26 Tex. Admin. Code § 554.2614 - Customized Power Wheelchairs
(a)
Customized power wheelchairs (CPWCs) are a service in the nursing facility
Medicaid program for Medicaid-eligible nursing facility residents when
medically necessary and prior authorized by the Health and Human Services
Commission (HHSC) or its designee.
(b) A CPWC is a wheelchair that consists of a
power mobility base and customized seating system.
(1) The power mobility base may include
programmable electronics and may utilize alternate input devices.
(2) The wheelchair must be medically
necessary, adapted, and fabricated to meet the individualized needs of the
resident, and intended for the exclusive and ongoing use of the
resident.
(3) Components of the
customized seating system must be in part or entirely usable only by the
resident for whom the power wheelchair is adapted and fabricated.
(c) When requested by a resident
or the resident's legal representative, the nursing facility must procure an
evaluation for a CPWC from a licensed physical or occupational therapist. If
the evaluation recommends a CPWC, the nursing facility must submit all required
forms to HHSC or its designee for prior authorization.
(d) After receiving prior authorization from
HHSC or its designee, the facility must purchase the CPWC.
(e) To be eligible for reimbursement, the
nursing facility must request and receive prior authorization from HHSC or its
designee before purchasing a CPWC. The prior authorization request must
include:
(1) a completed CPWC order
form;
(2) an occupational or
physical therapy evaluation of the resident;
(3) a statement signed by the resident's
attending physician that the CPWC is medically necessary; and
(4) a detailed breakdown of proposed CPWC
specifications from the customized power wheelchair supplier.
(f) To be eligible for
reimbursement for a CPWC, the nursing facility must obtain an evaluation of the
resident by an occupational or physical therapist licensed in the state of
Texas prior to purchase of the CPWC. The occupational or physical therapy
evaluation must include:
(1) a diagnosis
relevant to the need for a CPWC;
(2) the specific CPWC and adaptations being
recommended;
(3) a description of
how the CPWC will meet the specific needs of the resident;
(4) a description of specific training needs
for use of this device including training needs of the resident, nursing
facility staff, and family (when applicable); and
(5) written documentation from the therapist
indicating that the resident is physically and cognitively capable of
independently managing a power wheelchair.
(g) Payment for physical or occupational
therapy evaluations may be obtained for eligible residents in the same manner
as payment for physical or occupational therapy evaluations is obtained in the
Specialized and Rehabilitative Services programs, as described in §
554.1306 of this chapter (relating
to Payment for Specialized and Rehabilitative Services).
(h) Following a review of the prior
authorization request by HHSC or its designee, the nursing facility and
resident will receive a written approval or denial of the request. If the
request is approved, the nursing facility will promptly make arrangements to
purchase the CPWC. If the request is denied, HHSC or its designee will send a
notice of denial to the nursing facility resident informing the resident of the
right to request a Medicaid fair hearing in accordance with 1 TAC Chapter 357,
Subchapter A.
(i) A facility must
submit the request for reimbursement to DADS within one year after the date of
purchase of the CPWC. If DADS denies a request for reimbursement because the
facility failed to obtain prior authorization or submit the necessary
documentation for the CPWC to HHSC or its designee, the facility is responsible
for the cost of the CPWC and may not charge the cost to the resident or
family.
(j) A facility must fully
explore and use other funding sources to pay for a CPWC before submitting the
request for reimbursement to DADS. If another funding source will pay for part
of the CPWC expense, the facility may request reimbursement for the balance if
the requirements in subsections (d) - (f) of this section are met. If another
funding source is available, DADS reimburses only up to the remaining balance
after other sources are fully utilized.
(k) Only the resident can use the CPWC, and
it must be identified as the personal property of the resident.
(l) The resident's comprehensive care plan
must document that the CPWC is medically necessary.
(m) Upon discharge from the facility, the
resident retains the CPWC. If the resident dies, the CPWC becomes property of
the resident's estate. As part of the estate, the CPWC is subject to all
applicable Medicaid Estate Recovery Program (MERP) requirements, as detailed in
1 TAC Chapter 373. If the CPWC is donated or sold to the facility by the
resident or executor of the resident's estate, the transaction must be
documented in accordance with §
554.416 of this chapter (relating
to Personal Property).
(n) As
required by §
554.2601(b)(8)(C)
of this chapter (relating to Vendor Payment
(Items and Services Included)), the nursing facility is required to maintain
and repair all medically necessary equipment for its residents, including CPWCs
obtained under this section.
(o)
Requests for replacement of a CPWC must be submitted in the same manner as the
original prior authorization of the CPWC outlined in this section. A
replacement CPWC may be requested no earlier than five years after the original
date of purchase, unless the request includes an order from the prescribing
physician familiar with the resident and an assessment by a physician or a
licensed occupational or physical therapist with documentation supporting why
the current CPWC no longer meets the resident's needs. DADS does not authorize
replacement in situations where the CPWC has been abused or
neglected.
Notes
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