Current through September 21, 2024
(a) Specialized
equipment shall be functionally necessary and meet at least two of the
following criteria:
(i) Be necessary to
increase ability to perform activities of daily living or to perceive, control,
or communicate with the environment in which the person lives;
(ii) Be necessary to enable the participant
to function with greater independence and without which the person would
require institutionalization; and
(iii) Be necessary to ensure the person's
health, welfare, and safety.
(b) The individualized plan of care shall
reflect the need for equipment, how the equipment addresses health, safety, or
accessibility needs of the participant, or allows them to function with greater
independence, and include specific information on how often the equipment is
used and where it is used.
(i) The case
manager shall inquire with Medicaid, Medicare, or a participant's other
insurance carrier to see if the requested equipment is covered under their
plans.
(ii) Medicaid is a payer of
last resort, and shall not pay for specialized equipment that can be paid
through another source.
(c) Specialized equipment may include but is
not limited to:
(i) Devices, controls, or
appliances, specified in the individualized plan of care, that enable
participants to increase their ability to perform activities of daily
living;
(ii) Devices, controls, or
appliances that enable the participant to perceive, control or communicate with
the environment in which they live;
(iii) Items necessary for life support or to
address physical conditions along with the ancillary supplies and equipment
necessary to the proper functioning of such items;
(iv) Durable and non-durable medical
equipment not available under the Medicaid state plan that is necessary to
address participant functional limitations; and
(v) Necessary medical supplies not available
under the Medicaid state plan or other insurance held by the
participant.
(d) Items
reimbursed with waiver funds are in addition to medical equipment and supplies
furnished under the Medicaid state plan and exclude those items that are not of
direct medical or remedial benefit to the participant. All items shall meet
applicable standards of manufacture, design, and installation.
(e) Specialized equipment shall not include
the following, even if prescribed by a licensed health care professional:
(i) Items paid for under the Medicaid state
plan or under Early Periodic Screening, Diagnosis, and Treatment
(EPSDT);
(ii) Educational or
therapy items that are an extension of services provided by the Department of
Education;
(iii) Items of general
use that are not specific to a disability, or that would normally be available
to any child or adult, including but not limited to furniture, recliners,
desks, shelving, appliances, bedding, bean bag chairs, crayons, coloring books,
other books, games, toys, videotapes, CD players, radios, cassette players,
tape recorders, television, VCRs, DVD players, electronic games, cameras, film,
swing sets, other indoor and outdoor play equipment, trampolines, strollers,
play houses, bike helmets, bike trailers, bicycles, health club memberships,
merry-go-rounds, golf carts, four wheelers, go-carts, scooters, vehicles,
automotive parts, and motor homes;
(iv) Pools, spas, or hot tubs;
(v) Computers and computer equipment,
including the CPU, hard drive, and printers, except for situations pursuant to
(c) of this Section;
(vi) Items
that are not proven interventions through either professional peer reviews or
evidence based studies; and
(vii)
Communication items such as telephones, pagers, pre-paid minute cards and
monthly services.
(f)
Repairs on specialized equipment shall be completed by the manufacturer, if a
warranty is in place.
(g) Requests
for repairs on specialized equipment not covered by warranty may be submitted
to the Division for approval.
(h)
Sale of specialized equipment shall not profit the participant or
family.
