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8.02 MEDICAL RESTORATION SERVICES

Introduction

Medical restoration services (physical or mental restoration) are those services designed to correct or substantially modify within a reasonable period of time a physical or medical condition which is stable or slowly progressive, and results in a substantial impediment to employability. Medical restoration services are provided to enable an individual to achieve and employment outcome by reducing or eliminating functional limitations resulting from the disability, thus lessening the impediment to employment and providing greater opportunity for vocational success.

Examples

Examples of medical restoration services include the following:

1. physicians and surgeons fees for eye treatment and medical/surgical treatment

2. surgery

3. diagnosis and treatment of mental or emotional disorders by a psychiatrist, licensed psychologist or certified psychotherapist

4. dental work

5. hospitalization for surgery or treatment including inpatient and outpatient services, room, board and special nursing services

6. drugs and supplies incidental to surgery and/or treatment

7. prosthetics or other assistive devices, including low vision devices and hearing aids

8. physical, occupational, or speech therapy

Criteria for the Provision of Medical Restoration Services

The following criteria are to be met prior to the authorization of medical restoration services:

1. eligibility for VR services

2. the physical or mental disability should be stable or slowly progressive

3. the plan for medical restoration services must be included on the IPE

4. the restoration service(s) must be expected to eliminate, substantially reduce or curb the impact of the disability within a reasonable period of time (as determined by the nature of the individual's disability, the prognosis regarding life expectancy and employability; and the individual's general health).

Prior to the provision of medical restoration services, the individual must have had a recent examination by a licensed physician or low vision specialist. In some cases, an examination within the past twelve months will suffice, e.g. for individuals with certain chronic diseases or disabilities such as controlled epilepsy, congenital defects or those from whom appliances such as orthoses or prostheses are needed. The determination as to whether or not a more recent exam is needed will be made by the counselor after consultation with the medical consultant or senior counselor

Consultation with Medical Specialists

When available, a medical consultant may be consulted during the provision of medical restoration services in order to advise and assist the counselor in planning the restoration service. If no medical consultant is available, the counselor can arrange a consultation with an appropriate medical specialist. Counselors may also request a second medical opinion when needed in order to determine the appropriateness of the medical restoration service.

Provision of Audiological Services

NYSCB will provide hearing aids to individuals who require the aid in order to function in employment. For individuals with a goal of homemaker, NYSCB will only provide hearing aids to those individuals who have hearing loss that meets the definition of severe hearing impairment (see below) as documented by an audiologist. Many individuals lose hearing as they age. This is considered to be a medical issue that must be addressed by the consumer's medical care provider. It is presumed that hearing loss becomes a rehabilitation issue when it meets the definition of severe hearing impairment. The provision of hearing aids is contingent upon the individual's economic need status unless the individual meets the definition of deafblind and is identified as being deafblind on the RSA-911.

Definition: Severe Hearing Impairment

Severe hearing impairment is defined as at least a 55db loss in the better ear, unaided, measured as an average loss in the speech range of 500, 1000 and 2000HZ or a speech discrimination score of 40% or less.

Provision of Psychological/Psychiatric Services

Psychological and psychiatric therapy may be provided to NYSCB consumers who have a mental or emotional disability that can be reduced or substantially modified through the provision of such services. However, this service is not intended to meet ongoing mental health needs. Individuals should be encouraged to use community resources that will be affordable and available after NYSCB funding for this service is completed.

Duration of Psychological Services

When psychological and psychiatric therapy is provided it must be short-term in duration, not to exceed 18 months. In all cases of psychological and psychiatric therapy, the counselor must arrange a review of the consumer's case with the senior counselor at every six month interval.

Medical Care for Acute Conditions

NYSCB may provide medical restoration services for treatment of either acute or chronic medical complications that arise out of the provision of other medical restoration services or are inherent in the condition under treatment which if not cared for would complicate or delay the rehabilitation program. If the seriousness of the complication is such that it interferes with the possibility of achieving the employment outcome, it may be necessary to re-evaluate the individual's IPE or determine that case closure is appropriate.

It is not necessary to revise the IPE to include medical care for acute conditions. However, a case note regarding the service provision must be entered into the record of service.

Provision of Dental Services

While NYSCB does not assume responsibility for a program of general dental care, dental services may be provided when the dental evaluation indicates that the condition of the teeth and gums are so severe that they will interfere with the individual's ability to achieve an employment outcome.

An evaluation of a consumer's dental condition may be indicated when the general and/or specialty medical examination reveal(s) the existence of serious maxillo-facial problems and/or diseases of the gums and teeth that may cause or aggravate problems of speech, personal appearance, personal adjustment or other specific health problems. Ordinarily, dental conditions such as caries, gum abscess or multiple extractions with the provision of dentures do not meet the criteria for provision of dental services. However, NYSCB may provide dental services if the criteria are met as a result of any of these conditions.

Selection of a Service Provider

For guidance in selecting a service provider refer to Chapter 14.00 Selection of Providers of Medical Services.

Economic Need

All medical restoration services, except low vision devices, are provided contingent upon the consumer's economic need.

Low vision devices are not contingent upon economic need.

Comparable Benefits

A full consideration of comparable benefits should be completed prior to authorizing medical restoration services.

Payment of Medical Restoration Services

If no comparable benefit is available for the payment of medical restoration services, NYSCB can purchase the service in accordance with the Medicaid Fee Schedule. For services not included in the Medicaid Fee Schedule, prior approval for the purchase must be obtained from the District Manager.