Title: Section 69-10.10 - Prior Approval Requests for Assistive Technology
69-10.10 Prior Approval Requests for Assistive Technology (AT).
(a) A request for AT, as defined in section 69-10.1 of this Subpart, will be considered to include a request for AT services, which is assistance provided to the enrollee in the selection, acquisition, and use of the appropriate AT device and necessary training of the enrollee, the enrollee's informal supports, and any paid staff who provide assistance to the enrollee at a time when he or she will be using the AT.
(b) Providers of AT to enrollees of the Fund must meet one of the following qualifications:
(1) be approved as provider pursuant to 18 NYCRR Part 504;
(2) be a provider of AT services to the Home and Community Based Services Waiver Program administered by the New York State Office for Persons with Developmental Disabilities or, if the enrollee lives in the District of Columbia or a state other than New York, be a provider for a similar waiver program in the district or other state;
(3) be a licensed and registered pharmacist;
(4) be a Durable Medical Equipment (DME) provider; or
(5) for Personal Emergency Response Systems (PERS), be an approved PERS provider with existing contracts with Local Social Services Districts, or if provided in another state, or the District of Columbia be approved by the appropriate state agency in that state or in the District of Columbia.
(c) A person or organization providing assessments must be:
(1) a New York State Acces-VR approved provider of rehabilitation technology or the equivalent in another state;
(2) a present or former Independent Living Skills Trainer for one or more of New York State's Home and Community Based Services Waivers; or
(3) another professional who is knowledgeable about the full range of devices and/or technology available to assist individuals with disabilities.
(d) Any AT device or supply requested from the Fund must meet standards established by Underwriters Laboratory and/or comply with any applicable Federal Communications Commission requirements, if applicable. Any AT that would constitute a fixture in the enrollee's residence or on the premises of the residence must meet any applicable ADA, Fair Housing Act, or other safety standards or guidelines that apply.
(e) A request for an AT must include:
(1) a written statement from the enrollee's treating physician on the physician's letterhead explaining why the requested AT is medically necessary, including how the specific equipment being requested will meet the needs and goals of the enrollee in terms of maintaining, increasing or improving his or her functional capacities in a safe, efficient, and reasonably cost effective manner;
(2) copies of all assessments made to determine the necessary AT, including an assessment of the enrollee's unique functional needs and the intended purpose and expected use of the requested AT. Any assessment submitted must include:
(i) information about the individual's expressed needs and preferences, functional limitations and prognosis;
(ii) information about the environment in and circumstances under which the AT will be used;
(iii) the basis for selecting the particular AT being requested, including advantages over other options, how it addresses the enrollee's functional limitations, how it meets the enrollee's needs safely, maintenance expenses, and cost/benefits;
(iv) a description of the alternatives to the particular AT that were considered, including a comparison of features, future expansion or adaptation capabilities, the safety of the enrollee, the overall cost, and the reliability, and if less than three options were considered, the reason for considering less than three must be provided; and
(v) a written explanation of why the AT requested was chosen.
(f) Once the request has been reviewed by the Fund Administrator, the Fund Administrator shall notify the enrollee or person authorized to act on the enrollee's behalf in writing which services or items have been approved and/or denied and inform the enrollee or person authorized to act on the enrollee's behalf of the bidding process that is required prior to the Fund Administrator approving payment for the requested AT. The enrollee or person authorized to act on the enrollee's behalf is then required to obtain a minimum of three acceptable bids from qualified providers for the particular AT requested, except as provided in subdivision (i) of this section.
(g) If the enrollee or person authorized to act on the enrollee's behalf obtains less than three bids for the requested AT, a written explanation of why three acceptable bids were not obtained must be provided as well as a written explanation of how the determination was made that the one or two bids being considered are reasonably priced.
(h) If the two lowest bids are within ten percent of each other, the enrollee or his or her legally authorized representative may choose one of the two lowest bids. If there is more than a ten percent difference between the two lowest
bids, the Fund Administrator shall choose the bid that represents the best overall value for the Fund and the enrollee based on factors including not only the price offered by each bidder but also the quality, durability, extent of any warranties provided, and safety of the product itself. The successful bidder will be notified after the Fund Administrator or a designee of the Fund Administrator (1) discusses the bids received with the enrollee or the person authorized to act on the enrollee's behalf and why a particular bid is chosen by the Fund Administrator and (2) obtains the consent of the enrollee or the person authorized to act on the enrollee's behalf to purchase that particular AT. If the enrollee or person authorized to act on behalf of the enrollee disagrees with the Fund Administrator's decision, the enrollee or person authorized to act for the enrollee can request a review of the Fund Administrator's decision.
(i) If the enrollee or the enrollee's authorized representative is able to obtain the AT equipment for less than twenty-five hundred dollars ($2,500), the enrollee or the enrollee's authorized representative may submit documentation showing the prices from three different suppliers of the AT equipment in lieu of obtaining formal bids from such suppliers, and the Fund Administrator will pay the lowest of the three prices. Documentation may include copies of catalog pages, webpages or price lists.
(j) Cost-effective repairs may be allowed. Items that wear out as a result of normal wear and tear (for example, keyboards and switches) may be replaced by submitting a request stating the item that needs to be replaced, the reason the item needs to be replaced, and two or more estimates for the repair. If appropriate, approval for repairs will be made contingent on development of a plan to minimize future loss or damage.
(k) Except for AT equipment priced pursuant to subdivision (i) of this section, payment for the AT equipment cannot be more than the wholesale cost of the equipment plus fifty percent. If deemed appropriate by the Fund Administrator, the cost of a one year maintenance contract for the AT also may be paid for by the Fund. Repairs, including the installation of replacement parts, will be paid for at full cost.
(1) In addition to the cost of AT equipment, payment for AT equipment shall include the cost of the assessment required by subdivision (c) of this section and the cost of the evaluation of required bids if the Fund Administrator finds it necessary to engage an outside expert.
VOLUME A-1a (Title 10)