Treatment Benefits Program of Choice (POC) 13 Equipment, Home Adaptations, and Vehicle Modifications Policy

Authority

Veterans Health Care Regulations, Parts I and IV, enacted under the authority of the Department of Veterans Affairs Act (R.S.C., 1985, c. V-1)

Policy Statement/Objective

Under the authority of the Veterans Health Care Regulations, the Treatment Benefits Program provides eligible Veterans and other qualified individuals with financial support to access benefits to meet their identified health care needs. The benefits available under POC (Program of Choice) 13 ensure eligible individuals obtain approved benefits considered an appropriate response to their assessed functional health needs. Such benefits (i.e., equipment, home adaptations, and vehicle modifications) should be approved subject to a hierarchy of effective, efficient, and economical interventions that may enable the individual to function independently.

Definitions

A-line Coverage: financial support provided by the Department, which enables an individual who is granted disability entitlement (i.e., pension, award or pain and suffering compensation), to access Treatment Benefits required to address the health condition for which the disability benefit entitlement is/was granted.

Activities of Daily Living: a defined set of activities necessary for self-care, which are essential to an individual’s health and survival. Activities of daily living are eating, dressing, completing personal hygiene, toileting, and ambulating.

B-line Coverage: financial support provided by the Department to enable an eligible individual to access Treatment Benefits required in respect of any health need, to the extent that the benefit is neither available as an insured service under a provincial/territorial health care system, nor recoverable from a third party.

Functional Health Need: unmet need causing a limitation that affects an individual’s ability to function independently, as determined by a health professional assessment.

Instrumental Activities of Daily Living: activities that individuals normally do, unassisted, to live independently, within their home and community. Instrumental activities of daily living are food preparation, shopping, housekeeping, money management, home maintenance and minor repairs, medication administration and taking public transportation or driving.

Seasonal Residence: a dwelling not intended for year-round occupancy nor occupied for more than six months per year.

Policy Requirements

Eligibility Criteria

1. Eligibility for Treatment Benefits is set out in section 3 of the Veterans Health Care Regulations. Subsections 3(1) to 3(3) of the Veterans Health Care Regulations describe eligible individuals with A-line coverage.
2. A former member or serving civilian member of the Royal Canadian Mounted Police (RCMP) with entitlement to a disability pension in respect of RCMP service is eligible for Treatment Benefits in respect of their entitled condition, in accordance with a Memorandum of Understanding between the RCMP and Veterans Affairs Canada (VAC).
3. The Treatment for a Disability Benefits Entitled Condition policy sets out principles to be applied by the decision-maker when determining if a relationship exists between a Treatment Benefit and an individual’s disability benefits entitled condition.
4. Subsections 3(4) to 3(6) of the Veterans Health Care Regulations describe eligible individuals with B-line coverage. See the Requirement to Access Provincial Programs policy for more information on determining B-line coverage, including where provincial or territorial programs are not sufficient to meet an eligible individual's needs, or are not provided promptly. See the Costs Recoverable from Third Parties policy for information related to situations where the benefit cost is recoverable from a third party.
5. Where an eligible individual qualifies for both A-line and B-line coverage, VAC's funding for Treatment Benefits is considered in the following sequence:
   1. Treatment Benefits related to a disability entitled condition;
   2. Treatment Benefits for non-entitled conditions:
      1. “topping-up” of any residual amounts payable by the eligible individual after accessing benefits provided under a provincial or territorial public health system; or
      2. eligible benefits not provided by the provincial or territorial public health system.

Exceptions/Exclusions

7. Regular Force members of the Canadian Armed Forces (CAF) (i.e., still-serving) are not eligible for Treatment Benefits from VAC.
8. Some serving Reserve Force members of the CAF who are entitled to a disability benefit may be eligible to access financial support provided by VAC to acquire Treatment Benefits.
9. Individuals with eligibility for rehabilitation services through the Veterans Well-being Act only are not eligible for home adaptions or vehicle modifications.
10. Canadian Forces Income Support benefit recipients are not eligible for Treatment Benefits under the Veterans Health Care Regulations.
11. Former members of a Resistance Group (defined in subsection 2(1) of the War Veterans Allowance Act) are not eligible for any VAC benefits.

Equipment

Description of Benefit

12. Any aid, approved by the Minister, which is designed to improve the function of the user by compensating for the effects of a disease, disorder, or injury.

