4/1/19 Kids Waiver for LDSS
The Authorization of Environmental Modification, Vehicle Modification, and Assistive Technology in Fee–for–Service Medicaid
Local Department of Social Services Responsibilities
March 13, 2019
Purpose
- Update the policies and procedures regarding the approval and payment by Medicaid for Environmental Modifications (E–Mods), Vehicle Modifications (V– Mods) and Assistive Technology (AT).
- Beginning April 1, 2019, the Local Department of Social Services (LDSS) will authorize E–Mods, V–Mods, and AT for children enrolled in the 1915(c) Children´s waiver.
- Beginning July 1, 2019, the LDSS will also authorize E–Mods, V–Mods, and AT for individuals eligible for Community First Choice Option (CFCO).
Background
- E–Mods, V–Mods, and AT are currently only available in a number of 1915(c) waivers, with the exception of E–Mods which may be accessed through the Managed Long Term Care benefit.
- These services are Home and Community Based Services (HCBS) that are typically provided by contractors or providers typically not enrolled in the Medicaid program. Accordingly, they have no direct pathway to Medicaid reimbursement.
- The Department is issuing an Administrative Directive (ADM) shortly, effective April 1, 2019, that will fully detail the authorization and payment process for E– Mods, V–Mods and AT.
Environmental Modification
- Environmental Modifications (E–Mods) are internal and external physical modifications to the home, which are necessary to assure the health, welfare, and safety of the individual, enable the individual to function with greater independence in the home, and prevent institutionalization.
- Examples:
- Grab bars in the tub or shower stall
- Ramps for ingress and egress
- Wider doors to accommodate wheelchairs
- Cabinet modifications
- Stair lifts
- Hoyer lifts
- Vehicle Modifications (V–Mods) are modifications made to a vehicle that are intended to enhance the individual´s independence and inclusion in the community, and substitute for human assistance, to the extent that expenditures would otherwise be made for human assistance.
- Examples:
- Hand or foot controls
- Wheelchair lock–down
- Lifts
- Deep dish steering wheel
- Repositioned seats
- Dashboard adaptions
Assistive Technology
- Assistive Technology (AT) is defined as an item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or to improve the functional capabilities of the child, and/or enhance the child´s independence in performing activities of daily living (ADLs). AT is not Durable Medical Equipment (DME) under the Medicaid State Plan.
- Examples:
- Augmentative and alternative communication devices (not included under DME in the Medicaid State Plan)
- Stand–up recliner to allow someone to get up and sit down on their own
- Self–leveling utensils to allow someone to feed himself
- Lights that flash when the doorbell or phone rings to alert someone who is deaf
Common Elements of AT, E/V–Mod Auth.
- All projects/devices/modifications must be specified in the Person Center Plan of Care based on a functional need identified in the individual´s assessment to address an ADL, IADL or health–related task need;
- Each project/device/modification requires an independent evaluation by a clinician, contractor or other person with experience in how the proposed remediation will help the individual meet his or her identified needs, goals, and interests to remain in the community.
- Each type of service requires the LDSS to make reasonable efforts to get three bids for all projects/purchases over $1,000. The LDSS must award a contract to the lowest responsible bidder following the authorization guidelines as well as State and local contracting/procurement rules.
- Each type of service has a $15,000 per year cost limit that may be exceeded for medical necessity with prior DOH approval.
