An official State of Texas website.
Revision 21-2; Effective March 10, 2021
Adaptive aids and medical supplies are specialized medical equipment and supplies, including devices, controls or appliances that enable members to increase their ability to perform activities of daily living (ADLs) or to perceive, control or communicate with the environment in which the member lives. 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 the individual a safe alternative to nursing facility (NF) placement.
Adaptive aids and medical supplies may also include items necessary for life support, ancillary supplies and equipment necessary for 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 (FSR).
Texas Health and Human Services Commission (HHSC) 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.
8410 List of Adaptive Aids and Medical Supplies
Revision 21-2; Effective March 10, 2021
Adaptive aids and medical supplies are covered by the STAR+PLUS Home and Community Based Services (HCBS) program only after the member has exhausted Texas state plan benefits and any third-party resources (TPRs) including product warranties, Medicare and Medicaid 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, the 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 or 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 or 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;
- augmentative communication devices:
- 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 durable medical equipment (DME) 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 TPR, if not covered under the Qualified Medicare Beneficiary (QMB) or the Medicaid Qualified Medicare Beneficiary (MQMB) 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;
- medically necessary 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 Texas 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; and
- 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 or 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 or ventilator care; and
- catheterization.
- assistive devices:
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 medically necessary);
- 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 or stockings, such as thromboembolic disease hose; and
- approved enemas, if not available through the state plan or other TPR.
Other
Necessary items related to hospital beds could include electric controls, manual cranks or other items related to the use of the bed. Medicare or 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 through 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 (two, three or four 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 or 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 activities of daily living (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 incontinent 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.
8420 Reserved for Future Use
Revision 22-3; Effective Sept. 27, 2022
8430 Reserved for Future Use
Revision 22-3; Effective Sept. 27, 2022
8440 Reserved for Future Use
Revision 22-3; Effective Sept. 27, 2022
8450 Time Frames for Purchase and Delivery of Adaptive Aids and Medical Supplies
Revision 21-2; Effective March 10, 2021
8451 Time Frames for Adaptive Aids
Revision 21-2; Effective March 10, 2021
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) on Form H1700-1, Individual Service Plan (Pg. 1), or the date the form is received, whichever is later. If delivery is not possible in 14 business days, the MCO will upload Form H2067-MC, Managed Care Programs Communication, to TxMedCentral in the MCO ISP folder, following the instructions in Appendix XXXIV, STAR+PLUS TxMedCentral Naming Conventions, documenting 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 coordinate with the provider and member to ensure the vehicle modification takes place as expeditiously as possible.
8452 Time Frames for Medical Supplies
Revision 21-2; Effective March 10, 2021
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 Services (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 business 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 one time.