6400, Adaptive Aids and Medical Supplies

Revision 19-1; Effective June 3, 2019

Adaptive aids and medical supplies are specialized medical equipment and supplies, including devices, controls or appliances that enable members to increase their abilities to perform activities of daily living (ADLs), or to perceive, control or communicate with the environment in which they live. Adaptive aids and medical supplies are reimbursed with STAR+PLUS Home and Community Based Services (HCBS) program funds, when specified in the individual service plan (ISP), with the goal of providing individuals a safe alternative to nursing facility (NF) placement.

This service also includes items necessary for life support, ancillary supplies and equipment necessary to the proper functioning of such items; and durable and non-durable medical equipment not available under the Texas state plan, such as vehicle modifications, service animals and supplies, environmental adaptations, aids for daily living, reachers, adapted utensils and certain types of lifts.

The annual cost limit of this service is $10,000 per ISP year. The managed care organization (MCO) may exceed the $10,000 cost limit; however, the MCO must not include any costs over the $10,000 on any cost reports, claims, encounters or financial statistical reports. 

The state allows a member to select a relative or legal guardian, other than a legally responsible individual, to be the member's provider for this service if the relative or legal guardian meets the requirements for this type of service.

Adaptive aids and medical supplies are limited to the most cost-effective items that:

  • meet the member's needs;
  • directly aid the member to avoid premature NF placement; and
  • provide NF residents an opportunity to return to the community.

6410 List of Adaptive Aids and Medical Supplies

Revision 18-2; Effective September 3, 2018

Adaptive aids and medical supplies are covered by the STAR+PLUS Home and Community Based Services (HCBS) program only after the member has exhausted state plan benefits and any third-party resources (TPRs), including product warranties or Medicare and Medicaid home health the member is eligible to receive.

If a vehicle modification costs $1,000 or more and the vehicle has been driven more than 75,000 miles or is over four years old, the managed care organization (MCO) contracted provider must:

  • obtain a written evaluation by an experienced mechanic to ensure the sound mechanical condition of all major components of the vehicle;
  • document the experience of the mechanic doing the evaluation; and
  • include the actual cost of the written evaluation as part of the invoice cost not to exceed $150.

Adaptive aids, including repair and maintenance (to include batteries) not covered by the warranty, consist of but are not limited to following:

  • lifts:
    • wheelchair porch lifts;
    • hydraulic, manual or other electronic lifts;
    • stairway lifts;
    • bathtub seat lifts;
    • ceiling lifts with tracks;
    • transfer bench;
  • mobility aids, including batteries and chargers:
    • manual or electric wheelchairs and necessary accessories;
    • customized wheelchair with documentation of cost effectiveness;
    • three- or four-wheel scooters;
    • mobility bases for customized chairs;
    • braces, crutches, walkers and canes;
    • forearm platform attachments for walkers and motorized/electric wheelchairs;
    • prescribed prosthetic devices;
    • prescribed orthotic devices, orthopedic shoes and other prescribed footwear, including diabetic shoes if the member does not have Medicare and there is a documented medical need and a physician order for the shoes;
    • diabetic slippers or socks;
    • prescribed exercise equipment and therapy aids;
    • portable ramps;
  • respiratory aids:
    • ventilators or respirators;
    • back-up generators;
    • oxygen containers or concentrators, and related supplies;
    • continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) machines, including headgear;
    • nebulizers;
    • portable air purifiers and filters for a member with chronic respiratory diagnosis such as asthma, Chronic Obstructive Pulmonary Disease (COPD), bronchitis or emphysema;
    • suction pumps;
    • incentive spirometers and peak flow meters;
  • positioning devices:
    • standing boards, frames and customized seating systems;
    • electric or manual hospital beds, tilt frame beds and necessary accessories;
    • hospital beds, including electric controls, manual cranks or other items related to the use of the bed (Medicare/Medicaid can cover hospital beds, specialty mattresses and specialty hospital bed sheets for skin breakdown);
    • replacement mattresses;
    • egg crate mattresses, sheepskin and other medically related padding;
    • wheelchair cushions;
    • elbow, knee and heel protectors and hand rolls for positioning;
    • arm slings, arm braces and wrist splints;
    • abdominal binders;
    • trapeze bars;
  • communication aids (including repair, maintenance and batteries):
    • augmentative communication devices:
      • direct selection communicators;
      • alphanumeric communicators;
      • scanning communicators;
      • encoding communicators;
      • speaker and cordless telephones for persons who cannot use conventional telephones;
    • speech amplifiers, aids and assistive devices;
    • interpreters;
  • control switches or pneumatic switches and devices:
    • sip and puff controls;
    • adaptive switches or devices;
  • environmental control units:
    • locks;
    • electronic devices;
    • voice-activated, light-activated and motion-activated devices;
  • medically necessary (MN) durable medical equipment not covered in the state plan for the Texas Medicaid Program;
  • temporary lease or rental of medically necessary durable medical equipment to allow for repair, purchase, replacement of essential equipment or temporary usage of the equipment;
  • payment of premium deductibles and co-insurance (for items covered under the STAR+PLUS HCBS program), including rentals for Medicare or TPRs, if not covered under the Qualified Medicare Beneficiary or the Medicaid Qualified Medicare Beneficiary programs;

