4800, Adaptive Aids, Minor Home Modifications, and Transition Assistance Services

Revision 22-2; Effective September 1, 2022

4810 Adaptive Aids

Revision 19-1; Effective June 3, 2019

Adaptive aids are devices necessary to treat, rehabilitate, prevent or compensate for conditions resulting in disability or loss of function and enable members to:

  • perform activities of daily living (ADLs); or
  • control the environment in which they live.

A member must exhaust any applicable Medicare, Medicaid or other third-party resources for durable medical equipment and adaptive aids before adaptive aids available under the Medically Dependent Children Program (MDCP) are authorized. A member may take an adaptive aid to an out-of-home respite facility for use while residing there.

4811 Service Limits on Adaptive Aids

Revision 22-3; Effective Dec. 1, 2022 

The service limit on all adaptive aids combined is $4,000 per annual individual service plan (ISP) period. The amount paid for an adaptive aid must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the member's case file. 

Adaptive aids are available through the Medically Dependent Children Program (MDCP) only after benefits available through Medicare; Medicaid, including the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, known in Texas as Texas Health Steps – Comprehensive Care Program (THSteps-CCP); or other third party resources have been exhausted. Items reimbursed with waiver funds are only accessible for items not covered under the state plan.

Health and safety of the individual are ensured through the use of non-waiver services, the Medicaid State Plan, and THSteps-CCP. 

The services under the waiver are limited to additional services not otherwise covered under the state plan, but consistent with waiver objectives of avoiding institutionalization.

After any applicable benefits (e.g., durable medical equipment) are exhausted, adaptive aids, including repair and maintenance not covered by warranty (i.e., batteries), covered through MDCP include, but are not limited to, the following:

  • van lifts;
  • vehicle modifications;
  • jump seats;
  • tumble form chairs;
  • feeder seats;
  • medically appropriate strollers;
  • barrier-free lifts;
  • stair lifts;
  • environmental control units;
  • alarm systems;
  • support rails;
  • electrical work related to use of authorized adaptive aids;
  • installation of authorized adaptive aids; and
  • repairs to adaptive aids.

This is not an exhaustive list. For adaptive aids not specifically listed above, the service planning team must determine the member has an established assessed need and a compromised health status without the requested equipment or supplies. Items must be prescribed by a physician and be determined to meet the criteria specified in 4810, Adaptive Aids.

The managed care organization (MCO) may authorize bids for adaptive aids, such as vehicle modifications, as applicable. The cost of these bids does not count against the member's annual limit for adaptive aids.

If the cost of a requested adaptive aid exceeds the service limit, the MCO may approve the request only if the member agrees to pay any costs that are in excess of the service limit. The MCO must document the member's agreement to pay these costs in the member's case file. MCOs may also choose to pay the excess costs on a case-by-case basis with MCO funds. Documentation must include, at a minimum, a description of the adaptive aid, rationale for exceeding the service limit, the cost incurred to the MCO, the cost incurred to the member, the member's signature, the date of the member's agreement, and signature of the provider. Documentation must be on file prior to the MCO authorizing an adaptive aid that exceeds the service limit.

4812 Time Frames for Adaptive Aids

Revision 22-2; Effective September 1, 2022

When an adaptive aid (AA) is included in an individual service plan (ISP), the managed care organization (MCO) must purchase and ensure delivery of the AA within 14 business days of being authorized (except for vehicle modifications), counting from one of the following dates, whichever is later:

  • the start date of the ISP; or
  • the date of the ISP revision, if the AA service is added after the ISP start date.  

The MCO must document and notify the member of any delay in delivering the AA, the reason for the delay and the new proposed delivery date. The notification must be provided on or before the 14th business day following authorization. If the provider does not deliver the AA by the new proposed date, the MCO must document and notify the member about any additional delays until the AA is delivered. Throughout the process, the MCO must continue to meet the member’s health and safety needs. The MCO must work with the provider and member to ensure timely delivery of the AA. 

4820 Minor Home Modifications

Revision 22-2; Effective September 1, 2022

A minor home modification is a physical modification to a member's residence necessary to prevent institutionalization or support de-institutionalization. Minor home modifications are necessary to ensure the health, welfare and safety of the member or to enable the member to function with greater independence in their home. If a home modification is requested and the member or their legally authorized representative (LAR) does not own the home in which the modification will take place, the member, LAR, or the service coordinator must obtain written agreement from the homeowner before a modification is authorized. STAR Kids managed care organizations (MCOs) may not require minor home modification providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for minor home modifications services.

