Community Living Assistance and Support Services Provider Manual
Revision 12-2; Effective October 17, 2012
Adaptive aids are items or services necessary to assist an individual to maintain function or to treat, rehabilitate, prevent or compensate for conditions resulting in disability or loss of function. Adaptive aids enable individuals with functional impairments to perform activities of daily living or to control the environment in which they live. Adaptive aids purchased through the Community Living Assistance and Support Services (CLASS) program are essential items or services provided to enhance the individual's independence in the community. For some individuals, adaptive aids are basic to making the environment usable so activities such as preparing food, eating, dispensing medications, dressing and grooming, maintaining the home, and moving within the community, can be performed as independently as possible. Adaptive aids are devices, controls, appliances or services that enable individuals with related conditions to:
- increase their abilities to perform activities of daily living and decrease the need for paid staff;
- prevent the risk of institutionalization;
- control the environment in which they live;
- modify or improve the individual's ability to live successfully in the community;
- increase the individual's safety, security and accessibility; and
- improve service accessibility and delivery.
Adaptive aids may be provided to meet the needs identified in an assessment conducted by an appropriate, licensed professional, as outlined in this appendix. The long-range cost effectiveness of adaptive aids will be considered since these items often provide several years of service.
Limits on the amount, frequency, or duration of this service:
Nutritional supplements and enteral feeding formulas and supplies are limited to those documented by the Statistical Analysis DME Regional Carrier Product Classification List for Enteral Nutrition in effect at the time. Adaptive Aids are provided under this waiver when no other financial resource is available or when other available resources have been exhausted.
Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation, is required for all requested adaptive aids. Requests for adaptive aids that require additional information to be provided by the appropriate licensed professional (as listed below) or require bids must accompany Form 3660, as applicable.
If the requested adaptive aid is related to transportation services, the case manager must complete Form 3598, CLASS/DBMD — Individual Transportation Plan, based on the deliberations of the service planning team (SPT). This form must be submitted to the Department of Aging and Disability Services (DADS) in conjunction with applicable forms as outlined below.
All assessments for adaptive aids requested through the CLASS program must:
- be based on a face-to-face evaluation of the individual by the licensed professional conducted not more than one year before the date of purchase of the adaptive aid;
- include a description of and a recommendation for a specific adaptive aid listed in this appendix and any associated items or modifications necessary to make the adaptive aid functional;
- include the individual's diagnosis of a related condition(s) and how the requested adaptive aid will address this diagnosis (for example, cerebral palsy, quadriplegia or deafness);
- include a description of the symptom(s) related to the diagnosis (for example, unable to ambulate without assistance); and
- include a description of the specific needs of the individual and how the adaptive aid will meet those needs (for example, the individual needs to ambulate safely and independently from room to room and the use of a walker will allow him to do so).
Adaptive aids needed on an ongoing basis will require documentation to justify the need for the adaptive aid(s) once per Individual Plan of Care (IPC) period. Repair and maintenance of items purchased through the CLASS program do not require justification from a medical professional.
However, the repair does require justification from a licensed professional if the cost exceeds $300 or the repair is to an adaptive aid not purchased through CLASS.
The service planning team must:
- consider a written assessment recommending an adaptive aid;
- document any discussion about the recommended adaptive aid; and
- agree that the recommended adaptive aid is necessary and should be purchased.
The case management agency (CMA) must obtain one of the following as proof of non-coverage by Medicaid:
- a letter from Texas Medicaid Healthcare Partnership (TMHP) that includes:
- a statement that the requested adaptive aid is denied under the Texas Medicaid Home Health Services or the Texas Health Steps programs; and
- the reason for the denial, which must not be one of the following:
- Medicare is the primary source of coverage;
- information submitted to TMHP was incomplete, missing, insufficient or incorrect;
- the request was not made in a timely manner; or
- the adaptive aid must be leased; or
- a provision from the current Texas Medicaid Providers Procedure Manual stating the requested adaptive aid is not covered by the Texas Medicaid Home Health Services or the Texas Health Steps programs.
In addition to the documentation described above, for an individual eligible for Medicare, a CMA must obtain one of the following for an adaptive aid:
- a letter from Palmetto Government Benefits Administrators (Palmetto GBA) that includes:
- a statement that the requested adaptive aid is denied under Medicare; and
- the reason for the denial, which must not be one of the following:
- information submitted to Palmetto GBA was incomplete, missing, insufficient or incorrect;
- the request was not made in a timely manner; or
- the adaptive aid must be leased;
- a letter from Palmetto GBA stating the adaptive aid is approved and the amount to be paid, which must be less than the cost of the requested adaptive aid; or
- a provision from the current Region C DMERC (Durable Medical Equipment Region C) DMEPOS (Durable Medical Equipment Prosthetics, Orthotics, and Supplies) Supplier Manual stating the requested adaptive aid is not covered by Medicare.
