Medical qualifications for operators of motor vehicles

540 CMR: REGISTRY OF MOTOR VEHICLES

540 CMR 24.00: MEDICAL QUALIFICATIONS FOR OPERATORS OF MOTOR VEHICLES

Section

24.01: Purpose, Scope and Applicability 24.02: Definitions 24.03: General Requirements and Procedures 24.04: Driving Relevant Functional Impairment 24.05: Visual Standards and Procedures 24.06: Seizure and Loss of Consciousness Standards and Procedures 24.07: Cardiovascular and Respiratory Disease Standards and Procedures 24.08: Arthritis Disease Standards and Procedures 24.09: Cognitive Impairment Standard and Procedures 24.10: Driving Relevant Impairments and Individual Consideration

24.01: Purpose, Scope, and Applicability

The purpose of .00 is to promote the safety of the public and that of the licensee by providing minimum physical and mental qualification standards determined to be necessary for the safe operation of a motor vehicle. .00 is enacted pursuant to M.G.L. c. 90, § 8, as standards of fitness established by the Registrar for the operation of a motor vehicle. In adopting .00 the Registrar has consulted with the Medical Advisory Board, created by M.G.L. c. 90, § 8C. The provisions of .00 apply to all applicants and licensees for learner’s permits or licenses to operate motor vehicles in the Commonwealth of Massachusetts. Applicants or licensees for motor vehicle license classes other than class D or M licenses, may be subject to distinctive medical qualification standards set forth in 540 CMR 2.15 and 540 CMR 14.04, and such Registry policies in conjunction with .00.

24.02: Definitions

In .00, the following definitions apply:

AHA Class I: The American Heart Association (AHA) functional guidelines for classifying heart disease: patients with cardiac disease, but without resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.

AHA Class II: The American Heart Association (AHA) functional guidelines for classifying heart disease: patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.

AHA Class III: The American Heart Association (AHA) functional guidelines for classifying heart disease: patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.

AHA Class IV: The American Heart Association (AHA) functional guidelines for classifying heart disease: patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.

Bioptic Telescopic Lens: A particular system of lenses which uses magnification as the principal means of obtaining visual acuity for one eye. Such system must be afocal and suited for optical infinity.

Carrier Lens: A lens in which a telescopic device is mounted. It may or may not have a refractive correction.

Corrective Lens: A lens which corrects a refractive condition in the eye. A corrective lens, as used in .00, does not include bioptic telescopic lenses (except that a “corrective lens (B)” restriction must be imposed on any license or learner’s permit issued to a person using a bioptic telescopic lens).

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Episode: A seizure, syncope, or any other form of altered consciousness which will or may affect the safe operation of a motor vehicle.

FEV-1: The forced expiratory volume, in liters, of O2 that a person can breathe out in one second. This amount is usually expressed in liters with 4.00 liters representing the normal amount.

Functional Impairment: Any symptom of a disease or medical condition that results in full or partial decrease in any or several sensory or motor functions including but not limited to peripheral sensation of the extremities, strength, flexibility, motor planning and coordination.

Health Care Provider: A registered nurse, licensed practical nurse, physician, physician assistant, psychologist, occupational therapist, physical therapist, optometrist, ophthalmologist, osteopath or podiatrist who is a licensed health care provider under M.G.L. c. 112.

Physician: A medical doctor who is licensed to practice in the Commonwealth of Massachusetts.

O2 Saturation Level: The amount of oxygen “O2” that one vial of blood contains. This amount is usually described as a percentage with 100% representing the normal amount.

Self-care: The ability to perform the functions of daily living and of survival, such as feeding oneself, toilet functions, bathing, dressing, and so on.

24.03: General Requirements and Procedures

(1) Any licensee or applicant who is unable to meet the medical qualification standards described in .00 is not eligible to obtain or hold a learner’s permit or license. That licensee or applicant is required to report his or her medical condition to the Medical Affairs Branch of the Registry and that licensee shall voluntarily surrender his or her license or the Registry shall suspend or revoke the license, until such time as the licensee can meet the medical qualification standards of .00.

