CurrentCareSourcePolicy N/A

Adaptive Equipment (AR PASSE)

Policy governing coverage, authorization, and documentation requirements for adaptive equipment (adaptive, therapeutic, augmentative devices, vehicle modifications, and service animals) for Arkansas PASSE Medicaid members; applies to providers requesting adaptive equipment on behalf of members in Arkansas.

Policy Summary

PayerCareSource

PolicyAdaptive Equipment (AR PASSE)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2024

Next Review DateN/A

Key ActionObtain preauthorization from CareSource before performing any vehicle modification work and include required documentation such as physician order, PCSP, and three bids for projects over $1,000.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Arkansasapplicable state

$1,0003-bids threshold

5 yearsreplacement interval

case-by-caserequests reviewed

Coverage Criteria for Adaptive Equipment

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General adaptive equipment criteria: A. Item requested is clearly documented in the member's Person-Centered Service Plan (PCSP) and is the most cost-effective way to address the disability-related need(s); B. Item is not a general utility item; C. The item or equipment will enable the member's integration in the community, prevent institutional placement, or enable participation in specialized habilitative activities; D. The item or equipment is not available under the Medicaid State Plan or comparable resources; E. A licensed medical professional who has a relationship with the member has documented medical need, including date and signature certifying the request as a medical necessity and identification of the member's need and expected benefit; F. CareSource may request specialized assessments (e.g., PT, OT, speech) when necessary to determine medical necessity; G. Requests are reviewed on a case-by-case basis and the item/service is not available through Medicaid/State Plan coverage

From General Criteria section

Vehicle Modifications

Vehicle modification-specific criteria (must meet ALL):

Vehicle ownership and provider requirements: 1) All modifications must be preauthorized and approved in writing by CareSource prior to any work; 2) Provider performing the work must meet state licensure/bonding/certification requirements and ensure work meets vehicle modification standards and state/local codes; 3) Vehicle must be owned by the member or the member's family, be for the member's use, and be the member's primary means of transportation; 4) A signed and dated physician order from a medical professional with a relationship to the member and specialized assessments if necessary must be provided; 5) Three bids/estimates are required for any modification over $1,000 or an explanation why three bids could not be obtained; 6) A certified mechanic evaluation of the vehicle's life expectancy is required if the vehicle is older than five years in relation to the modifications being made; 7) A detailed project description including estimated material and labor costs, shipping and delivery fees must be submitted; 8) If purchasing a vehicle with modifications already installed, the cost of installed modifications will be assessed against the current value and the member may not take possession prior to CareSource approval; 9) Vehicle modifications will not be replaced less than every 5 years except in extenuating circumstances and upon review by CareSource

Vehicle modifications subsection

Operating a Motor Vehicle Modifications

Criteria for modifications to allow operation of a motor vehicle (must meet ALL):

Operation-based vehicle modifications: 1) The member must possess a current, valid driver's license that lists any disability-related restrictions (if license obtained before onset of disability, it must be updated to list restrictions); 2) Safe operation of the motor vehicle must be within the member's functional ability; 3) The member must have unrestricted access to the vehicle proposed for modification; 4) The modifications must be necessary for the individual to drive the vehicle

Operation functions subsection

Service Animals

Service animal coverage considered when ALL of the following are met:

Service animal prerequisites: 1) Traditional, evidence-based alternatives have been tried and documented (examples include medication and outpatient therapy for PTSD; glucose monitoring devices; applied behavior analysis for autism; dietician education and epinephrine for severe allergies; ergonomics for wheelchair users; hearing aids/cochlear implants; surgery/eyeglasses/medication/Braille education for vision deficits); 2) Documentation must outline current status of treatment progress and barriers, specific tasks the animal will perform, how tasks will benefit the member and encourage community integration, and the risk of institutionalization without the service; 3) Three quotes are required if cost is over $1,000 or a rationale provided why three quotes could not be obtained; 4) If training is required, submit training program options, specific tasks to be taught, number and length of sessions, a quote for the complete training program, and training logs; CareSource may request video documentation and training completion documentation

Service animal subsection

CareSource will not reimburse or authorize costs associated with vehicle purchase transactions or ongoing vehicle ownership expenses. This includes down payments, monthly vehicle or lease payments, insurance costs, fines or tickets, and the purchase of warranties. Regularly scheduled vehicle maintenance and general vehicle repairs (for example: brake work, body work, tires) are not reimbursable. Additionally, CareSource does not cover purchase, installation, repair, or replacement of vehicle parts or items that are not related to the accessibility modification.

Items that are excluded under this policy include those intended primarily for utility, comfort, or convenience rather than addressing a documented disability-related functional need. Specifically, CareSource does not cover comfort, convenience, or recreational adaptations, experimental devices or devices that do not meet applicable safety standards, or items/services billed for adaptations to provider-owned vehicles. Emotional support animals are excluded, as are ongoing non-task-related expenses for animals such as regular maintenance, food, vaccinations, collars, leashes, bedding, and ongoing training beyond the initially approved training. Training for animals that lack a disposition for safe public work and costs related to travel to/from training are also not covered.