For situations in which the requested adaptive aid exceeds Medicaid's or Medicare's standards/specifications, the CMA must provide a letter from TMHP or Palmetto GBA stating that the adaptive aid is approved, but the amount to be paid is less than the cost of the requested adaptive aid. For example, a standard hospital bed has been approved, but the individual has a justified need for a specialized hospital bed.
The following are examples of documentation that are not acceptable as proof of non-coverage:
- a statement from a Medicaid enrolled durable medical equipment (DME) provider that the adaptive aid requested is not covered by the Texas Medicaid Home Health Services or the Texas Health Steps programs; and
- a statement from a Medicare DME provider that the adaptive aid requested is not covered by Medicare.
The CMA is responsible for assisting the individual or legally authorized representative (LAR), as necessary, to pursue all non-CLASS resource options for an adaptive aid prior to requesting an adaptive aid through CLASS. Some examples may include private insurance coverage or other state or local program resources for which the individual may be eligible.
Within five business days of receipt of this record, the CMA must provide copies of all documentation to the direct services agency (DSA) verifying that non-CLASS resources were exhausted.
DSAs must submit Form 3660 to the case manager along with written documentation as outlined in Section 3500, Service Initiation.
For adaptive aids with a cost of $500 or higher, a DSA must obtain comparable bids for the requested adaptive aid from three vendors. Comparable bids describe the adaptive aid and any associated items or modifications identified in an assessment for an adaptive aid. A bid must:
- state the total cost of the requested adaptive aid;
- include the name, address and telephone number of the vendor;
- include a complete description of the adaptive aid and any associated items, modifications or specifications, which may include pictures or other descriptive information from a catalog, website or brochure;
- include the number of hours of direct service to be provided and the hourly rate of the service (only for those adaptive aids that are services); and
- be obtained within one year after the written assessment is obtained.
A DSA may obtain only one bid for the following adaptive aids:
- hearing aids, batteries and repairs; and
- orthotic devices, orthopedic shoes and braces.
A DSA may obtain only one bid or two comparable bids for an adaptive aid if the DSA has written justification for obtaining less than three bids because the adaptive aid is available from a limited number of vendors.
If a DSA will request authorization for payment for an adaptive aid that is not based on the lowest bid, the DSA must have written justification for payment of a higher bid.
The following are examples of justifications that support payment of a higher bid:
- the higher bid is based on the inclusion of a longer warranty for the adaptive aid; and
- the higher bid is from a vendor that is more accessible to the individual than another vendor.
The only items and services purchasable by the DSA as adaptive aids are listed in this appendix. The maximum amount DADS authorizes as payment to the DSA for all adaptive aids purchased for an individual receiving CLASS program services is $10,000 per IPC period.
With the exception of a vehicle modification, all adaptive aids purchased for an individual through the CLASS program are the exclusive property of that individual.
Adaptive aids identified on the IPC must include documentation describing how the item or service:
- is necessary to protect the individual's health and welfare in the community;
- addresses the individual's related condition;
- is not available to the individual through any other source, including the Medicaid state plan, other governmental programs, private insurance or the individual's natural supports;
- enhances an individual's integration in the community and prevents admission to an institution while maintaining and improving independent functioning;
- is the most appropriate type and amount of CLASS program services to meet the individual's needs; and
- is cost effective.
Individuals must be assessed by the most qualified, licensed professional who can justify the need and appropriateness of a requested adaptive aid.
Following are licensed professionals who may assess the need for an adaptive aid in the CLASS program.
- Audiologist (AU) — A person licensed as an audiologist in accordance with Chapter 401 of the Texas Occupations Code.
- Licensed Psychological Associate (PSA) — Texas Occupations Code, Chapter 501.
- Licensed Professional Counselor (LPC) — Texas Occupations Code, Chapter 503.
- Dietitian (DI) — A person licensed as a dietitian in accordance with Chapter 701 of the Texas Occupations Code.
- Registered Nurse (RN) — A person licensed to practice professional nursing by the Texas Board of Nurse Examiners in accordance with Chapter 301 of the Texas Occupations Code.