(2) Procedure. Upon Registry determination that an applicant or licensee is unable to meet the medical qualification standards of .00 or otherwise medically unfit to drive, the Registry shall deny the applicant a license or shall request that the licensee voluntarily surrender the license. (a) If an applicant is denied a license, he or she may seek an appeal before the Board of Appeals on Motor Vehicle Liability Policies and Bonds in accordance with the provisions of M.G.L. c. 90, § 28. (b) If a licensee is requested to voluntarily surrender the license, the Registry shall notify the licensee in writing that he or she has ten days from issuance of the letter to surrender the license. If the licensee does not voluntarily surrender the license, the Registry shall issue a notice to the licensee requesting that he or she attend a hearing on the matter. The licensee may bring legal representation and may present any and all written or oral testimony that he or she deems pertinent to said hearing. 1. The hearings officer shall enter a decision within ten days from the date of the hearing. Notice of the decision shall be issued to the licensee as of the date of entry of the decision. 2. If the licensee does not attend this hearing, the Registry shall conclude that the licensee has waived his or her right to a hearing and shall conclude that the licensee is unfit to operate a motor vehicle. That individual’s license shall accordingly be indefinitely revoked ten days from the date of the hearing. Notice of the decision shall be issued to the individual as of the date of entry of the decision. 3. If at any time thereafter, the individual wishes to seek reinstatement of his or her license privileges, he or she may request a hearing on the matter. 4. Any individual aggrieved by the decision may seek an appeal before the Board of Appeals on Motor Vehicle Liability Policies and Bonds in accordance with the provisions of M.G.L. c. 90, § 28.

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(3) Effect of Voluntary Surrender of License. Any licensee who elects to voluntarily surrender his or her license upon Registry request or of his or her own initiative shall have his or her license status placed on Medical Hold and shall be issued a Massachusetts identification card free of charge. If at such time the licensee wishes to resume driving, he or she must comply with the Registry’s medical clearance procedure which shall include submission of appropriate medical documentation indicating the medical qualifications to operate a motor vehicle safely and may also include a competency road examination. Upon a determination by the Registry that the individual may resume driving, the Medical Hold shall be lifted and the license shall be restored to active status. The individual must turn in his or her Massachusetts identification card in order to receive his or her license. In addition there shall be no fee for restoration of a license which was medically surrendered, except where a renewal period has elapsed between the time the license was surrendered and restored. In such circumstances, the fee imposed shall be the normal renewal fee. There shall be no reinstatement fee.

24.04: Driving Relevant Functional Impairment

(1) Driving Relevant Functional Impairment means observed or identified evidence of any functional impairment that limits a person's physical activity, or sensory or motor functions, or physical ability, or visual acuity or visual-spatial processing necessary to exercise safe control at all times over a motor vehicle, including the strength, flexibility, reflexes, sensory perception and physical coordination necessary to maintain safe control of a vehicle on the road. (a) Evidence of impaired strength includes but is not limited to: 1. the inability or diminished capacity to consistently maintain a firm grasp on or manipulate a steering wheel or driving hand controls; or 2. the inability or diminished capacity to apply consistent pressure with legs and feet to vehicle foot controls or manipulate or release vehicle foot controls; or, 3. weakness or paralysis of muscles affecting the ability to consistently maintain sitting balance or exercise safe control of a vehicle for prolonged distances. (b) Evidence of impaired flexibility includes but is not limited to rigidity or limited range of mobility in neck, torso, arms, legs or joints.

24.05: Visual Standards and Procedures

(1) Visual Acuity and Horizontal Peripheral Field of Vision Standards (Excluding Individuals Who Use Bioptic Telescopic Lenses). An individual, excluding individuals who use bioptic telescopic lenses or are registered with the Massachusetts Commission for the Blind, shall be deemed vision qualified to apply for, or continue to hold, a learner’s permit or license to operate a motor vehicle, if he or she meets the requirements in .04(3) and (4) and: (a) has a distant visual acuity of at least 20/40 (Snellen) in either eye, with or without corrective lenses, and has a combined horizontal peripheral field of vision of not less than 120°. If corrective lenses are used to meet the requirements in .04, a corrective lens restriction shall be added to the learner’s permit or license; or (b) has a distant visual acuity of between 20/50 and 20/70 (Snellen) in either eye, with or without corrective lenses, and has a combined horizontal peripheral field of vision of not less than 120°. Individuals who meet the requirements in .04 will be eligible to receive a learner’s permit or license restricted to operation during daylight hours only. Accordingly, a daylight only restriction will be added to the learner’s permit or license. This restriction may be removed if the licensee passes a night time road test. In addition, where corrective lenses are used to meet this standard, a corrective lens restriction will be added to the learner’s permit or license.

