finding the funds for assistive technology
TRANSCRIPT
FINDING THE FUNDS FOR ASSISTIVE TECHNOLOGY
KIM SINGLETON, MS, CCC-SLP, DIRECTOR OF ASSISTIVE TECHNOLOGY PROGRAMS
@ THE INSTITUTE ON DISABILITIES @ TEMPLE UNIVERSITY
November 2017
PENNSYLVANIA’S INITIATIVE ON ASSISTIVE TECHNOLOGY (PIAT)
• The Commonwealth’s “AT Act” Program; a national and statewide network
• Charged with:
• ACCESS: activities designed to help people of all ages make a decision about if/what AT can help through (1)
demonstration and (2) device lending
• ACQUISITION: activities designed to help people obtain the AT they need through (1) reuse and (2) “state financing”
HOW MUCH DOES AT COST?
From $ 0 to…100,000+
WHY SHOULD YOU CARE?• “Billing” may be a job
function (Medicare;
Medicaid [ACCESS] in the
schools)
• OT’s role as an advocate
for children and families,
to obtain AT “from the
system”
• People with
disabilities/families can’t
afford high cost AT
devices on their own
• OT’s role to help people
with disabilities/families
make informed decisions
PUBLIC FUNDING SOURCES
• Early Intervention
• Public education
• Medicaid
• Vocational Rehabilitation
• Medicare
• CHIP
• TDDP
PRIVATE FUNDING SOURCES
• Buy Outright
• Use Private insurance
• Approach Private
foundations or
charitable organizations
• Get a Loan
• Get it Used
• Crowd funding
GETTING READY TO REQUEST $$
• Know what is NEEDED
• Identify potential funding sources
• Know how what is recommended fits or
meets the mandates and restrictions of
the possible funding source(s)
• For public sources: Understand whether
the funding source is an ENTITLEMENT or
an ELIGIBILITY programs
• If you are denied:
• Ask/identify the reason for the denial.
• BE PREPARED TO APPEAL!
SCHOOL
IDEA definition of AT, as well as needed
SERVICES in child’s IEP
SPECIAL FACTORS
• positive behavioral interventions
• language needs of a child with LEP
• Braille instruction as appropriate
• communication needs of a child who is
deaf/hard of hearing
consider whether the child needs [requires]
assistive technology devices and services
EARLY INTERVENTION• Early intervention 0-3; in PA administered through DHS, Office for Child Development and Early
Learning
• Includes assistive technology as a named service
• Use of AT must be in the IFSP and linked to outcomes
• Permits access to sources of funding (e.g. insurance) for AT devices and services listed in the IFSP
(differs from the “FAPE” standard)
• State funds are “last resort”, no infant/toddler may go without IFSP listed services because of inability
to pay
MEDICAID
• Authorized by Title XIX of the Social Security Act
• A health insurance program for POOR PEOPLE (income and assets)
• Regulations are complicated and are continually revised
• 30% of costs in the PA General Fund
• In PA, “MA”, Medical Assistance” or “ACCESS”…or HealthChoices…or
“School Based Access Program”
MEDICAL ASSISTANCE (MA) A FEDERAL/STATE PROGRAM
• Shared costs (formula based on
average income in the state) [PA
approx. 2.6 million recipients (2015)]
• State must follow federal rules, and
file a “state plan”
• Some flexibility left to states
regarding eligibility, co-pays, scope of
and limitation on services, how
program will be administered
• Menu of both required
(“mandatory”) and optional services
SOCIAL SECURITY (SSI) DEFINITION
A child is disabled if s/he has a medically determinable
physical or mental impairment or combination of
impairments that causes marked and severe functional
limitations and that can be expected to cause death or
has lasted or can be expected to last for a continuous
period of less than 12 months.
Marked limitations in two domains or extreme
limitation in one domain. Domains include:
• acquiring and using information
• attending and completing tasks
• interacting and relating with others
• moving about and manipulating objects
• self-care
• health and physical well-being
AT AND MEDICAID (PA)
• Assistive technology is often considered durable
medical equipment (DME) (medical in nature; not
typically useful in absence of disease; not used for
educational purposes; not used for the convenience of
others)
• Not all AT will qualify as DME
MEDICAID MANAGED CARE
• Almost all MA in PA is now delivered in a managed care model
• The “plans” (HMO/MCO) have “Special Needs Units” that may help
• The plan uses “in-network” providers
• The network must be sufficient (e.g. does the OT in the network have
expertise in AT?)
