards in 9 CSR 40-9 or 9 CSR 40-10.

If you wish to become a provider through DMH, contact:
Office of Licensure and Certification
PO Box 687
Jefferson City, MO 65102
(573) 751-4024

The Child and Adult Care Food Program (CACFP)

Administered by the DHSS.

CACFP provides meal reimbursement to eligible adult day care centers. The target population of this program is elderly and functionally impaired adults, 18 years of age or older and adults 60 years of age or older who are unable to live independently or perform activities of daily living. Functionally impaired adults include victims of Alzheimer's disease and related disorders with neurological and organic brain dysfunction, who are physically or mentally impaired to the extent that their capability for independence and ability to carry out functions of daily living is markedly limited.

Eligible facilities must serve meals meeting eligibility requirements; maintain accurate and complete records; operate a nonprofit food service, train center personnel in program requirements and operations; and collect income eligibility information on all participants claimed as free or reduced.

Eligibility Requirements

To participate in CACFP, an adult day care facility must be licensed by an approved state or federal authority and be nonresidential. In other words, the same participants cannot be maintained in care for more than 24 hours on a regular basis.

DHSS Child and Adult Care Food Program Weblink

The DHSS CACFP provides reimbursement for allowable meals served; provides technical assistance on nutrition, food service operations, program management, and record keeping; and reviews and monitors program services to ensure good nutrition for all enrolled participants. For assistance, contact:

Community Food and Nutrition Assistance
Missouri Department of Health and Senior Services
PO Box 570
Jefferson City, MO 65102
Telephone: 573-751-6269 or
(Toll-free) 800-733-6251
Email: CACFP@health.mo.gov

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