- Physician (MD) — A person licensed as a physician in accordance with the Texas Occupations Code, Chapter 155.
- Occupational Therapist (OT) — A person licensed as an occupational therapist in accordance with Chapter 454 of the Texas Occupations Code.
- Ophthalmology (OPH) — A person licensed as a physician in accordance with the Texas Occupations Code, Chapter 155, and certified by the American Board of Ophthalmology.
- Optometrist (OPT) — A person licensed as an optometrist or therapeutic optometrist in accordance with the Texas Occupations Code, Chapter 351.
- Physical Therapist (PT) — A person licensed as a physical therapist in accordance with Chapter 453 of the Texas Occupations Code.
- Psychologist (PS) — A person licensed as a psychologist, provisionally licensed psychologist or psychological associate in accordance with Chapter 501 of the Texas Occupations Code.
- Speech-Language Pathologist (SP) — A person licensed as a speech-language pathologist in accordance with Chapter 401 of the Texas Occupations Code.
- Social Worker (SW) — A person licensed as a social worker in accordance with the Texas Occupations Code, Chapter 505.
Other Abbreviations and Numbers
(1) — The item must meet Medicaid standards/specifications.
(2) — Equipment rental is highly recommended by DADS prior to purchase.
Adaptive aids that may be covered in the CLASS program must be included on the following list and include the installation, maintenance and repair of approved items not covered by warranty:
- wheelchair lifts (OT, PT)
- porch or stair lifts (OT, PT)
- stairway lifts (only in residences owned by the individual/family) (OT, PT)
- bathtub seat lifts (OT, PT)
- ceiling lifts that transport the individual around the home via tracks (only in residences owned by the individual and/or family) (OT, PT)
- other hydraulic, manual or other electronic lifts (OT, PT)
- Mobility Aids (including batteries and chargers)
- manual/electric wheelchairs and necessary accessories (OT, PT, MD)
- adult stroller/travel chair (OT, PT)
- mobility bases for customized chairs (OT, PT)
- braces, crutches, walkers, canes (including white canes) and necessary accessories (OT, PT, MD)
- prescribed prosthetic devices (OT, PT, MD)
- orthopedic shoes and other prescribed footwear (OT, PT, MD)
- hydrotherapy appliances and necessary adaptations/accessories
- bus passes, metro transit services, taxi services for non-medical transportation only (for specific purposes related to individual's habilitation goals; not to be used in lieu of medical transportation) (any listed licensed professional)
- portable ramps that do not require installation (OT, PT)
- automatic door openers (OT, PT)
- gait trainer (OT, PT)
- mobility aids for individuals with a diagnosed visual impairment listed on the DADS-approved ICD-9 list, such as: (OT, PT, MD, OPH, OPT)
- materials to construct adaptive mobility aids (for example, PVC pipes to construct an adapted cane or pre-cane device);
- color contrast or reflective tape (to mark paths, drop-offs, etc);
- global positioning systems (GPS) and appropriate accessories to allow independent travel within the community;
- tinted glasses, visors and sunshields to regulate glare;
- flashlights; and
- magnifying devices.
- Position Devices
- standing frames/boards (OT, PT)
- removable bathtub rails (OT, PT)
- toilet chair (OT, PT)
- orthotic devices (OT, PT, MD)
- hospital beds and necessary accessories (must meet Medicaid standards/specifications) (OT, PT)
- egg crate mattresses, sheepskin and other medically related padding (OT, PT, MD)
- lift recliners (OT, PT)
- trapeze bars (OT, PT)
- Communication Aids
- direct selection communicators (SP)
- alphanumeric communicators (SP)
- scanning communicators (SP)
- adapted telephones for an individual diagnosed with visual and/or hearing impairments listed on the DADS-approved ICD-9 list (for example, amplified telephones, phones with enlarged keypads, phones with Braille displays, captioned telephones and speaker phones for people who cannot use conventional telephones) (SP, OT)
- Telecommunication Device for the Deaf (TDD) or telephone typewriter/ teletypewriter (TTY) machines with Braille displays (SP)
- Video relay phone and equipment for video relay service (the monthly service fee is not included or covered) (SP)
- telebraille and teletype machines (SP)
- materials to construct communication aids (SP, PS, PSA, LPC, OT)
- communication books, communication symbols, experience books and calendar systems (to include calendar boxes, shelves and charts)
- speech amplifiers and assistive listening devices (SP, OT)
- hearing aids beyond the Medicaid limit (SP, AU)
- hearing aid supplies beyond the Medicaid limit (SP, AU, MD, RN)
- sign language interpreter service for non-routine communications, such as SPT meetings or medical/professional appointments (SP, PS, PSA, LPC, AU, MD)
- Computers and Appropriate Accessories
The following items may be purchased under the adaptive aids category for communication needs not met by an augmentative communication device, to operate adaptive software, for assistance with money management or for environmental control purposes.
