COVID-19 has put aging services across the continuum under pressure, and adult day services providers in particular are at significant financial risk because of the pandemic.

While other aging services providers are able to remain open and deliver care during this period, adult day services providers are facing closure and a halt to revenue. To limit the spread of the virus, a growing number of states and localities are requiring adult day services providers to suspend services and several other providers across the country are doing so voluntarily. For those that remain operational, significantly fewer people are showing up to receive services.

As a result, adult day services providers across the country seeing a collapse in revenue and there is no guarantee they will have the staff and/or financial resources to re-open after the pandemic. This jeopardizes both the sustainability of individual provider organizations as well as long-term access to adult day services nationwide. Before the pandemic, more than 260,000 people received adult day services.

To help adult day services providers through this period, several states are providing funds even for those providers who have suspended services. States are allowing providers to bill administrative per diem rates, including retainer payments in Medicaid HCBS waiver emergency response plans and taking other approaches to provide at least some cash flow to adult day services providers.

In addition to these payments, some states are allowing adult day services providers to be reimbursed for providing in-home services, home-delivered meals and telephone and/or electronically-based wellness checks. 

Notably, it appears that a majority of states do not offer such payments. Because of this, LeadingAge has requested dedicated federal funds for adult day services both from Congress and from the U.S. Department of Health and Human Services.

A list of states LeadingAge identified as doing so as of April 27 is below, along with a description of their respective payment policies for adult day services. On April 27, this list was updated to include: Connecticut, DC, Florida, South Carolina, Utah and Washington. 