  • modifications or additions to primary transportation vehicles:

    • van lifts;
    • driving controls:
      • brake or accelerator hand controls;
      • dimmer relays or switches;
      • horn buttons;
      • wrist supports;
      • hand extensions;
      • left-foot gas pedals;
      • right turn levers;
      • gear shift levers;
      • steering spinners;
    • MN air conditioning unit prescribed by a physician for individuals with respiratory or cardiac problems or people who can't regulate temperature;
    • removal or placement of seats to accommodate a wheelchair;
    • installation, adjustments or placement of mirrors to overcome visual obstruction of wheelchair in vehicle;
    • raising the roof of the vehicle, lowering the floor or modifying the suspension of the vehicle to accommodate an individual riding in a wheelchair;
    • installation of frames, carriers, lifts for transporting mobility aids;
    • installation of trailer hitches for trailers used to transport wheelchairs or scooters;

    Note: If the adaptive aid is a vehicle modification, the program provider must obtain written approval from the vehicle’s owner before making the modification. The owner must sign and date the approval. The MCO must maintain documentation that the contracted provider ensured the specifications for a vehicle modification included information on the vehicle to be modified, including:

    • the year and model of the vehicle;
    • a determination that the vehicle is the member's primary vehicle;
    • proof of ownership of the vehicle;
    • current state inspection and registration for the vehicle;
    • any required state insurance for the vehicle;
    • mileage of the vehicle;
    • an itemized list of parts and accessories, including prices;
    • an itemized list of required labor, including labor charges; and
    • warranty coverage.
  • sensory adaptations:
    • corrective lenses including eyeglasses not covered by the state plan;
    • hearing aids not covered by the state plan;
    • auditory adaptations to mobility devices; and
  • adaptive equipment for activities of daily living (ADLs):
    • assistive devices:
      • reachers;
      • stabilizing devices;
      • weighted equipment;
      • holders;
      • feeding devices, including:
      • electric self-feeders;
      • food processors and blenders – only for members with muscular weakness in upper body or who lack manual dexterity and are unable to use manual conventional kitchen appliances;
    • variations of everyday utensils:
      • shaped, bent, built-up utensils;
      • long-handled equipment;
      • addition of friction covering;
      • coated feeding equipment;
    • medication reminder systems, including those for the visually disabled;
    • walking belts and physical fitness aids;
    • specially adapted kitchen appliances;
    • toilet seat reducer rings unless member resides in an assisted living facility (ALF);
    • bedside commodes;
    • hand-held shower sprays unless member resides in an ALF;
    • shower chairs unless member resides in ALF/residential care facility;
    • electric razors;
    • electric toothbrushes;
    • water picks;
    • service animals and maintenance including veterinary expenses;
    • over-bed tray tables unless member resides in an ALF;
    • safety devices, such as:
      • safety padding;
      • helmets;
      • elbow and knee pads;
      • visual alert systems;
    • medically necessary heating and cooling equipment for members with respiratory or cardiac problems, people who cannot regulate temperature or people who have conditions affected by temperature;
    • one window or portable air conditioner, including wiring, for a member’s main living area, such as a bedroom;
    • medical supplies necessary for therapeutic or diagnostic benefits for:
      • tracheostomy care;
      • decubitus care;
      • ostomy care;
      • pulmonary, respirator/ventilator care; and
      • catheterization.

