Adult Day Care Regulations in Idaho

Who regulates adult day care in Idaho

In Idaho, adult day standards appear in the Medicaid rules for the Aged and Disabled (A&D) Waiver. The Idaho Department of Health and Welfare (IDHW) covers adult day health under IDAPA 16.03.10, Medicaid Enhanced Plan Benefits, enrolls waiver providers and conducts periodic quality assurance reviews.

IDAPA 16.03.10.329 ties each adult day health setting to existing facility standards. The sources reviewed for this guide do not describe a separate adult day license, so confirm requirements with IDHW before you open, especially for a private-pay program.

Types of adult day programs in Idaho

Idaho uses the term adult day health. Under IDAPA 16.03.10.326, it is a supervised, structured service generally furnished four or more hours per day on a regular schedule, for one or more days a week. It is provided outside the participant's home in a non-institutional, community-based setting.

The service includes health services, social services, recreation, supervision for safety and help with activities of daily living. Respite care may also be provided in an adult day health facility.

Opening an adult day center in Idaho

To serve A&D Waiver participants, follow these steps from IDAPA 16.03.10.329 and IDHW's provider enrollment page:

1. Choose a setting that meets the standards assigned to it. A facility must meet the building and health standards in IDAPA 16.03.21 (Developmental Disabilities Agencies). Services in a home must meet certified family home standards (IDAPA 16.03.19), and services in a residential assisted living facility must meet IDAPA 16.03.22.
2. Screen staff. Everyone providing direct care needs a background check clearance under IDAPA 16.05.06.
3. Train staff to the Idaho provider training matrix, through formal training or demonstrated competency.
4. Get enrollment forms through the Idaho Medicaid provider portal and apply with the department's enrollment vendor.
5. Meet the person-centered planning and HCBS setting requirements in IDAPA 16.03.10 Sections 311 to 318.

Key requirements

• Service hours: adult day health is generally furnished four or more hours per day on a regular schedule.
• Setting: a non-institutional, community-based setting outside the participant's home that meets the standards for its setting type.
• Staff: background check clearance, freedom from communicable disease and completion of the provider training matrix.
• Care planning: care must match the participant's needs as stated in the plan. If services are provided in a certified family home other than the participant's residence, the provider notifies IDHW.
• Quality reviews: IDHW sends quality review results within 45 days, and the provider must respond within 45 days and carry out a quality improvement plan if problems are found.
• Room and board: waiver payments for adult day health do not include room and board.

The current versions of Sections 326 and 329 are effective July 1, 2024.

Medicaid funding for adult day in Idaho

Adult day health is an A&D Waiver service. Under IDAPA 16.03.10.324, the waiver serves people over 18 who would be Medicaid eligible if they lived in a nursing facility, need nursing facility level of care, and show significant disability on the department's assessment (the UAI). IDHW's home and community-based services page lists adult day health among the available services.

For people over 21 with Medicare Parts A, B and D plus Medicaid, IDHW offers two health plan programs. Idaho Medicaid Plus covers all Medicaid enhanced plan benefits and is mandatory in listed counties for people not in the Medicare Medicaid Coordinated Plan (MMCP). The MMCP is voluntary and combines Medicare and Medicaid enhanced plan services. Participating plans are Molina Healthcare of Idaho and UnitedHealthcare Community Plan of Idaho.

Billing basics

The Idaho Medicaid provider portal, run by Gainwell Technologies, handles provider enrollment, eligibility checks and claims processing. The fee schedules are posted in an IDHW document repository, and the procedure code and unit for adult day health were not confirmed for this guide.

If you serve dual-eligible members enrolled in Idaho Medicaid Plus or the MMCP, confirm authorization and billing with the member's health plan. No Idaho source reviewed addresses electronic visit verification for adult day health.

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

• IDHW Long-Term Care Provider Enrollment
• IDAPA 16.03.10: Medicaid Enhanced Plan Benefits
• IDAPA 16.03.10.326: A&D Waiver Coverage and Limitations
• IDAPA 16.03.10.329: A&D Waiver Provider Qualifications
• IDHW Home and Community Based Services
• IDHW Medicaid/Medicare Participants
• IDHW Managed Care Providers
• Idaho Medicaid Provider Portal
• VA Adult Day Health Care
• National Adult Day Services Association

Frequently asked questions

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

The sources reviewed do not describe a separate adult day license. To serve A&D Waiver participants, your setting must meet the standards IDAPA 16.03.10.329 assigns to it and you must enroll with Idaho Medicaid. Confirm other requirements with IDHW.

Does Idaho Medicaid pay for adult day care?

Yes. Adult day health is an Aged and Disabled Waiver service for adults who need nursing facility level of care. For dual-eligible members in Idaho Medicaid Plus or the MMCP, check with the member's health plan about authorization and billing.

Who reviews adult day providers in Idaho?

IDHW conducts periodic quality assurance reviews of home and community-based providers and sends results within 45 days. Providers must respond within 45 days.