Assistive Technology & Environmental Modifications-2013

1. Department of Medical Assistance Services Assistive Technology & Environmental Modifications-2013 http://dmasva.dmas.virginia.gov 1

2. DURABLE MEDICAL EQUIPMENT (DME) • State Plan Option Service • Individuals in any Waiver may receive any medically necessary DME available to the general Medicaid population. • Specific documentation requirements and coverage criteria are in the DME Manual, Chapter IV.

3. ASSISTIVE TECHNOLOGY (AT) Assistive Technology is a waiver service Examples: • Sensory Integration Equipment • Computers • Specialized software to facilitate communication

4. Assistive Technology Under the DD Waiver: Definition Specialized medical equipment and supplies, including those devices, controls, or appliances specified in the POC but not available under regular DME criteria.

5. Assistive Technology Under the DD Waiver: Definition • Assistive Technology are devices which enable individuals to increase their abilities to perform activities of daily living or • to perceive, control, or communicate with the environment in which they live or which are necessary to their proper functioning.

6. Equipment and Activities Under AT in the DD Waiver The equipment and activities are: • Specialized medical equipment and ancillary equipment, necessary for life support not available under the State Plan for Medical Assistance; • Durable or non-durable medical equipment and supplies (DME) not available under the State Plan for Medical Assistance;

7. Equipment and Activities Under AT in the DD Waiver Cont’d • Adaptive devices, appliances, or controls, or all, not available under the State Plan for Medical Assistance which enable an individual to be more independent in areas of personal care and activities of daily living; • Equipment/devices not available under the State Plan which enable an individual to communicate more effectively.

8. AT Criteria • Service is available to individuals who are receiving at least one other DD Waiver service. • Equipment or supplies already covered under regular DME criteria may not be purchased under the DD Waiver Assistive Technology. • Equipment/supplies must be purchased from a DMAS approved Assistive Technology provider.

9. Provider Requirements • Assistive Technology and Environmental Modifications can be provided by companies with a Durable Medical Equipment(DME) provider agreement. • Each individual must be evaluated to determine the need for Assistive Technology, and to recommend specific items to address the identified needs

10. Evaluation of Need for Assistive Technology • An independent consultation must be obtained for each AT request prior to approval by DMAS. • All assistive technology items must be prior authorized by DMAS. • The Consultation needs to discuss the benefits of each item recommended for the individual

11. Evaluation of Need for Assistive Technology • Independent consultants include: • speech/language therapists • physical therapists • occupational therapists • physicians • behavioral therapists • certified rehabilitation specialists, or rehabilitation engineers. 

12. Authorization of AT Items • Each item requested in the POC must be specifically recommended by the appropriate professional • Each item must be approved by DMAS on the POC, and listed in the evaluation report or supporting documentation from the appropriate medical or rehabilitation professional.

13. AT Criteria Cont’d. A Rehabilitation Engineer may be utilized if, for example: • The assistive-technology will be initiated in combination with environmental modifications involving systems which are not designed to go together; or • An existing device must be modified or a specialized device must be designed and fabricated.

14. AT Service Units and Service Limitations • Service must be prior authorized by DMAS • Service unit is the total cost of the item • And/or Supplies or hourly labor costs for Rehabilitation Engineering.

15. Evaluation must match the authorization request • Recommendations by the appropriate professional for items covered under assistive technology must include the specific items needed by that individual. • The documentation must justify the need for each item listed on the invoice from the provider and be included with the service authorization request

16. AT Service Units and Service Limitations Cont’d • Maximum expenditure is $5000.00 per calendar year • Costs for AT shall not be carried over from year to year

17. AT Provider Documentation Requirements • Supporting documentation that describes the need for the service (POC), the process to obtain this service (contracts with potential vendors/contractors of service, etc.) and the time frame during which the service is to be provided • DMAS 225 and POC from Case Manager • Separate notation of evaluation by an appropriate professional.

18. AT Provider Documentation Requirements…Cont. • Documentation of the need for a Rehabilitative Engineer if one is needed (if disability expertise is required that a general contractor will not have) • Documentation that the item is not covered by the State Plan for Medical Assistance under DME or is not available from a DME provider.

19. Provider Documentation Requirements…Cont. • Documentation of the date services are rendered and the amount of service needed • Any other relevant information about the device or modification, including family contacts, as appropriate

20. Provider Documentation Requirements… Cont. • Documentation in the Case Manager record of notification by the individual or individual’s parent or legal guardian of satisfactory completion of the service.

21. Example of DME Patient Lift: HCPCS E0630 1.) Recipient-based outcome: anticipated to stabilize the recipient’s medical condition by getting recipient up twice a day. 2.) Supportive Activities to Accomplish Outcome: (must document all of the following) • Part of care plan (use up to twice a day)

22. Example of DME Cont’d • Recipient/caregiver knows how to use the lift. • Alternatives did not work (caregiver is unable to lift recipient out of bed twice a day). • Recipient has no health condition that prohibits the use of the lift. • Equipment reduces the need for other services (nurse’s aide).

23. Example of AT Purchase • A hand-held shower device is not covered under the State Plan for Medical Assistance (regular DME criteria). However, it could be needed to assist the individual in performing activities of daily living.

