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Kimberley M. Erickson M.S.
Jefferson County Public Schools School
202 Kipling Building #3
Lakewood, CO 80026
Voice (303) 239-6075
The awareness of assistive technology for individuals with disabilities has steadily increased over the last ten years by human service professionals. People with disabilities, family members and human service professionals have come to realize the benefits of assistive technology. Still many devices remain expensive and funding for the devices seem to be a major barrier. Some state agencies and programs have been embracing funding for this new technology, while others have been denying these services to their customers. This presentation will focus on the rights and responsibility for funding assistive technology through Medicaid. First you must understand who is eligible for Medicaid and how to utilize the definitions to support the request for funding assistive technology.
The definition for assistive technology devices and services are as follows:
Assistive technology device is "any piece of equipment or product system whether acquired commercially or off the shelf, modified, or customized that is used to increase, maintain or improve functional capabilities of individuals with disabilities."
Assistive technology services is "any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive technology device including evaluation, purchasing or leasing, selecting, designing, fitting, customizing, maintaining, repairing, coordination with other services and therapies, and training or technical assistance."
The purpose of Medicaid is "To enable states, as far as practicable under the conditions in such state, to furnish: 1) Medical assistance for eligible individuals; and 2) Rehabilitation and other services for independence or self care" (42 U.S.C. Section 1369) Most state Medicaid programs do not use the definition for assistive technology, therefore you must be familiar with the definitions of rehabilitation services, prosthetic, devices, and durable medical equipment.
Each state has discretion in determining which groups their Medicaid programs will cover and the financial criteria for Medicaid eligibility. For a state to be eligible for federal funds, they must provide Medicaid coverage for most individuals who receive federally assisted income maintenance payments.
"Categorically needy" includes recipients of Aid to Families with Dependent Children (AFDC),
Supplemental Security Income (SSI), recipients of adoption assistance and foster care, infants born to Medicaid-eligible pregnant women and other similar programs determined by the State.
"Medically needy" is an optional program that allows States to extend Medicaid eligibility to additional qualified persons who may have too much income to qualify under the mandatory or optional categorically needy groups. It allows individuals to spend down income for medical and/or remedial care expenses to qualify for Medicaid.
Rehabilitative Services is defined as any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his or her practice under State law, for maximum reduction of physical or mental disability and restoration of a recipient to his best possible functional level. 42 C.F.R. Section 440.130(d) Included in rehabilitation services is Home Health Services. Home health services are provided to the recipient at their place of residence and on their physicians' orders. These services as defined by 42 C.F.R. Section 440.70 include a) nursing services (required); b) home health aid services (required); c) medical supplies and equipment (required); and d) therapy (optional).
Any necessary supplies and equipment are included in the definitions of occupational therapy, physical therapy and services for individuals with speech, hearing and language disorders. 42 C.F.R. Section 440.110 (c)(1) Many states also provide "prosthetic devices" which is defined as replacement, corrective, or supportive devices prescribed by physician or other practitioner of the healing arts to (1) artificially replace a missing portion of the body; (2) prevent or correct physical deformity or malfunctions; or (3) support a weak or deformed portion of the body. 42 C.F.R. Section 440.120(c)
Another service provided under Medicaid is Preventive Services. These services are provided by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law to a) prevent disease, disability, and other health conditions or their progression; b) prolong life; and c) promote physical and mental health and efficiency. Additionally under federal regulation 42 C.F.R. Section 440.110, physical and occupational therapy services can be provided. The services are prescribed by a physician and provided to recipient by or under the directions of a qualified therapist. It includes any necessary supplies and equipment. Supplies and equipment could include assistive technology devices. The same federal regulation provides services for individuals with speech, hearing, and language disorders. These services include a) diagnostics; b) screening; and c) preventive and corrective services. Again this includes any necessary supplies and equipment.
Finally, under Medicaid is the Early and Periodic Screening, Diagnostic, and Treatment (E.P.S.D.T) program. E.P.S.D.T. is Medicaid's comprehensive and preventative children's health care program geared toward early assessment of children's health care needs through periodic examinations. The goal is to assure that health problems are diagnosed and treated as early as possible, before the problems become complex and treatment more costly. E.P.S.D.T. provides necessary health care, diagnostic services, treatment, and other measures described in subsection (a) of this section (42 U.S.C. 1396d(a)) to correct or ameliorate, defects and physical and mental illness and conditions discovered by mental illness and conditions discovered by the screening services, whether or not such services are covered under the State Plan. In other words, children who are identified as needing services under E.P.S.D.T. are entitled to the full range of services available from Medicaid whether the individual state plan subscribes to them or not. Assistive technology devices and services can be purchased under this section.
While Medicaid services must have a medical bases federal law 42 U.S.C 1996b(c) states that treatment of educationally related services is not restricted. This means that if a device is also used in an educational setting, that does not restrict
Medicaid from paying for it or the related services. This regulation is very important to States and school districts that want to seek reimbursement for school-based health and health related services.
School health services play a very important role in the health care of children. Whether Medicaid reimbursable services are offered to children with special needs under the Individuals with Disabilities Education Act (IDEA), or for routine preventive care, on-going primary care through school-based clinics, school operated health programs are often able to provide medical care efficiently and easily without extended absences from school. The Medicaid programs in many states have been supportive of school based health care as effective methods of providing access to essential medical care to Medicaid eligible children. Remember that Medicaid is a partnership between the state and federal government where local school districts can seek at least 50% reimbursement for health and health related services. The following types of services are services that school districts may provide that are reimbursable under Medicaid; diagnostic services, rehabilitative services, casemanagement, nursing services, transportation, durable medical equipment, clinic services, physical therapy, occupational therapy and services for individuals with speech, hearing and language disorders. Again, school-based health care is an efficient method in providing necessary medical care to Medicaid-eligible children and youth. For schools, the Medicaid program presents an opportunity for funding medical services provided to children both under and apart from IDEA.
Funding assistive technology can be a frustrating experience for families and service providers. It is critical that those individuals who are trying to secure funding be aware of the laws and regulations that govern the payment for assistive technology from Medicaid. The better families understand the laws, regulations, and policies the better their chances of receiving assistive technology funding. People must also understand the appeals process and be willing to appeal or seek assistance in appealing denials. Families and advocates need to understand the programs and the language to be successful with their appeals.
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