Using Traditional Medicaid and Medicaid Waivers to

Fund Assistive Technology to Support Work

February 18, 2015

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Today’s Presenters

Diana M. Straube, Staff Attorney &

James R. Sheldon, Jr., Supervising Attorney

National Assistive Technology Advocacy Project

Neighborhood Legal Services, Buffalo, NY

dstraube@nls.org * jsheldon@nls.org

716-847-0650 ext. 220 (Diana) ext. 262 (Jim)

CUEs

The RESNA Catalyst Project offers CEUs for this webinar session. The RESNA Catalyst Project is an approved

authorized provider for CEU credits by the International Association for Continuing Education and Training (IACET).

You can receive 0.1 CEUs for a sixty to ninety minute webinar. There is a $16 fee to receive credits for each

webinar.

To learn more about CEUs or to apply for CEUs from an archived webinar, contact Paul Galonsky,

pgalonsky@resna.org.

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Earlier Sessions in this Webinar Series

• Obtaining or Retaining Medicaid While Working: The Section 1619(b) and Medicaid Buy-In for Working People Programs

• Funding Work-Related AT for the Transition-Aged Special Education Student

• State Vocational Rehabilitation Agencies: Using VR Agency to Fund AT to Support a Work Goal

• Using SSI’s Plan for Achieving Self Support (PASS) to Fund AT to Support a Work Goal

• A Review of Lesser Known Funding Sources and Funding Strategies for Work-Related AT

All previous sessions (and soon this one) are archived at http://www.resnaprojects.org/statewide/webedarchive.html

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Services of the NationalAT Advocacy Project

A Technical Assistance and Training Project• Call or email speakers for technical assistance• Any topic covered in the webinars• Any issue related to funding of AT• We can assist you in thinking through funding issues and

appeals

Additional materials available on most topics• Contact us for copies and/or links.

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Purpose of Webinar Series

Barriers to Funding AT to Support Work• It can be expensive.• Individuals and service providers may not be familiar

with funding sources and funding criteria.

Sessions discuss funding sources, funding criteria:• Most common funders – Medicaid, special education,

vocational rehabilitation• Less common funding sources• Special rules within programs that support funding for

work, education, training.6

Format for Today’s Session• Walk through power point (on screen, received via email)• Participants can post questions in question or chat box.• Will attempt to address questions during presentation.• Follow up questions can be emailed to presenters.• Contact presenters for more resources on any of the

content.• Additional resources-This ppt and additional documents

will be posted at http://www.resnaprojects.org/statewide/webedarchive.html

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Purpose of this Session

Look at Traditional Medicaid and Medicaid Home and

Community Based Services (HCBS) Waivers• How used to fund AT – in general

• How used to fund AT – that can support a work goal

• General overview of traditional Medicaid, then waivers

• Present case scenario - How do we use traditional Medicaid and HCBS waivers to fund AT needed by Mario?

– Justify through traditional criteria, then use for work?

– Use work goal as part of justification? (more likely with waivers)

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Traditional Medicaid & How it

Can be Used To Fund AT

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What is Medicaid?

• Cooperative federal-state program

• Health insurance program designed to serve persons with limited income/resources

• Purpose of Medicaid –to furnish rehabilitation and other services to help “attain or retain capability for independence or self-care.” 42 USC 1396-1

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Medicaid is NOT Medicare

• Medicare is federal health insurance program for disabled and retired persons

• Eligible after 24 months of eligibility for SSDI, Railroad Retirement, etc., or upon reaching 65 years

• Four primary components: Part A (inpatient hospital); Part B (various outpatient services; Part C (Medicare Advantage); Part D (prescription drugs)

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Why is Medicaid Important for

Persons with Disabilities?

• May be only insurance for persons with disabilities with limited income

• May be available to higher income persons through waivers, work incentives (1619(b), Medicaid buy-in)

• Lack of adequate health insurance may be primary barrier to ability to live in community, succeed in employment

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What Services Does Medicaid Cover?

• Will vary by state;

• Medicaid mandates certain medical services, makes other services optional;

• States must comply with federal law, meaning they must, among other things, provide the mandated services.

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Required Services Include

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Optional Services Include

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Determining Whether Item is Covered

• Is person eligible for Medicaid?

• Does item meet criteria for mandatory service category or any optional service category included in state plan?

