Environmental Modification 525-05-30-25

(Revised 4/1/23 ML #3723)

Purpose

The purpose of Environmental Modification Service is to modify a recipient's or family member's home (the recipient must reside in the family home) or vehicle modifications to enhance the recipient's ability to function as independently as possible in the home or family member's home.

The purpose of Environmental Modification, vehicle modifications is to enhance the recipient’s ability to access and function as independently as possible while using the recipient's primary means of transportation to accommodate the special needs of the participant.

Service Eligibility, Criteria for

The individual receiving Environmental Modification Service must meet the following service eligibility criteria:

Must be eligible for the programs of SPED, ExSPED, or Medicaid Waiver for Home and Community Based Services.
The recipient or family member must own or rent the home prior to application. If the owner of the property is someone other than the service recipient, the file must include the owner’s written approval for the modification, consistent with the property owner’s obligations pursuant to section 804(f)(3)(A) under the Fair Housing Act [42 U.S.C. 3604(f)(3)(A)] prior to the installation of the environmental modification.
The individual has a need for a safer and/or adapted environment in which to live, such as the installation of grab bars in the individual's bathroom.
The home modification must directly facilitate the applicant's/recipient's ability to complete his/her own cares independently or to receive care. It must be evident that without the home modifications, adequate care or the ability to perform self or environmental care is not possible.
The vehicle that is adapted may be owned by the individual, a family member with whom the individual lives or has consistent and ongoing contact. Payment may not be made to adapt vehicles that are owned or leased by non- family paid providers of waiver services.
Environmental Modification, vehicle modifications are adaptations or alterations to an automobile or van that is the waiver participant's primary means of transportation in order to accommodate the special needs of the participant.
Vehicle adaptations are specified by the service plan as necessary to enable the participant to integrate more fully into the community and ensure the health, welfare and safety of the participant.
The benefit outcome of the home modifications must be proportionate to the cost. Factors to consider are: the age of applicant/recipient, life expectancy, the value of the house, the applicant's/recipient's commitment to remain in the home including the family's commitment to assist.
Physical adaptations to the home required which are necessary and without which, the recipient would require institutionalization.

Limits

SPED and ExSPED costs are limited to: maximum monthly cost limit for SPED and ExSPED.

For the Waiver programs see section Environmental Modification, Scope of which cannot exceed the amount budgeted (per person) for environmental modification in the federally approved Medicaid Waiver for the State of North Dakota.

Modifications are not for routine home maintenance, (such as carpeting and/or floor repair, plumbing repair, roof repair, central air conditioning, appliance repair, electrical repair, etc.) but are to promote independence. Adaptations, which add to the total square footage of the home, are not allowed. All services shall be provided in accordance with applicable state and local building codes.

For environmental modification the dollar limit is the lesser of the highest monthly rate for the highest cost skilled nursing facility or 20% of the tax evaluation of the home. This cap may be increased as determined by legislative action. Exceptions to this service cap may be approved by program administration. The cost of the evaluation must be included in the cost estimate submitted to the department and the total cost of the modification and the assessment cannot exceed the current funding cap. If the recipient’s needs cannot be met within the allowed rate case management would explore other service options with the participant and may request a reasonable modification from program administration to exceed the cap. The case manager makes participants aware of the service cap.

Vehicle adaptations specifically excluded:

Adaptations or improvements to the vehicle that are of general utility and are not of direct medical or remedial benefit to the individual.
Purchase or lease of a vehicle; and
Regularly scheduled upkeep and maintenance of a vehicle except upkeep and maintenance of the modifications.

Funds for this service may only be accessed to meet the excess disability related expenses that are not covered through the Medicaid State Plan to maintain a recipient living in their own home or in the home of their family member.

A written recommendation by an appropriate professional is required to ensure that the home modification will meet the needs of the recipient if the estimated cost of the modification is more than $500. The cost of the assessment to provide a written recommendation is an allowable expense if the cost of the assessment is not covered under the State Plan. The cost of the evaluation must be included in the cost estimate submitted to the Department and the total cost of the modification and the assessment cannot exceed the current funding cap.

