CurrentWyoming Department of HealthPolicy N/A

Environmental Modifications and Specialized Equipment for Medicaid Home and Community-Based Waiver Services

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Requirements for Wyoming Medicaid coverage, authorization, documentation, and limitations for environmental modifications and specialized equipment provided to participants under the Comprehensive and Supports DD Waivers.

Policy Summary

PayerWyoming Department of Health

PolicyEnvironmental Modifications and Specialized Equipment for Medicaid Home and Community-Based Waiver Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain Division prior authorization and a qualified professional recommendation before purchasing specialized equipment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 of 3Minimum qualifying criteria

$20,000Environmental modification lifetime cap

$2,000/yearSpecialized equipment annual cap

20%

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CurrentWyoming Department of HealthPolicy N/A

Environmental Modifications and Specialized Equipment for Medicaid Home and Community-Based Waiver Services

Customize your policy alerts

Sign up for all Wyoming Department of Health policy alerts

Know when Wyoming Department of Health releases new policies or updates existing guidance.

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Policy Summary

PayerWyoming Department of Health

PolicyEnvironmental Modifications and Specialized Equipment for Medicaid Home and Community-Based Waiver Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain Division prior authorization and a qualified professional recommendation before purchasing specialized equipment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 of 3Minimum qualifying criteria

$20,000Environmental modification lifetime cap

$2,000/yearSpecialized equipment annual cap

20%

Maximum equipment markup

5 yearsElectronic technology replacement interval

Covered Services and General Limitations

Environmental Modifications

Covered when all applicable requirements are met and at least two of the following criteria are satisfied:

Environmental modification coverage

At least 2 of 3 criteria
- Functional necessity: Be functionally necessary.
- Home and institutional-avoidance support: Contribute to the participant's ability to remain in or return to the participant's home and out of an ICF/IID or other institutional setting.
- Health, welfare, and safety: Be necessary to ensure the participant's health, welfare, and safety.

Specialized Equipment

Covered when all applicable requirements are met and at least two of the following criteria are satisfied:

Specialized equipment coverage

At least 2 of 3 criteria
- Activities of daily living or environmental interaction: Be necessary to increase the participant's ability to perform activities of daily living or to perceive, control, or communicate with the environment in which the participant lives.
- Independence or institutionalization prevention: Be necessary to enable the participant to function with greater independence and, without the equipment, the participant would require institutionalization.
- Health, welfare, and safety: Be necessary to ensure the participant's health, welfare, and safety.

Environmental modifications are not covered when they provide general utility or primarily benefit caregivers or family members rather than the participant, or when they lack a direct medical or functional benefit. Excluded examples include carpeting, roof repair or replacement, central air conditioning, new or repaired carports, porches, patios, garages, porticos or decks, pools, spas, hot tubs, landscaping, new-construction costs, added square footage except for qualifying bathroom modifications, window replacements, structural-component repairs or replacement, and modifications costing more than the residence’s pre-modification value.

Adaptations are not covered when they are available through another responsible source, including a state independent living center or vocational rehabilitation provider. The waiver does not duplicate coverage available from those sources.

Specialized equipment is excluded when it is paid under the Medicaid state plan or EPSDT, or when it is an educational or therapy item that extends services provided by the Department of Education. Excluded items also include general-use furniture, appliances, bedding, recreational items, vehicles and similar items; pools, spas and hot tubs; computers and computer equipment except qualifying specialized situations; items without professional peer-review or evidence-based support; and telephones, pagers, prepaid minute cards and monthly communication services.

Coverage requires a participant-specific medical or functional need. The modification or equipment must directly benefit the participant and address a disability-related functional limitation, health, safety, accessibility, independence or institutional-avoidance need; items primarily intended for general convenience do not qualify. Environmental modifications must meet at least 2 of 3 criteria: functional necessity, support for remaining in or returning to the home rather than an institutional setting, and the participant’s health, welfare and safety. Specialized equipment must also meet at least 2 of 3 criteria: improving activities of daily living or interaction with the living environment, enabling greater independence and avoiding institutionalization, and addressing health, welfare and safety.

Authorization, Documentation, and Denial Risks

Prior Authorization

Division Authorization for Environmental Modifications

The plan of care team may request environmental modifications during the six-month or annual plan of care meeting, or at another time when significant health, safety, or access concerns are identified. The case manager must submit the request to the Division through the individualized plan of care service authorization process.

Submit the overall project scope and required supporting documentation to the Division.
Environmental modifications must meet at least two applicable Section 4(a) criteria.

Prior Authorization

Prior Authorization Required

Specialized equipment requires prior authorization from the Division before purchase. The request must also include a recommendation from a therapist or other professional with expertise in the area of need.