• Is item medically necessary?– State may have prior approval process– State may deny experimental items– State may deny for a less costly equally medically

effective item

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Early and Periodic Screening, Diagnostic and Treatment

(EPSDT) Program

• A mandatory service category for all Medicaid recipients under age 21

• Mandates periodic screening

• Mandates treatment to “correct or ameliorate” defects or conditions identified by the screen

• All optional categories become mandatory for recipients under age 21 – 42 USC 1396d(r),

42 USC 1396a(a)(10)(A), 42 USC 1396d(a)(4)(B)

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What Covered Services Might Include AT?

• Home health care services – includes “medical supplies and equipment” = DME

• EPSDT

• Physical therapy; occupational therapy; and speech, hearing, language therapy – includes funding for necessary equipment and supplies

• Prosthetic devices – to extent device replaces or replaces functioning of part of body

• Rehabilitation services

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Medicaid Waivers & How They

Can be Used to Fund AT

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HCBS Waiver –What Medicaid Requirements are Waived?

Statewideness• Waiver could offer level of coverage, special services in

one area of state not available elsewhere.

Comparability• Could select targeted group (e.g., persons with brain

injury) & offer services not available to other disabilities.

Income and Resource Rules• E.g., could make children with specific disabilities eligible

without regard to parental income, resources.20

Services Possible through HCBS Waiver

• Case management, homemaker services

• Home health aide, personal care services

• Adult day health, habilitation, respite

• Other services requested by the agency and approved by CMS as cost effective and necessary to avoid institutionalization. 42 CFR 440.180(b)(9).– States use this “other services” category to approve

specialized medical equipment, home or environmental modifications, modifications to vehicles.

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Expanded Habilitation Services

• Includes “prevocational services,” “educational services,” and “supported employment” services.

• Services include:– Teaching an individual such concepts as compliance,

attendance, task completion, problem solving, and safety;

– Supported employment services provided in integrated work settings;

– Any combination of special supervisory services, training, transportation, and adaptive equipment that the state demonstrates are essential for engaging in paid employment.

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State-Specific Examples,

Using HCBS Waiver to Fund

AT to Support Work

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Terminology to Look for in Waiver

• Assistive technology

• Environmental modifications, adaptations

• Specialized medical equipment

• Home and vehicle modifications

• Prevocational services, supported employment services

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Selected State Examplesof AT Covered

• Alabama Technology Assisted Waiver for Adults– Serves individuals who previously got private duty nursing

through EPSDT, but not eligible after age 21– AT available up to $20,000, with higher amounts needing special

approval.

• Idaho Waivers for Adults with Developmental Disabilities or residents of Idaho State School and Hospital– Environmental accessibility adaptations (e.g, ramps and lifts,

widened doorways, modified bathrooms & kitchens)– Specialized medical equipment to “perceive, control or

communicate with the environment in which they live” (includes devices, controls, or appliances)

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Selected State Examplesof AT Covered

• Iowa Brain Injury Waiver, ages 30 days to age 64– Specialize medical equipment, $6,060 annual limit (electronic

aids and organizers, communication devices, environmental controls)

– Home and vehicle modifications, $6,060 annual limit (ramps, lifts, adapted appliances, widened doorways, vehicles modifications, garage door modifications to accommodate larger, modified vehicle

– Pre-vocational services (to prepare for paid/unpaid work) (teaching readiness skills: following directions, attending to task, task completion … Could smart phone or tablet be funded to support this service?)

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Selected State Examplesof AT Covered

• Minnesota Community Alternatives for Disabled Individuals Waiver (children and adults)– Specialized equipment includes electronic tablet for system of

environmental controls and as speech generating device; equipment repair and maintenance covered

– Pre-vocational services as necessary to gain greater independence. Services include teaching concepts such as attendance, attention span, problem solving, task completion.

• Ohio Individual Options Waiver (for individuals with mental retardation or developmental disability– Very similar services as Minnesota waiver above (menus of

services from state to state tend to be similar)

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Selected State Examplesof AT Covered

• Virginia Intellectual Disabilities Waiver (serves children and adults age 6 and older with diagnosis of intellectual disability)– Similar to other states covering specialized medical equipment,

devices, controls and appliances– Environmental modifications to home, vehicle or workplace

(when modification exceeds Americans with Disabilities Act requirements) to aid in individual’s independence.

• Room for broad interpretation of coverage categories– E.g., if waiver covers specialized equipment, pre-vocational

services, and supported employment, should fund equipment that complements the vocational services.