WAIVER PROGRAMS
• “medical and non-medical services designed
to help persons with disabilities and older
Pennsylvanians live independently in their
homes and communities”
• States may “waive” certain requirements to
carve out special programs (PA has more
than a dozen waivers, e.g. BAS; CommCare;
Consolidated; etc.)
• Good news: Allows states to provide
services, not otherwise furnished, to a
specific population within the state
• Bad news: Results in a fragmented system
WAIVERS
• Autism waiver
• Consolidated waiver
• Person/family directed supports
waiver
• Also: Independence waiver, others…
• Resource
• http://www.phlp.org/wp-
content/uploads/2012/08/HC
BS-Waivers-BasicFactSheet-
2012.pdf
PA MEDICAL NECESSITY• The service or benefit will…
• Prevent the onset of an illness,
condition, or disability
• Reduce or ameliorate the
physical, mental, or
developmental effects of an
illness, condition, or disability
• Assist the individual to achieve
or maintain maximum functional
capacity in performing daily
activities, taking into account
both the functional capacity of
the individual and those
functional capacities that are
appropriate for individuals of the
same age
MEET THE CRITERIA “MEDICALLY NECESSARY”
• DOCUMENT medical necessity including
the following components:
consumer’s medical condition or
disability
the functional limitation caused by
that condition or disability
how the device assists in
compensating for that functional limitation,
e.g. “reduce” or “ameliorate” the physical,
mental, or developmental limitation OR
”maintain existing function” which would
otherwise deteriorate
MEET THE CRITERIA “NOT EXPERIMENTAL”
• Is the item commonly accepted by the medical or
rehabilitation community for the purpose for which it has
been described? (evidence based practice)
• Is there some published study as to the effectiveness of the
item in addressing the functional limitation for which it has
been prescribed?
ALSO…• Address less expensive (or more expensive) alternatives that were tried, and why they
were not appropriate or adequate.
• Document the consumer’s ability to use the requested AT:
• (1) the environment can support the use
• (2) the individual has the capacity to use (especially for individuals with cognitive
disabilities)
• (3) training will be provided to assure use
GETTING AT THRU MEDICAID CONTINUED…
• Include a prescription from the doctor.
Draft or suggest language for the
physician to use in the letter of medical
necessity
ADVANTAGES TO MA FUNDING (FOR CHILDREN)
• Child “owns” device
• Eliminates issues of taking the
equipment home
• Repairs may be covered
• Replacement allowed every 3 years or
when substantial change in medical
need
• May facilitate transition (e.g. no
ownership issues)
• Note: When kids are eligible for
services through school and MA,
neither system is permitted to turn the
child down because they are eligible
under the other
FOR FUNDING THRU PA MA HEALTHCHOICES
1. Client's age
2. Client's diagnosis
3. Client's doctor’s prescription for the SGD
4. Client's speech evaluation
5. Results of trial of other assistive device(s)
6. Documentation of visual-motor skill and auditory
comprehension
7. Documentation of ability to use device independently
8. Documentation of treatment plan
9. Vendor name, provider number
10. Estimated pricing
11. Letter of Medical Necessity from physician
MEDICAID AND NURSING FACILITIES
• Nursing facilities must provide for all needs through their
“per diem” Medicaid rate
• In PA, nursing facilities may apply to DPW for additional
Medicaid funds to offset the cost of expensive SGDs (cost
greater than $5000)
• However, facilities must provide all medically necessary
devices and equipment regardless of cost and additional
funding received
• The SGD must go with the person if s/he leaves the nursing
facility
• www.drnpa.org/publications/toolkits/nursing-facility-
advocate-toolkit/
CHALLENGES WITH MEDICAID
• “Preferred providers” or “selective contracting”, “in-network” Managed Care
models (devices and services)
• Fee schedules
• Required trials when lending programs have long waiting lists (or don’t have the
item)
• Threats: co-pays; reductions in frequency/duration of service; eligibility changes
(including elimination of the “loophole”)
OFFICE OF VOCATIONAL REHABILITATION
Purpose
• To empower individuals [with disabilities] to
maximize employability, economic self-
sufficiency, independence and integration into
the workplace and community through
“comprehensive and coordinated state of the
art programs”
Eligibility
• You have a disability (physical, mental,
emotional impairment) that results in
substantial impediment to employment
• You can benefit in terms of an employment
outcome from services provided
• Vocational rehabilitation services are
necessary for you to prepare for, enter in, or
retain gainful employment
EVALUATION/EXTENDED EVAL (OVR)
• Put it in the plan (Individualized Plan for
Employment [IPE])
• Specify devices and services
• Need in job development
• Worksite accommodations
• OVR has no obligation to provide AT for
students in transition
• There may be a cost-share
• “Most Severely Disabled” receive priority
• There may be waiting lists for funding
• Note: help with denials may be available
from the Client Assistance Program
MEDICARE
• Federal health insurance benefits program
• Created by Congress in 1965 (operational in 1966)
• Sometimes called Title XVIII (for the chapter of the Social Security Act in which
the program is codified)
• www.medicare.gov/publications
PURPOSE OF MEDICARE• Reduce out-of-pocket expenses for those who qualify
• Offers basic protection against the cost of health care, but does not cover all expenses
• Medicare Eligibility
• NOT income-based
• Must have paid into social security
• 65+ or
• Persons under 65 (as of 1972, including many adults with developmental disabilities who receive SSDI on the earnings record of a
parent) receiving SSDI for longer than 24 months (“waiting period”)
“PART B” MEDICARE
• Also known as supplemental medical insurance
• Out patient services, including physician services, DME, SLP, prosthetics, orthotics, home health.