(2) Visual Acuity and Horizontal Peripheral Field of Vision Standards for Wearers of Bioptic Telescopic Lenses. Individuals who use bioptic telescopic lenses to meet the vision standards, shall be deemed vision qualified to obtain and hold a learner’s permit or license to operate class D vehicles only, provided the individuals meet the requirements of .04(3) and (4) and: (a) have a distant visual acuity of at least 20/40 (Snellen) through the telescope, at least 20/100 (Snellen) through the carrier lens, at least 20/100 (Snellen) through the other lens, and a combined horizontal peripheral field of vision of not less than 120°; and

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(b) if the bioptic telescopic lens used to meet the minimum visual standards and used while operating the motor vehicle meets all of the following criteria: 1. the telescope must be fixed focus; and 2. the telescope must be monocular (on one eye only); and 3. the magnification of the telescope must be no greater than 3x; and 4. the telescope must be spectacle mounted and an integral part of the lens; and 5. the telescope must not occlude the line of sight through the carrier lens or through the other lens. (c) the individuals pass a road examination while using the bioptic telescopic lens when such individuals are applying for a license or seeking renewal of license for the first time after being fitted with the bioptic telescopic lens. Individuals who meet this minimum standard shall be eligible to receive a learner’s permit or license restricted to operation during daylight hours only. Accordingly, all such individuals shall have a daylight only restriction put on their learner’s permit or license as well as a corrective lens restriction. The daylight only restriction may be removed if the licensee takes and passes a night time road test.

(3) Color Vision Standard. All licensees or applicants must be able to distinguish the colors red, green, and amber. If an individual cannot distinguish the colors red, green, and amber, that individual is ineligible to receive or hold a learner’s permit or a license.

(4) Vision Impairment Standard. Licensees or applicants who have unresolvable diplopia, (double vision which cannot be resolved through a suppressive device, such as an eye patch) are not eligible to receive or hold a learner’s permit or license.

(5) The Vision Test. Any licensee or applicant for a learner’s permit or license may establish his or her ability to meet the visual acuity requirements through a test administered by the Registry, with the exception of applicants or licensees who are registered with the Massachusetts Commission for the Blind or use bioptic telescopic lenses. Such applicants or licensees must submit a vision screening certificate pursuant to the requirements of .04(6).

(6) The Vision Screening Certificate. If the licensee or applicant fails the vision test administered by the Registry, declines to take the test, is registered with the Massachusetts Commission for the Blind, or wears a bioptic telescopic lens, he or she must submit a vision screening certificate to demonstrate compliance with the minimum visual standards to obtain and hold a learner’s permit or license provided that persons identified as Massachusetts Commission for the Blind registrants must also submit a letter from the Commission indicating that the individual is not presently registered with the Massachusetts Commission for the Blind. To be acceptable, the vision screening certificate must: (a) be fully completed by a physician or optometrist and the licensee or applicant; and (b) be six months old or less from the date of screening; and (c) bear the original signatures of the certifying physician or optometrist and the licensee or applicant. No photocopies will be accepted.

(7) The Registrar, or his or her designee, may require such additional evidence of the medical qualification criteria as he deems appropriate, or may modify these standards as an individual case may require.

24.06: Seizure and Loss of Consciousness Standard and Procedures

(1) Seizure and Loss of Consciousness Standard. When the Registry receives information that a licensee or applicant for a learner’s permit or license has experienced a seizure, syncope, or any other form of altered consciousness which will or may affect the safe operation of a motor vehicle, that licensee or applicant shall be deemed ineligible for a license to operate a motor vehicle. That licensee shall voluntarily surrender his or her license or the Registry shall suspend or revoke the license, until the licensee has been episode free for a minimum of six months, subject to the exception of .05(2), and the licensee or applicant submits an evaluation completed by his or her physician confirming that he or she has been free from episodes for a minimum of six months, and which states all of the following:

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(a) the cause of the episode (type of disorder suffered); and (b) the means by which the condition is controlled (including any medications and dosages); and (c) the degree of impairment or disability suffered during the episode (extent of episode); and (d) the probability of recurrence of the episode (including frequency of occurrence, degree of assurance that the event will not reoccur, and basis for estimate of probability); and (e) date of most recent episode; and (f) a certification, to a reasonable degree of medical certainty, that the individual’s medical condition and medications will not interfere with the safe operation of a motor vehicle.

