GUIDELINES FOR AUTHORIZING VEHICLE MODIFICATIONS

These guidelines outline the process for authorizing vehicle modifications under Community First Choice Option (CFCO) as a covered State Plan service. Vehicle modifications (V–Mods) are adaptations 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. V–Mod expenditures must be related to an assessed Activity of Daily Living (ADL), Instrumental Activity of Daily Living (IADL), or health–related need and must be tied to a goal reflected in an individual´s person–centered Plan of Care (POC). The scope of vehicle modifications may include the performance of necessary assessments to determine the type(s) of modifications that are necessary. V–Mods may only be made to one vehicle that is the primary means of transportation for the individual. This primary means of transportation may be owned by the individual, or a family member or non–relative who provides primary, long– term support and/or transportation for the individual. Routine maintenance and repairs related to the vehicle itself are not covered under CFCO. Payment may not be made to adapt vehicles that are owned or leased by paid Medicaid providers.

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

  • Adaptive equipment to enable an individual to operate the vehicle, including:
    • Hand controls, deep dish steering wheel, spinner knobs, wheelchair lock downs, parking brake extensions, foot controls, wheelchair lifts (including maintenance contracts), and left foot gas pedals.
  • Additionally, changes to the structure and internal design of the existing equipment including:
    • Floor cut–outs, replacement of a roof with a fiberglass top, extension of steering column, raised door, repositioning of seats, wheelchair floor, and dashboard adaptions.

For a driver to be eligible for a V–Mod, the individual, as the driver, is expected to have a current valid driver´s license that lists restrictions related to their disability. If the license was obtained prior to onset of disability, the individual must obtain an updated license which lists the individual´s restrictions. The individual must be functionally able to drive a vehicle and have unrestricted access to the vehicle. In addition, the covered changes must be necessary for the individual to drive the vehicle. For a non–driving individual to be eligible for a V–Mod, the modification must be essential to ensure his/her safe travel and access into and out of the vehicle.

The individual (and/or family member) is expected to assume the cost of the vehicle purchase and all optional equipment available from the dealer through factory installation, i.e., air conditioning, sound systems. A van can only be considered for modification if a car cannot be modified to meet the individual´s needs.

Agreements for V–Mods cannot exceed $15,000 per year without prior approval from the New York State Department of Health (Department). The Department of Health may delegate this responsibility to Medicaid Managed Care Organizations (MCO) for their enrollees. The Local Departments of Social Services (LDSS) and 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.

Modifications made to vehicles become the responsibility of the owner to maintain and repair. Repairs for a modification made to a vehicle may be covered if authorized. Removing modifications or returning property to its original state is not the responsibility of the MCO, LDSS, or Developmental Disabilities Regional Office (DDRO). Additional items beyond those deemed necessary by the LDSS, MCO or DDRO are the responsibility of the individual.

The modification of used vehicles 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 five years old or register less than 50,000 miles on the vehicle´s odometer.

Used adaptive equipment and modification devices are sometimes available for purchase. To ensure the greatest safety and performance, used equipment will only be approved if it is purchased from licensed businesses dealing in the sale of vehicles or adaptive equipment.

Providers of Vehicle Modifications

  • Mods must be completed by individuals who are qualified and/or licensed to comply with State and/or local rules. The V–Mod provider must arrange for a mandatory comprehensive evaluation of the individual´s needs for adaptive equipment or comprehensive vehicle modifications by an ACCES–VR approved Certified Driver Rehabilitation Specialist (if the individual is working toward employability) or V–Mod vendors approved under the Quality Assurance Program of the National Mobility Dealers Association. These are listed at http://www.nmeda.com/locate–dealer/search–by–state/?state=NY. The evaluation must specify the most cost effective and least complicated vehicle modification that will ensure safe transportation and exit from and entrance into the vehicle for the participant. The evaluation must also include a dated and detailed scope of work and specifications. When arranging for the evaluation, the V–Mod provider must also arrange for a post– modification evaluation. The role of the V–Mod vendor is to provide vehicle modifications in accordance with the bid specifications. Vehicle modifications must be completed by individuals who are qualified and/or licensed to comply with State and local rules. The V–Mod provider is responsible for obtaining the necessary bids from entities approved by ACCES–VR to provide vehicle modifications. The lowest bid among substantially equivalent bids that conforms to the approved pre–evaluation must be selected.

Providers may also be approved by the Office for People with Developmental Disabilities (OPWDD). In addition, an organization that has both the personnel and expertise to complete the V–Mod and is an approved Medicaid provider may also be approved by the Department to provide these services. LDSS, DDRO, State Agencies and MCOs are encouraged to identify providers in advance of service requests to ensure adequate capacity.

Procedure for Authorizing V–Mods:

  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 a V–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 request for home care form such as the M11Q used by NYC Human Resources Administration or Form 4539 used by the Rest of the State, or a letter on physician´s letterhead stating the need for service(s)).
  2. Once a V–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 V–Mod.
  3. The care/case manager and the individual will explore potential payment sources for the identified V– Mod including private insurance, community resources, and other 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 V–Mod to support the request.
  5. For individuals NOT enrolled in an MCO, (LDSS only), the package should be reviewed for completeness. The LDSS will notify the care/case manager that they may begin seeking bids. The care/case manager and individual/family should obtain the required number of bids (one for V–Mods less than $1,000, three for those over $1,000) and submit them to the LDSS.
  6. Please note that MCOs are NOT required to obtain bids.
  7. The LDSS is responsible for evaluating the bids and selecting the vendor to provide the V–Mod based on the lowest responsible bid that meets the assessed need. Reasonable efforts must be made to obtain three bids, when required. If it is 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 individual´s case file.
    • Payment for an assessment completed by the V–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 V– 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, a copy of the POC, a copy of the clinical justification, a copy of the physician´s order and all evaluations and bids will be submitted to the State´s CFCO–Children´s Approval Unit for review and approval. As indicated on the Description and Cost Projection Form, any request from the State Special Project Fund should be clearly made. Upon satisfactory review, the State will issue a letter to the LDSS supporting the project/product and submit the SPF advance request to OTDA on behalf of the LDSS. The State may also deny the project or request additional information.
  9. The MCO or LDSS will notify the care/case manager, the individual, and the selected V–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 an FFS request for services.
    • If the provider finds that changes/additional work are necessary while completing the V–mod that will result in a cost difference from the original projected cost, the provider must obtain approval of the changes before proceeding, or risk non–payment for such changes.
  10. Upon completion of the V–Mod, the provider must submit a Final Cost Form to the LDSS or MCO that includes a description of the completed V–Mod and the final cost.
  11. The LDSS or MCO will review the Final Cost Form and notify the provider that they may submit a claim for payment.
  12. 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 Vehicle Modification

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 vehicle that are of general utility, and are not of direct medical or remedial benefit to the individual; and
  • Adaptations that exceed the vehicle´s Current Market Value.
6/11/19