Qualifying Conditions and Considerations

13. Simpler, less costly equipment should be considered before more complex and costlier equipment. Where appropriate, consider rental versus purchase. The Department does not recommend purchasing used equipment.
14. Equipment may be approved if an eligible individual has a functional health need requiring the use of equipment considered appropriate to restore independent functioning.
15. The decision-maker determines the appropriate equipment that addresses the eligible individual’s functional health need based on applicable evidence and consultations.
16. The decision-maker must identify the specific equipment being approved, and the amount to be paid.
17. The amount the Department is authorized to pay is limited to the usual and customary cost of the specific equipment in the relevant geographic area, as described in the Rates Payable for Treatment Benefits policy.
18. The usual and customary costs of commonly approved equipment are listed in the benefit grids. Other equipment may be found in other POCs.
19. The decision-maker shall determine the cost normally paid in the applicable geographic area for a benefit not appearing on the benefit grid.
20. The decision-maker authorizes the cost of the equipment to the extent required to address the eligible individual’s unmet functional health need. Any amount over and above that cost (i.e., for additional features not required to address the functional health need) shall be the responsibility of the eligible individual.
21. If an eligible individual’s functional health need(s) have changed, equipment that was previously declined may again be considered for approval.
22. A benefit that was previously approved may subsequently be declined for renewal or replacement if the decision-maker determines the equipment does not meet or no longer meets the criteria for approval.
23. Equipment purchased by the Department becomes the property of the eligible individual. The Department assumes no ownership of, or legal responsibility for, the equipment.
24. It is the responsibility of the occupational therapist/other health professional/supplier to ensure that a Veteran is properly instructed in the safe use and care of the equipment.
25. As the owner of the equipment, the eligible individual, either by themselves or with assistance from a spouse or family member, caregiver, or health professional, is responsible for reasonable care of the equipment, its storage and disposal.
26. A request for home adaptations must be included as part of the request for the equipment. If the eligible individual moves, a subsequent assessment may be required regarding equipment and home adaptation requirements at the new residence.
27. Equipment should not be authorized or replaced if there is a reasonable probability that the equipment will be operated in a manner or environment that creates a risk of injury to the eligible individual or others. This would include, for example, an eligible individual with visual, cognitive, or physical disabilities that would impact safe operation.
28. When the qualified individual requires assistance to use equipment (i.e., lift, hospital bed) effectively and safely, the equipment should not to be authorized unless the individual is able to obtain assistance from a spouse, family member, caregiver, or health professional.
29. Equipment should not be approved for the sole purpose of pain management. Pain management is treated under other POCs.
30. Equipment should not be approved for an eligible individual residing in a care facility, unless the equipment is not available from, or provided by, the facility.
31. Equipment should not be approved for leisure activities/social purposes, or for reasons of comfort/convenience. This limitation does not apply to sporting equipment.
32. The Department will pay for maintenance and repairs for items not covered by a manufacturer's/supplier’s warranty, if performed by a recognized qualified professional. Reasonable service charges (i.e., shipping fees) may be paid to obtain repairs for equipment under warranty, where such charges are not covered by the warranty.

Power Mobility Equipment

33. Power mobility devices (i.e., an electric wheelchair or scooter) are to be authorized primarily for the purpose of performing activities of daily living; however, aspects of instrumental activities of daily living requiring ambulation may also be considered.
34. Power mobility equipment shall be approved to compensate for loss of ability to ambulate, not as a replacement for vehicle transportation.
35. Only one power mobility item may be approved per eligible individual. When the eligible individual’s functional health needs require an additional mobility item, manual equipment may be approved.
36. The eligible individual, a caregiver, or another responsible individual must be able to provide reasonable care of power mobility equipment, such as ensuring that it is safely stored and maintained, as well as protected from the elements. The Department is not authorized to buy storage facilities for power mobility equipment, including covered trailers; however, home adaptations to accommodate or facilitate the use of equipment may be authorized (e.g., widening a doorway).
37. If there is a requirement for modifications of the power mobility equipment, these must be included as part of the original request, unless the eligible individual has experienced a change in medical condition and/or functional status following initial request.
38. If there is a requirement to transport the power mobility equipment, and a vehicle cannot be modified to accommodate a wheelchair chair lift / scooter lift, other options not considered to be standard equipment, and which are necessitated by and support an individual’s health condition may be considered.

Ergonomic Equipment

Description of Benefit

39. Ergonomic equipment is equipment that allows for compatibility between an eligible individual and their home workstation/home study space.