The recommendation must address functional need, home use, independence, accessibility, health, or safety.
The Division may review the quote and functional necessity with appropriate professionals.

Policy Context

The policy supports individuals with intellectual or developmental disabilities who need environmental modifications or specialized equipment to remain in or return to their homes rather than enter an ICF/IID or another institutional setting. Covered supports address participant-specific functional limitations, activities of daily living, communication or environmental control, accessibility, independence, and health or safety.

Key Terms

Case manager

DefinitionAn individual who provides case management services, as established in Chapter 45, Section 9.

Relative

DefinitionA participant's biological, step, or adoptive parent or parents.

Functional Qualification Criteria

Specialized Equipment Functional Criteria

Specialized equipment shall be functionally necessary and meet at least two of the following criteria:

Specialized equipment medical necessity

Activities of daily living or environmental interaction: Be necessary to increase the participant's ability to perform activities of daily living or to perceive, control, or communicate with the environment in which the participant lives.
Independence or institutionalization prevention: Be necessary to enable the participant to function with greater independence and, without the equipment, the participant would require institutionalization.
Health, welfare, and safety: Be necessary to ensure the participant's health, welfare, and safety.

Purchase Requirements

Equipment	Purchase rule	Applicable purchase requirements
Specialized equipment	Purchase through the Division approval process; prior authorization is required before purchase.	A therapist or qualified professional must recommend the equipment. Submit two purchase quotes with a maximum 20% markup; justified expert assembly and training costs may be listed separately. If two quotes cannot be obtained, explain why only one was submitted. Purchases may not exceed $2,000 per year unless an Extraordinary Care Committee exception is approved. The Division may require documentation that a less expensive, comparable alternative is unavailable or impractical.

Replacement Frequency

Electronic technology devices

Replacement frequencyElectronic technology devices are allowed only once every five years; like items may not be purchased during those five years.

ExceptionAugmentative and alternative communication devices are exempt from the five-year limitation when accompanied by a letter of necessity from a Speech Language Pathologist.

Required Supporting Records

Documentation Required

Document equipment use and participant-specific need

The individualized plan of care must describe the equipment need, how it addresses the participant’s health, safety, accessibility, or independence needs, and how often and where it will be used.

Documentation Required

Document payer-of-last-resort review

The case manager must inquire with Medicaid, Medicare, and the participant’s other insurance carriers to determine whether the requested equipment is covered. Medicaid is the payer of last resort and will not pay for equipment available through another source.

Documentation Required

Obtain a qualified professional recommendation

A therapist or professional with expertise in the area of need must recommend the equipment. The recommendation must address functional need, home use, independence, accessibility, health and safety, the participant’s capability to use the equipment, delivery, training, payer-of-last-resort status, and purchase quotes.

Excluded Items and Services

The following are not covered: items paid under the Medicaid state plan or EPSDT; items available from another payer or source; general-use furniture, appliances, bedding, recreational items, vehicles and similar non-disability-specific items; pools, spas and hot tubs; computers and computer equipment except qualifying specialized situations; items without professional peer-review or evidence-based support; telephones, pagers, prepaid minute cards and monthly communication services; insurance for specialized equipment; and environmental modifications for general maintenance, convenience of others, or enhancement of a provider-owned or provider-leased home.

Policy Summary

PayerWyoming Department of Health

PolicyEnvironmental Modifications and Specialized Equipment for Medicaid Home and Community-Based Waiver Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain Division prior authorization and a qualified professional recommendation before purchasing specialized equipment.

SourceLink

On This Page

Unsupported block type: documentation

Unsupported block type: prior_auth

Documentation Required

Verify Completion

After the environmental modification is completed, the provider must have the homeowner sign the original quote verifying completion and submit the signed quote to the participant's case manager.

The Division or its representative may conduct an on-site review to confirm completion as described in the original quote.
Report homeowner concerns to the case manager, who must notify the Division.

Documentation Required

Specialized Equipment Clinical Documentation

The recommendation for specialized equipment must be prepared by a therapist or professional with expertise in the area of need and must establish the equipment's participant-specific functional necessity.

Describe the functional need and how the equipment supports remaining at or returning home.
Explain how it increases independence and decreases the need for other services.
Address accessibility, health, and safety needs; the participant's capability to use the equipment; delivery; and training.
Document that the waiver is the payer of last resort and specify how often and where the equipment will be used.

Billing Rule

Specialized Equipment Quote Requirements

The request must include two purchase quotes for specialized equipment. Each quote must include a maximum equipment markup of 20%; allowable additional costs must be separately described and justified.

Quotes may include detailed costs for expert assembly in addition to the 20% markup.
Quotes may include detailed costs for training in addition to the 20% markup.
If two quotes cannot be obtained, explain why only one was submitted; the Division may review the request.

