Revision 15-1; Effective March 26, 2015

 

6100 Adaptive Aids

Revision 12-1; Effective February 10, 2012

 

 

6110 General Description of Service Component

Revision 12-1; Effective February 10, 2012

 

An adaptive aid is an item or service that enables an individual to retain or increase the ability to perform activities of daily living or to control the individual's environment.

 

6120 Billable Adaptive Aids

Revision 12-1; Effective February 10, 2012

 

The only billable items and services for the adaptive aids service component are listed in Appendix IV, Billable Adaptive Aids. The repair and maintenance of a billable item not covered by warranty is also billable for the adaptive aids service component.

 

6130 Items and Services Not Billable

Revision 14-1; Effective April 10, 2014

 

  1. Items and Services Not Listed in Appendix IV
    Any item or service not listed in Appendix IV, Billable Adaptive Aids, is not billable under the adaptive aids service component.
  2. Examples of Non-Billable Items and Services
    The following are examples of items and services that are not billable for the adaptive aids service component:
    • an appliance (for example, washer, dryer, stove, dishwasher or vacuum cleaner);
    • swimming pool;
    • hot tub;
    • eye exam;
    • shoes not specifically designed for the individual;
    • automobile;
    • lift for a vehicle other than one owned or leased by the individual's care provider, the individual or the individual's relative (Appendix VI, Degree of Consanguinity or Affinity, explains who is considered a relative for purposes of these guidelines);
    • toy, game or puzzle;
    • recreational equipment (for example, swing set or slide);
    • personal computer or software for purposes other than to augment expressive and receptive communication (for example, educational purposes);
    • medication, including a co-payment for a medication;
    • daily hygiene products (for example, deodorant, lotions, soap, toothbrush, toothpaste, feminine products, adhesive bandages or cotton swabs);
    • rent;
    • utilities (for example, gas, electric, cable or water);
    • food;
    • ordinary bedding supplies (for example, bedspread, pillow or sheet);
    • exercise equipment;
    • pager, including a monthly service fee;
    • conventional telephone, including a cellular phone or a monthly service fee;
    • home security system, including a monthly service fee;
    • non-sterile gloves for use by paid service providers;
    • iPads, iPods or tablets; and
    • iPad, iPod or tablet accessories or applications.

 

6140 Property of Individual

Revision 12-1; Effective February 10, 2012

 

Except for a vehicle lift, a billable item must be the exclusive property of the individual to whom it is provided.

 

6150 Payment Limit

Revision 15-1; Effective March 26, 2015

 

The maximum amount DADS pays a program provider for all adaptive aids provided to an individual is $10,000 per IPC year.

 

6160 Required Documentation for an Adaptive Aid

Revision 13-1; Effective January 1, 2014

 

  1. Adaptive Aid Costing $500 or More

For an adaptive aid costing $500 or more, a program provider must obtain the documentation described below before purchasing the adaptive aid.

  1. Written Assessment

A program provider must obtain a written, legible assessment by one of the licensed professionals noted for the specific adaptive aid, as shown in Appendix IV, Billable Adaptive Aids. The written assessment must:

  • be based on a face-to-face evaluation of the individual by the licensed professional conducted not more than one year before the date of purchase of the adaptive aid;
  • include a description of and a recommendation for a specific adaptive aid listed on Appendix IV and any associated items or modifications necessary to make the adaptive aid functional;
  • include a diagnosis that is related to the individual's need for the adaptive aid (for example, cerebral palsy, quadriplegia or deafness);
  • include a description of the condition related to the diagnosis (for example, unable to ambulate without assistance); and
  • include a description of the specific needs of the individual, including information justifying medical necessity, if required, and how the adaptive aid will meet those needs (for example, the individual needs to ambulate safely and independently from room to room and the use of a walker will allow him to do so).
  1. Individual and Program Provider Agreement

An individual or legally authorized representative and program provider must:

  • meet and consider the written assessment required by Item a.;
  • document any discussion about the recommended adaptive aid;
  • agree that the recommended adaptive aid is necessary and should be purchased; and
  • document their agreement in writing and sign the agreement.
  1. Proof of Non-coverage by Medicaid and Medicare
    1. Adaptive Aids Noted with a (1) or (2) on Appendix IV, Billable Adaptive Aids
      1. Documentation Required

