Adult Day Health - NaviCare only, effective January 1, 2026 Form

Adult Day Health Clinical Coverage Criteria Page 1 of 5 Effective 01/01/2026

Adult Day Health Clinical Coverage Criteria Description Adult Day Health (ADH) is a structured, daytime service offered in community settings to individuals who face challenges related to physical health, cognitive function, complex medical conditions, or behavioral health. It is designed to provide clinical oversight, personal care, and therapeutic engagement in a non-residential environment. ADH also serves as a source of relief for caregivers and family members during program hours.
Transportation Services ADH includes coordinated transportation to and from the program site. Staff assist members with safely entering and exiting vehicles, ensuring accessibility and comfort throughout the journey.
Service Components Delivered in a group setting at the provider’s location, ADH encompasses a wide range of services tailored to meet each participant’s assessed needs. These include: • Nursing Services and Health Monitoring: Ongoing clinical supervision and skilled nursing care. • Therapies: Access to physical, occupational, and speech-language therapy as needed. • Support with ADLs: Assistance with daily self-care tasks such as eating, toileting, and mobility. • Nutrition and Meals: Provision of a hot lunch, accommodations for special diets, and two daily snacks (morning and afternoon). • Counseling and Social Services: Emotional support and case management to address psychosocial needs. • Therapeutic and Recreational Activities: Structured programming to promote engagement, cognitive stimulation, and social interaction.
Program Goals The primary objective of ADH is to support members in maintaining their health and independence while avoiding unnecessary institutionalization. Services are tailored to address both skilled nursing needs and functional limitations, ensuring that each participant receives appropriate care in a community-based setting. Policy This Policy applies to the following Fallon Health products: ☐ Fallon Medicare Plus, Fallon Medicare Plus Central (Medicare Advantage)
☐ MassHealth ACO ☒ NaviCare HMO SNP (Dual Eligible Medicare Advantage and MassHealth) ☐ PACE (Summit Eldercare PACE, Fallon Health Weinberg PACE) ☐ Community Care (Commercial/Exchange)

Adult Day Health Clinical Coverage Criteria Page 2 of 5 Effective 01/01/2026

Prior authorization is required for Adult Day Health Fallon Health Clinical Coverage Criteria Fallon Health considers Adult Day Health Services medically necessary when all the following criteria is met and validated through outlined documentation:

1. Medical Need: Member has a chronic or post-acute condition requiring ongoing nursing observation and intervention. Without ADH, deterioration is likely.
2. PCP Order: ADH must be ordered by the member’s Primary Care Provider within the past six months of the prior authorization (PA) request.
3. Clinical Assessment: Completed by the ADH provider within the past six months of the PA request. It must support the need for ADH and specify the level of care (basic or complex). Fallon Health will validate this against the most recent HRA.
4. NaviCare Health Risk Assessment, Minimum Data Set (MDS), and Functional Assessment; completed and validated within the past 3 months
5. Services must be incorporated into the Individualized Care Plan.
6. Additional Documentation: Fallon Health may request nursing, medical, or psychosocial evaluations to support the PA review.
7. Service Need: Member must require:
   o At least one daily skilled service ordered by a physician, or o Assistance with one or more qualifying ADLs, either through hands-on help or cueing/supervision throughout the task. Levels of Care and Payment Basic Level • Requires at least one skilled service or ADL assistance • Services must be provided during ADH attendance and align with the care plan Complex Level • Requires daily skilled services* (1–5 or 8), or • A combination of three needs, including:
   o One qualifying ADL o One skilled service (9–12 or 15) ordered by a physician • Services must be delivered during ADH attendance and follow the care plan Skilled Services (Physician Ordered)
8. Injections or IV feeding
9. Tube feeding (nasogastric, gastrostomy, jejunostomy)
10. Tracheostomy care and aspiration
11. Wound care requiring sterile dressings or irrigation
12. Oxygen therapy requiring skilled monitoring
13. Frequent skilled nursing interventions for unstable conditions
14. RN oversight of complex care plans involving unskilled services
15. Catheter care (suprapubic or medically necessary urethral)
16. Medication management and monitoring
17. Behavioral health plan oversight for:
    o Wandering, exit-seeking, elopement o Verbal or physical aggression o Socially disruptive behaviors o Impaired judgment or executive function
18. Intake/output monitoring for chronic conditions

Adult Day Health Clinical Coverage Criteria Page 3 of 5 Effective 01/01/2026

12. Gait training post-neurological or orthopedic events
13. Range-of-motion therapy for mobility loss
14. Heat or hydrotherapy for circulatory or wound complications
15. Physician-directed physical, speech, or occupational therapy with documented goals **Qualifying ADLs
16. Bathing: Full or partial bath with hygiene tasks
17. Toileting: Incontinence care or catheter/colostomy support
18. Transferring: Physical assistance or supervision during position changes
19. Mobility: Support during ambulation or wheelchair use

20. Eating: Supervision or physical help during meals

    Medicare Variation N/A

    MassHealth Variation N/A

    Exclusions Fallon Health determines that Adult Day Health (ADH) is not medically necessary and will not authorize payment to ADH providers under the following conditions, which include but are not limited to:

21. Concurrent Home Health Services o If the member is receiving services from a Home Health Agency or a similar provider during the same time they are attending the ADH program, as outlined in 130 CMR 403.000.
22. Institutional Residency or Inpatient Status o If the member is currently admitted to a hospital, nursing facility, or an intermediate care facility for individuals with intellectual disabilities. Exceptions are made only for the dates of admission and discharge.
23. Lack of Prior Authorization o If the ADH provider has not obtained prior authorization from Fallon Health before delivering services.
24. Program Cancellations or Member Absences o If the ADH program is canceled or the member misses scheduled attendance for any reason, reimbursement will not be provided for those time periods.

