Provider Alert! MDCP Adaptive Aids Available through the Consumer Directed Services (CDS) OptionTexas Children's Health Plan
Date: June 25, 2021
Attention: FMSA Providers
Effective Date: December 1, 2020
Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event. TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.
Call to action: Effective December 1, 2020, MDCP adaptive aids will be available through the CDS option.
How this impacts providers: Adaptive aids are devices necessary to treat, rehabilitate, prevent or compensate for conditions resulting in disability or loss of function and enable members to perform activities of daily living; or control the environment in which they live. Adaptive aids needs are determined during the Screening and Assessment Instrument (SAI) initial assessment or re-assessment, or at the time of a significant change in condition. The service coordinator will review the need for the adaptive aid and add the service to the member’s Individual Service Plan (ISP). Qualified members may speak with their service coordinator to review all CDS employer responsibilities related to self-directing this service.
TCHP must ensure that a member has exhausted any applicable Medicare, Medicaid state plan or other third-party resources for durable medical equipment and adaptive aids before authorizing adaptive aids under the MDCP waiver. For purposes of ‘exhausting any applicable Medicare, Medicaid state plan or other third-party resources,’ HHSC considers a denial due to not meeting requirements to mean that resources have been exhausted.
Adaptive Aides are limited to:
- Van lifts;
- Van modifications;
- Jump seats;
- Tumble forms;
- Feeder seats*;
- Medically appropriate strollers*;
- Barrier-free lifts;
- Environmental control units (generators and A/C units);
- Alarm systems;
- Support rails;
- Electrical work related to use of Adaptive Aids;
- Installation costs for Adaptive Aids; and
- Repairs to Adaptive Aids.
* For these items, members should follow the normal Prior Authorization Request Process and submit a Texas Standard authorization form. Should the request be denied, members have the option to acquire their AA with the MDCP waiver benefit by following the process outlined below.
- Adaptive Aids: Annual service limit $4,000
Steps to complete for Adaptive aids through CDS Option:
Steps to complete for Adaptive aids through CDS Option:
- The Service Coordinator will ensure the CDS employer/LAR understands the process, is willing and able to perform the required functions of selecting an Adaptive Aid provider of their choice.
- If the CDS employer/LAR selects the CDS option for Adaptive Aids, the Service Coordinator will document on form 2603, the MDCP services along with the rationale for the service.
- TCHP must ensure the CDS employer/LAR is able to select the adaptive aid provider of their choice. The CDS employer/LAR’s selected vendor is not required to be a TCHP contracted provider.
- If the CDS employer/LAR elects to use the CDS option to acquire Adaptive Aids, the Service Coordinator (SC) must:
a) review with them all CDS employer/LAR responsibilities related to self-directing this service,
b) ensure that they understand the process and is willing and able to perform the required functions;
c) ensure the CDS employer is able to select the adaptive aids provider of their choice ensure the CDS employer signs the following CDS forms:
1581 CDS option overview
1582 CDS responsibilities
1584 Consumer participation choice
1586 Acknowledgement of information regarding support consultation services in CDS option
- Selected Vendor must meet both the Vendor and eligibility Qualifications. Adaptive Aid vendors must meet the following eligibility qualifications:
a) Be a durable medical equipment supplier or be a manufacturer of items not supplied through durable medical equipment suppliers. Source: Texas Administrative Code Verification of Eligibility for Vendors Rule Section 41.235 states the following:
An employer or Designated Representative must:
(1) obtain, verify, and retain documentation that a vendor meets and maintains the eligibility requirements of an individual’s program for the services to be delivered; and
(2) submit documentation of the vendor’s eligibility and continued eligibility to the CDSA before services are delivered.
(b) A vendor must be in compliance with any requirements of law or of the individual’s program, including:
(1) applicable licensing or certification standards;
(2) local building codes;
(3) the Americans with Disabilities Act of 1990 as amended; and
(4) state requirements for automotive adaptive equipment and vehicle modifications.
(c) An employer or DR must obtain written approval from the CDSA that a vendor has met the requirements detailed in subsection (a) of this section before the vendor
delivers services to the individual.
- The CDS employer/LAR is responsible for obtaining written specifications for the items, in coordination with TCHP as appropriate. The CDS employer/LAR will request an order and the Service Coordinator will submit a Texas Standard Prior Authorization Form for the selected Provider and complete form 2416 for approval. The Texas Standard Prior Authorization Form should be sent to Utilization Management. Section 5, of the Texas Standard Prior Authorization Form stating medical necessity must be completed to include why there is a need for the Adaptive Aid.
- After the written specifications/Prior authorization are obtained and approved by the Team Lead/MDCP Manager, the Service Coordinator authorizes the CDS employer to begin collecting bids. The Service Coordinator recommends that CDS employer/LAR collect three different bids from three different Vendors. If CDS employer decline to get multiple bids, this should be documented in the member record.
- If a denial is received from the PA form that is submitted
- The CDS employer and the Service Coordinator reviews the bids and the CDS employer selects the vendor of choice. The MDCP Team Lead/Manager must review the CDS employer selection to ensure the selection meets the written specification and spending limit.
- The CDS employer must send copies of all bids that were collected to TCHP’s Service Coordinator. The CDS employer and TCHP must retain copies of all obtained bids.
- The MDCP Team Lead/Manager reviews and approves the selected Vendor.
- Once the Vendor is approved, the Service Coordinator will send Form 2416 to the CDS employer and the Vendor will review and sign, acknowledging the authorized amount for the adaptive aid.
- After obtaining signatures from the CDS employer and Vendor on Form 2416, the service coordinator will provide a copy of the completed form to the FMSA, indicating the authorized total amount approved for payment for the adaptive aid.
- The revised Individual Service Plan is sent to the FMSA.
- Upon receipt of the invoice, the service coordinator must complete a home visit, within 30 days to verify the adaptive aid has been provided and is appropriate based on the written specifications for the adaptive aid. Photograph documentation of Adaptive Aids completed work are acceptable during the Public Health Emergency.
Vendor Selection: LARs should make their Adaptive Aid Vendor selection carefully. Once the authorization is approved, the AA cannot be changed. Payment is based on the AA listed on the approved authorization letter.
Next steps for providers: STAR Kids Billing Matrix
|Service||HCPC Codes||Modifier||Units||Service Description||Effective|
|1 unit per service
1 unit per service
1 unit per service
|Adaptive Aid- NOS, CDS Option
Adaptive Aid- Medical Equipment, CDS Option
Adaptive Aid- Vehicle Modification, CDS Option
How to handle unsatisfactory work results of an adaptive aid:
If the Team Lead/MDCP Manager determines the Adaptive Aid is not approved, the Service Coordinator completes a denial request on the LTSS form, sends this to TCHP’s Utilization Management Department. The member may then request an appeal. The appeal process should be completed before Form 2416 is sent to the FMSA.
Per HHSC Guidance, the CDS employer/LAR should work directly with the Vendor to resolve any issues if the CDS employer is unsatisfied with the vendor’s work, with assistance from Texas Children’s Health Plan’s Service Coordinator as needed.
The CDS employer may be responsible for payment owed to the vendor if the CDS employer approves the adaptive aid and submits the invoice to the FMSA for payment, and later changes their mind regarding satisfaction with the adaptive aid provided after the FMSA has paid the invoice. The CDS employer must retain the original invoice in its file for the contractor/vendor. A copy is retained by the contractor/vendor and the FMSA.
If you have any questions, please email Provider Network Management at: firstname.lastname@example.org.
For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers
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