4821 Service Limits on Minor Home Modifications

Revision 22-2; Effective September 1, 2022

The minor home modification lifetime limit is $7,500. The service coordinator may authorize up to $300 per the individual service plan (ISP) period for maintenance or repairs of minor home modifications previously approved and reimbursed with waiver funds. The service coordinator does not include $300 maintenance and repair limit as part of the $7,500 lifetime limit. The amount paid for a modification or for the repair of a minor home modification must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the member's case file. A minor home modification must not create a new structure or add square footage to the home.

The managed care organization (MCO) may authorize bids for minor home modifications, as applicable. The cost of these bids does not count against the member's lifetime limit for minor home modifications.

Minor home modifications are limited to:

  • purchase and installation of permanent and portable ramps not covered by other sources;
  • widening of doorways;
  • modification of bathroom facilities; and
  • modifications related to the approved installation or modification of ramps, doorways or bathroom facilities.

Minor home modifications must:

  • adhere to Americans with Disabilities Act (ADA) requirements;
  • meet Texas Accessibility Standards;
  • meet all applicable state and/or local building codes; and
  • have a minimum one-year warranty.

Minor home modifications do not include the use of deluxe materials, such as granite, marble or high-end fixtures.

If a request for repair or maintenance to a minor home modification is not covered by the provider's warranty, the service coordinator may authorize up to $300 for the member or their legally authorized representative to select a provider contracted with the STAR Kids MCO. The $300 limit is available per the member’s ISP year for maintenance and repair and is not included in the $7,500 lifetime minor home modification service limit.

If the cost of a requested minor home modification exceeds the service limit, the MCO may approve the request only if the member agrees to pay any costs that are in excess of the service limit. The MCO must document the member's agreement to pay these costs in the member's case file. Documentation must include, at a minimum, a description of the home modification, rationale for exceeding the service limit, the cost incurred to the MCO, the cost incurred to the member, the member's signature, the date of the member's agreement, and signature of the provider. Documentation must be on file prior to the MCO authorizing a home modification that exceeds the service limit.

4822 Time Frames for Minor Home Modifications

Revision 21-1; Effective April 1, 2021

When a minor home modification (MHM) is included in an individual service plan (ISP), the managed care organization (MCO) must ensure completion of the MHM within 90 business days after:

  • the start date of the ISP; or
  • the date of the ISP revision, if the MHM service is added after the ISP start date.  

The MCO must document and notify the member of any delay in completing the MHM, the reason for the delay and the new proposed completion date. If the provider does not complete the MHM by the new proposed completion date, the MCO must document and notify the member about the additional delay. Throughout the process, the MCO must continue to meet the member’s health and safety needs. The MCO must work with the provider and member to ensure timely completion of the MHM.

4830 Transition Assistance Services

Revision 22-3; Effective Dec. 1, 2022

The service coordinator must advise individuals who reside in a nursing facility (NF), or members whose Medically Dependent Children Program (MDCP) services are suspended due to NF placement, of the availability of Transition Assistance Services (TAS). TAS may be used if the individual needs assistance in setting up a household when relocating into the community from the NF. STAR Kids managed care organizations (MCOs) may not require TAS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for TAS. The individual may access TAS if they:

  • plan to rent an apartment;
  • plan to rent a house;
  • have a home, but the utilities have been off while in the NF;
  • have a home, but it may need cleaning, pest eradication or allergen control before it can be occupied again; or
  • need belongings moved from the NF to the new residence.

TAS may be available to pay for non-recurring set-up expenses for individuals transitioning from NFs into MDCP and to individuals suspended from MDCP services due to a temporary NF placement. TAS may be used for those necessary expenses identified as barriers to the individual’s transition into the community to set up a household. TAS may include, but is not limited to, payment or purchases of:

  • security deposits required to lease an apartment or house, or deposits required to establish utility services for the home;
  • essential furnishings for the apartment or house;
  • moving expenses required to move into the house or apartment; and
  • site preparation services, such as pest eradication, allergen control or a one-time cleaning before occupancy.