Coding and Thresholds

inv-07: 3 bids/quotes threshold

ThresholdThree bids/estimates required for any modification or item with total cost >= $1,000; if three bids cannot be obtained, provide written explanation

Documentation requiredSubmit the three bids/estimates (or rationale why three could not be obtained) as part of the project documentation

Applies toVehicle modifications and adaptive equipment purchases or installations where total cost meets or exceeds $1,000

PurposeEnsures cost-effectiveness and competitive pricing for high-cost modifications

inv-08: vehicle modification replacement interval

Replacement intervalVehicle modifications will not be replaced less than 5 years except in extenuating circumstances and upon review by CareSource

Extenuating circumstancesExceptions allowed only after review by CareSource and documentation of medical necessity or other justifying factors

Mechanic evaluationFor vehicles older than five years, submit a certified mechanic evaluation of vehicle life expectancy as part of documentation

Provider Requirements and Actions

Prior Authorization

Prior Authorization Required for Vehicle Modifications

All vehicle modifications must be preauthorized and approved in writing by CareSource prior to any work. Providers must ensure work meets vehicle modification standards and state/local codes, hold required licensure/bonding/certification, and complete work according to a documented estimate submitted to CareSource.

Provider must submit a signed and dated physician order from a treating medical professional and any required specialized assessments (e.g., physical, occupational, speech)
Vehicle must be owned by the member or member's family, intended for the member's use, and be the member's primary means of transportation
Three bids/estimates required for any modification over $1,000 or provide rationale why three could not be obtained
Evaluation of vehicle life expectancy by a certified mechanic if vehicle is older than 5 years relative to proposed modifications
Detailed project description including material and labor costs, shipping/delivery fees, and documented estimate received by CareSource
If purchasing a vehicle with preinstalled modifications, the cost of the modifications may be assessed based on current value; member/family may not take possession prior to approval
Modifications will not be replaced less than 5 years except in extenuating circumstances upon CareSource review

Documentation Required

PCSP and Medical Documentation Required

When requesting vehicle modifications, providers must document medical necessity in the member's Person-Centered Service Plan (PCSP) and include certification from a licensed medical professional with an established relationship to the member.

PCSP must clearly list the requested item/modification and demonstrate it is the most cost-effective means to address the disability-related need(s)
Medical certification must include date and signature of the licensed professional and a statement that the request is medically necessary
Documentation must identify the member's specific needs and expected benefits from the equipment/modification
CareSource may request specialized assessments (e.g., PT/OT/speech) to determine medical necessity

Documentation Required

Vehicle Modification Documentation Requirements

For vehicle modification requests, providers must submit comprehensive project documentation to support approval and payment.

Signed and dated physician order from a treating medical professional and any required specialized assessments
Three bids/estimates for modifications over $1,000 or written explanation why three bids could not be obtained
Detailed project description with estimated materials, labor, shipping and delivery costs
Documented estimate that matches work completed and confirms compliance with state/local vehicle modification codes
Certified mechanic evaluation of vehicle life expectancy if vehicle is older than 5 years, addressing suitability for proposed modifications
If authorizing transfer of equipment between vehicles, documentation that transfer is medically necessary; training on use is not considered medically necessary

Prior Authorization

Evidence-Based Alternatives Required Prior to Service Animal Approval

Before CareSource will authorize a service animal, providers must document that traditional, evidence‑based, lower‑cost alternatives were tried and failed and submit supporting documentation.

Examples of alternatives to document include medication and outpatient therapy (e.g., for PTSD), glucose monitoring devices, applied behavior analysis for autism, dietitian education and epinephrine for severe allergies, ergonomics/interface prescriptions for wheelchair users, hearing aids/cochlear implants, surgery/eyeglasses/medication/Braille education for vision deficits
CareSource may request medical records that substantiate attempted lower-cost evidence-based treatment alternatives prior to authorization
Documentation should describe current treatment status, barriers to successful treatment, and lack of progress despite alternatives

Billing Rule

Payer of Last Resort

CareSource is the payer of last resort. Providers must seek coverage from Medicaid State Plan benefits, other private insurance, vocational rehabilitation, or other available resources prior to requesting CareSource-funded adaptive equipment or vehicle modifications.

If an item or service is available under the State plan (e.g., covered durable medical equipment), that resource must be used before CareSource will consider payment
Providers should document efforts to obtain coverage from other payers and include explanations if other resources are unavailable or inapplicable

Denial Risk

Exclusions and Non‑Reimbursable Items

CareSource will not authorize or reimburse certain items and services. Providers must not bill CareSource for excluded items and should document exclusions in the member record.