- computers and appropriate accessories (OT, PT, SP)
- appropriate software to address the needs listed above (limited to three per year) (OT, PT, SP)
- adapted workstations/chairs (OT, PT, SP)
- Braille displays (OT, PT, SP)
- Braille printers/embossers (OT, PT, SP)
- electronic Braille note takers (OT, PT, SP)
- Environmental Controls
- electronic environmental control devices (OT)
- voice activated, light activated and motion activated devices (to include amplified features) (OT)
- control switches/pneumatic switches and devices (OT)
- sip and puff controls (OT)
- adaptive switches/devices (OT)
- sensory adaptations (OT)
- Adaptive Equipment for Activities of Daily Living
The following are based on the needs of the individual as authorized on the Individual Program Plan.
- assistive devices
- reachers (OT, PT, MD, RN)
- stabilizing devices (OT, PT, MD)
- weighted equipment (OT, PT, PS, PSA, LPC)
- holders (for example, book stands, page turners, cup holder) (OT, PT, MD, RN)
- signature stamp or signature guide (OT, PT, MD, RN, OPT, OPH)
- electric self-feeders (OT, PT) (2)
- microwave ovens (only for individuals with muscular weakness or who lack manual dexterity and those individuals who cannot use conventional ovens) (OT, PT)
- food processors and blenders (only for individuals with muscular weakness in upper body or who lack manual dexterity and are unable to use manual conventional kitchen appliances or for individuals with visual impairment that would be necessary for the individuals' safety) (OT, PT, DI)
- variations of everyday equipment
- shaped, bent, built-up utensils (OT, PT, DI)
- long-handed equipment (OT, PT, DI)
- addition of friction coverings (OT, PT, DI)
- coated feeding equipment (OT, PT, DI)
- count-a-medication dose systems/manual medication reminder systems (OT, PT, MD, RN)
- pill crushers/splitter (OT, PT, MD, RN)
- specially adapted kitchen appliances (OT, PT, DI)
- toilet seat reducer rings (OT, PT, MD, RN)
- food preparation utensils (OT, PT, DI)
- specially adapted clocks/wristwatches for individuals with visual or hearing impairment (OT, PT, AU, OPH, OPT)
- adapted scale (OP, PT, MD, RN, DI)
- prescribed therapy aids (to be used with therapist oversight) (OT, PT, OPT, OPH, SP, PS, PSA, LPS, DI)
- service animals and required maintenance (cost effectiveness of medical intervention to be determined on an individual basis) (OT, MD, OPH)
- quad gloves (OT, PT, MD, RN)
- safety devices
- bed rails (OT, PT, MD, NU, PS, PSA, LPC)
- safety padding (OT, PT, MD, NU, PS, PSA, LPC)
- helmets (OT, PT, MD, NU, PS, PSA, LPC)
- walking belts/gait belts (OT, PT, MD, RN)
- flutter boards (OT, PT, MD)
- personal floatation devices (in context with therapeutic purposes) (OT, PT, MD,)
- elbow and knee pads (OT, PT, MD, RN, PS, PSA, LPC)
- emergency response systems (OT, PT, MD, RN)
- water walkers (OT, PT, MD)
- adapted fire extinguishers (OT, PT, MD, RN)
- adapted smoke and CO² extinguishers (OT, PT, MD, RN)
- visual alert systems (OT,PT, OPT, OPH)
- vibrating alert systems (OT, PT)
- shower chairs/transfer benches (OT, PT, MD)
- electric razors (for individuals with muscular weakness or who lack manual dexterity and those individuals who cannot use conventional hygiene tools) (OT, PT, MD, RN)
- flexible, disposable drinking straws for individuals with muscular weakness or who cannot drink from a regular drinking glass or cup (OT, PT, MD, RN)
- hand-held shower attachments that are portable and do not require installation (OT, PT, MD, RN)
- assistive devices
- Medically Necessary Supplies
- tracheostomy care (MD, RN)
- decubitus care (MD, RN)
- ostomy care (MD, RN)
- respirator/ventilator care (MD, RN)
- catheterization (MD, RN)
- diapers, linens and other incontinence supplies not covered by the Medicaid state plan (MD, RN)
- nutritional supplements (MD, RN, DI)
- internal feeding formulas and supplies (MD, RN, DI)
- transcutaneous electrical nerve stimulation (TENS) units/supplies/repairs (OT, PT, MD, RN)
- specialized thermometers (OT, PT, MD, RN)
- diabetic supplies (OT, PT, MD, RN, DI)