• Alaska: Using an Appendix K application, Alaska provides retainer payments for adult day services when “an individual is under medical quarantine for the duration of the quarantine and shall not exceed the total amount that the provider would have received had services been provided as expected.” Retainer payments are limited to 30 consecutive days.
• Colorado: Adult day services providers that “stopped or reduced services in response to the COVID-19 pandemic may bill for retainer payments.” Providers can bill for Medicaid HCBS participants only and must do so in accordance with the amount of services authorized in each participant’s service plan. Providers can also deliver services using alternative methods, including the use of technology. CMS also has an Appendix K application for the state posted online.
• Connecticut: Using an Appendix K application, the state is allowing adult day services providers to deliver and be reimbursed for services delivered “electronically or telephonically”.
• District of Columbia: Using an Appendix K application, DC is paying for adult day health providers to deliver services remotely. These payments will “equal to 75% of the FFS per diem rate to Adult Day Health Programs for wellness checks provided via video conferencing/other electronic modality (e.g., Skype, Zoom, FaceTime) or telephone for the duration of the public health emergency, in accordance with HIPAA requirements.” The application details requirements for the wellness checks and provider documentation. Retainer payments are also available for those providers that fully suspend services. Rate data from DC show the remote services rate at $102 per diem and the closure retainer rate at $34 per diem. 
• Florida: Using an Appendix K application, Florida provided both retainer payments for adult day providers as well as flexibility for service delivery. Adult day centers in Florida are closed as of March 2020. During the pandemic, adult day services providers can bill for in-home services, medication management and meal delivery services. In addition, the state wrote in retainer payments that “will be based upon the average payment amount made to the provider over a retrospective three-month period; payments will be limited to 30 consecutive days of billing or the number of days for what the State authorizes a payment for “bed-hold” in nursing facilities, which will continue during the state of emergency.”
• Georgia: Using an Appendix K application, Georgia is authorizing retainer payments for adult day services “in the event that the provider is not serving the member through other comparable or substituted services or using differential staff such as family caregivers to provide service. The retainer payment with be authorized at the level, duration, and amount as outlined in the prior authorization. Retainer payments can be made throughout the temporary authorization period.”
• Illinois: Following a statewide closure of adult day services, Illinois plans to issue a “capacity grant per site to be used for maintaining staff, space, utilities, cleaning and other necessary operational expenses.” Exact grant amounts have yet to be determined but will likely be based on previous billing for Medicaid services.
• Iowa: Using an Appendix K application, Iowa is authorizing retainer payments for adult day services “when a member is unable to receive normally authorized and scheduled services due to hospitalization, short term facility stay, isolation, or closure of a service line for any of the services listed below of no more than 30 days related to the COVID-19 emergency.”
• Kentucky: While not specific to adult day services, Kentucky included retainer payments in its Appendix K application. Specifically, “In response to the defined emergency, and in order to maintain a viable workforce, the state may elect to make retainer payments to waiver providers in instances where the agency has been directed to close and the provider cannot enter the participant’s home or provide services through other electronic platforms.” Kentucky closed adult day services centers statewide in March, so they may be eligible for these payments. In addition, the state says it will “determine the rate and scope of retainer payments based on the severity of the situation” and that retainer payments will last no longer than 24 days. The application also allows adult day providers to be reimbursed for services delivered in-home and via electronic means. The state also expanded which services adult day services providers may deliver to include home-delivered meals and in-home nursing services.
• Maryland: Adult day services providers are allowed to bill an administrative per diem rate for participants funded by Medicaid. Providers can bill the rate in accordance with each participant’s care plan. The administrative rate is 85% of the typical Medicaid rate for adult day services. Billing for this rate is based on a participant’s enrollment in adult day services, not actual attendance or previous billing to Medicaid. To receive these funds, providers are required to call all of their participants every day to check in on them.
• North Carolina: While there is not a statewide closure mandate, most adult day services providers in the state have suspended services. North Carolina is allowing adult day services providers to bill the state “based on the daily participant count as of March 10, 2020 effective until June 30, 2020”. In addition, “providers who remain open but have reduced attendance may bill for the total participant count on March 10, 2020.” Providers receiving these funds must ”conduct a daily telephone wellness check with all enrolled participants, document the results, and seek assistance from local and state resources as needs arise.” Based on the state document announcing this policy, there may be a cap of how much funds are available to all providers for these payments.
• Oregon: While adult day in Oregon are closed, the state will reimburse providers 75% “of their average total monthly revenue for a three-month period running from mid-March through mid-June. Total average revenue may be from any source other than Oregon’s Developmental Disabilities program.” In exchange for this payment, adult day services providers are instructed to make contact with participants at least twice per week and can be by phone, email, text or other means.
• Oklahoma: Using an Appendix K application, Oklahoma’s retainer payments for adult day provide coverage “up to the lesser of 30 consecutive days or the number of bed hold days the State will pay (60 per year). Retainer payments won’t exceed 60% of the monthly average of total billing.” Payments are limited to the equivalent of 6 hours per day of services and a total of 5 days per week.
• South Carolina: Using an Appendix K application, the state is allowing adult day providers to deliver nursing services in participants’ homes if the provider has suspended services. Providers may bill for this care per hour at one-fifth the per diem rate for adult day. The per diem rate in South Carolina is $56.40, so the hourly rate for these services should be about $11.30.
• South Dakota: Using an Appendix K application, the state extended retainer payments to day services providers. Specifically, agencies “will be eligible to receive retainer payments when individuals receiving services are displaced from those settings due to the COVID-19 pandemic. Retainer payment can only be billed for participants receiving day or residential services and only for the amount authorized. Retainer payments may not exceed the lessor of 30 consecutive days. Retainer payments can only be billed when the individual is not receiving day or residential services in another setting by the provider authorized to receive retainer payments.” Notably, retainer payments are extended only to day settings for the state’s I/DD waiver, not its HCBS waiver for older adults.
• Utah: Using an Appendix K application, the state is providing retainer providers for in-home and adult day services. Specifically, “may be provided for circumstances in which providers have experienced significant decline in service utilization due to COVID-19 containment efforts because the waiver participant is sick due to COVID-19; or the waiver participant is sequestered and/or quarantined based on local, state, federal and/or medical requirements/orders.” While the payments are subject to availability of funds (the amount of which isn’t specified in the application), providers may receive “up to 100% of average monthly pre-COVID-19 costs associated with these services.” The application includes detail on how the state is ensuring the integrity of retainer providers (e.g., supporting evidence), and limits payments to “lesser of 30 consecutive days or the number of days for which the state authorizes a payment for “bed-hold” in nursing facilities.”
• Washington: The state is providing retainer payments to adult day programs. While the exact amount will vary by provider, LeadingAge Washington estimates that payments should cover about 70% of typical Medicaid reimbursement. Payments will be based on number of days participants would attend services and are limited to 30 days. The state announced that $500,000 are initially available to providers for these payments. In addition, if providers are closed, the state is temporarily expanding the service definition of adult day to allow services to be delivered in participant homes (including meal delivery) and/or through telephonic wellness checks.