Appendix C: Complex Rehabilitation Technology

Revision 19-1, Effective March 1, 2019

C 1 Hearing Aid Devices and Services

C 1.1 Hearing Aids

C 1.1.1 Qualifications

Audiologist – Provides audiological examinations, may dispense hearing aids, and may provide basic audiometric assessments. Must be licensed by the State Board of Examiners for Speech-Language Pathology and Audiology. To dispense hearing aids, the audiologist also must be licensed by the State Committee of Examiners in the Fitting and Dispensing of Hearing Instruments.

Hearing aid specialist – Dispenses hearing aids, may provide basic audiometric assessments, and may provide hearing aid evaluations. Must be licensed by the State Committee of Examiners in the Fitting and Dispensing of Hearing Instruments.

C 1.1.2 Required Procedures

Hearing aids are designed to be:

  • monaural (involving one ear); or
  • binaural (involving both ears).

Hearing aid models may be described as:

  • in-the-ear (ITE);
  • behind-the-ear (BTE); or
  • complete-in-canal (CIC).

Hearing aids may only be purchased based upon the medical recommendation of a physician or audiologist.

Once the purchase of a hearing aid has been recommended by the physician or audiologist, evaluation services may be purchased to determine which hearing aid model is most appropriate based on the consumer's individualized needs and informed choice.

Evaluation services may be purchased from a physician, audiologist, or licensed hearing aid fitter and dispenser.

Evaluation services should always include:

  • a complete hearing aid evaluation;
  • identification of the most appropriate hearing aid by manufacturer and model; and
  • identification of recommended accessories (if needed).

Ear mold impressions are generally required. Contact the vendor to determine if this service will be completed at the time of the hearing aid evaluation or at a later date (for example, after the vendor has submitted a written report and received approval for the purchase.)

Schedule and purchase the initial fitting as soon as it is verified that the dispenser has the correct product.

C 1.2 Cochlear Implant Components

Cochlear implants may be authorized when they are expected to improve the consumer’s ability to participate in activities in the home and community according to the consumer’s planned independence goals. Document the expected outcomes, such as an improved ability to understand spoken communication or respond to environmental cues clearly. Place the documentation in the case file as part of the assessing and planning process.

In addition, before planning to provide the consumer with cochlear implant services, ensure that the consumer has:

  • good general health, as evaluated by a general history and physical examination;
  • no serious medical problems that would preclude surgery or participation in the aural rehabilitation program;
  • a significant-to-profound hearing loss in both ears and is unable to effectively use a hearing aid in the implanted ear; and
  • been evaluated by an otologic surgeon who is active in cochlear implant surgery.

The evaluation report completed by the otologic surgeon must:

  • include diagnosis;
  • include recommendations for treatment;
  • include a prognosis; and
  • ensure that:
    • consultation with a licensed medical provider has occurred;
    • an effective aural rehabilitation program following surgery is available; and
    • the consumer, through counseling and guidance:
      • understands the prescribed cochlear implant program and is willing and able to complete it;
      • is aware of the potential side effects from receiving a cochlear implant and is aware of the availability of communication enhancements that are similar to the cochlear implant, such as tactile stimulation instruments, but elects to receive the cochlear implant to stimulate hearing; and
      • has expressed realistic expectations that the implant:
        • may be enhanced by a hearing aid in the better ear and/or the use of other assistive listening devices; and
        • can create the perception of sound, but will not restore normal hearing.

C 1.3 Hearing Aid Repair

The costs for repairing a hearing aid, including the costs for labor, shipping and handling, should not exceed the cost of buying a new hearing aid.

Reprogramming hearing aids is allowable, especially if necessary to allow the consumer to make use of other training being provided.

C 1.4 FM System

Purchase a frequency modulation (FM) system directly from a manufacturer or an audiologist.

The required procedures are as follows:

  • Do not pay a fitting and dispensing fee when purchasing an FM system through an audiologist.
  • When additional training is needed for an FM system, and if the necessary training is not available from a comparable benefit, negotiate payment for the time to train the consumer to use an FM system.

C 2 Home Modifications

Qualified vendors may purchase an assessment from a licensed occupational therapist, physical therapist, or professional engineer specializing in assistive technology.

Rehabilitation Engineering Services - Only licensed professional engineers may provide rehabilitation engineering services. Consider using an engineer's services when the service includes design or modification of a product.