Other types of supplies include:

  • incontinence supplies, including diapers, disposable or washable bed pads, briefs, protective liners, pull ups, wipes, moisture protective mattress covers, moisture barrier cream, regular or antiseptic wipes (if a medical need is documented), sheets, towels and washcloths (if MN);
  • nutritional supplements;
  • enteral feeding formulas and supplies;
  • mouth swabs and toothettes;
  • diabetic supplies (strips, lancelets and syringes);
  • Transcutaneous Electrical Nerve Stimulation (TENS) units/supplies/repairs;
  • stethoscopes, blood pressure monitors and thermometers for home use;
  • blood glucose monitors;
  • medical alert bracelets;
  • sharps or biohazard containers;
  • anti-embolism hose/stockings, such as thromboembolic disease hose; and
  • approved enemas, if not available through the Medicaid state plan or other TPRs.

Other

Necessary items related to hospital beds could include electric controls, manual cranks or other items related to the use of the bed. Medicare/Medicaid can cover hospital beds and specialty mattresses. Specialty sheets, such as hospital bed sheets, may be covered.

The STAR+PLUS HCBS program will pay for a Geri-chair if the member is alert, oriented and able to remove the tray table without assistance and as desired. Otherwise, the Geri-chair is considered a restraint and the STAR+PLUS HCBS program does not pay for restraints.

Gloves

Gloves may be purchased through the STAR+PLUS HCBS program for family or caregiver use in the care of a member with incontinence, or if the member has an active infectious disease that is transmitted via body fluids. Examples of active infectious diseases that qualify are Methicillin-resistant Staphylococcus aureus (MRSA) and hepatitis. Gloves may be purchased for family or caregiver use to provide wound care to protect the member. Documentation by the MCO-contracted provider must support the need of gloves to be left at the residence and for family or caregiver use only. If the member has other conditions requiring frequent use of gloves, the MCO nurse must give his or her approval.

Adaptive Aid Exclusions

The following are examples of items that may not be purchased using STAR+PLUS HCBS program funds. These items include, but are not limited to:

  • hot water heater;
  • combination heater, light and exhaust fan;
  • heating and cooling system filters;
  • non-adapted appliances, such as refrigerators, stoves, dryers, washing machines and vacuum cleaners;
  • water filtration systems;
  • central air conditioning and heating;
  • multiple air conditioning units to cover an individual's residence;
  • non-adapted home furnishings to include (except as allowed through Transition Assistance Services (TAS) or Supplemental Transition Support):
    • cooking utensils;
    • non-hospital bed mattresses and springs, including Adjustamatic, Craftmatic, Tempur-Pedic®, Posturepedic and Sleep Number® beds;
    • pillows (excluding neck pillows and support wedge pillows);
  • electrical heating elements (heating pads, electric blankets);
  • recreational items, equipment and supplies including:
    • bicycles and tricycles (2, 3 or 4 wheels);
    • helmets for recreational purposes;
    • trampolines;
    • swing sets;
    • bowling and fishing gear;
    • karaoke machines;
    • entertainment systems;
    • off-road recreational vehicles;
  • memberships to gyms, spas, health clubs or other exercise facilities;
  • communication items, including:
    • telephones (standard, cordless or cellular);
    • pagers;
    • pre-paid minute cards;
    • monthly service fees;
  • computers for the following justifications:
    • educational purposes;
    • self-improvement/employment purposes;
    • improvement of general computer skills;
    • internet and email access;
    • games and fun/craft activities;
  • office equipment and supplies to include:
    • fax machines;
    • printers/copiers;
    • scanners;
    • internet and email services;