24. Example of AT Purchase • Documentation required to obtain the device: • Need for the shower device must be documented in the individual Service Plan (CSP) and supporting documentation. • Itemized quotes are required when providing AT/EM quotes to DMAS, Drawings of the modification proposal may be used to clarify home modifications

25. Example of AT Purchase • The Invoice from the vendor should indicate the supply cost of item. • documentation of the applied 30% mark up above supply cost (to the vendor) will equal cost on the CSP.

26. Example of AT Purchase • Evaluation report from an Occupational Therapist or Rehab engineer suggesting a specific model of hand held shower to support the needs of the individual

27. Documentation Requirements…Cont. • Documentation of the cost of the device and installation cost, if needed. • Documentation in the record that this is a non-covered device under the State Plan. • Date the device is provided to the individual. • Documentation of the individual’s satisfaction with the device.

28. Documentation Requirements…Cont. • Instruction on warranties and service agreements • Instruction on repairs and complaints

29. Environmental Modifications

30. Environmental Modifications • Under the State Plan for Medical Assistance, home and environmental modifications are non-covered services • Under the State Plan for Medical Assistance, items solely for safety and/or convenience of the individual are non-covered services

31. Definition of Environmental Modifications: • Environmental modifications are physical adaptations to a house, place of residence, vehicle, or work site, when the modification exceeds reasonable accommodation requirements of the Americans with Disabilities Act, necessary to ensure individuals’ health and safety or to enable functioning with greater independence.

32. Definition of Environmental Modifications..Cont. • The adaptation is not to be used to bring substandard housing up to standard • The adaptation is to be of direct medical or remedial benefit to the individual • Environmental modifications are available to individuals receiving at least one other waiver service

33. Definition of Environmental Modifications… Cont. • The need for the adaptation must be documented in the individual’s Plan of Care (POC) • The adaptation must be necessary to ensure the health, welfare, and safety of the individual; or enable the individual to function with greater independence in the home, and without which, the individual would require institutionalization.

34. Environmental ModificationExclusions • Adaptations or improvements to the home that are of general utility and not of direct medical or remedial benefit, such as carpeting, roof repair, central air conditioning, etc.

35. Modifications and Activities • All adaptations must be provided in accordance with applicable state or local building codes. Modifications and activities are: • Physical adaptations to a house or place of residence necessary to ensure an individual’s health or safety (installation of specialized electric and plumbing systems to accommodate medical equipment).

36. Modifications and Activities Cont’d • Physical adaptations to a house or place of residence that enable an individual to live in a non-institutional setting and to function with greater independence (ramps, grab bars, widening of doorways, modifications to bathroom facilities, etc) • Environmental adaptations to the work site.

37. Modifications and Activities Cont’d • Modifications to the primary vehicle used by the individual (car or van)

38. Criteria to Receive Environmental Modifications • Demonstrated need for the modification as a medical or remedial benefit in the individual’s home, vehicle, community activity setting, or day program. • The modification cannot be covered under the State Plan for Medical Assistance, or another program, such as DRS, or the Consumer Service Fund.

39. Criteria…Cont’d • A Rehabilitation Engineer may be used to evaluate the individual’s needs and act as project manager. • A Rehabilitative Engineer may design and complete the modification.

40. Criteria…Cont’d A Rehabilitation Engineer may be required if (for example): • The environmental modification involves combinations of systems which are not designed to go together; or • The structural modification requires a project manager to assure that design and functionality meet ADA accessibility guidelines.

41. Service Units and Service Limitations • Must be authorized by DMAS • Cap of $5000.00 per POC year • Costs for EM can not be carried over from year to year.

42. Provider Documentation Requirements • Supporting documentation that outlines the need for the service (POC), the process to obtain this service (contracts with potential vendors/contractors of service, etc.) and the time frame during which the service is to be provided. • DMAS 225 and POC from case manager

43. Provider Documentation Required..Cont’d • Separate notation of costs for evaluation/design, labor, and supplies/materials. • Documentation in the POC of the reason a Rehabilitation Engineer is needed, if involved.

44. Provider Documentation Required…Cont’d • Documentation of the dates of service and amount of service. • Documentation of any other relevant information. • Documentation of notification by the individual or individual’s parent or legal guardian of satisfactory completion of the service.

45. Provider Documentation Required…Cont’d • Instructions regarding any warranty and servicing that may be needed. • Instructions regarding complaints and repairs.

46. Example of Environmental Modification Wheelchair ramp • Non-covered service under the State Plan for Medical Assistance (DME criteria). • Covered service under the DD Waiver Documentation requirements: • Included in POC as needed service • If Rehabilitation Engineer is needed, document need in POC.

47. Example of E-Mod…Cont’d • Documentation regarding the timeline for completion of the individual components of the service • Documentationof date of service and cost of installation and supplies for the ramp. • Itemized quotes are required when providing AT/EM quotes to DMAS, Drawings of the modification proposal may be used to clarify home modifications

48. Example of E-Mod… Cont’d • Documentation of notification by the individual or individual’s parent or legal guardian of satisfactory completion of the service. • Instructions regarding any warranty and servicing that may be needed. • Instruction on complaints and repairs.

49. Contact Information Long-Term Care Division Division of Long-Term Care Telephone 804-225-4222 Fax 804-612-0050 www.dmas.virginia.gov