Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Effective for dates of service on or after August 1, 2019, some mobility aid benefits will change for Texas Medicaid.
Overview of Benefit Changes
Major changes to this medical benefit policy include the following:
- Updated benefit information for client lifts
- New benefits for overhead and fixed client lifts through the Comprehensive Care Program (CCP)
- Revised growth allowance prior authorization guidelines for wheelchairs and wheeled mobility systems
Updated Benefit Information for Client Lifts
Client lifts will no longer be required to accommodate a 20 percent change in the client’s height or weight.
In addition, client lift benefit information in the current Texas Medicaid Provider Procedures Manual, Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, will be updated for clarification as follows:
- A lift is an item of durable medical equipment (DME) that is a mechanical system used to lift or transfer a non-ambulatory client between a bed, chair, wheelchair, bedside commode, bathroom, or other location. A lift may be medically necessary to ameliorate a client’s medical condition or disability that results in impaired functional mobility impacting mobility related activities of daily living (MRADLs).
- Repair or replacement of components, such as a sling, to client-owned equipment may be a benefit as needed with documentation of medical necessity. Rental of an electric or hydraulic lift may be considered during repair of a client lift.
- Electric and hydraulic lifts that are a benefit through Title XIX Home Health Services refer to movable single-stand mechanisms, often on casters, with a lifting arm attached to a sling, and lifting power provided by a manual hydraulic pump or an electric motor.
- A client lift will not be prior authorized solely for the convenience of a caregiver. Prevention of caregiver injury or consideration of client safety during transfer due to caregiver factors, such as physical abilities, is not considered “caregiver convenience.”
- Final set up and installation costs of client lifts, including labor costs associated with ceiling or other fixed lifts, are included in the initial purchase price of the client lift and will not be separately reimbursed. Components and accessories are also considered part of the initial purchase price of a client lift. These may include, but are not limited to, the following:
- Lift motor and gear box
- Any type of sling
- Hand controls and connectors
- Carry or spreader bar, and sling attachments or straps
- Ceiling tracks or rails, and components
- All mounting hardware and brackets
- Batteries
- Charger system
- Emergency stop and lowering systems
- Lifting tape
- Wheels or castors of any type
- Installation of the fixed lift systems
New Benefits for Overhead and Fixed Client Lifts
Overhead and fixed client lifts will be considered for reimbursement through CCP for clients who are 20 years of age or younger who are CCP-eligible. Consideration must be given to the client’s medical needs (e.g., muscle tone, pain, fear, etc.), environmental factors, and caregiver abilities.
Overhead Client Lifts
The purchase of a free-standing overhead client lift (procedure code E0639) will be a benefit in the home setting when services are provided by home health DME and medical supplier (DME) providers.
An overhead lift is anticipated to last a minimum of five years but may be replaced in less than five years with documentation of medical necessity.
Delivery and labor to assemble the overhead lift are not separately reimbursed.
Prior Authorization for Overhead Client Lifts
Procedure code E0639 will require prior authorization.
A free-standing overhead lift may be considered for prior authorization when the client meets the criteria for a hydraulic or electric lift, and additional documentation explains why a hydraulic or electric lift will not meet the client’s needs. Documentation that supports the medical necessity of the requested free-standing overhead lift must include all of the following:
- A written statement from a licensed physical therapist, licensed occupational therapist, or physician that clearly outlines the client’s medical need to be transferred with a free-standing overhead lift versus a hydraulic or electric lift.
- Diagrams of the home (rooms) indicating the location where the free-standing lift will be used. Diagrams must include dimensions of the room(s) including doorways, as well as the dimensions and placement of all furnishings and equipment (i.e., hospital bed, wheelchair, bedside commode, etc.) in the room.
- A list of all equipment the lift will interact with (i.e., wheelchairs, hospital bed, therapy equipment). Documentation should clearly indicate if the client owns other mobility aids, including any type of bath chair or bath lift, and explain why those pieces of equipment are not sufficient for mobility.
Fixed Client Lifts
The purchase of a fixed client lift (procedure code E0640) will be a benefit in the home setting when services are provided by home health DME and medical supplier (DME) providers.
A fixed lift is anticipated to last a minimum of five years but may be replaced in less than five years with documentation of medical necessity.
Home modifications that are necessary for the final set up and installation of a fixed lift are not a benefit of Texas Medicaid. Suppliers must not submit claims for any structural changes or remodeling necessitated by the installation of a lift system.
Note: Home modifications are physical changes to the home to prepare the structure for the final set up and installation of the equipment.
Delivery and labor to assemble and install the fixed lift are not separately reimbursed.
Prior Authorization for Fixed Client Lifts
Procedure code E0640 will require prior authorization.
A fixed lift may be considered for prior authorization when the client meets criteria for a hydraulic or electric lift, and additional documentation explains why a hydraulic, electric, or free-standing overhead lift will not meet the client’s needs. Documentation that supports the medical necessity of the requested fixed lift must include all of the following:
- A signed and dated statement from the DME provider attesting that the home in which the lift will be installed meets the manufacturer’s requirements for installation, including documentation that the ceiling and wall structures of the residence are adequate to safely support the fixed lift.
- Documentation of whether the home is owned by the client/parent/guardian/responsible party, such as a signed and dated document attesting ownership of home. If the home is not owned by the client/parent/guardian/responsible party, written consent from the home owner or property manager must be submitted, allowing the DME company to install the lift.
- A written statement from a licensed physical therapist, licensed occupational therapist, or physician that clearly outlines the client’s medical need to be transferred with a fixed lift.
- Indication of what type of home the client lives in (i.e., traditional 1-story or 2-story home, mobile home, apartment), including the following:
- Diagrams of the home where the fixed lift system will be installed. Diagrams must include dimensions of the room(s) including doorways, as well as the dimensions and placement of all furnishings and equipment (i.e., hospital bed, wheelchair, bedside commode, etc.) in the room. Diagrams must also include the proposed placement of all fixed components (i.e., railing or track) of the system.
- A list of all equipment the lift will be used to interact with (i.e., wheelchairs, hospital bed, therapy equipment). Documentation should clearly indicate if the client owns other mobility aids, including any type of bath chair or bath lift, and explain why those pieces of equipment are not sufficient for mobility.
- Attestation from the DME provider that the provider has personnel who have been trained to install the lift system.
- Documentation confirming the home modifications necessary to allow for installation of the lift, have been done or are scheduled to be completed prior to installation.
Growth Allowance Guidelines for Wheelchairs
The requirement for wheelchairs or wheeled mobility systems to accommodate a 20 percent change in the client’s height or weight, will change to the following, which must be documented in the Wheelchair/Scooter/Stroller Seating Assessment Form:
- For clients who are 12 years of age and younger:
- The wheelchair frame must allow for at least a 3 inch growth potential in both width and depth.
- For clients who are 13 through 17 years of age:
- The wheelchair frame must allow for at least a 2 inch growth potential in both width and depth.
- For clients who are 18 years of age and older:
- The wheelchair frame must allow for at least a 1 inch growth potential in depth and 2 inches in width.
Growth allowance to the dimensions specified may be made with a frame modification or growth kit.
For more information, call the TMHP Contact Center at 800-925-9126.