Except as provided in II, Nutritional Supplements, below, for an adaptive aid noted on Appendix IV, Billable Adaptive Aids, with a (1) or, for an adaptive aid noted with a (2) for an individual who is under 21 years of age, the program provider must obtain one of the following as proof of non-coverage by Medicaid:

  • a letter from Texas Medicaid & Healthcare Partnership (TMHP) that includes:
  • a statement that the requested adaptive aid is denied under the Texas Medicaid Home Health Services or the Texas Health Steps programs; and
  • the reason for the denial, which must not be one of the following:
    • Medicare is the primary source of coverage;
    • information submitted to TMHP to make payment was incomplete, missing, insufficient or incorrect;
    • the request was not made in a timely manner; or
    • the adaptive aid must be leased;
  • a letter from TMHP stating that the adaptive aid is approved and the amount to be paid, which must be less than the cost of the requested adaptive aid; or
  • a provision from the current Texas Medicaid Providers Procedure Manual stating that the requested adaptive aid is not covered by the Texas Medicaid Home Health Services or the Texas Health Steps programs.
  1. Additional Documentation Required for Individuals Who are Eligible for Medicare

In addition to the documentation required by Item i above, for an individual eligible for Medicare, a program provider must obtain one of the following for an adaptive aid noted with a (1) or (2) on Appendix IV:

  • a letter from Cigna Government Services that includes:
    • a statement that the requested adaptive aid is denied under Medicare; and
    • the reason for the denial, which must not be one of the following:
    • information submitted to Cigna Government Services to make payment was incomplete, missing, insufficient or incorrect;
    • the request was not made in a timely manner; or
    • the adaptive aid must be leased;
    • a letter from Cigna Government Services stating that the adaptive aid is approved and the amount to be paid, which must be less than the cost of the requested adaptive aid; or
    • a provision from the current Region C DMERC (Durable Medical Equipment Region C) DMEPOS (Durable Medical Equipment Prosthetics, Orthotics, and Supplies) Supplier Manual stating that the requested adaptive aid is not covered by Medicare.
  1. Unacceptable Documentation

The following are examples of documentation that are not acceptable as proof of non-coverage:

  • a statement from a Medicaid enrolled Durable Medical Equipment (DME) provider that the adaptive aid requested is not covered by the Texas Medicaid Home Health Services or the Texas Health Steps programs; and
  • a statement from a Medicare DME provider that the adaptive aid requested is not covered by Medicare.
  1. Nutritional Supplements

For a nutritional supplement (service code 121), the program provider must obtain one of the following as proof of non-coverage by Medicaid:

  • the documentation described under clause (I)(i) above; or
  • a written statement from the individual's program provider that the individual:
  • is 21 years of age or older;
  • is not fed through a G-tube; and
  • is not dependent on the nutritional supplement as the individual's sole source of nutrition.
  1. Bids

 

  1. Required Number of Bids

A program provider must obtain comparable bids for the requested adaptive aid from three vendors, except as provided in Item III. below. Comparable bids describe the adaptive aid and any associated items or modifications identified in the assessment required by Item a. above.

  1. Required Content and Time Frame

A bid must:

  • be cost effective according to current market prices for the adaptive aid and be the lowest cost based on availability unless contraindicated by specific written justification for using a higher bid;
  • state the total cost of the requested adaptive aid;
  • include the name, address and telephone number of the vendor, who may not be a relative of the individual (Appendix VI, Degree of Consanguinity or Affinity, explains who is considered a relative for purposes of these guidelines);
  • for an adaptive aid other than interpreter service (service code 126) and specialized training for augmentative communication programs (service code 259), include a complete description of the adaptive aid and any associated items or modifications as identified in the written assessment required by Item a. above, which may include pictures or other descriptive information from a catalog, website or brochure;
  • for interpreter service (service code 126) and specialized training for augmentative communication programs (service code 259), include the number of hours of direct service to be provided and the hourly rate of the service; and
  • be obtained within one year after the written assessment required by Item a. above is obtained.
  1. Program Provider Not Required to Obtain Three Bids
    1. One Bid

A program provider may obtain only one bid for the following adaptive aids:

  • eyeglasses (service code 220);
  • hearing aids, batteries and repairs (service code 260); and
  • orthotic devices, orthopedic shoes and braces (service code 107).
  1. One or Two Bids

A program provider may obtain only one bid or two comparable bids for an adaptive aid, other than one listed in Item i. above, if the program provider has written justification for obtaining less than three bids because the adaptive aid is available from a limited number of vendors.

