ELIGIBILITY

Who can qualify to attend an adult day health care center?

• Disabled adults 18 years old and over, and the elderly
• Individuals who live in their own homes alone or with spouses, children, or guardians
• Individuals who live in the homes of their spouses, children, or guardians.
• Individuals who live in board and care facilities
• Individuals who live in intermediate care facilities (i.e. retirement homes, assisted living), and developmentally disabled-habilitative (ICF-DDH) homes.
  
  

NOTE:  Individuals living in skilled nursing facilities DO NOT qualify for adult day health   
  care services

Eligibility for services at an adult day health care programs are regulated by the California Code of Adult Day Health Care Regulations, Title 22. 

Adult Day Health Care services may be provided to eligible Medi-Cal beneficiaries who have medical or psychiatric impairment(s).

Medi-Cal authorization or reauthorization for services may be granted only if ALL of the following conditions exist:

• A medical condition that requires treatment or rehabilitative services prescribed by a physician, AND
• Mental or physical impairments which handicap daily living activities, AND
• Reasonable expectation that preventative service(s) will maintain or improve the present level of functioning, AND
• High potential for further deterioration and probable institutionalization if adult day health care were not available.

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In determining the need for adult day health care services, the Medi-Cal consultant shall consider the following factors:

• Medical factors
  • For nursing care, supervision or observation on an ongoing intermittent basis to abate health deterioration
  • To see a physician or psychiatrist no less than every 60 days
  • To monitor medications for response and effect on an intermittent basis
  • For medications which cannot safely be self-administered due to physical or mental disabilities
  • For individualized therapeutic treatment designed to restore optimal functional potential or to prevent deterioration
    
    
• Functional status
  • Limitations in movement, with or without an assistive device such as a cane, walker, crutches, prosthesis, or wheelchair, or the need for training in the use of these devices
  • Inability to perform toileting, bathing, eating, dressing, grooming, transferring, and self-medication, or the need of training and assistance in the activities of daily living (ADL’s)
  • Incontinency and the probable benefit from continence retraining
  • Vision, hearing, or sensory loss to some degree
  • Dependency and the need for part-time or full-time basic supervision by persons other than day health center staff
    
    
• Psychosocial limitations
  • Inability of person or family to cope adequately with problems associated with the persons disability
  • Need for a psychosocial environment involving peer group membership and social rehabilitation
  • Mild or moderate confusion or depression, or tendency to wander
  • Inappropriate affect, appearance, or behavior