Section 11000, Nursing Facility Services

Revision 20-1; Effective March 16, 2020

 

 

11100 CPWC Benefit for NF Residents Enrolled in STAR+PLUS or a Medicare-Medicaid Plan

Revision 20-1; Effective March 16, 2020

 

Custom power wheelchairs (CPWCs) are a benefit for STAR+PLUS/Medicare-Medicaid Plan (MMP) members residing in a Medicaid enrolled nursing facility (NF) when the CPWC is medically necessary and prior authorized by the Texas Health and Human Services Commission (HHSC) or its designee. CPWC is a Medicaid benefit for Medicaid-only NF residents, as well as NF residents who are dually eligible for Medicare and Medicaid.

Eligibility Requirements

The managed care organization (MCO) must ensure the following criteria are met to establish eligibility for the CPWC benefit for NF residents. The MCO must ensure the resident:

The evaluation must show the resident is:

 

Required Elements of a CPWC

A CPWC is defined as a professionally manufactured wheeled mobility system that consists of a power base and customized seating system and provides motorized wheeled mobility and body support specifically for individuals with impaired mobility.

The power mobility base may include programmable electronics and may utilize alternate input devices.

The wheelchair must be medically necessary, adapted and fabricated to meet the individualized needs of the resident, and intended for the exclusive and ongoing use of the resident.

For safety, all chairs must include a stop switch for use by the client sitting in the chair.

Components of the customized seating system must be in part, or entirely usable, only by the resident for whom the power wheelchair is adapted and fabricated. This means at least one of the components of the seating system may be usable only by that resident.

For a combination power tilt and recline seating system (reclining capabilities), the resident should demonstrate the need to rest in a recumbent position two or more times per day when the resident cannot transfer between the bed and the wheelchair without assistance and/or be at risk for skin breakdown because of an inability to reposition in the chair to relieve pressure areas.

The CPWC must be:

It becomes the personal property of the resident’s estate upon death.

 

Prior Authorizations and Billing

The MCO/MMP is responsible for the prior authorization and reimbursement of CPWCs.  

When a resident changes MCO/MMP for any reason (i.e., choice, moves out of the service delivery area, etc.), and the prior authorization has already been approved but the chair has not yet been delivered to the NF resident, the MCO issuing the initial authorization is responsible for reimbursement of the CPWC. This is consistent with the Uniform Managed Care Contract, Section 5.06, Span of Coverage.

When the MCO receives a prior authorization request from a contracted DME provider
to construct a CPWC for an NF resident, the MCO is required to respond with a decision of approval, denial or modification within three business days of the receipt of the request.

Medicare does not cover CPWCs for skilled nursing facility (SNF) residents. MCOs must not deny NF CPWC claims or prior authorization requests nor require a Medicare Explanation of Benefit (EOB) for dual-eligible NF residents, in compliance with Uniform Managed Care Manual (UMCM) Chapter 2.0, Claims Manual, Section VII, Claims Processing Requirements, F. STAR+PLUS and STAR Kids Services for Dual-Eligibles. STAR+PLUS MCOs and MMPs should ensure staff processing CPWC prior authorization requests and claims are informed of this benefit for dual-eligible NF residents. MCO systems must have the functionality to prevent the request of a Medicare EOB or the denial of a CPWC with a reason related to the resident having Medicare as their primary insurance.

Denial notices should include responses that are specific and individualized, reference criteria outlined in this policy, and outline the process and timelines for filing an appeal to the decision. Refer to UMCM Chapter 3.21.

Upon the MCO’s approval of the prior authorization request, the MCO must instruct the provider to proceed with construction of the chair and request that claims be billed directly through the MCO portal upon delivery of the chair to the NF resident. Specific billing codes should be used to identify the power base type and each accessory or component.

To be eligible for Medicaid reimbursement, the member must be on a Medicaid NF stay at the time of assessment and upon the CPWC delivery.

The MCO/MMP must adjudicate a clean claim within 30 days. MCOs will be required to pay providers interest at an 18 percent annual rate if a claim, or portion of a claim, remains unadjudicated beyond the 30-day claims processing deadline.

The MCO is responsible for chair modifications and adjustments.

The MCO/MMP is responsible for the prior authorization and reimbursement for Modifications, as described below. CPWC modifications are the replacement of components due to changes in the resident’s condition.

The MCO/MMP is responsible for prior authorization and reimbursement for CPWC Adjustments, as described below. Adjustments require labor only and do not include the addition, modification or replacement of components or supplies needed to complete the adjustment.

The MCO/MMP is responsible for the prior authorization and reimbursement for medically necessary CPWC replacement requests at or after five years of the original date of purchase.

The MCO/MMP is responsible for prior authorization and reimbursement of replacement chairs prior to five years of the original date of purchase when the CPWC no longer meets the resident’s needs. Other circumstances that would warrant chair replacement prior to the passage of five years from the purchase date are indicated below:

The following items are not a benefit and cannot be billed additionally:

In all other circumstances from those listed above, the NF is responsible for the routine maintenance and repair, including battery and battery charger replacement of the resident’s CPWC.