• Coordination of Benefits
• Medicare is secondary payer if you have other insurance with: auto; employer group plans; VA; Workers
Compensation; Public Health Service; Black Lung Program
• Medicare is PRIMARY payer if you also have Medical Assistance
• For MA recipients, MA may pay the Part B premium
WHAT’S COVERED IN PART B
• Services or supplies that are medically necessary:
• Prosthetic devices
• Replace all or part of the function of a
permanently inoperative or malfunctioning
external body member or internal body organ
• Artificial larynges vs SGD
• Durable Medical Equipment
• Can withstand repeated use (“durable”). Note:
Useful life of 5 years is assumed, EXCEPT when
there is a significant change in beneficiary’s
status
• Primarily and customarily used to serve a medical
purpose (more than a convenience)
• Generally not useful to an individual in the
absence of illness or injury
• Appropriate for use in the home or institution
that is used as a home (NOT a hospital or SNF,
except for in some prosthetics, orthotics, and
supplies)[place of service limitation]
THE “MEDICARE SOLUTION”
• Manufacturers developed “clones” in which the
“generic” functions were “disabled”, ”locked”, or
“turned off”; the “disabled” or “locked” features
were available for private purchase
• Steps to Procuring AAC through Medicare
• Is the item or service covered? For example:
evaluation is covered (SLP service), device may be
covered (DME), training is covered (SLP service),
repair is covered (after expiration of warranty)
• Is the provider/vendor qualified as a Medicare
provider? (e.g. SLP AAC evaluator?) NOTE: NO
fiduciary relationship between the vendor and the
evaluator is allowed!!!
• Is the beneficiary enrolled in “original” Medicare or
HMO or M+C plan? (may require prior approval or
specific forms/procedures)
• Does the vendor/manufacturer “accept
assignment”?
PRIVATE INSURANCE
• Costs
• premiums
• co-pays
• deductible
• More than 1000 different
insurers have paid for AT!
• Read Client's policy!
• Know the appeal process!
• If denied, appeal!
A “contract” between you and the insurance company (or
between Client's employer “on Client's behalf”)
If what is needed is not a “named exclusion”, GO FOR IT!
CHALLENGES IN PRIVATE INSURANCE
• Where’s the evidence?
• Limitations on scope of coverage
• In-network limitations
• Delays in getting proof of denial or non-coverage
necessary to proceed with secondary insurances
TELECOMMUNICATION DEVICE DISTRIBUTION PROGRAM
• Goal: Provide specialized telecommunications equipment free of charge to
eligible Pennsylvanians so they can access telephone services
• Eligibility: Any disability; 6 years old; have the ability to learn how to use
the equipment; LOW INCOME
• Currently, AAC for TELECOMMUNICATION may be covered for eligible
individuals, through an exceptions process
OTHER OPTIONS• Pennsylvania Assistive Technology Foundation (PATF) – low
interest cash LOANS to individuals with disabilities,
http://www.patf.us
• Veterans’ Administration
• Champus; TriCare
• Civic Organizations
• Crowd Funding
For assistance in locating other resources
for funding AAC, contact PIAT at 800-204-
7428 or [email protected]
RESOURCES• www.aacfundinghelp.org
• www.drnpa.org
• www.phlp.org
• www.aac-rerc.com
• www.ataporg.org
• www.resna.org
• www.passitoncenter.org
“TAKE AWAY” MESSAGES
• There are many potential
sources for funding AT devices
and services
• It is YOUR responsibility to help
see your recommendations
carried through (e.g. funding
obtained)
• There are resources to help
you/your client through the
funding process
• APPEAL, APPEAL, APPEAL
• Availability of funding is
dynamic; ongoing vigilance and
advocacy are needed to retain
public coverages