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Insurance, Medicare and Medicaid Funding
for Assistive Technology
The health care system is a major resource of technological devices for people with disabilities. Private insurance, Medicare and Medicaid cover medical equipment, depending on the policy and patient's medical diagnosis. An often-used term is "durable medical equipment", meaning items that are intended for long-term use, such as a wheelchair. Officially, DME is defined under Part B of the Social Security Act as equipment that can withstand repeated use; is primarily and customarily used to serve a medical purpose; is generally not useful to a person in the absence of an illness or injury; and is appropriate for use in the home. All requirements of the definition must be met before an item can be considered to be durable medical equipment.
These funding sources can provide a range of devices that can be defined as assistive technology. There is a great deal of flexibility as well as confusion in this area; most insurance policies are silent about technological devices and neither the Medicare nor Medicaid rules address assistive technology. Also, the trend towards "managed care" and other medical cost-cutting moves can cloud the picture.
Insurance companies still are largely unregulated when it comes to assistive technology. Insurance plans and policies usually don't even refer to funding assistive technology devices and services, but they fund specific equipment such as wheelchairs or scooters, other medical equipment, and even things like air-conditioners, when they are medically necessary. For instance, a person with acute asthma may require an air-conditioner at home. Private insurance companies require documentation and/or prescriptions so be sure to provide them.
Private insurance companies also challenge or deny claims because the equipment costs more than what is termed "standard and customary." When this happens, call around to medical equipment dealers in your area that sell the same piece of equipment and get three quotes. You will most likely find that "standard and customary" costs considerably more than what an insurance company says it should cost, granting the policy-holder a higher reimbursement! It could mean the difference of $600 or more reimbursement if you are persistent and do your homework. (A woman who bought a used wheelchair for $1000.00 was told by her insurance provider that used wheelchairs normally cost about $150.00 in her area. She called around and got quotes of up to $1400.00 and re-submitted her claim. She was reimbursed $850.00, a typical scenario.)
Medicare is a federal health care funding program available to people older than age 65 and those younger than 65 who have been entitled to receive Social Security Disability Insurance benefits. Medicare does not use the term assistive technology (AT). AT falls under one or more Medicare categories such as durable medical equipment (DME), prosthetic devices or orthotics. All three categories are included under Medicare Part B.
Medicare coverage is limited to services that are "reasonable and necessary for the diagnosis or treatment of illness or inury or to improve the functioning of a malformed body member." This serves as the basis for Medicare's "medical necessity" test.
A beneficiary can ask for a determination of coverage in advance (ADMC) of actually purchasing durable medical equipment. This is important for customized items. Because Medicare only covers the DME you need to function in your home, the medical determination should talk about what you need for activities of daily living in your home. See this 2011 presentation, Medicare Funding of Assistive Technology for more information.
Accessing Assistive Technology, Third Edition, 2007. Written by Disability Rights California
Medicare Claims Processing Manual, Chapter 20, Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) 4-19-13. This manual may be helpful in understanding coverage under Medicare.
Affordable Care Act of 2010
While a lot is still unknown regarding this act, we do know this:
Medicaid is a joint federal/state program that provides health care services to people with low incomes. To be funded by Medicaid, assistive devices must specifically address medical problems and be prescribed by a physician, so he or she is the starting point for accessing assistive technology through Medicaid.
The physician must provide a medical diagnosis, define the technology as "medically necessary treatment" and as the least costly of treatment alternatives. This can include prosthetics, orthotics, and certain speech-language and rehabilitation services.
Complicating Medicaid is the fact that the states differ widely in the range of Medicaid services they provide. The law requires states to cover a set of "mandatory services," but also lists "optional services" which states may or may not provide through Medicaid. States also define services differently and put different cost or duration limits on services which sometimes seem arbitrary (with no or little relation to diagnosis). Still, many people have secured assistive technology through Medicaid, most commonly, augmentative communication devices.
Medicaid Waivers - Waivers are developed by individual states and may cover specialized equipment and supplies.
Preparing Letters of Medical Justification, 2006 AT Advocate Newsletter, National Assistive Technology Advocacy Project
A Practical Guide for Families and Individuals with Developmental Disabilities published by the Governor's Council on Developmental Disabilities, 2006.
Persistence in dealing with health care providers
Insurance companies, Medicare and Medicaid all have an automatic denial policy.
Never accept an initial denial as the final word. Provide whatever documentation that will support your appeal, such as a letter of medical necessity from your physician.
ATAP was established in 1997 to provide support to state AT Program members to enhance the effectiveness of AT Programs on the state and local level, and promote the national network of AT Programs. ATAP facilitates the coordination of state AT Programs nationally and provides technical assistance and support to its members. ATAP represents the needs and interests of the state AT Programs and is the national voice of the AT Programs. This organization may be able to assist in your funding research.