Note: An individual accessing the Consumer Directed Services (CDS) option may purchase office equipment and supplies through the CDS budget.

  • gloves for universal precautions, or gloves that are used by MCO contracted provider, an adult foster care (AFC) provider or any contracted provider staff;
  • personal items for ADLs, such as hygiene products including soap, waterless soap, toothbrush, toothpaste, deodorant, powder, shampoo, lotions (except moisture barrier products), feminine products (except when documented for use as an incontinence supply), manual razors, washcloths, towels, bibs and first-aid supplies;
  • clothing items;
  • food;
  • bottled water (for drinking and cooking);
  • nutritional drinks and products, such as Carnation Instant Breakfast, V-8 Juice, Slim Fast, fruit juices, flavored water, vitamin enhanced water, nutrition and protein bars, breakfast cereals;
  • vitamins, minerals and herbal supplements and over-the-counter drugs;
  • title, license and registration for trailers or vehicles;
  • wheelchairs and scooters for the purpose of facilitating participation in recreational activities and sports;
  • vehicle repairs, as part of normal maintenance; repairs are part of normal vehicle maintenance and cannot be covered. Installation of heavy-duty shocks as required by a lift installation may be included as part of the vehicle modification. trailers (including taxes) for transporting wheelchairs or scooters;
  • experimental medical treatment and therapies, such as equestrian therapy; and
  • installation of gas or propane lines.

6420 Approval of Adaptive Aids and Medical Supplies

Revision 21-2; Effective August 1, 2021

In the initial pre-enrollment assessment and at reassessment, the managed care organization (MCO) service coordinator identifies the basic needs of the member for adaptive aids and STAR+PLUS Home and Community Based Services (HCBS) program medical supplies along with the estimated costs on Form H1700-1, Individual Service Plan. The MCO must provide documentation supporting the medical need for all adaptive aids and medical supplies. The documentation must be provided by the member's ordering, referring or prescribing provider. This can be a physician, physician assistant, nurse practitioner, registered nurse (RN), physical therapist, occupational therapist or speech pathologist. The service coordinator must use Form H1700-2, Individual Service Plan – Addendum, to document medical need and the rationale for purchasing the item(s).

Adaptive aids and medical supplies are approved for purchase as a STAR+PLUS HCBS program service by the MCO only if the documentation supports the requested item(s) as being necessary and related to the member's disability or medical condition.

The MCO determines if the documentation submitted is adequate, and makes the decision as to whether an adaptive aid or medical supply is needed and related to the member's condition. The MCO makes the final decision if the purchase is necessary and will be authorized on the individual service plan (ISP). The acute care benefit for any equipment or medical supplies must be expended before STAR+PLUS HCBS program benefits may be used.

If the member's request for a particular adaptive aid or medical supply is denied, the member must receive written notice of action of the denial of the specific item following the requirements outlined in the Uniform Managed Care Manual, Chapter 3.21.

If the member requests an item the MCO deems is not medically necessary or related to the member's disability or medical condition, the MCO must send a notice of action to the member.

For situations in which the member requests an adaptive aid or medical supply, and the item(s) are documented by the nurse or other medical professional to be medically necessary, the MCO has the option of approving the item(s). If not approved, the MCO must send a notice of action to the member.

The member may appeal the denial by filing an appeal with the MCO. The member does not receive the adaptive aid or medical supply unless the denial is reversed. If the denial is reversed, the item is added to the ISP. The cost of the item is reflected in the ISP in effect at the time of the appeal.

