Acute Medicaid SuppliesAdaptive Aids

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• Acute Medicaid Supplies/Adaptive Aids

DADS 2008 Medicaid 1915(c) Waiver
Conference October 27-30, 2008 Austin,
Texas Presented by Gilbert Estrada Program
Specialist Policy Development and
Support Provider Services - Community Services
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Introduction

• Purpose of Presentation
• To inform attendees of an initiative to
  streamline the processes used by Home and
  Community Support Services agencies (HCSSAs) to
  purchase adaptive aids and medical supplies for
  Community Based Alternatives (CBA) consumers.
• To supplement information to be presented at the
  General Waiver - Adaptive Aids and Home
  Modifications session on 10/29 at 11 a.m.

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Definitions

• Adaptive aids - Devices that are medically
  necessary to treat, rehabilitate, prevent, or
  compensate for medical conditions resulting in
  disability or loss of function.
• Adaptive aids enable persons with functional
  impairments to perform the activities of daily
  living or control the environment in which they
  live.
• Medical Supplies - Items that either have
  therapeutic or diagnostic benefits specific to
  the participant's diagnosis and are necessary in
  carrying out the individual service plan (ISP).

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Background

• CBA program rules (48.6050) require HCSSAs to
  provide a certain array of home and community
  support services in accordance with the CBA
  consumers individual service plan (ISP), Form
  3671.
• Included in that array are adaptive aids and
  medical supplies.
• The processes that HCSSAs follow to purchase and
  deliver adaptive aids and medical supplies are
  outlined in Section 4424 of the CBA Provider
  Manual.

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Program Requirements

• The CBA program is not intended to provide every
  participant with any and all adaptive
  aids/medical supplies the participant may receive
  as a nursing facility resident.
• HCSSAs must ensure that purchases of adaptive
  aids and medical supplies are
• cost effective and
• delivered in a timely manner.
• HCSSAs must limit adaptive aids and medical
  supplies to the most cost-effective items that
  can
• meet the participant's needs,
• directly aid the participant avoid premature NF
  placement, and
• provide NF residents an opportunity to return to
  the community.

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Program Requirements

• The CBA waiver is the last payor for adaptive
  aids and medical supplies.
• Adaptive aids/medical supplies are covered by the
  CBA waiver only after the consumer has exhausted
  any third-party resources (TPRs), including
  Medicare and Medicaid Home Health (MHH), that he
  is eligible to receive.
• HCSSAs are required to have knowledge of services
  available through Medicare and MHH and not
  request services through CBA when the participant
  is eligible to receive services from other
  resources.
• Adaptive aids and durable medical equipment (DME)
  are one-time purchases and should not be
  authorized through CBA for consumers potentially
  eligible for MHH, unless the Texas Medicaid
  Healthcare Partnership (TMHP) has denied the
  coverage or the HCSSA specifically documents that
  the client does not meet MHH eligibility
  requirements.

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Program Requirements

• HCSSAs should not submit adaptive aid requests to
  the CBA case manager until a denial is received
  from Medicare or Medicaid, or the HCSSA documents
  the client does not meet the homebound
  requirements.
• For lift chairs, Medicare may pay 80 of the lift
  mechanism. The lift chair should not be
  incorporated into the ISP until approval is
  obtained from Medicare for the cost of the lift
  mechanism.
• Medicare will pay for glucose monitors, test
  strips, and lancets for all diabetic clients at
  80 of the cost. CBA can cover the 20
  co-insurance if no other resources are available.
  
• Insulin syringes and needles are obtained by the
  client through the Health and Human Services
  (HHSC) Vendor Drug Program , not through the CBA
  program.

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Issues

• In accordance with program requirements, CBA case
  managers request documentation of a TPR denial
  before approving adaptive aids and medical
  supplies for the CBA waiver consumers ISP.
• HCSSAs and DME suppliers advised the State that
  the process and documentation requirements for
  purchasing adaptive aids/medical supplies are
  problematic.

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The Solution

• A workgroup consisting of representatives from
  HHSC, DADS, TMHP, and other stakeholders (HCSSAs,
  DME suppliers) met and recommended that the
  program requirements be streamlined to
• expedite delivery of adaptive aids/medical
  supplies,
• expedite payment, and
• provide prompt service to CBA consumers.
• Workgroup Recommendations
• The State would create a list of adaptive
  aids/medical supplies and identify which items
  would never be approved by Medicare/MHH.
• Case managers would refer to this list, thereby
  eliminating the step to receive a denial letter
  from TMHP for these items and.
• Case managers would approve these items on the
  CBA consumers ISP.

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The List Major Sections

• Adaptive Aids (Includes repair and maintenance,
  to include batteries, not covered by the
  warranty.)
• Mobility aids (Including batteries and charges)
• Respiratory Aids
• Positioning Devices
• Communications Aids (Including repair,
  maintenance, and batteries.)
• Control Switches/pneumatic switches and devices

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The List Major Sections

• Environmental Control Units
• Modifications/additions to primary transportation
  vehicles
• Sensory Adaptations
• Adaptive Equipment for Activities of Daily Living
• Assistive Devices
• Safety Restraints and Safety Devices
• Medical supplies, necessary for therapeutic or
  diagnostic benefits

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The List Major Sections

• Other types of supplies
• Diapers, linens, and other incontinence supplies
• Nutritional supplements
• Enteral feeding formulas and supplies
• Diabetic supplies (strips, lancelets, syringes)
• Transcutaneous Electrical Nerve Stimulations
  (TENS)
• Stethoscopes, blood pressure monitors, and
  thermometers for home use
• Blood glucose monitors

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Implementation Plan

• Coordinate with HHSC and TMHP to finalize list of
  adaptive aids/medical supplies
• Present list to external stakeholders for review
• Determine implementation date
• If necessary, revise program rules, provider
  policy, and case manager policy
• Notify staff/providers of revised policy and
  procedures

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QUESTIONS???
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Contact Information

• Gilbert Estrada
• DADS CBA Provider Policy Specialist
• gilbert.estrada_at_dads.state.tx.us
• [phone]