The required procedures include the following:

  • A full assessment of the consumer’s needs, followed by consideration of accommodation alternatives, including the need for consumer training and/or education regarding the use of rehabilitation technology. Assessment services identify options that will allow the consumer to function as independently as possible.
  • Adaptive equipment may require installation, but usually does not result in permanent structural changes. Household equipment may be specially designed, selected, or altered to enable the consumer to perform independently in the home despite his or her functional limitations.
  • Modifications are limited to equipment that can be removed from the residence without permanent damage to the property should the consumer move, fail to cooperate in achieving the planned objective, and so on.
  • A written agreement from the property owner, before equipment such as a porch or ramp is attached (for example, bolted or nailed) to the property.
  • For purchases over $1,000, the service provider must develop policies and procedures that include an approval process, internal controls, and an oversight process.
  • The purchase of a lien examination from either a title insurance company or other source such as a law office. If there is a lien, notify the lien holder of the proposed modification and request that the lien holder expressly disclaim in writing any interest in the equipment installed in the residence. If the lien holder will not sign the disclaimer, get legal advice to determine whether it is advisable to continue with the plan for modification.
  • Related documentation, to be kept in the consumer’s case file.

C 3 Prosthetics

C 3.1 Qualifications

Prosthetist and Orthotist – Fabricates and supplies prostheses and orthotics. Must be licensed by the State Board of Orthotics and Prosthetics.

Pedorthist – Fabricates and supplies below-the-ankle orthotics. Must be certified by the Board for the Certification in Pedorthics.

Occupational therapist – Must be licensed by the Executive Council of Physical Therapy and Occupational Therapy Examiners to practice in the state where services are rendered.

Physical therapist – Must be licensed by the Executive Council of Physical Therapy and Occupational Therapy Examiners to practice in the state where services are rendered.

Oculist – Must have board certification from the National Examining Board of Ocularists.

C 3.2 Required Procedures

Ocular prosthesis should be provided by an Ocularist that is a member of the American Society of Ocularists. Members of this organization adhere to the society’s standard operating procedures for the fitting and fabrication of custom-made ophthalmic prosthetics. To find a list of ocularists in Texas, see the American Society of Ocularists website.

Before agreeing to purchase any ocular prosthesis, the service provider must have verification from an ophthalmologist that treatment has been completed and the consumer is ready to be fitted for a prosthesis. Additionally, the service provider must obtain a written estimate from the ocularist detailing the expenses to be incurred in the process of fitting and fabricating the artificial eye.

For other prosthetics, based on the prescription, the orthotist or prosthetist recommends the design of a device that best meets the consumer's needs.

For orthoses, a physician's examination is required before the purchase of an initial orthosis or if the consumer is having difficulty using the current orthosis.

Orthoses include:

  • corsets;
  • orthopedic shoes;
  • braces;
  • splints; and
  • artificial muscles.

For prostheses, an orthopedist's or physiatrist's examination is required before the purchase of the first prosthesis. If the consumer has difficulty using his or her current prosthesis, an orthopedist's or physiatrist's evaluation is required before planning the purchase of a second prosthesis.

All vendors of orthoses and prostheses must:

  • be currently licensed by the Texas Board of Orthotics and Prosthetics;
  • perform all measurements, fittings, alignments, and final checkouts for purchased devices;
  • fabricate or directly supervise the fabrication of these devices; and
  • provide final delivery and instructions for use.

Consider purchasing more technologically advanced devices or components only if required by the consumer's unique independent living or medical needs.

If the cost is $12,500 or more, prior approval by the HHSC Independent Living Program manager is required.

The vendor should agree to replace, without cost to the service provider or the consumer, defective parts and materials within 90 days of the consumer receiving the completed orthosis or prosthesis.

The following are not covered by—and do not create exclusions to—the vendor’s warranty:

  • Straps, evidence that the device has been altered by anyone other than the vendor; or
  • changes in the consumer's condition that affect the use of the device.

The vendor honors the manufacturer warranties and pays all costs associated with warranty replacements.

The consumer pays all costs associated with extended warranties.

Repair the current orthosis or prosthesis unless the repair cost is more than 60 percent of the replacement cost.

