1915(c) Children's Waiver: Environmental Modifications, Vehicle Modifications and Assistive Technology

  • Waiver is also available in Portable Document Format

June 2019

Overview of Today´s Discussion on E–Mods, V–Mods and AT

  • Today´s webinar will review the overall process and role of the Local Departments of Social Services (LDSS) in service authorization and provisioning process for implementing Environmental Modifications (E–Mods), Vehicle Modifications (V– Mods) and Assistive Technology (AT).
  • The process we will review today includes new elements to take into account many LDSS concerns raised during NYS Department of Health (NYSDOH)/LDSS bi–weekly CFCO meetings and the NYPWA and White Eagle Conferences regarding their role and responsibilities with respect to E–Mods, V–Mods and AT.
    • In response to LDSS concerns around the use of Schedule E, including cash flow implications and other issues related to LDSS upfronting costs with subsequent reimbursement the State has implemented two payment options: 1) the Special Project Fund Advance process and 2) MMIS provider ID approach.
    • In response to LDSS concerns around the authorization and bidding process for E–Mod, V–Mod, and AT, the Department has made new changes to the approval processes.
  • The role of the LDSS described in today´s Webinar and the April 1, 2019, Administrative Directive (ADM) now under final review at the NYSDOH, applies to all children eligible for E–Mods, V–Mods and/or AT in the Children´s 1915(c) Waiver.
  • Many of the processes are similar to those that were employed in the predecessor Care at Home Waiver for E–Mods and V–Mods.
    • Almost all of the counties have experience in arranging for such services under the Care At Home Waiver.
  • Effective October 1, 2019, E–Mods, V–Mods, and AT will become part of the Managed Care Benefit package. Children enrolled in plan will work with the plan (not the LDSS) to arrange for these services.
  • These processes will remain in effect when E–Mods, V–Mods, and AT are implemented under Community First Choice Option, effective January 1, 2020.
  • The Department is continuing to work on streamlining the contracting process, but for now LDSS will need to be engaged in this process.
  • Note: Any AT, E–Mod and/or V–Mod approval process that began prior to April 1, 2019will continue to be processed and paid under procedures in place prior to April 1, 2019. Work to initiate the provision of services which began prior to April 1, 2019 should not be stopped or delayed due to the implementation of the new Consolidated Children´s Waiver on April 1, 2019.

Agenda

  • The steps necessary for the LDSS to approve all E–Mods, V–Mods and AT requests for children receiving 1915(c) waiver services
  • The LDSS authorization process for E–Mods, V–Mods and AT
  • Initiating a service request
  • Payment options
  • E–Mod, V–Mod and AT service definitions

Administrative Directive (ADM) for Authorization and Implementation of Services

  • The April 1, 2019, ADM is now under review at NYSDOH and the draft will be posted shortly.
  • Provides information to the LDSSs so they may authorize and pay for AT, E–Mods and V–Mods provided through the 1915(c) Children´s Waiver.
  • Additionally, service authorization guidelines are appended to the ADM to explain each service and related procedures.

Care Manager/C–YES Coordinator

  • Children and youth who are enrolled in the Children´s Waiver and are getting Home and Community Based Services (HCBS) need to have care management.
  • Health Homes will provide comprehensive care management services for children and youth getting Home and Community Based Services (HCBS).
  • If a child/youth and their family do not want Health Home care management and opt–out, they must get HCBS care management from the Children and Youth Evaluation Service (C–YES).
  • Effective April 1, 2019, 1915(c) Children´s Waiver provides children and youth an expanded array of Home and Community Based Services inclusive of E–Mods, V– Mods and AT.
  • Health Home care managers and C–YES Coordinators assess whether the child/youth is eligible for the Children´s Waiver and then develop a person– centered Plan of Care (POC) that would outline the needs for E–Mods, V–Mods or AT.
  • The role of the Health Home care manager and C–YES Coordinator is to assist with the coordination of HCBS with the child/youth and family.
  • The LDSS should assist the care managers and C–YES coordinators to arrange E–Mods, V–Mods and AT identified in the POC.

Care Manager/C–YES Coordinator Roles and Responsibilities for Authorization of These Services

The Care Manager/C–YES Coordinator will:

  • Identify a specific assessed need for E–Mod, V–Mod or AT services and indicate the presented need in the child´s person–centered POC.
  • Secure a physician´s order/statement supporting the need for service/device/adaptation.
  • Assist the child/family to secure a clinical justification from the appropriate clinician (e.g., Occupational Therapist, Speech Language Therapist, Driver Rehabilitation Specialist, Behavioral Health Specialist or other licensed professional).
  • Explore potential payment sources including private insurance, community resources and other local/State/federal programs prior to requesting the Medicaid service.
  • Collaborate with the family and LDSS in securing bids. The LDSS should help wherever possible. However, the ultimate responsibility for obtaining bids lies with the Care Manager/C– YES Coordinator.
  • Submit all necessary documentation to the LDSS (see slide: "What the Care Manager will send to the LDSS").

