What It IsAdult daycare services at a facility outside the home
What’s CoveredIn most cases, Medicare Part B doesn’t cover any adult daycare.
Medicare covers some adult daycare services in limited circumstances. Medicare Part B covers mental health treatment, prescribed by a physician and provided at an outpatient mental health clinic. If the clinic is also an adult daycare center, the patient can get the benefit of those services while receiving mental health treatment. Medicare will only cover care if it involves actual medical treatment — administration and monitoring of medication, for example, treatment to recover from a medical crisis, or individual or group psychotherapy.
If you have a Medicare Part C Medicare Advantage plan: Medicare Part C Medicare Advantage plans, also called Medicare Advantage plans, must cover everything that’s included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B.) To find out whether your plan provides extra coverage or requires different co-payments for adult daycare, contact the plan directly.
What Medicare PaysIf Medicare Part B covers some adult daycare as part of mental health care, it pays only 50 percent of the amount Medicare approves for the service.
Note: In some states, Medicare partners with Medicaid to sponsor what’s called the Program of All-Inclusive Care for the Elderly (PACE). PACE provides comprehensive in-home and community care, including adult daycare, for frail elders who would otherwise require nursing home care. In the states that have a PACE program, it may be available only to those people with low income and few assets who are eligible for both Medicare and Medicaid. See Medicare’s official website for a list of PACE programs.
Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:
The care must be “medically necessary.” This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?
The care must be performed or delivered by a healthcare provider who participates in Medicare.