Arrange training in the use of above-knee prosthesis to consumers who:

  • have not worn one previously;
  • will have a different type of prosthesis than previously; or
  • have not worn one for a prolonged period.

A prosthetist may provide training in the use of a below knee prosthesis. If the prosthetist recommends additional training, arrange for it from a qualified physical or occupational therapist.

A qualified physical or occupational therapist may provide training in the use of an upper extremity prosthesis.

C 4 Vehicle Modification Consumer Service

Service providers and installers must adhere to health and safety standards that can be found at the Texas A&M Transportation Institute (TTI) website: https://tti.tamu.edu/twc. Service providers must obtain prior approval by the HHSC Independent Living Program manager or designee for vehicle modifications that the cost $5,000 or more. Oversight, planning and inspection is subject to review by and must be coordinated with TTI or similar entity by contract with the service provider/Independent Living Center.

Modifying a consumer’s vehicle may be necessary when all other options for transportation have been explored and exhausted and the consumer cannot meet the planned goals for independence without the adaptive equipment. Procedures for evaluating the consumer’s ability to operate or travel safely as a passenger in a modified vehicle must be developed before agreeing to provide a modification service. These procedures must be guided by the TTI requirements and ILS requirements outlined in these Standards related to vehicle modification and detailed in the consumer’s Independent Living Plan. Consumers must be fully informed of the evaluation process, and those interactions should be clearly documented in case management software, before the consumer is instructed to purchase a vehicle. Some vehicles cannot be modified and maintain their structural integrity; therefore, safety standards must be strictly followed. Vehicle modifications range in cost from less than $1,000, for simple hand controls, to many thousands of dollars for van conversions with complex steering controls.

Deciding that vehicle modification is reasonable and necessary requires careful consideration of numerous factors, including:

  • available transportation alternatives;
  • consumer's financial ability to purchase vehicle, insurance and maintenance;
  • effect of vehicle selection on the cost of modification;
  • cost of the modification; and
  • complexity of the modification.

Carefully guide the consumer through the entire process, including making an informed choice.

To guide the consumer:

  • provide the consumer with information regarding:
    • vehicle selection;
    • vehicle modification rebate programs; and
    • the need to visually inspect any used vehicle before agreeing to pay for modifications;
  • obtain the consumer's written commitment to maintain the vehicle and the installed modifications and ensure that the consumer has the resources to do so;
  • counsel the consumer on the ultimate cost of replacing the vehicle and modifications (consumers should plan to drive the vehicle for the life of the adaptive equipment, which averages seven to 10 years); and
  • ensure and document that the consumer has the financial resources to:
    • make vehicle and insurance payments; and
    • maintain the vehicle and adaptive equipment.

C 4.1 Overview of Vehicle Modification Equipment

This appendix applies to contracted vehicle modification equipment (VME) purchased by ILS service providers. Contracted VME items purchased for customers by ILS includes, but is not limited to:

  • lowered floor conversions;
  • mobility aid hoists;
  • mechanical and electronic primary control systems (i.e., hand controls);
  • reduced effort powered steering;
  • access battery systems;
  • seating systems;
  • driver and passenger restraint systems.

A complete list of vehicle modifications accepted for purchase can be found at the TWC/TTI website: https://tti.tamu.edu/twc/.

C 4.2 Limitations on Vehicle Modification Services

Do not sponsor vehicle modification or purchase equipment available from the vehicle manufacturer or dealer ( e.g. air conditioner, automatic transmission, power steering, power windows, or power brakes) for:

  • a vehicle that is not owned by the consumer or an immediate family member of the consumer, such as a spouse or parent;
  • a vehicle without a current Texas state vehicle inspection; or
  • appearance rather than function.

Carefully weigh the specific vehicle modification against:

  • the consumer's functional abilities; and
  • intended use of the vehicle.

C 4.3 Service Provider Requirements

The ILS service provider is required to coordinate with Texas A&M Transportation Institute (TTI) to ensure that the vehicle modification proposed to be purchased is an accepted vehicle (for lowered floor conversions) or an acceptable product. The coordination includes obtaining a pricing review from TTI by submitting the driving evaluation, service estimate from the vehicle modification vendor and the consumer’s medical reports. Upon completion of an installation of a vehicle modification, the ILS service provider is required to coordinate with TTI to purchase an inspection when the cost is $9,000 or higher, or the service provider will provide or coordinate an inspection of the vehicle modification when the cost is less than $9,000. Any inspection, by service provider or TTI, will occur prior to delivery of the vehicle to the consumer.