(2) Exemptions From and Extensions of the Six Month Period. The Registrar or his designee may exempt an individual from the six month episode free requirement upon receipt of a certification from the physician containing all of the information specified in .05(1) and requesting that the individual be granted an exemption from the six month episode free policy because the physician has determined that the individual’s medical condition and medications will not interfere with the safe operation of a motor vehicle, with specific reasons provided for such determination. Conversely, the Registrar or his or her designee may require that a person be episode free for longer than six months prior to issuing, renewing, or reinstating a license.

(3) The Registrar, or his or her designee, may require such additional evidence of the medical qualification criteria as he or she deems appropriate, or may modify these standards as an individual case may require.

24.07: Cardiovascular and Respiratory Disease Standards and Procedures

(1) Cardiovascular Disease Standards. (a) Any licensee or applicant who is medically determined to be an AHA functional Class IV heart patient is not eligible for a learner’s permit or license. Any licensee who is an AHA functional Class IV heart patient shall voluntarily surrender his or her driver’s license, or the Registry shall suspend or revoke the license. (b) Individuals who are determined to be AHA functional Class I, II, or III are presumed safe to operate a motor vehicle and will continue to be eligible to receive or hold a learner’s permit or license until the Registry has cause to believe such individuals are unsafe to operate a motor vehicle. In instances where the Registry has cause to believe that an AHA functional Class I, II, or III heart patient is unsafe to operate a motor vehicle, the Registry may restrict, suspend, or revoke driving privileges. The Registry may, in its discretion, request the information specified in .06(2) in determining whether an AHA functional Class I, II, or III heart patient is safe to operate a motor vehicle.

(2) Change of Cardiovascular Disease Functional Status. Individuals who were formerly determined to be AHA functional Class IV heart patients and have since been re-evaluated by a physician and are now classified as an AHA functional Class I, II, or III heart patient must submit the following documentation from the physician to the Registry in order to become eligible for licensing or reinstatement of operating privileges: (a) status of the individual’s heart condition, including AHA functional class, and accompanying symptomatology; and (b) a certification, to a reasonable degree of medical certainty, that the individual is medically qualified to operate a motor vehicle safely.

(3) Implantable Cardiac Defibrillators. (a) Any individual who has an implanted cardiac defibrillator (AICD) as the result of a sudden death event is not eligible for a learner's permit, license, or renewal until six months has elapsed after such device has been implanted and submission of the certification described in .06(3)(c). Such individuals shall voluntarily surrender their license or the Registry shall suspend or revoke the license.

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(b) If at any time after implantation of an AICD for either a sudden death event or for prophylactic reasons the AICD has been appropriately triggered, whether during the initial six month period or at any time thereafter, the individual shall voluntarily surrender his or her license or the Registry shall suspend or revoke the license until such time as the individual can provide the information listed in .06(3)(c). (c) Upon completion of the six month "trigger free" period, the individual is eligible to apply for reinstatement of his or her license privileges or for initial licensure, provided he or she can submit the following information from his or her physician: 1. a description of the individual’s current heart condition, including AHA functional class and accompanying symptomatology, if any; and 2. status of the implantable cardiac defibrillator including whether the device has triggered and if so, the exact date of the last trigger; and 3. a certification from the physician that, to a reasonable degree of medical certainty, the physician has determined that the individual is asymptomatic; the device has not been triggered for at least six months; and the individual is medically qualified to operate a motor vehicle safely, with specific reasons provided for that determination.

(4) Respiratory Disease Standards- O2 Saturation Level. (a) Any licensee or applicant for a learner’s permit or license whose O2 saturation level is greater than 88% at rest or with minimal exertion, with or without supplemental oxygen, is presumed safe to operate a motor vehicle until such time as there is cause to believe that the person is unsafe to operate. (b) Any licensee or applicant whose O2 saturation level is 88% or less at rest or with minimal exertion, even with supplemental oxygen, is not eligible to receive or hold a learner’s permit or license. Licensees whose O2 saturation rate is 88% or less at rest or with minimal exertion, even with supplemental oxygen, shall voluntarily surrender their license or the Registry shall suspend or revoke the license.

