Assistive Technology Funding Overview
What is Assistive Technology?
Assistive technology (AT), which includes both devices and services, is a powerful means of enabling people with disabilities to participate and to achieve independence at work, school, at home, and at play. AT goes by different names under a variety of laws, policies, and regulations. For example, in the Rehabilitation Act amendments of 1998 (Public Law 105-220), AT is called rehabilitation technology. In insurance circles, it is termed durable medical equipment (DME), and is called Home Medical Equipment (HME) by some DME suppliers. Many commonly used 'low tech' devices, as well as more sophisticated environmental controls, may be called aids for daily living. All may be considered AT. In the Assistive Technology Act of 1998, Congress defined an AT device as
" ...any item, piece of equipment or product system, whether acquired off the shelf, modified or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities" [29 U.S.C. 3002, Section 3 (a)(3)].
Put simply, AT might include any item that would enable a person to function better or more easily than he/she could without that item. It could be as simple as a piece of foam rubber taped to a pencil to make it easier to hold, or as sophisticated as a computer with Braille output, or a motorized wheelchair. The legal definition of AT service is
" ...any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive technology device."
According to the AT Act, these services include:
- Evaluation of AT needs, including a functional evaluation of the impact of the provision of appropriate AT devices and services in an individual's customary environment
- Purchasing, leasing, or otherwise providing for the acquisition of AT devices and services
- Selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing AT devices
- Coordinating and using other therapies, interventions, or services with AT services
- Training or providing technical assistance to individuals with disabilities, family members, guardians, advocates, and authorized representatives of an individual with disabilities
- Training or providing technical assistance to professionals, employers, or other individuals who provide services to or are otherwise substantially involved in the major life functions of individuals with disabilities.
Getting the Right Assistive Technology
The issue of device selection is of critical importance—both in terms of funding and in terms of its benefit to the user. The first and single most important step in obtaining AT is the completion of a thorough evaluation and assessment of the person's needs. Of course, evaluations should be done by appropriately trained/certified professionals. For instance, a person with a communication deficit might consult a speech/language pathologist (SLP). Someone who has problems with mobility might need to be evaluated by a physical or occupational therapist. Sometimes a team of clinicians needs to be involved in the decision-making process. In all cases, a person's needs have to be identified before an appropriate device or device system can be selected. Also, the information obtained during the evaluation is often the key to accessing funding for AT. Nearly all funding sources require some form of documentation of an individual's need for AT before they approve payment. For funding purposes, the most effective documentation will include an equipment justification that: a) addresses the individual's functional needs relative to the person's disabilities; and b) is based on evaluation(s) performed by one or more qualified professionals.
Funding "Rules of Thumb" for Consumers
No matter what AT funding source you pursue, the following tips will save you a lot of time and help increase your likelihood of success.
- Do Not Give Up! Persevere!
- Get your AT needs properly evaluated and documented. Most AT funding sources require documented proof of your need for the equipment or services you are requesting. An appropriately certified professional such as a doctor or therapist, or sometimes a team of professionals, may do this. The evaluation process itself will help determine which particular device(s) and services are right for you.
- Keep accurate records. Write down any disability-related services you receive. Remember to note the location, the date, and the reason for the service. You may be asked to recall or access this information several months (or even years) afterward. Keep copies of all documents related to your disability, such as prescriptions, reports of evaluations, receipts for treatments/medications, and expenses you incur that are in any way associated with your disability. Such documents may enable you to be reimbursed for equipment/services or to purchase them through Social Security Administration work incentive programs.
- Be prepared to work. Accept responsibility for locating and/or working with your AT funding source. Do not assume it is someone else's job or expect that service providers will automatically understand your needs. You know your situation best; that makes you your own best advocate.
- Keep asking questions until you understand what is expected of you and what you can expect from others. Make notes before and after the call. Gaining access to funding can sometimes be a complex process, and understanding the system greatly enhances your likelihood of success...so be determined when seeking information. If you don't quite get it, don't be ashamed to say, "I don't understand—please explain again more simply...more slowly." Most service representatives respond positively to such requests. If not, simply ask politely for someone who will. Along similar lines, precise communication is crucial. Formulate your questions before you make the call and write them down. Leave space for responses and write them in during the discussion. Even when you've carefully worded your question, it is still possible that the service representative may misunderstand. Try asking the same question another way, perhaps in simpler terms.