Qualifying Conditions and Considerations

40. Workplace ergonomic equipment that is required in support of a disability, disorder or injury is the responsibility of the eligible individual’s employer in accordance with federal/provincial human rights legislation and the duty to accommodate".
41. A letter from the employer stating why they cannot accommodate their employee’s request may be required.
42. Ergonomic equipment may be authorized if:
    1. The eligible individual works from home, and the employer is unable to accommodate their at-home ergonomic need(s) because of undue hardship; or
    2. The eligible individual is participating in a formal course of study; all or a portion of the course work must be done online; and the individual’s established ergonomic need(s) are not being met by the existing equipment.
43. On the occasion that the costs of ergonomic equipment are not recoverable from the employer, VAC could consider authorizing payment under the Treatment Benefits Program for an individual who is deemed eligible. Similarly, when a delay exists in obtaining necessary ergonomic equipment which could place the eligible individual’s health or recovery at risk, the Department may consider coverage.
44. Self-employed individuals are responsible for ensuring that equipment used in the course of employment meets ergonomic needs. VAC will not fund ergonomic equipment for self-employed individuals.
45. Requests for VAC coverage of ergonomic equipment must be supported by a recommendation from a VAC approved Health Professional and be prescribed by the appropriate health professional, as per VAC’s POC 13 Benefit Grid.

Ergonomic Equipment Included as part of a VAC Rehabilitation Plan

46. Comprehensive guidance on the potential funding of rehabilitation services, including but not limited to ergonomic equipment, can be found in the following policy: Rehabilitation Services and Vocational Assistance Plan: Assessments, Development and Implementation.

Sporting Equipment

Description of Benefit

47. Manual equipment that allows an individual with a disability and/or specific health condition to participate in organized sports that would have required locomotor skills. Locomotor skills are physical actions that allow an individual to move from one location to another (e.g., walking, running, hopping, skipping).

Qualifying Conditions and Considerations

48. Activity-specific sport mobility equipment (e.g., sport wheelchairs, hockey sledges, adaptive ski equipment, modified bicycles) that is manual and non-motorized may be approved to facilitate an eligible individual’s participation in an organized competitive or adapted sport(s).
49. The eligible individual must:
    1. have a long-term physical limitation due to illness, injury or disability that impacts their mobility; and
    2. engage in regular performance of the sport(s), have a specific goal, and demonstrate a commitment to the sport(s) for which they require the sporting equipment.
50. The decision-maker, based on a seating and mobility evaluation from an approved health professional, should consider a device that is suitable for multiple sports if more than one sport is being played versus numerous pieces of equipment (i.e., an all-sports wheelchair).
51. Payment may be made for the transport of activity-specific sport mobility equipment in accordance with paragraph 37 of this policy.
52. Activity-specific prosthetics are considered under the Prostheses (POC 11) policy.

Home Adaptations

Description of Benefit

53. Home adaptations as a treatment benefit are those required to accommodate equipment and prosthetic appliances.

Qualifying Conditions and Considerations

54. When an individual has eligibility for home adaptations under both the Treatment Benefits program and the Veterans Independence Program, provision of home adaptations should be considered under Treatment Benefits policies and procedures first.
55. Home adaptations to accommodate storage of a surgical or prosthetic device or equipment may be authorized.
56. Safe access to, and exit from, the residence may be considered as justification for home adaptations. Modifications to a secondary entryway to the residence, sufficient to ensure safe exit in the event of an emergency (e.g., fire, medical), may be authorized.
57. The decision-maker, in consultation with a qualified professional (e.g., occupational therapist, carpenter, electrician), determines if the residence lends itself to home adaptations without major construction or enlargement; and if the home adaptations are appropriate for the condition of the property.
58. The decision-maker approves home adaptations considering the eligible individual’s functional health needs. Home adaptations are approved when the decision-maker determines such adaptations are the only intervention that will accommodate the surgical or prosthetic device or equipment or facilitate its use.
59. Proposed home adaptations must be economical. The decision-maker approves reasonable costs. Approval is to be based on the expected effectiveness in responding to the client’s needs.
60. When the eligible individual is not the owner of the property, home adaptations cannot be approved unless the property owner has expressly authorized the home adaptations (i.e., written consent provided by the property owner).
61. Home adaptations for the eligible individual’s primary residence (i.e., full time occupancy) may be covered. Home adaptations may also be covered in a seasonal residence that is owned by the eligible individual, and continuously occupied by that individual for a minimum of two months per year. Home adaptations will only be approved for one seasonal residence in the eligible individual’s lifetime. The same considerations apply to the approval of home adaptations to a seasonal residence, as to the primary residence.
62. A recreational vehicle (e.g., camper) or temporary structure is not considered either a residence, or a seasonal residence.
63. An eligible individual who purchases or constructs a residence which clearly does not meet their functional health needs is not eligible for home adaptations to that residence.
64. The Department assumes no responsibility for any part of the home adaptations. The Department is not responsible for the selection of contractors (service providers), or for oversight of the provider’s work. The Department is not liable for work undertaken by the service provider.
65. The Department is not responsible for restoring the residence to its former state upon the death or relocation of the eligible individual. If home adaptations are in progress at the time of the eligible individual’s death, the Department will consider covering a restoration of the residence to its former state or completing the unfinished work. The decision-maker will consider the advancement of the work and reasonableness of the restoration.
66. Home adaptations should not be approved for an eligible individual whose functional health needs are temporary or would be more appropriately met through admission to an assisted living facility.
67. Home adaptations cannot be approved when the only purpose for the home adaptation is to meet building codes.
68. Normal maintenance and upkeep costs for an eligible individual’s residence cannot be approved. Repairs and maintenance required as part of the normal upkeep of a home (e.g., roof repairs, sidewalk repairs, painting) are not considered home adaptations.
69. Funding for temporary accommodation while home adaptations are being completed cannot be approved.