Purchase down payments, monthly vehicle or lease payments, insurance costs, fines, tickets, or warranties
Regular vehicle maintenance and general vehicle repairs (e.g., brakes, body work, tires)
Purchase, installation, repair, or replacement of vehicle parts not related to accessibility modifications
Adaptation/repair/replacement costs for provider‑owned vehicles
Comfort, convenience, or recreational adaptations
Replacement or repair due to misuse, abuse, or damage from accidents (owner must insure modifications)
Experimental devices or items that do not meet applicable federal or state safety standards
Emotional support animals, attack/aggression training, training for animals that cannot safely work in public, routine maintenance or care for animals (food, shots, bedding, collars), travel to/from training, ongoing training beyond initial approved program, and damages caused by the animal

Background

Adaptive equipment is intended to enable members with behavioral health conditions or intellectual/developmental disabilities to increase, maintain, or improve functional capacity to perform daily life tasks. Examples range from enabling technology and occupational therapy devices to vehicle modifications and Personal Emergency Response Systems. The goal of such equipment is to support community integration, prevent institutional placement, and facilitate participation in habilitative activities when the device is the most cost-effective means to address the disability-related need. Requests are reviewed on a case-by-case basis and must meet documentation and medical necessity requirements, including inclusion in the member's Person-Centered Service Plan and certification by a licensed medical professional.

Definitions

inv-17: Adaptive Equipment definition

DefinitionAdaptive Equipment: A piece of equipment or product system used to increase, maintain, or improve functional capabilities of members, whether commercially purchased, modified, or customized

ScopeIncludes adaptive, therapeutic, or augmentative equipment that enables performance of daily life tasks that would not be possible otherwise

PurposeEnables increase, maintenance, or improvement in functional capacity to perform daily life tasks

inv-18: Service Animal definition

DefinitionService Animal: A dog individually trained to do work or perform tasks for the benefit of an individual with a disability

Examples of tasksAlert/assist with detection of medical issues (e.g., seizures, allergens); assist with navigation or mobility (e.g., pull a wheelchair); retrieve objects or medications; prevent or interrupt impulsive/destructive behaviors; provide balance and stability

ExclusionsSupport animals (comfort/companionship) are not considered service animals under this policy

Medical Necessity Requirements

General DME Medical Necessity

Medical necessity requires ALL of the following:

DME medical necessity: 1) Item is documented in the member's PCSP; 2) Item is the most cost-effective means to address the disability-related need; 3) Item is not a general utility item; 4) Item enables community integration or prevents institutional placement; 5) Item is not available under the State plan or other resources; 6) A licensed medical professional with a relationship to the member certifies medical necessity with date and signature and identifies the need and expected benefit; 7) CareSource may request specialized assessments as needed to determine medical necessity

General DME medical necessity

Item	Rental / Purchase Rules
Personal Emergency Response Systems (PERS)	May include assessment, purchase, installation, and monthly rental fees as part of the service; requests reviewed case-by-case and must meet medical necessity and payer-of-last-resort requirements.

Replacement Intervals

inv-21: vehicle modifications replacement interval

Typical replacement intervalVehicle modifications: typical replacement every 5 years

Review processReplacements sooner than 5 years require review and documentation of extenuating circumstances by CareSource

Related documentationSubmit mechanic evaluation of vehicle life expectancy if vehicle is older than five years when requesting modifications or replacements

Documentation Requirements

Billing Rule

Three bids/quotes (≥ $1,000) or documented rationale

Obtain three independent bids/quotes for any item or vehicle modification with total cost over $1,000 and include detailed cost estimates; if three bids cannot be obtained, provide a rationale explaining why not and include supporting assessments and orders.

Include estimated material, labor, shipping, and delivery costs in each quote.
Attach relevant physician orders and specialized assessments that support the cost and medical necessity.

Documentation Required

PCSP entry and signed medical certification required

Ensure the requested item is documented in the member's PCSP and include a dated signature from a licensed medical professional certifying medical necessity on the request.

Medical professional must identify the member's need and any expected benefit.
Signature and date are required on the certification.

Not Covered

This policy does not address or cover environmental home modifications; providers should refer to the Environmental Modification Services policy for those requests. The following categories are not covered under this adaptive equipment policy: vehicle purchase costs (including down payments, monthly payments, insurance, fines, and warranties), regular vehicle maintenance and general vehicle repairs, parts or items of a vehicle that are not related to accessibility modifications, adaptations or repairs to provider-owned vehicles, comfort or recreational adaptations, experimental or non-safety-compliant devices, and expenses related to emotional support animals or routine maintenance and supplies for service animals (for example, food, shots, collars, leads, bedding). Costs such as travel to training, training of animals unsuited for public work, and replacement necessitated by misuse or uninsured accidents are likewise not covered.

Policy Summary

PayerCareSource

PolicyAdaptive Equipment (AR PASSE)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2024

Next Review DateN/A

SourceLink

On This Page

OpenPayer

Adaptive Equipment (AR PASSE)

Coverage Criteria for Adaptive Equipment

Coding and Thresholds

Provider Requirements and Actions

Background

Definitions

Medical Necessity Requirements

Rental and Purchase Rules

Replacement Intervals

Documentation Requirements

Not Covered