Pre-Approval Service Eligibility Determination

Environmental Modification Service requires prior approval from HCBS Program Administration. The following procedure is used in determining service eligibility:

The individual must make application for services to the HCBS Case Management Agency in their county of physical residence using "Application for Services" (SFN 1047).
The HCBS Case Management Agency will determine whether or not the need for home modification is related to the care needs of the applicant. The comprehensive assessment is used to identify functional impairments.
A visual inspection of the home is completed by the HCBS Case Manager and, whenever possible, a professional of another discipline with experience in evaluating home care needs of the elderly and disabled. They will determine if the applicant's/recipient's request for Environmental Modification Service will be of direct benefit to the applicant's self- care needs. If it is found the requested/proposed modifications will not be of direct benefit to the applicant/recipient, the Department must deny the service request following the service denial policy procedures.
If the home is in poor condition and not structurally sound, Environmental Modification will not be approved.
A summary of the applicant's/recipient's service request and the recommendation(s) resulting from the home inspection is documented in the case file records. Included in the documentation must be an explanation of the proposed home modifications and how they will enable self-care or enhance care provided by others.
Written construction bids must be obtained for any work funded under this service chapter. When the estimated cost exceeds $500.00, bids must be obtained from at least two licensed general contractors or unlicensed contractor if possible. Exceptions may be made to the two bid requirement if it can be demonstrated that there is a lack of available service providers in the area. All bids must include a breakdown of the labor AND material costs of the modifications. See section 525-05-45 for Contractor Standards.

If an unlicensed contractor is providing environmental modification the time and materials of the project may not exceed $4000.

Upon receipt of the written bid(s), the following information is sent to the HCBS program administrator: written bids, narrative explanation of the proposed work and how it will assist the applicant/recipient to complete or receive self-care, a copy of the most recent Comprehensive Assessment, and the Person Centered Plan of Care that lists Environmental Modification Service. If an exception is being requested to the two bid minimum include a written explanation of the facts supporting the request. HCBS Program Administration’s decision will be based on this information.
If the proposed Environmental Modification Service is not approved, the Case Management Agency will issue a denial notice following the procedures of denying services.
After the HCBS Case Management Agency is notified that the environmental modification project is approved, the Case Manager will assist the contractor (awarded the bid) to complete the forms required for enrollment as a Qualified Service Provider. The Authorization to Provide Services is issued to the contractor awarded the bid once the successful bidder has met the requirements of a Qualified Service Provider. The service period dates entered on the Authorization to Provide Service is the time span in which the contractor agrees to finish the project.

Upon completion of the home modification, the HCBS Case Manager and the home care professional that participated in the initial home inspection and service recommendations, will inspect the job to determine if it was completed according to the bid. If not, the HCBS program administrator must be contacted immediately. Any cost overruns are the responsibility of the contractor.
Upon completion of Environmental Modification Service, a new care plan must be completed, having deleted the reference to Environment Modification Service.

Environmental Modification, Scope of

The modifications to the home allowed within the scope of this service must be of direct and substantial benefit to the applicant's/recipient's need to perform self-care or receive care from others that cannot be met by the current physical characteristic of a part of the home.

Examples of allowable home modifications include but may not be limited to the following:

Labor and materials to widen doorways to accommodate wheelchair.
Labor and materials to install a wheelchair ramp when structural changes to the house are required.
Labor and materials to install or relocate plumbing and/or electrical systems to accommodate specialized equipment.
Labor and materials to modify a bathroom, including installation or relocation of fixtures to accommodate the individual's personal care needs.
Labor and materials to modify a kitchen to enable accessibility for independent meal preparation.
Adaptations may include the installation of ramps, and grab bars, widening of doorways, modification of bathroom facilities, or installation of specialized electric and plumbing systems, which are necessary to accommodate the medical equipment and supplies and necessary for the welfare of the recipient.

Materials Authorized for Purchase

The materials authorized for purchase must be directly related to the health and safety of the individual.