CurrentCareSourcePolicy N/A

Environmental Modification Services — Arkansas PASSE

Policy governing coverage, requirements, and exclusions for environmental modifications to a member's home under the Arkansas PASSE program; affects members requesting home adaptations and providers/contractors performing those modifications.

Policy Summary

PayerCareSource

PolicyEnvironmental Modification Services — Arkansas PASSE

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2024

Next Review DateN/A

Key ActionSubmit full documentation including assessment, medical necessity statement signed within 6 months, contractor bids if > $1,000, and property owner permission before work begins.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>$1,000Bid threshold

6 monthsMedical necessity recency

licensedContractor requirement

requiredProperty permission

Coverage Criteria

Covered criteria

Policy Summary

PayerCareSource

PolicyEnvironmental Modification Services — Arkansas PASSE

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2024

Next Review DateN/A

Key ActionSubmit full documentation including assessment, medical necessity statement signed within 6 months, contractor bids if > $1,000, and property owner permission before work begins.

SourceLink

On This Page

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Core medical necessity: Modification is necessary for the member's health, welfare, and safety or without the modification the member would require institutionalization.

Assessment of prior interventions: Assessment documents any assistive devices, therapies, prior modifications, or other interventions the member has attempted and whether those interventions were successful or unsuccessful.

Functional need and expected benefit: Assessment demonstrates the requested modification will meet the member's physical needs, will support safe performance of ADLs/IADLs, and will increase, maintain, or improve the member's functional capabilities that would not be possible otherwise.

Care coordinator determination: Care coordinator has determined there are no additional benefits or community resources (private insurance, Medicaid State Plan, Division of Rehabilitation Services, or other resources) that can cover the identified modification; PASSE is payer of last resort.

Medical necessity statement and order: A statement of medical necessity from a licensed medical professional, documented within the last 6 months, including a signed order for the modification, is provided.statement within 6 months

Project scope and compliance: Identification of materials, expected outcomes, time for project completion, labor and materials, and assurance that work will comply with applicable state and local building codes and the Americans with Disabilities Act (ADA).

Licensed contractor requirement: All environmental modifications must be completed by a licensed, qualified contractor (general, residential, or building) in accordance with Arkansas law; builder-grade materials are included except where specific materials are identified and stylistic upgrades are the member's responsibility.

Property authorization: Proof of home ownership or written permission from the property/homeowner must be documented prior to modification.

Bids for larger projects: Two construction bids must be included when the modification exceeds $1,000 unless a waiver is granted on a case‑by‑case basis.>$1,000

The following situations are not covered and may result in claim denial: maintenance or regular wear-and-tear of an environmental modification (including damage caused by provider staff) — once completed, ongoing maintenance is the homeowner’s responsibility; modifications for temporary medical conditions expected to resolve; adding to the square footage of the home or relocating a room (e.g., relocating a bathroom); and utility or aesthetic changes that do not provide a direct medical or habilitative benefit (for example, carpeting, central air conditioning, or general home repairs).

Requests for swimming pools, hot tubs, landscaping, ponds, paint or flooring in areas not directly modified, items intended for diversion or recreation, and residents in federally funded housing programs are excluded. Payments for room and board, monthly rent, or mortgage expenses are also not reimbursable under this policy.

Modifications or repairs performed for purely cosmetic reasons or that are general in nature and do not provide a specific medical or habilitative benefit are not covered. In addition, Durable Medical Equipment (DME) previously denied for lack of medical necessity under the member’s medical benefit will not be covered as an environmental modification.

CareSource will review requests case-by-case, but services that duplicate benefits available through private insurance, the Medicaid State Plan, the Division of Rehabilitation Services, or other resources (including programs under the Rehabilitation Act or IDEA) are not covered by PASSE; the PASSE program is the payer of last resort and coverage requires documentation that other coverage is unavailable and the service is medically necessary.