How the Authorization Process Works: Part 1

Health Home Care Manager OR C–YES Coordinator

  1. Identified Need (AT/E–Mod/V–Mod)
  2. Physician´s Order
  3. Plan of Care
  4. Clinical Justification
  5. Collect Bids

Assemble the Request for Service packet to send to the LDSS for review

Process Details

  • The POC provides an initial justification that the child can benefit from the service/adaptation/technology. The POC will establish that the service is necessary to assist and enhance the child´s independence in performing ADLs, IADLs, and/or health– related tasks and/or will substitute for human assistance.
  • The physician´s order supports the initial justification and request for service. This may be an approved request for home care form such as the M11Q used by HRA or Form 4539 or a letter on physician´s letterhead stating the need for the service.
  • The clinical justification must be from the appropriate clinician (e.g., Occupational/Physical Therapist, Home Evaluation Specialist, Driver Rehabilitation Specialist, Universal Design/Accessibility Specialist, Behavioral Health Specialist or other licensed professional). The justification should define the scope and appropriateness of the project. (Note: all other resources must be exhausted before seeking this service and should be documented in the request.)

Securing The Bids

Securing bids will be a collaborative effort between the family, LDSS and the Care Manager or C–YES Coordinator. The LDSS may assist in obtaining bids, if necessary.

  • Bids should be based on the specifications delineated in the evaluation/clinical assessment/project description.
  • The contractor must adhere to the following requirements when preparing a bid and completing the project:
    • Base the bid on contractor grade materials;
    • Stipulate that all work will comply with applicable building and zoning codes;
    • Obtain the local municipality´s permit to perform the adaptation;
    • Provide verification that the work has been inspected by the local municipal branch of government that issued the initial permit; and
    • Submit verification that appropriate and adequate insurance coverage is maintained.
  • All estimates should identify the costs of each component of the project e.g. inspections, materials, permits and labor costs.
  • The Care Manager/C–YES Coordinator will send all evaluations and bids to the LDSS for review and approval.
  • The LDSS will identify the preferred bid and execute a provider agreement.

What the Care Manager will send to the LDSS

The Care Manager/C–YES Coordinator will send a Request for Service packet for submission to the LDSS. This packet must include:

  • POC which identifies assessed need
  • Physician´s order supporting medical necessity (signed and dated)
  • Professional assessment/clinical justification identifying the scope of the project and documentation detailing project/product specifications including scope, estimated material and labor costs and other required expenditures
  • Bids: if the AT, E–Mod or V–Mod request costs $1,000 or more, 3 bids or justification for why 3 bids could not be secured is required
  • Any required documentation that is needed for the modification/service/adaptation/device such as landlord´s permission if the home is leased or proof that a used car is less than 5 years old/less than 50,000 miles for a V–Mod (all requirements are included in the Authorizing Guidelines)
  • Completed Description and Cost Projection Form

The LDSS may request additional information necessary to consider the request

Note: The process for approval and authorization of these services mirrors the CAH protocols.

How the Authorization Process Works: Part 2

How the Authorization Process Works: Part 2

Authorization Details

  • The LDSS is responsible for evaluating the bids and selecting the preferred vendor to provide the service/adaptation/technology. This decision is based on an assessment of whether the lowest responsible bid meets the assessed need of the child.
  • The LDSS will contact the selected vendor and secure a provider agreement so that the service request may proceed upon approval by NYSDOH.
  • The LDSS collects all of the documents and submits the service request to NYSDOH for review.

What the LDSS will send to NYSDOH

The LDSS will submit the following information to the NYSDOH:

  • POC
  • Physician´s order
  • Professional assessment/clinical justification identifying the scope of the project and supporting documentation detailing project/product specifications including scope, estimated material and labor costs and other required expenditures
  • Bids, with the recommended bid identified
  • Provider agreement from the selected bidder
  • Any required documentation that is needed for the modification/service/adaptation/device such as landlord´s permission if the home is leased or proof that a used car is less than 5 years old/less than 50,000 miles for a V–Mod (all requirements are included in the Authorizing Guidelines)
  • Completed Description and Cost Projection Form
  • Justification for the need to exceed soft service limits, if applicable
    Note: The Department may request additional documentation and information as needed.
  • The LDSS will not submit a request to the NYSDOH if it does not support the request.

