GUIDELINES FOR AUTHORIZING ENVIRONMENTAL MODIFICATIONS

These guidelines outline the process for authorizing environmental modifications (E–Mods) under Community First Choice Option (CFCO) as a covered State Plan service. E–Mods are internal and external physical adaptations 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. E– Mods must be related to an assessed Activity of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), or health–related need and be tied to a goal reflected in the individual´s written person–centered Plan of Care (POC). E–Mods are intended to increase an individual´s independence or substitute for human assistance, to the extent that expenditures would otherwise be made for human assistance.

The scope of home accessibility modifications may include the performance of necessary assessments to determine the types of modifications that are necessary. Provider–owned or leased homes are not eligible for E–Mods.

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

  • Ramps
  • Lifts that require modifications to the home: hydraulic, manual or electric
  • Widened doorways
  • Roll–in showers and/or accessible tubs
  • Cabinet and shelving adaptations
  • Installation of hand rails, grab bars
  • Automatic or manual door openers and doorbells
  • Water faucet controls
  • Electrical and plumbing accommodations for new equipment

E–Mods may only be provided where the individual lives. E–Mods cannot cover home improvements such as central air conditioning, new carpet, roof repair, etc. that are unrelated to the individual´s POC. All materials must be construction grade.

Agreements for E–Mods may not exceed $15,000 per year without prior approval from the New York State Department of Health. The Department of Health may delegate this responsibility to Medicaid managed care plans for their enrollees. The Local Departments of Social Services (LDSS) or the Developmental Disability Regional Office (DDRO) must contact the Department of Health to obtain this approval. In all cases, service limits are soft limits that may be exceeded due to medical necessity.

Providers of Environmental Modifications

All E–Mod providers must be a Medicaid enrolled provider, an approved 1915c waiver service provider or approved by Office for People with Developmental Disabilities (OPWDD), or have a provider agreement with the LDSS, the DDRO or a Managed Care Organization (MCO). Providers of E–Mods must also adhere to any State and local safety standards pursuant to Article 18 of the New York State Uniform Fire Prevention and Build Code Act, as well as local building codes. LDSS, DDRO, State agencies and MCO are encouraged to identify providers in advance of service requests to ensure adequate capacity.

Procedure for Authorizing Environmental Modifications

  1. Through the person–centered planning process, during a POC meeting, the care/case manager, individual, and anyone involved in the development of the POC will determine if an E–Mod is necessary to assist and enhance the individual´s independence in performing ADLs, IADLs, and/or health related tasks and/or will substitute for human assistance (to the extent that expenditures would otherwise be made for human assistance). This should be consistent with a physician´s order stating the need for assistance (this may be an approved form requesting home care such as the M11Q used by NYC´s Human Resources Administration or the Form 4539 used by the rest of the State or a letter on physician´s letterhead stating the need for assistance). The individual´s residence must be identified, and residential information must also include the name of the home owner or landlord and their written permission for the modifications/adaptations.
  2. Once an E–Mod has been requested, the care/case manager on behalf of the individual seeks a clinical justification from the appropriate clinician (e.g., Occupational Therapist, Speech Language Pathologist, clinician from Article 16 or 28 clinic, Physical Therapist, or other licensed professional) and/or service specialist to assess the individual´s need for the requested E–Mod.
  3. The care/case manager and the individual will explore potential payment sources for the identified E– Mod including private insurance, community resources, and other Local/State/Federal programs before a request for payment under CFCO will be considered.
  4. Following the completion of the clinical justification, the care/case manager must submit the Description and Cost Projection Form requesting the service or device to the MCO or LDSS to initiate the authorization process. The care/case manager will also submit a copy of the physician´s order, clinical justification and the individual´s POC to the MCO or LDSS for review. The documentation submitted by the care/case manager must detail the need and intended purpose of the E–Mod to support the request.
  5. For individuals NOT enrolled in an MCO, (LDSS only), the package should be reviewed for completeness. After satisfactory review, the LDSS will notify the care/case manager that they may begin seeking bids. The care/case manager and the individual/family should obtain the requested number of bids (one for E–Mods less than $1,000, three for E–Mods of $1,000 or more) and submit them to the LDSS.
  6. Please note that MCOs are NOT required to obtain bids.
  7. The LDSS is responsible for evaluating bids and selecting the vendor to provide the E–Mods based on the lowest responsible bid that meets the assessed need. Reasonable efforts must be made to obtain three bids. If not possible to obtain the three required bids without jeopardizing the individual´s care, health and/or safety, the LDSS may make the determination to proceed with fewer than three bids with sufficient justification documented in the case file.
    • Payment for an assessment completed by the E–Mod provider, for helping select a specific modification, or for training in the use of any equipment, must be included in the cost of the E– Mod if the expertise needed for assessing, selecting and training is NOT available as part of a Medicaid State Plan service, or through other sources that are already involved with the individual.
  8. For projects approved by the LDSS only, the completed package comprised of the Description and Cost Projection Form and a copy of the physician´s order, the POC, the clinical justification, as well as all evaluations and bids (with the selected bid marked) will be submitted to the DOH for review and approval. As indicated on the Description and Cost Projection Form, any request from the Special Project Fund should be clearly made. Upon satisfactory review, the DOH will issue a letter to the LDSS supporting the project/product and submit the SPF Advance request to the Office of Temporary and Disability Assistance (OTDA) on behalf of the LDSS. The State may also deny the project or request more information.
  9. The MCO or LDSS will notify the care/case manager, the individual, and the selected E–Mod provider of its determination. MCOs will follow notification requirements in the Managed Care model contracts. The LDSS will issue a Notice of Decision (NOD) to the individual and care/case manager when they authorize or deny a FFS request for services.
  10. The E–Mod provider will be responsible for coordination of the project, including the following tasks:
    • provide a detailed description of the project including estimated material and labor costs;
    • secure and maintain necessary permits;
    • provide detailed expenditures/receipts;
    • ensure compliance with all state and local construction and building codes and ADA requirements;
    • ensure compliance with safety issues in Article 18 of the NY State Uniform Fire Prevention and Building Code;
    • complete necessary inspections;
    • maintain sufficient insurance and bond requirements;
    • secure licensed personnel, where applicable, to complete the required work;
    • determine the beginning and end dates of the project; and
    • ensure the satisfactory completion of the project.
  11. Upon completion of the E–Mod, the provider must submit a Final Cost Form to the LDSS or MCO that includes a description of the completed E–mod and the final cost.
  12. The LDSS or MCO will review the Final Cost Form and notify the provider that they may submit a claim for payment.
  13. The LDSS, only, must submit the Final Cost Form to the State´s CFCO–Children´s Approval Unit to reconcile payment and for tracking/reporting purposes.

Services and Supports Not Included Under Environmental Modifications

CFCO will not fund services/items/devices that are not for an assessed need including, but not limited to the following:

  • 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).
  • Adaptations that add to the total square footage of the home.
6/11/2019