Service plans should be individualized to the member. All items must be related to the member's disability or medical condition and used to support or increase level of independence.

If the provider cannot deliver the adaptive aids by the appropriate time frames, the provider must notify the MCO via Form H2067-MC, Managed Care Programs Communication, and include the reasons the adaptive aid will be late. The MCO reviews the information to determine if the reason given for the delay is adequate or if additional intervention is necessary. It may be necessary for the MCO to discuss the reasons for the delayed delivery with the member and provider staff.

If the adaptive aid requested will not be delivered in the current ISP, the item must be transferred to the new ISP. If the authorization on the new ISP causes the ISP to exceed the annual cost limit, the nurse may authorize the service using the date the item was ordered by the provider as the date of service delivery and the provider may bill against the previous ISP.

6421 Lift Chair Approvals

Revision 21-2; Effective August 1, 2021

Lift chairs may be authorized as adaptive aids as part of the STAR+PLUS Home and Community Based Services (HCBS) program service array. Use the following procedures if attempting to purchase the lift chair using Medicare funding.

Once the managed care organization (MCO) determines a lift chair may be needed or is requested by the member, the MCO assesses the member to determine if the member meets all of the following criteria required for Medicare to pay for the lift mechanism:

  • The member must have severe arthritis of the hip or knee or have a severe neuromuscular disease.
  • The seat lift mechanism must be a part of the physician's course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the member's condition.
  • The member must be completely incapable of standing up from any chair in her or his home. Once standing, the member must have the ability to ambulate with or without assistance.

Member Does Not Meet All Criteria

If the member does not meet all of the Medicare criteria, the MCO completes Form H1700-2, Individual Service Plan – Addendum. The MCO should state the following on Form H1700-2, I. Medical Information, "Lift Chair: Plus Mechanism." Along with Form H1700-2, the MCO must obtain a:

  • prescription or statement signed by the physician certifying the need for the lift chair, specifically stating the member has difficulty or is incapable of getting up from a chair; and
  • statement by the physician or provider specifically stating that once standing, the member has the ability to ambulate or transfer with or without assistance.

The MCO approves the cost of the lift chair plus the mechanism if the request meets all criteria and the above documentation is received.

Member Meets All Criteria

If the MCO determines the member meets all of the criteria for Medicare to pay for the lift mechanism, the MCO:

  • approves the cost of the lift chair minus the mechanism;
  • authorizes the durable medical equipment provider to deliver the lift chair and bill Medicare for the mechanism; and
  • must document that Medicare is covering the mechanism.

If a request for a lift chair minus the mechanism is approved by the MCO, but the provider later requests additional funds for the mechanism denied by Medicare, the MCO may approve the request if it meets all STAR+PLUS HCBS program criteria. To avoid billing issues, the effective date of the change to add the funds for the lift mechanism must be the same as the effective date of the first change completed to approve the lift chair minus the mechanism.

6430 Effects of Changing MCOs on Adaptive Aids Procurements

Revision 18-2; Effective September 3, 2018

If a member changes to another managed care organization (MCO) while an adaptive aid is on order or in the process of being delivered, the MCO which authorized the service is responsible for payment and delivery of the adaptive aid.

6440 Temporary Lease and Equipment Rental

Revision 18-2; Effective September 3, 2018

Rental of equipment allows for repair, purchase or replacement of the equipment, or temporary usage of the equipment. The length of time for rental of equipment must be based on the individual circumstances of the member. If the medical professional and/or the member is not certain the medical equipment will be useful, the equipment should be rented for a trial or short-term period before purchasing the equipment.

The cost of renting equipment versus purchasing equipment may be explored, if you are currently renting the equipment. Rentals can be more cost-effective than direct purchase of an item. The expected duration of the use of equipment may be considered in the decision to rent or purchase. It may be more cost-effective, after renting for a period of time, to purchase the equipment instead of continuing to rent.