NYSDOH Review

NYSDOH will:

  • Acknowledge receipt of the request from the LDSS
  • Internally track all requests
  • Review the content of the service request for completeness, accuracy and cost

What NYSDOH Provides to the LDSS

  • Approval determinations are made based on all information available at the time the service is requested. NYSDOH may request additional documentation and information as needed.
  • Upon review of the information provided, the NYSDOH will send a letter of support/denial of the project to the LDSS.
  • Upon receipt of the letter of support/denial, the LDSS will issue the Notice of Decision (NOD) to the child/family and the Care Manager/C–YES Coordinator.
    • If the NOD is for approval, the selected vendor will be notified and work will begin.

Note: All NODs are subject to Fair Hearing when requested, this process is explained to the waiver participant/family via their Care Manager/C–YES Coordinator.

How the Authorization Process Works: Part 3

How the Authorization Process Works: Part 3

LDSS Authorization Process

  • A NOD is a written document that notifies the individual of an action being taken by the LDSS, including an explanation of the reasons for the action.
  • Upon making a determination about a request for services and receiving prior approval from NYSDOH to exceed the soft limit, if applicable, the LDSS is responsible for sending a written NOD indicating authorization, denial or a reduction of the requested service to the individual, legal guardian (if applicable), authorized representative (if applicable) and the individual´s Care Manager or C– YES Coordinator.
  • NODs denying or reducing services must also include information regarding Fair Hearing rights and how to apply for a Fair Hearing.
  • The form used is: Notice of Decision to Authorize or Deny Assistive Technology, Environmental Modifications, Vehicle Modifications, Community Transitional Services and Moving Assistance.

Authorization Process

  • The Care Manager/C–YES Coordinator advises the family of the decision and discusses the next step in beginning the project, including the scope of the project and anticipated timelines.
  • The Care Manager/C–YES Coordinator works with the family and the selected vendor to initiate the project/request, including reviewing the bid and the terms of the project with the vendor.
  • The provider/vendor will be responsible for the coordination of the project with the LDSS and will provide detailed information regarding expenditures, compliance requirements and project timelines.

How the Authorization Process Works: Part 4

How the Authorization Process Works: Part 4

Completion of the Project

  • Upon completion of the services, the Care Manager/C–YES Coordinator will complete the Final Cost Form and submit it to the LDSS.
  • The form will include a description of the completed service and the final cost.
    • The LDSS must maintain the form in the child´s case file and send a copy to NYSDOH.
  • The LDSS will review the submitted form and validate the completion of the specification of the bid/purchase.
  • Once validated, the LDSS will notify the provider that they may submit a claim for payment/invoice to the LDSS.

Service Limits

  • Service limits are as follows:
    • Assistive Technology – $15,000 annual calendar year limit
    • Environmental Modification – $15,000 annual calendar year limit
    • Vehicle Modification – $15,000 annual calendar year limit
  • In all cases, service limits are soft limits that may be exceeded due to medical necessity. If the individual´s needs cannot be met within the established limits, the LDSS may request to exceed the limit by proving sufficient medical justification. This justification must be submitted to NYSDOH along with the request for service packet in order to obtain approval of the request.

Payment for AT, E–Mods and V–Mods

Due to feedback from the LDSSs, NYSDOH recognizes that implementation of these services requires significant time, resources and funding. NYSDOH continues to seek alternative methods to facilitate the provision of these services and reduce the burden to the LDSS including exploring other payment mechanisms and service providers.

Current payment options:

  • Option 1: Special Project Fund Advance Requests
  • Option 2: Provider Medicaid Management Information System (MMIS)

Note: Projects currently in progress for CAH participants that were previously approved by NYSDOH continue using CAH guidelines. These projects may be billed using Schedule E payment requests.

Option 1: Special Project Fund Advance

  • LDSS will be able to request advances to cover the full cost of these projects, including assessments/evaluations, to ensure the efficacy of the modification/ purchase.
  • Upon approval by NYSDOH, a check will be sent to the County Treasurer from the New York State Office of Temporary and Disability Assistance (OTDA).
  • Requests will be processed monthly.
  • LDSS may distribute the advances as needed. For example, the LDSS could advance separate payments for assessment/evaluation, initial payment to contractor to cover materials, weekly payments to cover labor, and a final payment after the project passes inspection and the individual/family indicates satisfaction. Alternatively, the LDSS could pass the entire advance to a contracted rehabilitation specialist/general contractor working under a separate provider agreement.

For the Children´s Waiver (4/1/19 – 12/31/19), the LDSS can use the Special Voucher Project for upfront distribution of funds.