Coding and Key Requirements

inv-04: Construction bid threshold

Threshold> $1,000 — two construction bids required

WaiverRequirement for two bids may be waived on a case-by-case basis

Documentation placementInclude both bids with prior authorization/assessment packet before work begins

inv-05: Medical necessity recency

Recency requirementStatement of medical necessity must be documented within the last 6 months

SignerMust be from a licensed medical professional with a signed order

Timing for submissionMedical necessity statement included with the pre-service documentation before modification begins

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization (pre-service) is required for all environmental modification requests. These requests are considered standard and require submission of full documentation prior to modification work beginning. Failure to obtain prior authorization may result in denial of payment.

Submit full clinical assessment and documentation before work begins
Environmental modification requests are standard prior authorization requests

Note

Prior Attempts / Conservative Measures

The assessment must document prior attempts and conservative measures. Include any assistive devices, therapies, home modifications, or other interventions the member has tried, and state whether each was successful or unsuccessful.

List prior devices, therapies, or modifications attempted and outcomes
Care Coordinator determination that no other benefits or community resources can cover the modification

Documentation Required

Required Documentation

Complete documentation must be submitted with the prior authorization request. ALL of the following are required: assessment, prior interventions, statement of medical necessity, homeowner/property owner permission, and bids when applicable.

Comprehensive assessment showing how the modification meets physical needs and supports ADLs/IADLs
Statement of medical necessity from a licensed medical professional dated within the last 6 months and a signed order for the modification
Proof of home ownership or written permission from homeowner/property owner; for rentals, owner authorization and liability release
Identification of materials, labor, time for project completion, expected outcomes, and assurance of compliance with local building codes and ADA
Two construction bids if modification exceeds $1,000 (waiver considered case-by-case)
Modifications must be completed by a licensed, qualified contractor per state law and building codes

Denial Risk

Triggers for Denial

Requests may be denied if required evidence or permissions are missing, or the requested modification is excluded. Common triggers for denial include absent documentation of medical necessity, no proof of homeowner/property owner permission, inclusion of excluded or cosmetic items, temporary-condition modifications, or missing contractor/licensing information.

Missing or insufficient statement of medical necessity or signed order
No documentation of prior conservative measures or unsuccessful interventions
No written permission from homeowner or property owner for permanent fixtures or structural work
Requests for items excluded from coverage (cosmetic, recreational, routine maintenance, pools/hot tubs, landscaping, paint not part of direct modification)
Failure to provide required bids when cost exceeds $1,000 (unless waived)
Modifications not performed by licensed/qualified contractors or noncompliant with local codes/ADA

Definitions

inv-11: Environmental Modification definition

DefinitionA necessary modification(s) to a member's home that ensures the health, welfare, and safety of that member or that enables the member to function with greater independence, and without which the member would require institutionalization.

Purpose examplesIncludes adaptations such as ramps, widened doorways, bathroom modifications, specialized electrical/plumbing for medical equipment, and fencing to prevent elopement (examples listed in policy background).

OutcomeIntended to prevent institutionalization by supporting independent functioning and safety at home

inv-12: Person-Centered Service Plan (PCSP)

DefinitionA member's total plan of care made in the member, specific member needs, member strengths, and a crisis plan.

Role in authorizationPCSP lists services and supports (including NCSS) used to prevent or avoid institutionalization and documents needs/strengths

Connection to IAPCSP content is informed by the Independent Assessment identifying functional deficits

inv-13: Nonmedical Community Supports and Services (NCSS)

DefinitionSupports and services nonmedical in nature, available under federal or state authority and listed on the PCSP to prevent entry into or assist a member in leaving an institutional setting; need is established by functional deficits on the Independent Assessment.

AuthorityAvailable under federal authority (sections 1905, 1915(c)) or state authority (Act 775)

IntegrationNCSS listed on the PCSP and used to support community living as alternatives to institutionalization

Background

Environmental modification services are home adaptations installed to ensure a member’s health, welfare, and safety or to enable greater independent functioning; without them the member may require institutionalization. Examples include installation of wheelchair ramps, widening doorways, bathroom modifications, specialized electrical or plumbing for medical equipment, sidewalks or pads, and fencing to prevent elopement or wandering. These modifications are intended to enhance a member’s quality of life and support safe performance of activities of daily living.