The individual selects a TAS agency from the list of contracted agencies. The STAR Kids MCO may require the individual or their legally authorized representative (LAR) to attest that the items requested for TAS are the basic, essential needs required to move into the community, and they agree the TAS agency selected is authorized to make the purchases for them. The service coordinator must explain to the individual or their LAR that the service will not be authorized until the individual is determined eligible for MDCP waiver services, and notified in writing that they are eligible. The service coordinator must contact the individual or their LAR before certification to verify they have made arrangements for relocating to the community and has finalized a projected discharge date. The amount of TAS a member received must be documented on Form 8604, Transition Assistance Services (TAS) Assessment and Authorization.

4831 Deposits

Revision 22-2; Effective September 1, 2022

The service coordinator may authorize Transition Assistance Services (TAS) to pay deposits, which include security deposits for residential leases and household utilities, including basic telephone service. Security deposits or utility deposits must be in the individual’s name.

Residential Leases – A security deposit is a one-time expense and the amount may be no more than the equivalent of two months' rent. The service coordinator must not authorize TAS to pay rent. TAS may be accessed to pay for pet deposits only if the pet is the individual’s service animal.

Household Utilities – TAS may be used to pay for utility deposits to establish accounts in the individual’s name or to pay for arrears on previous utilities if the account is in the individual’s name and they will not be able to get the utilities unless the previous balance is paid. TAS cannot be used for payment toward utilities. TAS may be used to pay for a telephone since it is a basic need but may not be used to purchase minutes or services for the telephone. The managed care organization (MCO) may have internal policies regarding the type of telephone that may be authorized.

TAS funds can be used to pay for initial setup or reconnection fees for propane or butane service, including the minimal supply of fuel if the utility company requires a minimal supply of fuel to be delivered during the initial or reconnection service call.

Essential Furnishings – TAS household items that, if absent, would pose a barrier to the individual’s transition into the community. Essential furnishings purchased with TAS funds may include furniture, appliances, housewares and cleaning supplies.

Furniture – TAS can be used to purchase furniture such as a bed, recliner or dinette if the individual’s place of residence does not have the needed furniture and the absence of the item prevents the transition into the community.

Appliances – TAS can be used to purchase appliances such as a refrigerator, stove, washer, dryer, microwave oven, electric can opener, coffee pot or toaster if the individual identifies these appliances as needed items.

Housewares – TAS can be used to purchase basic housewares such as pots, pans, dishes, silverware, cooking utensils, linens, towels, a clock and other small items required to set up the household.

Cleaning Supplies – TAS can be used to purchase basic cleaning supplies such as a mop, broom, vacuum, brushes, soaps and cleaning agents required for the household.

Other – TAS can be used to purchase any special request from the individual not included in the general list that meets the criteria as a basic essential furnishing to transition into the community, if approved by the STAR Kids MCO.
 

4832 Moving Expenses

Revision 22-2; Effective September 1, 2022

Transition Assistance Services (TAS) can be used to pay for moving expenses, which may include the cost of moving the individual’s belongings from the nursing facility to the community residence, or delivery charges on approved TAS items.

Moving expenses may include the cost of a designated mover or retail store to deliver or move furniture, major appliances and other items approved as required for relocation to the community. Moving expenses do not include the cost of transporting the individual from the nursing facility to their residence in the community.

4833 Site Preparation

Revision 22-2; Effective September 1, 2022

Transition Assistance Services (TAS) can be used to pay for preparing the individual’s place of residence for occupancy if the current condition of the residence prevents the individual’s transition from the nursing facility. Site preparation purchased with TAS funds may include one-time expenses such as pest eradication, allergen control and residential cleaning.

Pest Eradication – TAS can be used if the residence has been unattended and needs some type of extermination.

Allergen Control – TAS can be used if the residence has been unattended or the individual is moving into a place that poses a respiratory health problem.

One-time Cleaning – TAS can be used if the individual’s residence has been unattended or the individual is moving into a private home or apartment where pre-move-in cleaning should not be expected. For example, a family friend has an empty house available but cannot provide the cleaning.