  • The Description and Cost Projection Form will be used to request special project fund advances for the AT, E–MOD, or V–MOD. This form contains everything needed to initiate authorization of requested projects/purchases.
  • Billing related to these Children´s Waiver services must be separately identified and requested with OTDA using the RF–17 claim package for special project claiming, and the Schedule D DSS "Administrative Expenses Allocation and Distribution by Function and Program" (LDSS–2347).
  • Further instructions for completing the Schedule D and RF–17 claim package can be found in Chapters 7 and 18, respectively, of the Fiscal Reference Manual (FRM) Volume 3. The FRMs are available online at http://otda.state.nyenet/bfdm/finance/.
  • The Final Cost Form will be used to reconcile advances with total project/purchase costs.

Option 2: Provider MMIS

  • An LDSS may choose to bill eMedNY directly by securing a provider MMIS number.
  • NYSDOH has made arrangements to waive the eMedNY application fee.
  • Instructions for the submission of the eMedNY application will be discussed in a separate webinar dedicated to payment procedures.

What are Environmental Modifications?

  • Environmental Modifications (E–Mods) are internal and external physical adaptations made to the home or other eligible residences of the child.
  • Per the child´s approved POC, E–Mods are identified as necessary to support the health, welfare and safety of the child and/or enables the child to function with greater independence in the home and without which the child would require institutional and/or a more restrictive living setting.
  • The scope of E–Mods also includes the necessary assessments to determine the types of modifications needed.

Examples of Environmental Modifications

Modifications include, but are not limited to:

  • Installation of ramps, hand rails and grab–bars;
  • Widening of doorways;
  • Modifications of bathroom facilities;
  • Installation of specialized electric and plumbing systems that are necessary to accommodate the medical equipment and supplies needed for the welfare of the child;
  • Lifts and related equipment;
  • Modifications of the kitchen necessary for the child to function more independently in their home; and
  • Bed shaker alarm devices, strobe light smoke detection and alarm devices.

E–Mod: Exclusions

  • Adaptations or improvements to the home that are of general utility, and are not of direct medical or remedial benefit to the individual;
  • Adaptations that exceed the necessity of the service (e.g. roll–in showers or accessible tubs will not be provided if a shower chair will do); and
  • Adaptations that add to the total square footage of the home.

E–Mods: Limitations

  • Leased housing requirements/limitations for E–Mods:
    • Property owner sign–off on the modification.
    • No E–Mod may be completed on public spaces which are covered by the Americans with Disabilities Act (ADA). Spaces that are accessible to the general public cannot be modified using these resources.
  • Repair and replacement of modification:
    • In the majority of situations, E–Mods are considered a one–time benefit.
    • In reasonable circumstances determined and approved by the NYSDOH, a second modification may be considered for funding as follows:
      • If the child moves to another home;
      • If the current modifications are in need of repair, worn–out or unsafe; or
      • If the child wishes to spend considerable time with a non–cohabitating parent in their home and such modifications are required to ensure health and safety during these periods.

What are Vehicle Modifications?

  • Vehicle Modifications (V–Mods) are modifications made to a vehicle to accommodate the child. The vehicle modified must be the primary means of transportation for the child. As established in the child´s approved POC, V–Mods are made to a vehicle to enhance the child´s independence and inclusion in the community and substitute for human assistance.
  • The scope of V–Mods also includes the necessary assessments to determine the types of modifications needed.
  • Assessment activities include, but are not limited to:
    • Determining the need for the service;
    • Evaluating the safety of the proposed modification;
    • Considering the expected benefit to the child; and
    • Deciding the most cost–effective approach to fulfill the child´s need.

Examples of V–Mods

Examples of V–Mods include, but are not limited to:

  • Installation of wheelchair ramps;
  • Portable electric/hydraulic and manual lifts;
  • Wheelchair lock downs;
  • Repositioning of seats;
  • Wheelchair floor;
  • Foot controls;
  • Deep dish steering wheel;
  • Hand controls;
  • Parking break extension; and
  • Other ancillary equipment or modifications necessary to guarantee full access to, and safety in, a motor vehicle.

V–Mods: Exclusions

  • All equipment and technology used for entertainment is prohibited.
  • Costs may not exceed current market value of the vehicle.
  • Other exclusions include:
    • The purchase, installation or maintenance of items such as cellular phones, global positioning/tracking devices, or other mobile communication devices;
    • Repair or replacement of modified equipment damaged or destroyed in an accident;
    • Alarm systems;
    • Auto loan payments, insurance coverage; and
    • Costs related to obtaining a driver´s license, title/registration, license plates, emergency road service, or rental vehicles when a vehicle modification is in process.