  1. Request for Payment of Higher Bid
    1. Documentation Required

If a program provider will request authorization for payment, as described by Section 6170, Authorization for Payment, that is not based on the lowest bid, the program provider must have written justification for payment of a higher bid.

  1. Examples of Justification That May Be Acceptable

The following are examples of justifications that support payment of a higher bid:

  • the higher bid is based on the inclusion of a longer warranty for the adaptive aid; and
  • the higher bid is from a vendor that is more accessible to the individual than another vendor.
  1. Proof of Ownership

If applicable, a program provider must obtain proof that the individual, individual's family member or care provider owns the vehicle for which a vehicle lift (service code 101) is requested.

  1. Adaptive Aids Costing Less Than $500

For an adaptive aid costing less than $500, a program provider must obtain the documentation described in this paragraph before purchasing the adaptive aid.

  1. Individual and Program Provider Agreement, Proof of Non-Coverage, Bids and Proof of Ownership

For an adaptive aid costing less than $500, a program provider must obtain:

  • an individual and program provider agreement, as described in (1)(b) above (except that there may not be a written assessment to consider), made not more than one year before the date of purchase of the adaptive aid;
  • if applicable, proof of non-coverage by Medicaid and Medicare, as described in (1)(c) above;
  • bids, as described (1)(d) above, unless the program provider has obtained DADS approval of an annual vendor in accordance with Item b. below;
  • if applicable, written justification for less than three bids and payment of a higher bid as described in (1)(d)(III) and (IV) above;
  • if applicable, proof of ownership as described in (1)(e) above; and
  • documentation which justifies the medical necessity of the adaptive aid if required by the Medicaid State Plan.
  1. Approval of Annual Vendor

In lieu of obtaining bids in accordance with (1)(d) above for an adaptive aid costing less than $500 monthly, a program provider must, in accordance with this subparagraph, obtain DADS approval of an annual vendor.

  1. Documentation Required

To obtain approval of an annual vendor, a program provider must submit the following written documentation to DADS:

  • a list of the adaptive aids to be provided by an annual vendor;
  • documentation of the current price of each adaptive aid on the list from three vendors who are:
  • Durable Medical Equipment Home Health (DMEH) suppliers;
  • Medicare suppliers; and
  • not relatives of the individual (Appendix VI explains who is considered a relative for purposes of these guidelines);
  • documentation identifying the vendor for whom the program provider seeks DADS approval; and
  • documentation that the cost of the majority of the adaptive aids to be provided by the identified vendor is the lowest of the three vendors.
  1. Approval Period and Time Frame for Submission
    1. Approval Period

An approval of an annual vendor by DADS is only valid for a calendar year.

  1. Time Frame for Submission

To obtain approval of an annual vendor, a program provider must submit documentation required by No. I above:

  • no sooner than November 1 of the year prior to the calendar year for which the request is being made; and
  • no later than January 31 of such calendar year.
  1. Approval of Multiple Vendors

DADS may approve more than one annual vendor for a program provider per calendar year.

  1. Vendor Used for All Individuals

If DADS approves an annual vendor to provide an adaptive aid, a program provider must use the vendor to supply the adaptive aid to all individuals of the program provider who need the adaptive aid.