25. Absence from ADH Site Without Documented Off-Site Services o If the member is not physically present at the ADH location, payment will only be considered if the provider documents that the member received ADH services from program staff in a community-based setting outside the facility.

    Evidence Summary N/A

    Analysis of Evidence (Rationale for Determination) N/A

Adult Day Health Clinical Coverage Criteria Page 4 of 5 Effective 01/01/2026 Coding The following codes are included below for informational purposes only; inclusion of a code does not constitute or imply coverage. CPT/HCPCS Codes Code Description S5102 Day care services, adult; per diem.
(Use for adult day health-basic level of care services over three hours per day) S5102 TG Day care services, adult; per diem.
(Use for adult day health-complex level of care services over three hours per day) S5101 Day care services, adult; partial per diem.
(Use for adult day health-basic level of care services up to three hours per day) S5101 TG Day care services, adult; partial per diem.
(Use for adult day health-complex level of care services up to three hours per day) T2003 Nonemergency transportation, non-wheelchair (ambulatory) transportation. Use for transportation furnished on a single date or on consecutive dates. All transportation services must be billed as one-way trips; round trips should be billed as two one-way trips T2003 U6 Nonemergency transportation, wheelchair transportation, encounter/trip. Use for transportation furnished on a single date or on consecutive dates. All transportation services must be billed as one-way trips; round trips should be billed as two one-way trips.

References

1. 130 CMR 404.000 MassHealth Adult Day Health Services and Subchapter iv Adult Day Health Services Manual https://www.mass.gov/doc/130-cmr-404-adult-day-health- services/download
2. 101 CMR 310.00 Rates for Adult Day Health Services https://www.mass.gov/doc/101-cmr- 310-rates-for-adult-dayhealth-services/download
3. 105 CMR 158.000 Licensure of Adult Day Health Programs https://www.mass.gov/doc/105- cmr-158-licensure-ofadult-day-health-programs/download
4. MassHealth Guidelines for Medical Necessity Determination for Adult Day Health (ADH) Services https://www.mass.gov/doc/guidelines-for-medical-necessity-determination-for-adult- day-health-adh-0/download

5. MassHealth Adult Day Health Primary Care (PCP) Order Form Policy history Origination date:
   01/01/2026
   Review/Approval(s):
   Technology Assessment Committee: N/A Utilization Management Committee: 10/21/2025 (origination, approved as written).

   Instructions for Use Fallon Health complies with CMS’s national coverage determinations (NCDs), local coverage determinations (LCDs) of Medicare Contractors with jurisdiction for claims in the Plan’s service area, and applicable Medicare statutes and regulations when making medical necessity determinations for Medicare Advantage members. When coverage criteria are not fully established in applicable Medicare statutes, regulations, NCDs or LCDs, Fallon Health may

Adult Day Health Clinical Coverage Criteria Page 5 of 5 Effective 01/01/2026 create internal coverage criteria under specific circumstances described at § 422.101(b)(6)(i) and (ii). Fallon Health follows Medical Necessity Guidelines published by MassHealth when making medical necessity determinations for MassHealth members. In the absence of Medical Necessity Guidelines published by MassHealth, Fallon Health may create clinical coverage criteria in accordance with the definition of Medical Necessity in 130 CMR 450.204. For plan members enrolled in NaviCare, Fallon Health first follow’s CMS’s national coverage determinations (NCDs), local coverage determinations (LCDs) of Medicare Contractors with jurisdiction for claims in the Plan’s service area, and applicable Medicare statutes and regulations when making medical necessity determinations. When coverage criteria are not fully established in applicable Medicare statutes, regulations, NCDs or LCDs, or if the NaviCare member does not meet coverage criteria in applicable Medicare statutes, regulations, NCDs or LCDs, Fallon Health then follows Medical Necessity Guidelines published by MassHealth when making necessity determinations for NaviCare members.
Each PACE plan member is assigned to an Interdisciplinary Team. PACE provides participants with all the care and services covered by Medicare and Medicaid, as authorized by the interdisciplinary team, as well as additional medically necessary care and services not covered by Medicare and Medicaid. With the exception of emergency care and out-of-area urgently needed care, all care and services provided to PACE plan members must be authorized by the interdisciplinary team. Not all services mentioned in this policy are covered for all products or employer groups. Coverage is based upon the terms of a member’s particular benefit plan which may contain its own specific provisions for coverage and exclusions regardless of medical necessity. Please consult the product’s Evidence of Coverage for exclusions or other benefit limitations applicable to this service or supply. If there is any discrepancy between this policy and a member’s benefit plan, the provisions of the benefit plan will govern. However, applicable state mandates take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. Unless otherwise specifically excluded, federal mandates will apply to all plans.