Assessing Student's Needs for Assistive Technology (ASNAT)

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Chapter 10 – Funding Assistive Technology primarily and customarily used to serve a medical purpose, is generally not useful to a person in the absence of illness or injury, and is appropriate for use in the home. Examples of equipment covered include internal prosthetic devices, external braces, and artificial limbs or eyes. For more information, download Medicare, Managed Care and AAC Devices, a joint project between Assistive Technology Funding & Systems Change Project at the United Cerebral Palsy Associations and National Assistive Technology Advocacy Project http://www.nls.org/medihmo.htm Social Security Benefits In 1990 the U.S. Supreme Court (Zebley v. Sullivan) found that the childhood disability determination process used by Social Security was illegal. The law now provides that Supplemental Security Income (SSI) is available to children with serious disabilities, as based on functional assessments. Because of this ruling, children can be any age, even newborn. Family income is a factor in eligibility, but value of house, land, vehicle, personal and household belongings, pensions, and work property are exempt. In addition, Social Security Disability Insurance (SSDI) and Plan for Achieving Self-Support (PASS) can be a source of funding for some children. There are no age requirements, but PASS is most appropriate for students over 15. PASS allows a person with a disability to work, but set aside a portion of their earnings so that they are still eligible for SSI (or so they can receive higher payments). The money set aside must be used for job related expenses such as a job coach, attendant care, transportation, or assistive technology. TEFRA, the Tax Equity and Fiscal Responsibility Act of 1982, makes children, infants through age six, eligible for assistance. TEFRA provides coverage for children deemed diagnostically eligible, using SSI definition, but who would be financially ineligible for SSI due to parental income. Children must meet medical necessity requirements for institutional care; however, the technology can be used to help maintain the child at home. Private Health Insurance Private insurance companies represent a major source of third party funding. Because they are private, their coverage varies a great deal. In 1978, over 1200 separate companies provided group hospital coverage to 88 million Americans and covered almost 100 million people for surgical services and doctors visits. They also wrote individual insurance health policies for 21 million people and surgical policies for 10 million (Hofmann, 1989). Those numbers have grown since that time. Coverage for a computer or dedicated augmentative communication device by a private insurance company depends on the terms of the individual policy and its interpretation. Policies specifically mentioning "prosthetic services and supplies" are more likely to cover augmentative communication devices or other assistive technology than those that do not. The specific areas covered by the individual policy are the critical factor in seeking funding from private health insurance. Remember that the use of insurance cannot result in any cost to the family. And it cannot be required of the family to seek to use their insurance. It must be strictly voluntary. In general, funding an assistive technology device through private health insurance will require a doctor's prescription, supported by a funding justification prepared by someone working with the family. The justification must explain how the device is a covered service, and it must describe the medical need for the device, just as is required by Medicaid and Medicare. It is not unusual for the request to be denied initially, although appeals may lead to a reversal of an adverse decision. Sadler (1996) recommends approaching all applicable insurance carriers simultaneously to avoid delays. Assessing Students’ Needs for Assistive Technology (2004) 248
Chapter 10 – Funding Assistive Technology Steps to Securing Funding Pressman (1987) recommends the following steps when you attempt to secure funding from a third party payer. 1. Locate an advisor who can support and guide you through the funding maze. This may be a social worker, therapist, vocational rehabilitation counselor, or virtually anyone who has knowledge and is willing to help you with jargon and paperwork. 2. Begin collecting information that will help you figure out where to submit your first request. If the family has private medical insurance that is the place to start, if the family is willing. Work together with the family to complete and submit the appropriate forms. 3. Get a good technology evaluation. Be sure you are asking for the best and most appropriate device for your need. A computer search through a database such as AbleData or a call to your Regional AT Consultant can help assure that you have explored all of the possibilities. 4. When making the request, make sure that you build in training and ongoing support, if funds will be needed for those, and set aside some money for software and a small contingency fund for repairs. 5. Use the right words when developing the justification. Medical Assistance does not fund based upon "educational need". 6. Be prepared for at least one denial, and be ready to make an appeal. A significant number of denials are overturned. 7. Include written information about the device for which you are seeking funding. Claim adjusters may know nothing about the device you need. The heart of your application is the cover letter that explains exactly what you are requesting and why. The remainder of the packet that you will submit will be copies of evaluations and reports that support your request. Generally, the letter should contain the following information (Reed, 1991): ♦ A description of the child with age, diagnosis, prognosis (what is expected to happen), and his or her current level of functioning. ♦ An explanation of how the device will help. What the assistive technology will allow the child to do, its purpose (communication, recreation, vocational, homework, or some combination of these). Describe the settings in which it will be used and the advantages of this particular device. Be sure to explain why a cheaper device will not work. Include the total cost with shipping, support needs, software, additional parts, repair, etc. ♦ A chronological history of the evaluations that led to this conclusion. (Be sure to attach copies of those evaluations.) Include a doctor’s examination and evaluations by speech/language pathologists, occupational therapists, physical therapists, psychologists, or teachers. Be sure you include the disciplines that work directly with the device you are requesting. ♦ End with an explanation of why the request is being made to this particular funding source. Explain the family financial situation, other funding sources that have been tried or exhausted and why some funding sources are not available to you. Cohen (1987) points out that the wording of the letter is crucial. Subtleties in terminology are extremely important. A computer can be a "prosthetic device meeting basic medical needs" or a device which "enhances employment potential". It all depends on how you describe it. If at all possible, it often helps to end the letter with a picture of the child using the device for which you are seeking funding. Assessing Students’ Needs for Assistive Technology (2004) 249
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