The ILS service provider’s sub-contracted vendors must meet the following requirements:

  • be an authorized dealer of the VME being provided or serviced;
  • have a National Mobility Equipment Dealers Association (NMEDA) certified technician on staff for the VME being installed/purchased; and
  • have an American Welding Society (AWS) certified welder to perform any welding that may be necessary during VME installation.

C 4.4 Evaluating the Driver

Once written recommendation or a prescription is obtained from a licensed practitioner for a driver’s evaluation, evaluate the consumer's ability to drive using the services of a certified driving rehabilitation specialist. This evaluation also includes recommendations for the assistive equipment that will be necessary for a consumer to drive a vehicle. This evaluation is provided to the vehicle modification vendor for their cost estimate as well as to TTI for their pricing review.

The consumer must complete a driver evaluation and training with the appropriate equipment, if the consumer has:

  • never driven;
  • never driven with adaptive equipment;
  • progressive disabilities; or
  • significant changes in his or her condition.

The consumer should have a valid driver's license with appropriate restrictions before a beginning a vehicle modification. It is required that the ILS service provider obtain a front and back copy of the consumer’s current and valid Texas Driver’s License with restrictions.

If a valid Texas Driver’s License with appropriate restrictions has not been obtained, the ILS service provider can purchase additional driving training from a certified driving rehabilitation specialist who will be able to arrange for the consumer to take the driving test in the modified vehicle.

If the consumer currently drives a modified vehicle, this may be verified by obtaining a copy (front and back) of the valid Texas Driver’s license with appropriate restrictions listed.

C 4.5 Evaluating Used Vehicles

An ASE certified mechanic must evaluate the used vehicle before it is modified to ensure the sound mechanical condition of all major components when:

  • the cost of the modification is $1,000 or more; and
  • the vehicle has more than 50,000 miles or is more than four years old.

The service provider pays for the cost of the evaluation and obtains a detailed report from the mechanic.

C 4.5.1 Evaluating Used Vehicles for Lowered Floor Conversions

Consult the TTI website for acceptable vehicles for lowered floor conversions.
Due to manufacturer requirements for lowered floor vehicle conversions, they will only be completed on vehicles that:

  • have fewer than 30,000 miles;
  • pass a mechanic’s inspection; and
  • show no evidence of the vehicle ever having been in a wreck or damaged from flooding or other disasters.

The service provider pays for the cost of the evaluation and obtains a detailed report from the mechanic.

C 4.6 Obtaining the Modification Proposal

The service provider and the consumer will select a vehicle modification vendor. The service provider gives the consumer a list of approved vehicle modification vendors in the consumer's geographic area.

At no cost to the service provider or consumer, the vehicle modification vendor prepares a proposal for the modification. The vehicle modification vendor should be provided with a copy of the completed driver’s evaluation in order to estimate the cost of exact equipment necessary for the consumer’s modification. If the consumer currently drives an adapted vehicle and a driving evaluation was not required, the vehicle modification vendor may determine assistive equipment needs based on the existing vehicle modification being used by the consumer.

After the proposal is received, decide with the consumer which modifications are reasonable and necessary for achieving the planned goal.

C 4.7 Reviewing the Modification Plan Before the Vehicle Is Purchased

Before the consumer purchases a vehicle, the service provider should have processes in place for internal management to review a plan for modifications that cost more than $1,000. If the vehicle modification requires HHSC prior approval, this approval should be obtained before the consumer purchases a vehicle.

Review the information gathered to obtain a TTI pricing review and determine whether the:

  • vendor’s quoted cost of the modification equipment is reasonable;
  • modification prescribed by the service provider appears to meet the consumer's needs; and
  • specifications for equipment meet the standards.

Before issuing the authorization to modify, verify that the vehicle purchased is the same vehicle described in the quote and in the modification plan.

For modifications costing $1,000 or more, review a copy of:

  • the certificate of title; or
  • the tax collector's receipt for the Texas title application, registration, and motor vehicle tax.

The consumer or an immediate family member (such as the consumer’s spouse or parent) must own the vehicle.

If there is a lien on the vehicle, obtain in writing the lien holder’s expressed disclaimer of any interest in the installed equipment.