- glucose monitors (OT, PT, MD, RN, DI)
- medical supply cabinets (OT, PT, MD, RN)
- humidifiers (OT, PT, MD, RN)
- suctioning devices (MD, RN)
- prescription eyeglasses/accessories beyond Medicaid limit (OPT, OPH)
- muscle stimulators (OT, PT, MD, RN)
- medically necessary heating and cooling units prescribed by a physician for individuals with respiratory or cardiac problems or people who cannot regulate their body temperature (MD)
- urinary incontinence devices and supplies (MD)
- blood pressure monitors (MD, RN)
- vitamins with a prescription (MD)
- gloves (beyond Medicaid limit) (MD, RN)
- medication cups (beyond Medicaid limit) (MD, RN)
- Specialized Training and Instructions
- computer literacy training to educate individuals in use of adaptive software necessary to perform activities of daily living and prevent institutionalization (limited to 10 sessions per software unit) (OT, PT, SLP)
- driving lessons for vehicles fitted with adaptive equipment (OT, PT, MD)
- Modification/Additions to Primary Transportation Vehicles
A vehicle lift adaptation may be approved for a vehicle owned by an individual or an individual's family member if it is the primary mode of transportation for the individual, but it cannot exceed one lift/ramp modification every five years. Repairs and maintenance not covered by warranty are not limited to the five-year requirement.
A vehicle that is expected to be modified or adapted with any of the items/services listed in A. through K. below must meet one of the following criteria:
- vehicle is less than 5 years old and mileage is less than 50,000 miles; or
- vehicle passed an independent inspection performed by a certified automotive technician.
- vehicle lifts (OT, PT, MD)
- vehicle ramps (OT, PT, MD)
- wheelchair/scooter lifts and carriers (OT, PT, MD)
- turning/transfer seats (OT, PT, MD)
- driving controls
- brake/accelerator hand controls (OT, PT, MD)
- dimmer relays/switches (OT, PT, MD)
- horn buttons (OT, PT, MD)
- wrist supports (OT, PT, MD)
- hand extensions (OT, PT, MD)
- left foot gas pedals (OT, PT, MD)
- right turn levers (OT, PT, MD)
- gear shift levers (OT, PT, MD)
- steering spinners (OT, PT, MD)
- medically necessary air conditioning unit prescribed by a physician for individuals with respiratory or cardiac problems or people who can't regulate their body temperature (MD)
- removal or placement of seats to accommodate a wheelchair (OT, PT, MD)
- installation, adjustment or placement of mirrors to overcome visual obstructions of wheelchair in vehicle (OT, PT, MD)
- raising of the roof/lowering of the floor/modifying the suspension of the vehicle to accommodate an individual riding in a wheelchair (OT, PT, MD)
- manual wheelchair tie-downs/electronic wheelchair restraints (OT, PT, MD)
- seat belt covers (OT, PT, MD, PS, PSA, LPC)
- automatic door openers (OT, PT, MD)
- Repair and maintenance of items on the authorized list above as allowable by rule.
- Temporary lease/rental of DME to allow for repair, purchase or replacement of an essential support system or while non-CLASS resources reviews the necessity of an adaptive aid for an individual. Lease/rental shall not exceed 90 days.
Funding of copayments for therapeutic services is limited to those therapeutic services available in the CLASS program. Funding of copayments for prescription medication is unavailable through the CLASS Program. Prescription medication is covered through the Vendor Drug Program administered by the Texas Health and Human Services Commission. A CLASS individual is authorized to have funding available for an unlimited number of prescriptions per month as a benefit of being a CLASS program participant.
The following forms may need to be completed as part of the request process for adaptive aids:
- Form 3598, CLASS/DBMD — Individual Transportation Plan
- Form 3621, CLASS/CFC – Individual Plan of Care
- Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation
- Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications
- Form 8605, Documentation of Completion of Purchase
- Form 8606, Individual Program Plan (IPP)