 

6170 Authorization for Payment

 

Revision 12-1; Effective February 10, 2012

  1. Requesting Authorization for Payment
    1. Adaptive Aids Costing $500 or More
      To obtain authorization for payment for an adaptive aid costing $500 or more, a program provider must:
      • submit a completed Form 4116-MHM-AA, Minor Home Modification/Adaptive Aids Summary Sheet, to DADS in accordance with the form instructions; and
      • keep in the individual's record the documentation required by Section 6160, Required Documentation for an Adaptive Aid (see No. 1).
    2. Adaptive Aid Costing Less than $500
      To obtain authorization for payment for an adaptive aid costing less than $500, a program provider must:
      • submit a completed Form 4116-MHM-AA to DADS in accordance with the form instructions; and
      • keep in the individual's record the documentation required by Section 6160 (see No. 2).
    3. Requisition Fee
      A program provider may request authorization for payment of a requisition fee for an adaptive aid in accordance with the instructions on Appendix VII, Minor Home Modifications, Adaptive Aids or Dental Summary Sheet.

  2. Time Frame for the Request for Authorization for Payment
    A program provider must request authorization for payment for an adaptive aid no later than 12 months after the last day of the month in which the individual received the adaptive aid.
  3. Notification for Authorization for Payment
    1. Authorization for Payment Given or Denied
      DADS notifies a program provider on the CARE Reimbursement Authorization Inquiry (C77):
      • that authorization for payment is given or denied;
      • if given, the amount which DADS has authorized; and
      • if denied, the reason for denial.
    2. Corrected Requests
      If a request for authorization for payment is denied, a program provider must submit a corrected request no more than 12 months after the last day of the month in which the individual received the adaptive aid.

 

6200 Minor Home Modifications

Revision 12-1; Effective February 10, 2012

 

 

6210 General Description of Service Component

Revision 12-1; Effective February 10, 2012

 

A minor home modification is a physical adaptation to an individual's residence that is necessary to address the individual's specific needs and that enables the individual to function with greater independence in the individual's residence or to control his or her environment.

 

6220 Billable Minor Home Modifications

Revision 12-1; Effective February 10, 2012

 

The only billable adaptations for the minor home modification service component are listed in Appendix V, Billable Minor Home Modifications. The repair and maintenance of a billable adaptation not covered by warranty is also billable for the minor home modifications service component.

 

6230 Adaptations Not Billable

Revision 12-1; Effective February 10, 2012

 

  1. Adaptations Not Listed in Appendix V
    Any adaptation not listed in Appendix V, Billable Minor Home Modifications, is not billable under the minor home modification service component.
  2. Examples of Non-Billable Adaptations
    The following are examples of adaptations that are not billable for the minor home modification service component:
    • general repair of a residence (for example, repairing a leaking roof or rotten porch, controlling termite damage or leveling a floor);
    • general remodeling of a residence that does not address an individual's specific needs;
    • an adaptation that adds square footage to a residence;
    • construction of new room, including installation of plumbing and electricity;
    • a septic tank;
    • general plumbing or electrical work;
    • hot water heater;
    • central heating or cooling system;
    • heater;
    • fire sprinkler system;
    • fire alarm system;
    • appliance (for example, washer, dryer, stove, dishwasher or refrigerator);
    • fence;
    • carport;
    • driveway;
    • deck; and
    • hot tub.

 

6240 Payment Limit

Revision 12-1; Effective February 10, 2012

 

Payment by DADS to a program provider for minor home modifications is subject to the following limitations:

  • a program provider may be paid an initial amount of $7,500 for an individual, with such payment occurring in one or more IPC years; and
  • beginning the first full IPC year after the $7,500 amount is paid, the maximum amount DADS pays a program provider is $300 per individual, per IPC year.

 

6250 Required Documentation for a Minor Home Modification

Revision 12-4; Effective November 19, 2012

 

