Vol. 6, No. 4 Summer 1998	Previous Issues Subscribe to AT Messenger Download PDF Viewer
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Financing Assistive Technology

AT Funding for Persons with Cognitive Disabilities

With the exception of certain dedicated benefit programs and institutional financing procedures, assistive technology (AT) funding options for persons with cognitive disabilities are similar to those that are available to people with other types of disabilities. Unfortunately, however, there is typically less awareness about the appropriate types of AT interventions for cognitive disabilities than there is about other disability types.

Generally speaking, several factors must be considered when determining the appropriate AT funding source(s) for a given device. Typical considerations are: the person's age, type and severity of disability, eligibility for state or federal government benefit programs, insurance coverage, the type of equipment needed, and the intended use of the equipment. A person's age is probably the most basic consideration. Eligibility for programs or services that pay for or include assistive devices varies with age. Some services, like public special education services and certain types of public insurance programs, are reserved for children and youth with disabilities. In contrast, the State Division of Vocational Rehabilitation (DVR) provides services to qualified working age adults with disabilities.

AT interventions that are appropriate for use by people with cognitive difficulties usually incorporate alternative ways of managing language and/or information. Examples include a wide range of devices-from simple low-tech picture boards and memory aids to computer applications to assist with learning, reading, writing or speaking. The type of equipment a person needs and the nature of its application can determine which funding option is most likely to apply. Suppose, for example, a person is unable to communicate verbally and a qualified team (which includes a speech/language pathologist) determines that a computerized augmentative/alternative communication (AAC) device is needed. Such a device may be covered by Medicaid (or private insurance-if the policy covers durable medical equipment) as long as the device's selection was based on a proper evaluation by a qualified professional and the recipient's physician prescribes it. Note that public and private insurers only cover equipment that they determine to be medically necessary. The medical necessity requirement is usually met when the selected treatment (in this case the AAC device) can restore a physical function that has been absent or significantly diminished due to a diagnosed medical condition. Many state Medicaid programs, including Delaware's, cover AAC devices. However, Medicare and some private insurance carriers have been much less responsive.

Equipment that is used exclusively to enhance learning can be difficult to obtain through insurance, which brings us to the next issue: how the device will be used. The nature of the device's application can be viewed in terms of the task (the thing the person requires assistance to do) and/or the environment in which the task is to be carried out. Currently, equipment that is used for educational purposes (e.g., to enhance reading, writing, or computational skills) may be purchased by public agencies that provide educational or independent living services. Public school special education and State Division of Mental Retardation (DMR) programs are good examples.

A similar concept applies to work-related AT applications. Say, for instance, a person needs a specially designed filing system, document organizer, or software in order to perform certain functions on the job. A wise employer may purchase the needed device(s) to retain a dedicated and productive employee who has cognitive difficulties. In fact, if the person is otherwise capable of performing the essential functions of the job (putting the need for technology aside), the employer's provision of necessary devices and other types of reasonable accommodations would be legally required under the Americans with Disabilities Act (ADA). Also note that there are significant tax advantages for employers that provide such accommodations.

Now suppose that same person, prior to locating a prospective employer, is determined to be qualified for state vocational rehabilitation (VR) services. The person and a VR counselor could identify a vocational need for one or more devices in the process of developing that person's individualized written rehabilitation plan (IWRP). To the extent that the device(s) would be required in order for the person to attain or maintain employment, the equipment should be written into the IWRP, and the VR agency would be the provider or primary payer. VR money is not, however, the only financing option in this scenario. If this person, for example, requires medically necessary equipment in order to work, the person's insurance coverage could be brought to bear. If the person receives Social Security benefits and has other earned (or unearned) income, the person may opt to finance equipment through Social Security work incentive programs. In that case, the VR counselor could assist with developing the strategy or applying for a program as needed. These alternative ways of paying for equipment are examples of "comparable benefits." It is important to note that while the VR is permitted to consider other ways of paying for equipment to implement the IWRP, the search for alternatives cannot delay the person's receipt of the equipment. Also note that for individuals who cannot work or for those whose circumstances will not permit them access to VR services, nonwork-related funds for AT are available through DVR's Independent Living program.

Next, the equipment's intended use, the person's living circumstances, insurance coverage, and eligibility for various public programs can combine in interesting ways to determine how a device may be funded. The Medicaid and Social Security-related AT funding options that exist within the DMR administrative structure itself are an excellent case in point. Funding approaches can vary based on where beneficiaries live (community- or noncommunity-based living arrangements) and how residential facilities treat residents' Social Security benefits.

Depending on the intended use of equipment, Medicaid's AT funding for DMR's Medicaid beneficiaries who reside in ICFs/MR, nursing homes, or similar types of residential facilities can be administered in one of two ways. The first way involves the facility's use of its "per diem," the lump-sum financial allotment it receives from the State Medicaid program based on the number of Medicaid beneficiaries residing in the facility. The second approach is the individual claim or "fee for service" method. At times, the appropriate application of per diems has been a point of confusion. Much of the equipment utilized in residential facilities is supposed to be paid for by the facility through its Medicaid per diem allotment. However, that is not always the case. The intended purpose of the per diem is to pay for nonexclusive services and equipment; that is, devices that are not earmarked exclusively for individual client use. For example, a manual wheelchair and an electric hospital bed may be utilized over a period of time by any number of residents throughout the facility. It is appropriate to use per diem funds for such purchases. On the other hand, some equipment may be customized for and/or intended for use by a single resident; per diem funds should not be used here. In such instances, filing an individual claim to the insurer on the beneficiary's behalf, or "protecting" (setting aside) a portion of the beneficiary's SSI benefit are the procedures of choice.

For DMR's clients who reside in the community, the Medicaid Home and Community-Based Waiver enables DMR to provide several types of AT. The Services and Standards section of the Waiver [Appendix B, section (h)] calls for the provision of "environmental modifications," which are defined as "...those physical adaptations to the home, required by the recipient's plan of care, which are necessary to ensure the health, welfare and safety of the individual, or which enable the individual to function with greater independence in the home and without which, the recipient would require institutionalization."

Finally, there are times when an individual qualifies for AT funding from more than one agency. When policies permit several possible funding sources to be applied, the involved agencies may be willing to negotiate terms for cost sharing. Given the cost-effectiveness of this approach, it is certainly worth pursuing. However, the involved parties should understand that the negotiation process should not cause delays in delivery of devices or services.