V–Mods: Limitations

  • V–Mods are limited to the vehicle that is the primary means of transportation for the child. The vehicle may be owned by the child, family member or non–relative who provides primary, consistent and ongoing transportation for the child.
  • Repair and replacement of modification:
    • In most instances, a specific type of V–Mod is a one–time benefit to the motor vehicle used by the child. However, in reasonable circumstances determined and approved by NYSDOH, a second modification may be considered for funding if the current modifications are in need of repair, worn–out or unsafe.

Mods: Limitations for Used Vehicles

The modification of a used vehicle or the cost of modifications in a used vehicle will only be considered if the vehicle meets the following additional criteria:

  • The vehicle must pass New York State inspection, and be registered and insured for liability, comprehensive and collision;
  • The vehicle must be structurally sound, without need of mechanical repairs, and able to support/accommodate the needed adaptation;
  • The vehicle must not have any rust or deficiencies in the areas to be modified or in the areas already modified; and
  • The vehicle must be less than 5 years old or register less than 50,000 miles on the vehicle´s odometer.

What is Assistive Technology?

  • Assistive Technology (AT) provides technological aids and devices identified within the child´s POC which enable the child to accomplish daily living tasks that are necessary to support the child´s health, welfare and safety.

Examples of AT

AT includes, but is not limited to:

  • Direct selection communicators;
  • Alphanumeric communicators;
  • Scanning communicators;
  • Speech amplifiers;
  • Adaptive switches/devices;
  • Electronic speech aids/devices, voice activated, light activated, motion activated and electronic devices; and
  • Therapeutic equipment, not identified as Durable Medical Equipment (DME), for the purpose of maintaining or improving the participant´s strength, mobility or flexibility to perform activities of daily living.

What Else Does AT Include?

AT services include:

  • The evaluation of the AT needs of a participant, including a functional evaluation of the impact of the provision of appropriate AT and appropriate services to the participant in the customary environment of the participant;
  • Services consisting of purchasing, leasing or otherwise providing for the acquisition of AT devices for the participant;
  • Services consisting of selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing or replacing AT devices;
  • Training or technical assistance for the participant, or, where appropriate, the family members, guardians, advocates or authorized representatives of the participant; and
  • Training or technical assistance for professionals or other individuals who provide services to, employ, or are otherwise substantially involved in the major life functions of participants.

AT: Limitations and Exclusions

  • AT available through the authority of the 1915(c) Children´s Waiver cannot duplicate equipment otherwise available through the Medicaid State Plan or other federal/state funding streams. AT must be beyond the scope of DME.
  • A particular item of AT is generally expected to be a one–time only purchase. Replacements, repairs, upgrades or enhancements made to existing equipment will only be paid if documented as a medical necessity and approved by the NYSDOH or its designee. Ongoing monitoring associated with telecare support services or other approved systems authorized under this definition may be provided if necessary for the health and safety of the child and documented to the satisfaction of the NYSDOH or its designee.
  • Warranties, repairs or maintenance on AT may only be approved when they are the most cost–effective and efficient means to meet the need, and are not available through the Medicaid State Plan.

How to Send Request for Service Packets to NYSDOH

Requests for services, including associated documents, should be sent to NYSDOH using one of the secure options below:

Mail Fax Health Commerce System (HCS)
Attn: CFCO-Children´s Approval Unit
NYS DOH/OHIP
Division of Long Term Care
One Commerce Plaza, 16th Floor
99 Washington Avenue
Albany NY, 12210		 1–518–408–6045 We are creating a mailbox for purposes of receipt of service requests. The address will be distributed shortly.

Health Commerce System (HCS) Enrollment Process

  • HCS enrollment for electronic submission
    • Paperless HCS user account
    • Go to https://commerce.health.state.ny.us
    • Click Create an HCS Account
    • Click No for I am not a medical professional
    • Click Registerfor an account
    • Fill out all required information and print your confirmation.
    • See your HCS Coordinator with your account registration completion email printout and your Photo ID. S/he will finalize your registration.

Footnote:

  • As of April 1, 2019, participants of these waivers have been transitioned into the Consolidated1915(c) Children´s Waiver
    • OMH SED HCBS 1915(c) waiver
    • DOH Care at Home (CAH) I/II 1915(c) waiver
    • OPWDD Care at Home (CAH) 1915(c) waiver
    • OCFS Bridges to Health (B2H) SED 1915(c) waiver
    • OCFS B2H Medically Fragile (Med Frag) 1915(c) waiver
    • OCFS B2H DD 1915(c) waiver

Contact us:

We are creating a mailbox for purposes of receipt of service requests. The address will be distributed shortly.