  1. Minor Home Modification Costing $1,000 or More
    For a minor home modification costing $1,000 or more, a program provider must obtain the documentation described in this paragraph before purchasing the minor home modification.
    1. Written Assessment
      A program provider must obtain a written, legible assessment by one of the licensed professionals noted for the specific minor home modification on Appendix V, Billable Minor Home Modifications. The written assessment must:
      • be based on a face-to-face evaluation of the individual by the licensed professional conducted in the individual's residence not more than one year before the date of purchase of the minor home modification;
      • include a description of and a recommendation for a specific minor home modification listed Appendix V and any associated installation specifications necessary to make the minor home modification functional;
      • include a diagnosis that is related to the individual's need for the minor home modification (for example, cerebral palsy, quadriplegia or deafness);
      • include a description of the condition related to the diagnosis (for example, unable to ambulate without assistance); and
      • include a description of the specific needs of the individual and how the minor home modification will meet those needs (for example, the individual needs to enter and exit the home safely and the addition of a wheelchair ramp will allow him to do so).
    2. Individual and Program Provider Agreement
      An individual or legally authorized representative and program provider must:
      • meet and consider the written assessment required by Item a.;
      • document any discussion about the recommended minor home modification;
      • agree that the recommended minor home modification is necessary and should be purchased; and
      • document their agreement in writing and sign the agreement.
    3. Bids
      1. Required Number of Bids
        A program provider must obtain comparable bids for the requested minor home modification from three vendors, except as provided in No. III below. Comparable bids describe the minor home modification and any associated installation specifications identified in the written assessment required by Item a. above.
      2. Required Content and Time Frame
        A bid must:
        • be cost effective according to current market prices for the adaptive aid and be the lowest cost based on availability unless contraindicated by specific written justification for using a higher bid;
        • state the total cost of the requested minor home modification and, if it includes more than one modification, state the cost of each modification by service code;
        • include the name, address and telephone number of the vendor;
        • include a complete description of the minor home modification and any associated installation specifications, as identified in the written assessment required by Item a.;
        • include a drawing or picture of both the existing and proposed floor plans;
        • include a statement that the minor home modification will be made in accordance with all applicable state and local building codes; and
        • be obtained within one year after the written assessment required by Item a. above is obtained.
      3. Program Provider Not Required to Obtain Three Bids
        A program provider may obtain only two comparable bids for the requested minor home modification if the program provider has written justification for obtaining less than three bids because the minor home modification is available from a limited number of vendors.
      4. Request for Payment of Higher Bid
        1. Documentation RequiredIf a program provider will request authorization for payment that is not based on the lowest bid, as described by Section 6260, Authorization for Payment, the program provider must have written justification for the payment of a higher bid.
        2. Examples of Justification That May be Acceptable
          An example of justification that supports payment of a higher bid is the inclusion of a longer warranty for the minor home modification.
  2. Minor Home Modification Costing Less Than $1,000
    For a minor home modification costing less than $1,000, a program provider must obtain the following documentation before purchasing the minor home modification:
    • an individual and program provider agreement, as described in No. 1., Item b. above (except that there may be no written assessment to consider), made not more than one year before the date of purchase of the minor home modification; and
    • bids, as described in Item c. above; and
    • if applicable, written justification for less than three bids or payment of a higher bid as described in No. 1, Item c., (III) and (IV) above.

 

6260 Authorization for Payment

Revision 12-1; Effective February 10, 2012

 

  1. Requesting Authorization for Payment
    1. Minor Home Modification Costing $1,000 or More
      To obtain authorization for payment for a minor home modification costing $1,000 or more, a program provider must:
      • submit a completed Form 4116-MHM-AA, Minor Home Modification/Adaptive Aids Summary Sheet, to DADS in accordance with the form instructions.
      • keep in the individual's record the documentation required by Section 6250, Required Documentation for a Minor Home Modification (see No. 1).
    2. Minor Home Modification Costing Less than $1,000
      To obtain authorization of payment for a minor home modification costing less than $1,000, a program provider must:
      • submit a completed Form 4116-MHM-AA to DADS in accordance with the form instructions.
      • keep in the individual's record the documentation required by Section 6250 (see No. 2).
    3. Requisition Fee
      A program provider may request authorization for payment of a requisition fee for a minor home modification in accordance with the instructions in Appendix V.
  2. Time Frame for the Request for Authorization for Payment
    A program provider must request authorization for payment for a minor home modification no later than 12 months after the last day of the month in which the minor home modification was completed.
  3. Notification for Authorization for Payment
    1. Authorization for Payment Given or Denied
      DADS notifies a program provider on the CARE Reimbursement Authorization Inquiry (C77):
      • that authorization for payment is given or denied;
      • if given, the amount which DADS has authorized; and
      • if denied, the reason for denial.
    2. Corrected Requests
      If a request for authorization for payment is denied, a program provider must submit a corrected request no later than 12 months after the last day of the month in which the minor home modification was completed.

