| (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 §19.1306
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 §19.416
of this chapter (relating to Personal Property).
(n) As required by §19.2601(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.
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| Source Note: The provisions of this §554.2614 adopted to be effective May 1, 2008, 33 TexReg 3301; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871 |