4834 Limits on Transition Assistance Services

Revision 22-2; Effective September 1, 2022

The service limit on Transition Assistance Services (TAS) has a $2,500 lifetime limit per individual. The amount paid for TAS must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the member's case file. The service coordinator must be as specific as possible when describing the items purchased. A nursing facility resident eligible for Medically Dependent Children Program (MDCP) services or members whose MDCP services are suspended due to nursing facility placement may receive a one-time TAS authorization if the service coordinator determines that no other resources are available to pay for the basic services or items needed by the individual. TAS may not be used for:

  • monthly rent or mortgage expenses;
  • current or future use of utilities;
  • service upgrades;
  • food items; or
  • any diversional or recreational items or services, including televisions, video players or recorders, movies, games, computers, cable TV, satellite TV, exercise equipment, vehicles or other modes of transportation.

TAS does not include any items or services that may be accessed through other MDCP services, such as adaptive aids or minor home modifications. TAS is only available to individuals who are discharged from a nursing facility and require TAS to set up a household.

4835 Transition Assistance Services Agency Responsibilities

Revision 22-2; Effective September 1, 2022

The Transition Assistance Services (TAS) agency accepts all members referred by the managed care organization (MCO). Upon receipt of the authorization, the TAS agency must review the authorization carefully and contact the MCO if there are any questions regarding the authorization. This contact must occur by the next business day of receipt of the forms, and before any TAS purchase is made. The MCO contacts the member or their legally authorized representative (LAR), if necessary, to discuss the item in question. The MCO provides a revised TAS authorization within two business days if it clarifies an item is authorized or approves a change to the authorization.

The TAS agency purchases the authorized items/services and arranges and pays for the delivery of the purchased items, if applicable. The TAS agency only purchases services or items within the authorization made by the MCO. The TAS agency contacts the member or their LAR, if necessary, to coordinate service delivery. The TAS agency delivers the authorized services by the completion date recorded on the TAS authorization form. The agency provides a copy of the purchase receipts and any original product warranty information to the member. The TAS agency maintains the original purchase receipts, including sales tax, delivery or installation charges.

The TAS agency orally notifies the MCO of a delivery delay before the completion due date and documents the delay. The agency also contacts the member or the member's representative by the completion date to confirm that all authorized TAS services were delivered.

4836 Three-Day Monitor Requirement

Revision 17-1; Effective June 1, 2017

The managed care organization (MCO) monitors the member within three business days following the discharge date to assure the delivery of all services and items authorized through the Transition Assistance Services (TAS) agency. If the member reports that any items have not been delivered or services not performed, the MCO contacts the TAS agency by telephone and follows up in writing. Written documentation must be maintained in the member’s case record.

4837 Failure to Leave the Facility

Revision 22-2; Effective September 1, 2022

While the managed care organization (MCO) makes every effort to confirm the member has definite plans to leave the facility, there may be situations in which the member changes their mind or has a change in health making it impossible for them to relocate to the community as planned. In this situation, the MCO notifies the Transition Assistance Services (TAS) agency that the member is no longer moving and no further items are to be purchased.

The TAS agency must attempt to return any item(s) purchased on behalf of the individual and collect a refund for the purchase. The TAS agency also must attempt to recoup security, utility and other deposits paid on behalf of the individual. Failure to leave a facility does not count against a member's lifetime TAS limit.

  • If the TAS agency is unsuccessful in returning the item(s) for monies paid, or the deposits paid on behalf of the individual cannot be recouped, the TAS agency is entitled to the cost of the item(s) and/or reimbursement for deposits paid, not to exceed the authorized amount. The TAS agency sends the MCO written notice stating the item(s) could not be returned or the deposits could not be recouped. The MCO contacts a local charity to donate the items and makes arrangements for pick up. The charity must serve individuals whose needs are similar to those of the individual for whom the items were purchased or must be dedicated to assisting the individual to establish a home.
  • If the TAS agency is able to return the item(s) or receives the deposits back, the TAS agency is not entitled to reimbursement. If the TAS agency recoups part of the monies paid, the TAS agency is entitled to the costs of the item(s) or deposits less any monies recouped. Any claims that had been filed and paid for the item(s) or deposits would need to be adjusted by the TAS agency to pay the monies back to the MCO.
  • If a service has already been provided (for example, pest eradication), the TAS agency is entitled to the cost of the service, not to exceed the authorized amount.

If the member is only in the community for a few days and returns to the nursing facility, the member keeps the item(s) purchased through TAS.