- Be patient and be persistent. There is no one best approach that fits every situation. The solution may involve trying several options, or combining two or more to produce the desired outcome. Keep trying, be creative, and most of all, don't give up. In many cases, particularly with insurance, negative decisions can be reversed by appeal. Simply regard the denial as a "request for additional information."
- Take a firm approach, but always be polite. Remember that agency and service representatives are people too. Treat them with the same dignity and respect that you expect from them even when they fail to assist you properly. You'll get more cooperation (and better service) that way.
- Final Rule—Don't Forget Rule #1.
Key Terms and Acronyms
Approved/authorized provider is a health care provider or AT supplier that has contracted with a health insurance company to provide services or equipment to its members.
Assignment is a signed authorization by the insured for the insurance company to pay the cost of equipment or services directly to the health care provider or equipment vendor. Assignment is particularly important when requesting funding for technology through Medicare since it is a cost reimbursement program.
Assistive technology (AT) is any device or service that is used or will assist a person with a disability to increase, maintain, or improve his/her functional capabilities. AT devices can be acquired commercially, modified, or customized. They range from simple devices like adapted eating utensils and page magnifiers to high tech devices like voice output communication devices and power wheelchairs. AT is sometimes known as durable medical equipment (DME), home medical equipment (HME), rehabilitation technology, or prosthetic devices.
Caps typically refer to annual or other limits on the frequency or dollar amount of a covered benefit.
Certificate of coverage is a document that lists the benefit that will be covered under a health insurance plan, including exclusions and limits on coverage.
Certificate of Medical Necessity (CMN) is a form required by Medicare, and sometimes by Medicaid, authorizing the use of certain DME prescribed by a physician. The CMN is completed by the physician.
Co-payment is an amount the insured must pay out-of-pocket for a specified service at the time the service is provided.
Coordination of benefits applies when a person may be insured by more than one health insurance company. In such cases, payments from the insurance companies are coordinated so that payments do not exceed the actual cost of the service or equipment.
Covered expenses refers to the type and amount of medical expenses incurred by the insured that entitle him/her to payment of benefits under a health insurance policy.
Deductible is a flat amount that the insured must pay before the health insurance plan will make any payments. The deductible amount can change each year.
Fee-for-service plans are health insurance policies under which the insurance company pays for each service as it is provided, after receiving a claim form and a bill, according to a set fee schedule.
Managed Care Organization (MCO) is an organization consisting of hospitals, doctors, and other health care providers that provides health care services to the insured for a fixed prepaid amount without regard to the frequency or extent of services provided to any one person. An MCO is also known as a Health Maintenance Organization (HMO).
Medical necessity is the standard used by health insurance companies to decide whether an insured person is entitled to certain benefits. The definition of medical necessity varies depending upon the health insurance plan.
Medicare-approved amount is the fee that Medicare decides is reasonable for a covered medical service. This is the amount that Medicare will reimburse the supplier or the insured for a service or equipment.
Out-of-pocket maximum is the maximum amount that the insured has to pay each year in co-payments and deductibles.
Participating providers are physicians and other health care providers who contract with health insurance companies and agree to accept the plan's allowable charge as full payment. An MCO or HMO may employ their own staff physicians and other health care providers.
Payment cascade is a model that illustrates the order in which multiple payment sources must be accessed.
Payor of first resort refers to the public or private health insurance carrier that has the primary responsibility to fund a particular medical service or item of AT.
Payor of last resort refers to the public or private health insurance carrier that has the responsibility to fund a particular medical service or item of AT only when all other applicable funding sources have been exhausted.
Premium is the monthly or other periodic payment an insured must make to a health insurance company for coverage.
Prior authorization refers to the requirement that approval from the insurance company is secured in advance of equipment or services being provided. The criteria for prior authorization vary depending upon the terms of the particular health insurance policy.
Rider is an addition or an amendment to an insurance policy.