Documentation Required

IEP or IFSP Documentation

If the participant has an Individualized Education Plan (IEP) or Individual Family Service Plan (IFSP), the case manager must submit a copy with documentation explaining why the equipment is not sent home with the participant or why it is necessary at home but not at school.

Address educational or early-intervention responsibility directly.
Include the IEP or IFSP documentation with the specialized equipment request.

Denial Risk

Participant-Specific Necessity Required

Environmental modifications are at risk of denial when they are generally useful, primarily benefit caregivers or family members, or lack a direct medical or functional benefit to the participant.

Show that the modification is functionally necessary and participant-specific.
Connect the modification to the participant's ability to remain at or return home and to health, welfare, safety, independence, or accessibility.

Denial Risk

Excluded or Excessive Home Modifications

Environmental modifications are not covered when they are excluded by the policy, exceed the permitted scope, or are not qualifying improvements.

Excluded examples include carpeting, roof repair or replacement, central air conditioning, new or repaired carports, porches, patios, garages, porticos, decks, pools, spas, hot tubs, landscaping, pest extermination, and window replacement.
Do not include new-construction costs, added square footage except the specified bathroom modification, or structural building repairs or replacement.
The modification cost may not exceed the pre-modification value of the residence, and adaptations covered by another source are excluded.

Denial Risk

Rental Property Requirements

For a rented or leased home, the modification must be an extraordinary alteration uniquely needed by the participant and not ordinarily the property owner's responsibility. Written homeowner or landlord approval is required.

Limit the modification to the minimum necessary to meet the participant's functional requirements.
Do not purchase adaptations that add value to a home owned or leased by a waiver-service provider.
The homeowner remains responsible for general maintenance.

Denial Risk

No Provider Property Value Increase

A participant may not purchase home accessibility adaptations that add value to a residence owned or leased by a provider of waiver services.

Confirm property ownership or lease status before submitting the request.
Provider-owned or provider-leased home improvements that increase property value are not allowed.

Denial Risk

Reasonable Cost and Lifetime Cap

The Division may deny environmental modification requests that exceed usual and customary charges or industry standards. Environmental modifications have a $20,000 lifetime cap per family, regardless of waiver.

The cap applies to purchases made after July 1, 2013, including purchases under previous Wyoming waivers.
Critical health or safety requests exceeding the lifetime cap require available funding and Extraordinary Care Committee approval.
A relative provider may quote the work only if the case manager also includes one quote from a non-relative certified provider.
Providers must be Division-certified, and work must comply with state or local building codes.

Denial Risk

Specialized Equipment Exclusions and Duplication

Specialized equipment is not covered when it is duplicative, generally useful rather than disability-specific, or unsupported as a proven intervention. Waiver funding is also secondary to other available coverage.

Check Medicaid, Medicare, and other insurance first; Medicaid is the payer of last resort.
Items paid under the Medicaid state plan or EPSDT, or educational or therapy items extending Department of Education services, are excluded.
General-use items and numerous household, recreational, transportation, and consumer items are excluded.
Pools, spas, hot tubs, most computers and computer equipment, and communication services are excluded unless a stated policy exception applies.
Items must be supported by professional peer review or evidence-based studies; repairs under warranty must be completed by the manufacturer.

Denial Risk

Cost-Effective Alternative Available

The Division may deny the requested equipment or supplies when a less costly comparable alternative is available, or may approve only the less expensive alternative.

Be prepared to show why the requested item is necessary instead of a lower-cost comparable option.
The Division may request documentation that the alternative is unavailable or impractical.

Denial Risk

Annual and Replacement Limits

Specialized equipment purchases may not exceed $2,000 per year. If necessary equipment exceeds that amount, the team may request an exception through the Extraordinary Care Committee.

The Division may require a Certified Specialized Equipment professional assessment; the assessment cost counts toward the $2,000 cap.
Electronic technology devices are generally allowed only once every five years, and like items may not be purchased during that period.
Augmentative and alternative communication devices are exempt from the five-year limit when accompanied by a Speech Language Pathologist's letter of necessity.
Insurance for equipment is not covered by the waiver.

Environmental Modification Functional Criteria

Environmental modifications must satisfy at least two of the following criteria. The Division may require an on-site assessment to verify that at least two criteria are met and to evaluate the proposed modification and cost.

Environmental modification medical necessity

Functional necessity: Be functionally necessary.
Home and institutional-avoidance support: Contribute to the participant's ability to remain in or return to the participant's home and out of an ICF/IID or other institutional setting.
Health, welfare, and safety: Be necessary to ensure the participant's health, welfare, and safety.