(5) Change of O2 Saturation Level. Applicants or licensees whose O2 saturation level was 88% or less at rest or with minimal exertion, even with supplemental oxygen, and whose saturation level has changed to greater than 88% at rest or with minimal exertion, with or without supplemental oxygen, may be eligible to regain or obtain their licensing privileges by providing the following information from the physician to the Registry: (a) medical documentation that individual’s O2 saturation level is greater than 88% at rest or with minimal exertion; and (b) a certification that, to a reasonable degree of medical certainty, the individual is medically qualified to operate a motor vehicle safely.

(6) Respiratory Disease Standards- FEV-1 Levels (in Liters). Applicants or licensees whose FEV-1 level is 1.2 liters or less will be required to submit an O2 saturation level in order to be eligible to receive or hold a learner’s permit or license. Upon receipt of the O2 saturation level, the Registry shall use the O2 saturation level criteria set forth in .06(4) and (5) in determining license eligibility.

(7) The Registrar, or his or her designee, may require such additional evidence of the medical qualification criteria as he deems appropriate, or may modify these standards as an individual case may require.

24.08: Arthritis Disease Standard and Procedures

(1) Arthritis Disease Standard. So that an evaluation of safe driving ability can be made, any licensee or applicant for a learner's permit or license who is medically determined to have an arthritis condition which renders such individual unable to perform self care will be required to submit a written statement from the Physician which: (a) describes the status of the individual's arthritis condition, including accompanying symptomatology; and (b) contains a list of medications and dosages; and

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(c) certifies that, to a reasonable degree of medical certainty, the individual is medically qualified to operate a motor vehicle safely and that the individual's medications and dosages will not interfere with the individual's ability to operate a motor vehicle safely.

(2) The Registrar, or his or her designee, may require such additional evidence of the medical qualification criteria as he deems appropriate, or may modify these standards as an individual case may require.

24.09: Cognitive Impairment Standard and Procedures

(1) Definitions. (a) Cognitive Impairment. A Cognitive Impairment is defined as any condition that impairs any, or several, of the mental faculties of attention, perception, orientation, problem solving, sequencing, organization, comprehension, judgment, memory, reasoning, or physical action or response used by a person to understand and interact with the environment. (b) A Severe Driving Relevant Cognitive Impairment. A Severe Driving Relevant Cognitive Impairment is a significant deficit or impairment of any cause, in any of the above faculties, limiting the ability of a licensee or an applicant for a learner's permit or license to resist distraction, sustain attention, react with sufficient speed, understand the immediate driving context, refrain from impulsive responding, identify problems that arise in the driving context, and make appropriate decisions to address those problems necessary to the safe operation of a motor vehicle such that operating a motor vehicle is likely to produce an unacceptable risk to public safety.

(2) A licensee or an applicant for a license or learner's permit who is determined by a Health Care Provider to have a Severe Driving Relevant Cognitive Impairment shall be deemed ineligible for a license or permit to operate a motor vehicle.

(3) A licensee with a Severe Driving Relevant Cognitive Impairment shall voluntarily surrender his or her license or the Registry of Motor Vehicles shall suspend or revoke that license.

(4) Upon submission by a licensee, license applicant or holder of a learner's permit of an evaluation, including an assessment of cognitive function, completed by his or her health care provider as defined in M.G.L. c. 90, § 22I which confirms that the licensee, applicant or holder of a learner's permit: (a) No longer has a Severe Driving Relevant Cognitive Impairment; and (b) To a reasonable degree of medical certainty the licensee or license applicant has the cognitive capacity to safely operate a motor vehicle; and (c) Any currently prescribed medications or dosages related to cognitive function, if any, are not likely to interfere with the safe operation of a motor vehicle, then the Registry of Motor Vehicles shall determine that the licensee or applicant is eligible for licensure or to be issued a learner's permit.

(5) The Registrar, or his or her designee, may require such additional evidence of the medical qualification criteria relative to a Driving Relevant Cognitive Impairment as he or she deems appropriate.

24.10: Driving Relevant Impairments and Individual Consideration

(1) A driving relevant impairment is not based solely on age or solely on the diagnosis of a medical condition or cognitive or functional impairment, but is based on observations or evidence of the actual effect of that condition or impairment on the person's ability to safely operate a motor vehicle.

(2) A driving relevant impairment cannot be sufficiently corrected or controlled by medication, therapy, surgery, adaptive equipment, or by driving device or technique.

REGULATORY AUTHORITY

.00: M.G.L. c. 90, §§ 8 and 8c.

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