If the member prefers to buy the rented equipment, the managed care organization (MCO) must document the equipment functions properly and is appropriate for the member, so STAR+PLUS Home and Community Based Services (HCBS) program funds may be expended.

6450 Time Frames for Purchase and Delivery of Adaptive Aids and Medical Supplies

Revision 18-2; Effective September 3, 2018

 

6451 Time Frames for Adaptive Aids

Revision 18-2; Effective September 3, 2018

The managed care organization (MCO) must purchase and ensure delivery of any adaptive aid within 14 business days of being authorized (except for vehicle modifications) to purchase the adaptive aid, counting from either the effective date of the individual service plan (ISP) form or the date the form is received, whichever is later. If delivery is not possible in 14 business days, the MCO must document the reason for the delay.

The MCO must notify the member and document notification of any delay, with a new proposed date for delivery. The notification must be provided on or before the 14th business day following authorization. If the delivery does not occur by the new proposed date, the MCO must document any further delays, as well as document member notification, until the adaptive aids are delivered. The MCO must authorize a vehicle modification on the effective date of the member’s ISP. The MCO must work with the provider and member to ensure the vehicle modification takes place as expeditiously as possible.

6452 Time Frames for Medical Supplies

Revision 18-2; Effective September 3, 2018

Medical supplies are expected to be delivered to the member within five business days after the member begins to receive STAR+PLUS Home and Community Based Service (HCBS) program services. The provider must deliver medical supplies within five business days from the start date on the individual service plan (ISP). The member’s current supply of these items should be considered. For example, if the member has a supply of diapers that is expected to last for one month, the diapers authorized on the ISP do not need to be delivered immediately.

If the provider cannot ensure delivery of a medical supply within five business days due to unusual or special supply needs or availability, the provider must submit Form H2067-MC, Managed Care Programs Communication, to the managed care organization (MCO) before the fifth day explaining why the medical supply cannot be delivered within the required time frame and including a new proposed date for the delivery.

If there is an existing supply of medical supplies on the service initiation date, the MCO must write "existing supply of needed medical supplies on hand" in the progress notes as verification that supplies were available to the member and did not require delivery at this time.

Stockpiling of medical supplies must not occur. Supplies, such as incontinence and wound care supplies not covered through Medicaid Home Health and needed on an ongoing basis, should be delivered so there is no more than a three-month supply in the member's home at a time.

6460 Co-Insurance and Deductibles

Revision 21-2; Effective August 1, 2021

Reimbursement for the cost of co-insurance for the purchase or rental of adaptive aids or the purchase of medical supplies reimbursed by Medicare or private health insurance is available if the following conditions are met:

  • the member does not have coverage under the Qualified Medicare Beneficiary (QMB) or the Medicaid Qualified Medicare Beneficiary (MQMB) programs;
  • the adaptive aid or medical supply is listed in the service definition of this handbook or has been prior authorized by managed care organization (MCO) management; and
  • documentation submitted supports the necessity of the item(s) for the individual's disability or medical condition.

Reimbursement for the co-insurance amount to Medicare or private health insurance for therapy services or the rental of any adaptive aids is a cost-effective way to utilize third-party resources (TPRs). The cost of any co-insurance payment must be billed under adaptive aids.

For instances in which a member is not covered under the QMB or MQMB programs and cannot pay her or his premium deductible under a TPR for items covered under the STAR+PLUS Home and Community Based Services (HCBS) program, the deductible can be listed under adaptive aids on Form H1700-1, Individual Service Plan, for payment.

6470 Bulk Purchase of Medical Supplies

Revision 18-2; Effective September 3, 2018

The managed care organization (MCO) may choose to buy medical supplies in bulk. The cost of storing supplies can be reported on the annual cost report as an allowable expense. The medical supply is billed at the unit rate based on the invoice cost of the bulk purchase divided by the number of units purchased.