SECTION 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 §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.

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