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Finding the Funds for Assistive Technology

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resource for users of Assistive Technology and service providers to identify funding strategies

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Finding the Funds for Assistive Technology

  2. 2. 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”
  3. 3. HOW MUCH DOES AT COST? From $ 0 to…100,000+
  4. 4. 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
  5. 5. PUBLIC FUNDING SOURCES • Early Intervention • Public education • Medicaid • Vocational Rehabilitation • Medicare • CHIP • TDDP
  6. 6. PRIVATE FUNDING SOURCES • Buy Outright • Use Private insurance • Approach Private foundations or charitable organizations • Get a Loan • Get it Used • Crowd funding
  7. 7. 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!
  8. 8. SCHOOL IDEA definition of AT, as well as needed SERVICES in child’s IEP
  9. 9. 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
  10. 10. 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
  11. 11. 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”
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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?)
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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?
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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/
  26. 26. 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”)
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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”)
  31. 31. “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
  32. 32. 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]
  33. 33. 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”?
  34. 34. 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!
  35. 35. 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
  36. 36. 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
  37. 37. 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 ATinfo@temple.edu
  38. 38. RESOURCES • www.aacfundinghelp.org • www.drnpa.org • www.phlp.org • www.aac-rerc.com • www.ataporg.org • www.resna.org • www.passitoncenter.org
  39. 39. “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