(a) Purpose. This section details the requirements for receiving reimbursement for the provision of, or the performance of a major modification to, a wheeled mobility system. This section implements Texas Human Resources Code §32.0425.
(b) Definitions. The following words and terms when used in this section have the following meanings, unless the context clearly indicates otherwise.
  (1) Occupational therapist (OT)--A person licensed by the Texas Board of Occupational Therapy Examiners to practice occupational therapy, as defined in Texas Occupations Code §454.002(4) (relating to Definitions).
  (2) Physical therapist (PT)--A person licensed by the Texas Board of Physical Therapy Examiners to practice physical therapy, as defined in §354.1121 of this subchapter (relating to Definitions).
  (3) Qualified rehabilitation professional (QRP)--A person who holds one or more of the following certifications:
    (A) a certification as an assistive technology professional or a rehabilitation engineering technologist issued by, and in good standing with, the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA);
    (B) a certification as a seating and mobility specialist issued by, and in good standing with, RESNA; or
    (C) a certification as a certified rehabilitation technology supplier issued by, and in good standing with, the National Registry of Rehabilitation Technology Suppliers (NRRTS).
  (4) Wheeled Mobility System--An item of durable medical equipment (DME) that is a customized powered or manual mobility device or a feature or component of the device, including:
    (A) seated positioning components;
    (B) powered or manual seating options;
    (C) specialty driving controls;
    (D) multiple adjustment frame;
    (E) nonstandard performance options; and
    (F) other complex or specialized components.
(c) Roles and responsibilities. The following persons, when referenced in this section, shall have the following roles in the provision of, or the performance of a major modification to, a wheeled mobility system, unless the context clearly indicates otherwise.
  (1) The OT is responsible for completing the clinical assessment of a recipient required for obtaining a wheeled mobility system. The assessment must include detailed documentation of medical need for specific mobility or seating equipment and all necessary accessories.
  (2) The PT is responsible for completing the clinical assessment of a recipient required for obtaining a wheeled mobility system. The assessment must include detailed documentation of medical need for specific mobility or seating equipment and all necessary accessories.
  (3) The QRP is required to:
    (A) be present for and involved in the clinical assessment of the recipient;
    (B) be present at the time of delivery of the wheeled mobility system to direct the fitting of the wheeled mobility system to ensure that the system is appropriate for the recipient; and
    (C) verify that the wheeled mobility system functions correctly relative to the recipient.
  (4) A person that is licensed as an OT or a PT, and is also certified as a QRP, may perform either the role of the therapist or the QRP during the clinical assessment of the recipient, but cannot serve in both roles at the same time.
(d) Benefit. Wheeled mobility systems are a covered home health services benefit when the following criteria are met.
  (1) All the requirements for DME, as detailed in §354.1039 of this division (relating to Benefits and Limitations of Home Health Services) are met.
  (2) The wheeled mobility system is provided by an enrolled DME supplier that directly employs or contracts with a QRP.
  (3) An enrolled DME supplier obtains prior authorization for a wheeled mobility system from HHSC.
(e) Prior authorization requirements. The following documentation must be submitted in a manner approved by HHSC to obtain prior authorization for a wheeled mobility system.
  (1) A signed and dated physician's or allowed practitioner's prescription, or other such documentation as directed by HHSC, that details a wheeled mobility system, including all necessary components the recipient needs.
  (2) A clinical assessment that includes detailed documentation of medical need for specific mobility or seating equipment and all necessary accessories, signed and dated by an OT or PT authorized to perform the assessment.
  (3) Documentation in a form or manner directed by HHSC attesting that a QRP was present for and involved in the clinical assessment of the recipient.
  (4) Any other documentation deemed necessary by HHSC to adequately explain the medical necessity of the requested equipment.
(f) Requirements for reimbursement. Reimbursement for the provision of, or the performance of a major modification to, a wheeled mobility system will be considered only when:
  (1) the system is delivered to a recipient by a Medicaid-enrolled DME provider that directly employs or contracts with, a QRP, and the QRP was present and involved in the clinical assessment of the recipient for the requested wheeled mobility system; and
  (2) at the time the wheeled mobility system is delivered to the recipient, the QRP is present and responsible for:
    (A) directing the fitting to ensure that the system is appropriate for the recipient; and
    (B) verifying that the system functions correctly relative to the recipient.
(g) Documentation requirements for reimbursement. The following documentation must be submitted by the enrolled DME supplier with the claim for consideration of reimbursement for a wheeled mobility system in a manner approved by HHSC.
  (1) A signed and dated HHSC DME Certification and Receipt Form as required in §354.1185 of this subchapter (relating to Provider Compliance with Durable Medical Equipment (DME) Certification Requirements).
  (2) Documentation in a form and manner as directed by HHSC attesting that a QRP was present at the time of delivery and:
    (A) directed the fitting of the wheeled mobility system to ensure that the system was appropriate for the recipient; and
    (B) verified that the wheeled mobility system functions correctly relative to the recipient.
(h) Effective dates for services provided. The provisions of this section apply to the following services:
  (1) wheeled mobility systems delivered on or after September 1, 2011;
  (2) a major modification to a wheeled mobility system provided on or after September 1, 2011; and
  (3) QRP functions, including participating in a clinical assessment of a recipient and directing the fitting of a wheeled mobility system, related to the provision of, or a major modification to, a wheeled mobility system when:
    (A) the wheeled mobility system is delivered on or after September 1, 2011; and
    (B) the QRP functions are performed after the effective date of the associated rates as determined by HHSC.

Source Note: The provisions of this §354.1040 adopted to be effective February 3, 2011, 36 TexReg 407; amended to be effective September 21, 2022, 47 TexReg 5779