Vehicle Modifications

Description of Benefit

70. Any system or equipment necessary to change the structure or internal design of a vehicle to enable an individual to drive or be a passenger in the vehicle.

Qualifying Conditions and Considerations

71. The decision-maker may consider instrumental activities of daily living to approve vehicle modifications.
72. Vehicle modifications must be required due to the eligible individual’s functional health needs or to accommodate equipment approved by the Department.
73. The decision-maker may approve vehicle modifications required for the eligible individual to safely enter and exit the vehicle, and/or to enable the eligible individual to operate the vehicle. Eligible expenses are those which are over and above the normal costs of owning a vehicle, and may include driver training fees and costs related to the use of simulators and other specialized equipment, as well as administrative fees and travel costs to obtain driver education training on the proper and safe use of installed driving aids.
74. Vehicle modifications cannot be approved when the eligible individual resides in a care facility if reliable transportation is provided or can be arranged by the facility.
75. When a vehicle cannot be modified to accommodate a chair lift / scooter lift, other options not considered to be standard equipment, and which are necessitated by and support an individual’s health condition may be considered.
76. A trailer cannot be approved when it is used solely as storage for power mobility equipment.
77. The decision-maker approves reasonable costs to alter a vehicle. Payment may be made for factory-installed vehicle modifications, if the eligible individual is paying a premium to have the feature included. Payment for factory-installed standard equipment will not be considered.
78. When the eligible individual is not the owner of the vehicle, vehicle modifications cannot be approved unless the vehicle owner has expressly authorized the alterations (i.e., written consent provided by the vehicle owner).
79. The decision-maker may approve vehicle modifications when an eligible individual is either the driver or passenger of the vehicle, and the vehicle is regularly used by the individual (i.e., weekly/biweekly).
80. Vehicle modifications shall not be approved when the eligible individual is a passenger in a vehicle, and the vehicle’s driver is being paid.
81. If an eligible individual is regularly a passenger in a vehicle, the decision-maker may consider alternate modes of transportation (i.e., special services for individuals with cognitive or physical disabilities) prior to approving vehicle modifications.
82. The Department is not responsible for restoring the vehicle to its former state. Vehicle modifications will remain in place upon the eligible individual’s death or disposal of the vehicle.
83. Funding for a vehicle rental while vehicle modifications are being completed cannot be approved.

Duration and Continuity

84. An individual who purchases/acquires equipment, home adaptations, or vehicle modifications before it has been determined that they are eligible for the treatment benefits, may receive payment/reimbursement for the cost once it has been determined that the equipment, home adaptation or vehicle modification is an eligible benefit in accordance with this policy. Information about time limitations that apply to such approvals may be found in the Payment Time Limits for Benefits, Services, or Care policy.
85. Refer to the Continuation of Benefits, Services and Care policy for information regarding individuals who cease to be eligible for a benefit under this policy.

Redress

86. An individual who is dissatisfied with a decision rendered under this policy may ask to have the decision reviewed in accordance with the Review of Health Care Decisions policy.

Overpayments

87. Overpayments will be addressed in accordance with the Overpayments - Health Care Programs policy.

Appendix A – References and Related Policies

Legislation

• Department of Veterans Affairs Act (R.S.C., 1985, c. V-1)
• Veterans Well-being Act
• War Veterans Allowance Act
• Veterans Health Care Regulations

Policies

• Treatment for a Disability Benefits Entitled Condition
• Requirement to Access Provincial Programs
• Costs Recoverable from Third Parties
• Rates Payable for Treatment Benefits
• Prostheses (POC 11)
• Payment Time Limits for Benefits, Services, or Care
• Continuation of Benefits, Services and Care
• Review of Health Care Decisions
• Overpayments - Health Care Programs
• Rehabilitation Services and Vocational Assistance Plan: Assessments, Development and Implementation

Benefit Grids

• Benefit Grids