Recipient Restriction/ Exemption Codes
- K1: HCBS Level of Care
- K2: HCBS Level of Need
- K3: HCBS Diagnostic Group – Serious Emotional Disturbance
- K4: HCBS Diagnostic Group – Medically Fragile
- K5: HCBS Diagnostic Group –Developmentally Disabled
- K6: HCBS Diagnostic Group –Developmentally Disabled Medically Fragile
- K7: HCBS Diagnostic Group –Complex Trauma
- K8: Voluntary Foster Care Agency
- K9: Foster Care
- KK: Family of One
| HCBS Service Authorization | ||||||
|---|---|---|---|---|---|---|
| FFS Population | RR/E | Effective | CFCO Eligible? | Authorizing Entity / Authorizing Authority AT | Authorizing Entity / Authorizing Authority E–Mods | Authorizing Entity / Authorizing Authority V–Mods |
| 1915 (c) Children´s Waiver HCBS Developmentally Disabled & Medically Fragile and FFS | K6 | 4/1/2019 | N/A | DDRO 1915 (c) Children´s Waiver |
DDRO 1915 (c) Children´s Waiver |
DDRO 1915 (c) Children´s Waiver |
| 7/1/2019 | Y | LDSS CFCO State Plan |
LDSS CFCO State Plan |
LDSS CFCO State Plan |
||
| N | LDSS 1915 (c) Children´s Waiver |
LDSS 1915 (c) Children´s Waiver |
LDSS 1915 (c) Children´s Waiver |
|||
| 10/1/2019 | Y | LDSS CFCO State Plan |
LDSS CFCO State Plan |
LDSS CFCO State Plan |
||
| N | LDSS 1915 (c) Children´s Waiver |
LDSS 1915 (c) Children´s Waiver |
LDSS 1915 (c) Children´s Waiver |
|||
| 1915 (c) Children´s Waiver HCBS Developmentally Disabled & Medically Fragile and Enrolled in MMC | K6 | 4/1/2019 | N/A | DDRO 1915 (c) Children´s Waiver |
DDRO 1915 (c) Children´s Waiver |
DDRO 1915 (c) Children´s Waiver |
| 7/1/2019 | Y | MMC CFCO State Plan |
MMC CFCO State Plan |
MMC CFCO State Plan |
||
| N | LDSS 1915 (c) Children´s Waiver |
LDSS 1915 (c) Children´s Waiver |
LDSS 1915 (c) Children´s Waiver |
|||
| 10/1/2019 | Y | MMC CFCO State Plan |
MMC CFCO State Plan |
MMC CFCO State Plan |
||
| N | MMC 1915 (c) Children´s Waiver |
MMC 1915 (c) Children´s Waiver |
MMC 1915 (c) Children´s Waiver |
|||
| 1915 (c) Children´s Waiver HCBS Serious Emotional Disturbance, or HCBS Medical Fragility, or HCBS DD Foster Care, and FFS | K3, K4 or K5 |
4/1/2019 | N/A | LDSS 1915 (c) Children´s Waiver |
LDSS 1915 (c) Children´s Waiver |
LDSS 1915 (c) Children´s Waiver |
| 7/1/2019 | Y | LDSS CFCO State Plan |
LDSS CFCO State Plan |
LDSS CFCO State Plan |
||
| N | LDSS 1915 (c) Children´s Waiver |
LDSS 1915 (c) Children´s Waiver |
LDSS 1915 (c) Children´s Waiver |
|||
| 10/1/2019 | Y | LDSS CFCO State Plan |
LDSS CFCO State Plan |
LDSS CFCO State Plan |
||
| N | LDSS 1915 (c) Children´s Waiver |
LDSS 1915 (c) Children´s Waiver |
LDSS 1915 (c) Children´s Waiver |
|||
| 1915 (c) Children´s Waiver HCBS Serious Emotional Disturbance, or HCBS Medical Fragility, or HCBS DD Foster Care, and FFS | K3, K4 or K5 |
4/1/2019 | N/A | LDSS 1915 (c) Children´s Waiver |
LDSS 1915 (c) Children´s Waiver |
LDSS 1915 (c) Children´s Waiver |
| 7/1/2019 | Y | MMC CFCO State Plan |
MMC CFCO State Plan |
MMC CFCO State Plan |
||
| N | LDSS 1915 (c) Children´s Waiver |
LDSS 1915 (c) Children´s Waiver |
LDSS 1915 (c) Children´s Waiver |
|||
| 10/1/2019 | Y | MMC CFCO State Plan |
MMC CFCO State Plan |
MMC CFCO State Plan |
||
| N | MMC 1915 (c) Children´s Waiver |
MMC 1915 (c) Children´s Waiver |
MMC 1915 (c) Children´s Waiver |
|||
Payment
- The Department has developed a mechanism to ensure that the LDSS will not be burdened with the need to advance funds to pay for these services prior to Medicaid reimbursement.
- The DOH is working out the details including development of a form to appropriately request and report spending.
- We anticipate this option will be available before the LDSS must authorize any of these services.
- The DOH continues work on the development of a centralized authorization process.
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