(a) A specialized augmentative communication device
system (ACD), also referred to as a speech-generating device system,
is reimbursable if purchased by a program provider for a resident
and all requirements of this section are met.
(b) A program provider must request and receive authorization
from DADS before purchasing an ACD, referred to in this section as
"prior authorization." The request for prior authorization must include:
(1) an evaluation and recommendation from a licensed
speech therapist to purchase the ACD;
(2) a signed statement from the resident's attending
physician that the ACD is medically necessary for the resident to
maximize his functional communication; and
(3) a minimum of two bids for the ACD or a request
for an exception to the two-bid minimum if the recommended ACD is
available through only one vendor.
(c) The evaluation and recommendation from the licensed
speech therapist must include:
(1) a description of how the ACD will specifically
meet the needs of the resident;
(2) detailed instructions for training on the use of
the ACD for the resident, program provider staff, and resident's family
(if applicable);
(3) a diagnosis relevant to the need for the ACD; and
(4) the specific ACD being recommended.
(d) If an ACD costs more than $10,000, DADS facilitates
an independent speech language review, at DADS' expense, to determine
necessity for the ACD.
(e) After receiving prior authorization from DADS,
the program provider must purchase the ACD.
(f) To obtain reimbursement from DADS, a program provider
must submit to DADS the receipt for payment for the ACD and a copy
of the prior authorization from DADS.
(1) A program provider must fully investigate and use
funding sources to pay for an ACD before submitting the request for
reimbursement to DADS. If another funding source will pay for part
of the cost of the ACD, the program provider may request reimbursement
from DADS for the balance of the cost if the requirements in subsections
(b) and (c) of this section are met. If another funding source is
available, DADS reimburses the program provider no more than the
balance remaining after other sources are used fully.
(2) A program provider must submit the request for
reimbursement to DADS within one year after the date of purchase.
(3) DADS reimburses the amount of the authorized bid
or the balance remaining after all other sources are used fully.
(g) If DADS denies a request for reimbursement because
the program provider did not receive prior authorization or did not
submit the necessary documentation for the ACD, the program provider
is responsible for the cost of the ACD.
(h) If DADS denies a prior authorization request, the
resident may request a Medicaid fair hearing in accordance with 1
TAC Chapter 357, Subchapter A.
(i) Only the resident may use the ACD, and the program
provider must identify the ACD as the personal property of the resident.
(1) Upon discharge from the facility, the resident
must retain the ACD. If the resident dies, the ACD must be transferred
to the resident's estate. If the ACD is donated or sold to the program
provider by the resident or the resident's estate, the program provider
must document the transaction.
(2) The program provider is responsible for repairing
and maintaining the ACD while the resident resides in the facility.
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Source Note: The provisions of this §261.228 adopted to be effective August 1, 2009, 34 TexReg 4741; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127 |