Adult Day Care Regulations in Massachusetts

Who regulates adult day care in Massachusetts

The Department of Public Health (DPH) licenses adult day health programs under 105 CMR 158.00, Licensure of Adult Day Health Programs. No person may establish or maintain a program without an original DPH license. The regulation defines an adult day health program as a non-residential, community-based entity that provides nursing care, supervision and health related support services in a structured group setting.

MassHealth, part of the Executive Office of Health and Human Services (EOHHS), pays for adult day health under 130 CMR 404.000, Adult Day Health Services. To participate, a provider must be licensed by DPH under 105 CMR 158.00 and enter into a MassHealth provider contract. EOHHS sets the payment rates in 101 CMR 310.00.

Types of adult day programs in Massachusetts

• Adult day health (ADH): the DPH-licensed, MassHealth-covered program.
• Supportive day program: a service of the Frail Elder Waiver, a MassHealth home and community-based services waiver.
• Supportive day care and dementia day care: services listed, along with adult day health, by the state Home Care Program.

How to get licensed in Massachusetts

1. Apply to DPH on its forms, signed under penalty of perjury. DPH will not accept an application unless it is complete and the fees are paid.
2. Provide current local board of health certificates, an occupancy permit and a local fire inspection certificate.
3. Pass DPH's inspection or investigation, which must find the program compliant and the applicant suitable and responsible.
4. File each renewal application by the expiration date of the current license.
5. To bill MassHealth, sign a MassHealth provider contract and agree to follow 130 CMR 404.000 and 450.000.

Key requirements

Under 105 CMR 158.00 (most recently amended in the Massachusetts Register on September 29, 2023), a licensed program must:

• Be open at least Monday through Friday.
• Have a program director whose minimum hours depend on licensed capacity: at least 10 hours a week for 35 or fewer participants, 20 hours for 36 to 72, and 35 hours for 73 or more.
• Keep licensed nursing staff on site at least eight hours a day, four of them by a registered nurse. Coverage rises to 12 hours (four by an RN) at a census of 35 or more, 16 hours (eight by an RN) at 50 or more, and proportionally more above 75.
• Maintain at least one direct care staff person per six participants and at least one qualified program aide per 12 participants.
• Provide a social worker or other qualified staff member at least 20 hours a week when licensed capacity is 24 or more, and a therapeutic activity director on site at least four hours a day.
• Have a registered dietitian on site at least four hours every six months, and train staff on Alzheimer's disease and related disorders.

MassHealth adds a rule for members at its complex payment level. Under 130 CMR 404.000 (MassHealth transmittal ADH-26, July 2018), the minimum staffing ratio is one staff person to four complex payment level members.

Medicaid funding for adult day in Massachusetts

Under 130 CMR 404.000 (2018 text), MassHealth covers adult day health for eligible members age 18 or older. A member needs a primary care provider's order, a condition that requires active monitoring, treatment or intervention, and either a skilled service or regular hands-on help or cueing with qualifying activities of daily living. The provider must obtain prior authorization before the first date of service, then annually or after a significant change.

130 CMR 404.000 (2018 text) also recognizes capitated programs, which it defines as integrated care organizations (ICOs), Senior Care Options (SCO) plans, PACE organizations and other entities that cover adult day health on a capitated basis under an EOHHS contract. The Frail Elder Waiver, a MassHealth program operated day to day by the Executive Office of Aging and Independence for MassHealth-eligible residents 60 and older, includes a supportive day program. Providers interested in waiver services contact the local Aging Services Access Point (ASAP) and may also contract with SCO plans.

Billing basics

101 CMR 310.00, effective for dates of service on or after July 1, 2025, lists these adult day health codes:

• S5102: basic level of care, per diem. S5102 with TG: complex level of care, per diem.
• S5101: basic level of care, partial per diem. S5101 with TG: complex level of care, partial per diem.
• T2003: non-wheelchair transportation, one-way trip. T2003 with U6: wheelchair transportation, one-way trip.

A per diem covers services for more than three hours a day, and a partial per diem covers three hours or less. MassHealth will not pay for services beyond six hours a day (101 CMR 310.02).

Other ways centers are paid

The Home Care Program, run through the Executive Office of Aging and Independence and its ASAP network, serves adults 60 and older, people with disabilities and people under 60 with early-onset Alzheimer's disease or a related dementia. It lists adult day health, dementia day care and supportive day care among its services, with costs based on income. Enrolled veterans who meet VA eligibility and clinical criteria can get adult day health care through the VA (VA Adult Day Health Care).

Official resources

• 105 CMR 158.00, Licensure of Adult Day Health Programs
• 130 CMR 404.000, Adult Day Health Services (MassHealth)
• 101 CMR 310.00, Rates for Adult Day Health Services
• Frail Elder Waiver
• Home Care Program

Frequently asked questions

Do I need a license to open an adult day center in Massachusetts?

Yes, to run an adult day health program. 105 CMR 158.00 bars anyone from establishing or maintaining a program without an original DPH license, and MassHealth requires its adult day health providers to hold that license.

Does MassHealth pay for adult day care?

Yes. MassHealth covers adult day health under 130 CMR 404.000 with a primary care provider's order and prior authorization, paying basic or complex rates under 101 CMR 310.00. The Frail Elder Waiver covers a supportive day program.

Who inspects adult day health programs in Massachusetts?

DPH. Before granting a license, it conducts an inspection or investigation to confirm the program complies with 105 CMR 158.00 and that the applicant is suitable and responsible.

What is the difference between the basic and complex payment levels?

They are the two MassHealth payment rates for adult day health. Programs must keep at least one staff person for every four complex payment level members.