If the lien holder agrees and later reclaims the vehicle for any reason, the service provider may:

  • remove the installed equipment; and
  • repay the lien holder for any vehicle damage caused by the installation of equipment.

Procedures, which may include contacting a legal resource for advice, must be developed by the service provider when a lien holder will not sign the disclaimer.

C 4.8 Insuring the Vehicle

When providing vehicle modification services, the consumer must obtain, at the consumer's expense, insurance that covers the replacement cost of the sponsored modifications. Encourage the consumer to carry comprehensive coverage on the vehicle. The service provider must have a policy regarding proceeding with modifications for vehicles that do not have comprehensive coverage.

Obtain and file a copy of:

  • the paid insurance policy (front and back); or
  • verification from the insurance company that the consumer is eligible for insurance when the modification is completed.

C 4.9 Purchasing Equipment and Modification Repairs

The service provider may fund repairs to adaptive equipment and vehicle modifications.

The service provider may also fund repairs to adapted vehicles, when warranted.

Consider and document in a consumer case file that:

  • the vehicle is:
    • owned by the consumer or a family member; and
    • the consumer's primary means of transportation;
  • vehicle repair is a best-value decision to meet the consumer's transportation needs; that is, the decision is based on the:
    • vehicle's overall condition (ongoing repairs are not expected); and
    • fact that repair costs do not exceed the vehicle's fair market value;
  • there are no comparable services and benefits available to meet this consumer's transportation needs, such as public bus service; and
  • the consumer has a plan for meeting transportation expenses after case closure.

To fund equipment repairs:

  • obtain a price quote from an adaptive equipment specialist or certified mechanic;
  • ensure the safety of the modification (for example, the provision of tie downs); and
  • inspect the work before delivery to the consumer or payment for completion.

Do not reclaim equipment that is broken, outdated, or no longer under warranty.

All modifications must meet the standards required by TTI and will be subject to pricing review and/or inspection as required in the TTI/service provider memorandum of understanding.

C 5 Wheelchairs and Scooters

C 5.1 Required Procedures

When the service provider determines that the assistive device has no salvage value, the service provider may decide to relinquish ownership. The service provider must develop and follow policies and procedures that address relinquishing ownership of the assistive device.

Written recommendations are required for:

  • the initial purchase of medical assistive devices and supplies; and
  • replacement items when the medical condition is progressive.

If required to obtain a written recommendation and/or prescription, place the written recommendation and/or prescription for the assistive device in the consumer case file. This should be obtained from:

  • a physician;
  • a physician assistant;
  • an advanced practice nurse;
  • a dentist; or
  • an optometrist.

When the written recommendation and/or prescription does not describe the item, obtain a letter of specification from an appropriate, certified paramedical specialist (such as a physical or occupational therapist, orthotist, or prosthetist).

Replacement wheelchairs require that the service provider obtain from the local vendor of wheelchair repair services an estimate of the cost for refurbishing the original chair.

Consider whether repair or replacement is the more cost-effective course.

When a replacement chair that differs in size and other features from the chair previously prescribed and currently in use by the consumer, request that the consumer be reevaluated by a physiatrist or physical or occupational therapist.

Sports chairs generally do not purchase non-folding competition sports chairs intended primarily for sports-related activities.

When a consumer requests a non-folding chair that appears appropriate for the consumer's needs:

  • ensure that the consumer can use the non-folding chair as effectively as a folding chair in all activities related to completing the independence goal; for example, when:
    • driving; and
    • loading and unloading the chair into an automobile;
  • observe (or ask a physiatrist or physical therapist to evaluate) the consumer's ability to drive using a non-folding chair and load and unload the chair into an automobile; and
  • ensure that purchasing a non-folding chair will not result in additional expense, such as modifying a van or home to accommodate the new chair.

Lightweight chairs – Purchase a lightweight chair when appropriate for the consumer's needs.

Do not purchase:

  • more than one set of front casters (for example, 5" hard or 8" pneumatic);
  • more than one set of arm rests (for example, desk type or sloped); or
  • sports-related options (for example, spoke guards and anti-tip front casters).

Wet weather guards are not considered sports-related items.

Wheelchair accessories – Except for power units and controllers or seating and positioning systems, replacement parts can be purchased as needed.