 

6300 Dental Treatment

Revision 12-1; Effective February 10, 2012

 

 

6310 General Description of Service Component

 

Revision 12-1; Effective February 10, 2012

The dental treatment service component includes emergency dental treatment, preventive dental treatment, therapeutic dental treatment and orthodontic dental treatment.

 

6320 Age Requirement

Revision 12-1; Effective February 10, 2012

 

Dental treatment may be provided only to an individual 21 years of age or older.

 

6330 Billable Dental Treatment

Revision 12-1; Effective February 10, 2012

 

The only billable services for the dental treatment service component are:

  • dental treatment necessary to control bleeding, relieve pain or eliminate acute infection;
  • an operative procedure required to prevent the imminent loss of teeth;
  • treatment of an injury to a tooth or supporting structure;
  • a dental examination, an oral prophylaxis or a topical fluoride application;
  • pulp therapy for permanent or primary teeth;
  • restoration of carious permanent or primary teeth;
  • dental treatment related to maintenance of space;
  • the limited provision of a removable prosthesis (for example, dentures) when masticatory function is impaired, an existing prosthesis is unserviceable, or employment or social development is impaired due to aesthetic considerations;
  • treatment of retained deciduous teeth;
  • cross bite therapy;
  • treatment of a facial accident involving a severe traumatic deviation;
  • treatment of a cleft palate with a gross malocclusion that will benefit from early treatment; and
  • treatment of a severe, handicapping malocclusion affecting permanent dentition with a minimum score of 26 as measured on the Handicapping Labio-lingual Deviation Index.

 

6340 Services Not Billable

Revision 12-1; Effective February 10, 2012

 

  1. Items and Services Not Listed in Subsection (C)
    Any service not listed in Section 6330, Billable Dental Treatment, is not billable under the dental treatment service component.
  2. Examples of Non-Billable Services
    The following are examples of services that are not billable for the dental treatment service component:
    • cosmetic orthodontia; and
    • teeth whitening.

 

6350 Provider of Dental Treatment

Revision 12-1; Effective February 10, 2012

 

A provider of the dental treatment service component must be a person licensed to practice dentistry in accordance with Texas Occupations Code, Chapter 256.

 

6360 Payment Limit

Revision 12-1; Effective February 10, 2012

 

The maximum amount DADS pays a program provider for all dental treatment provided to an individual is $1,000 per IPC year.

 

6370 Authorization for Payment

Revision 12-4; Effective November 19, 2012

 

  1. Requesting Authorization for Payment
    1. Dental Treatment
      To obtain authorization for payment for dental treatment, a program provider must:
      • submit a completed Form 4116-Dental, Dental Summary Sheet, to DADS in accordance with the form instructions; and
      • keep in the individual's record:
        • a statement from the provider of dental treatment that includes:
          • the individual's name; and
          • a description of each dental service provided to the individual, itemized by cost;
        • proof that the program provider purchased the dental treatment, and the date of purchase; and
        • a completed Form 4116-Dental to DADS in accordance with the form instructions.
    2. Requisition Fee
      A program provider may request authorization for payment of a requisition fee for dental treatment in accordance with the instructions in Appendix IX. The requisition fee is not counted toward the payment limit that DADS pays a program provider for dental treatment, as described in Section 6360, Payment Limit.
  2. Time Frame for Request for Authorization for Payment
    A program provider must request authorization for payment for dental treatment no later than 12 months after the last day of the month in which the individual received the dental treatment.
  3. Notification for Authorization for Payment
    1. Authorization for Payment Given or Denied
      DADS notifies a program provider on the CARE Reimbursement Authorization Inquiry (C77):
      • that authorization for payment is given or denied;
      • if given, the amount DADS has authorized; and
      • if denied, the reason for denial.
    2. Corrected Request
      If a request for authorization for payment is denied, a program provider must submit a corrected request no later than 12 months after the last day of the month in which the individual received the dental treatment.