Adult Day Care Regulations in the District of Columbia

Who regulates adult day care in the District of Columbia

The DC Department of Health Care Finance (DHCF), the District's Medicaid agency, oversees adult day health providers. Under the District's Medicaid State Plan, Adult Day Health Program (ADHP) providers are not a licensed provider type. Instead, they are certified in accordance with District regulations, and DHCF verifies their qualifications.

DC Health's State Health Planning and Development Agency (SHPDA) also plays a role, because the State Plan requires ADHP providers to hold a valid Certificate of Need (CON).

Types of adult day programs in the District of Columbia

The District's adult day model is the Adult Day Health Program. DHCF describes ADHP as non-residential medical supports and supervised, therapeutic activities in an integrated setting for older adults and people with physical disabilities, including nursing and rehabilitation services.

Covered services include social service supports, therapeutic activities, meals and nutrition, direct care supports and medication administration by a registered nurse. The program's rules are in 29 DCMR Chapter 97, Adult Day Health Program Services. DHCF amended its eligibility, service limit and reimbursement sections in a rulemaking published in March 2020.

How to get certified in the District of Columbia

The State Plan sets these provider standards for ADHP:

1. Obtain a valid Certificate of Need from SHPDA. DC Health says a CON is needed to establish a new health care facility or health care service.
2. Enroll as an ADHP Medicaid provider and keep an approved, current Medicaid Provider Agreement with DHCF.
3. Successfully complete DHCF's Provider Readiness Review.
4. Carry malpractice and general liability insurance at the minimum levels set in the State Plan.

DHCF verifies these qualifications when you start and at least every two years after that.

Key requirements

• Who can attend: Medicaid participants age 55 or older with one or more chronic conditions or progressive illnesses diagnosed by a physician, income up to 150% of the federal poverty line, and a need for at least one ADHP service each month.
• Assessment: participants need a minimum score of four on the District's assessment algorithm, which covers functional, skilled care and cognitive or behavioral needs.
• Acuity levels: level 1 covers scores of four or five and level 2 covers scores of six or higher. The benefit package is the same at both levels.
• Service limits: providers cannot bill for more than five days a week or more than eight hours a day, and ADHP is not provided to people living in institutions.
• Payment basis: all services are paid through bundled per diem rates.

Medicaid funding for adult day in the District of Columbia

ADHP is a 1915(i) state plan home and community-based services benefit. CMS approved the latest renewal (SPA 24-0019) effective April 1, 2025, for five years through March 31, 2030.

Fee-for-service ADHP claims are paid at uniform per diem rates by acuity level. The State Plan also describes ADHP being furnished through contracted Dual Eligible Special Needs Plans and through one health plan under a 1915(a) contract that is paid capitated monthly rates.

ADHP is also a service of the Elderly and Persons with Physical Disabilities (EPD) Waiver, a 1915(c) waiver that CMS renewed for five years effective February 7, 2022.

Billing basics

DHCF Transmittal 24-41 (December 2024) updated ADHP per diem rates for dates of service on or after January 1, 2025. It lists procedure code S5100 with modifiers U1 and U2 for State Plan ADHP and S5100 with modifier U3 for the EPD Waiver. The transmittal does not define the modifiers and points providers to the DC Medicaid Fee Schedule on the DHCF website.

Before billing, confirm the current codes and claim rules with DHCF, and with any D-SNP or health plan that serves your participants. DHCF's electronic visit verification (EVV) page addresses personal care and home health services and does not mention ADHP.

Other ways centers are paid

Enrolled veterans who meet VA eligibility and clinical criteria can get Adult Day Health Care through the VA, which may be provided at VA medical centers, State Veterans Homes or community organizations.

Official resources

• DHCF EPD Waiver Services (including ADHP)
• DC State Plan Amendment 24-0019: Adult Day Health Program
• 29 DCMR Chapter 97: Adult Day Health Program Services (March 2020 rulemaking)
• DHCF Transmittal 24-41: ADHP Rate Changes
• DC Health Certificate of Need

Frequently asked questions

Do I need a license to open an adult day center in the District of Columbia?

The District's Medicaid State Plan says Adult Day Health Program providers are not a licensed provider type. To serve Medicaid participants, a provider must be certified, hold a Certificate of Need, enroll with DHCF and pass DHCF's Provider Readiness Review.

Does DC Medicaid pay for adult day care?

Yes. The Adult Day Health Program is a 1915(i) state plan benefit paid at per diem rates, and it is also offered through the EPD Waiver.

Who oversees adult day centers in the District of Columbia?

DHCF certifies ADHP providers and verifies their qualifications initially and at least every two years. DC Health's SHPDA issues the required Certificate of Need.

Can anyone attend an Adult Day Health Program?

Medicaid ADHP is for participants 55 or older with a physician-diagnosed chronic condition, income up to 150% of the federal poverty line and a qualifying assessment score.