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Hypothetical

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The Case of Mario

Mario is 17 years old and a high school senior.• Has cerebral palsy, uses a 7-year old power wheelchair for all

mobility, and relies on accessible transportation to go to school.

• Has speech limitations, learning disability affecting short term memory

• Will turn 18 in February 2015.

• Will graduate from high school in June 2015.

• Plans to go to college and study to become an English teacher at the high school level.

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Mario’s Current Education

Mainstreamed, some special education services:

• Physical therapy, occupational therapy, speech therapy

• Use of standing frame in physical therapy (allows medical benefits of standing program)

• Laptop with adapted keyboard, voice dictation software

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Mario’s Income

Social Security, SSI• Currently, Social Security dependent’s benefits - $420 per

month (Dad gets Social Security Retirement, Mom works).

• In February 2015, at age 18, dependent’s benefits will convert to SSDI as disabled adult child (same monthly amount).

• Currently, no SSI as parental income too high.

• In February 2015, will qualify for $321 SSI check (based on current rate) (parental income no longer counts).

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Mario’s Health Insurance

Private insurance• Covered as dependent on Mom’s insurance.• Will continue through age 26.

Medicaid• Was not eligible for SSI or Medicaid in past due to parental

income.• In February 2015, automatically eligible for Medicaid.• Application being submitted for HCBS waiver.

Medicare• Eligible in February 2017 after 24 months of SSDI eligibility.

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Mario’s VR Eligibility

Mario has recently applied to State VR agency.

• During a May 2014 “transition planning” meeting the special education chair handed him a VR agency brochure and stated something about them helping with college expenses.

• He seeks sponsorship to attain his English teacher goal.

• He and his parents will meet with an assigned VR counselor in early February 2015 to proceed with his application.

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AT Needed by Mario

• A ramp at the home, to come and go in his wheelchair

• A modified van, with hydraulic lift, hand controls, etc.

• A power standing wheelchair, to replace old wheelchair, allow him to benefit from standing therapy throughout the day, to do work-related activities best done in standing position.

• A new laptop, with modified keyboard, voice input software

• Ceiling track lift to transfer from wheelchair, travel from bed to bathroom, etc.

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AT Needed by Mario

• iPad Mini to be used as speech generating device• Apps for iPad

– To set up medication reminders– To create school and job-related videos to reinforce book

learning and oral instructions– To enhance any voice input capacity

• An environmental control device, allowing him to control a number of things from his wheelchair (setting thermostat, opening door to home, operating microwave & stove)– Can tasks be accomplished through one or more Apps?

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Can Mario’s Equipment/AT

Get Funded by Traditional Medicaid or Medicaid Waiver?

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Funding Mario’s AT

Ramp at home, to go to college or work• Can traditional Medicaid fund? • Can HCBS waiver fund?• Issues

Modified van, with hydraulic lift, hand controls• Can traditional Medicaid fund? • Can HCBS waiver fund?• Issues

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Funding Mario’s AT

Power standing wheelchair • To benefit from standing therapy, perform work related

activities from standing position• Can traditional Medicaid fund? • Can HCBS waiver fund?• Issues

Laptop, w/modified keyboard, voice input software• Can traditional Medicaid fund? • Can HCBS waiver fund?• Issues

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Funding Mario’s AT

iPad Mini as speech generating device • Can traditional Medicaid fund? • Can HCBS waiver fund?• Issues

iPad Mini • Use apps for medication reminders, blood pressure

monitoring, work duty reminders, videos to reinforce work activityw/modified keyboard, voice input software

• Can traditional Medicaid fund? HCBS waiver?• Issues

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Funding Mario’s AT

Environmental control unit • Can traditional Medicaid fund? • Can HCBS waiver fund?• Issues

Ceiling track lift • Can traditional Medicaid fund? • HCBS waiver?• Issues

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Thank you!

Please use your chat box to ask questions

James R. Sheldon, Jr., Supervising Attorney &

Diana M. Straube, Staff Attorney

National AT Advocacy Project

Neighborhood Legal Services, Inc.

jsheldon@nls.org * dstraube@nls.org

716-847-0650 ext. 262 (Jim), ext. 220 (Diana)

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Thank you!

An archive of this webinar series can be found athttp://www.resnaprojects.org/statewide/webedarchive.ht

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Email pgalonsky@resna.org for the CEU application for all webinars in this series

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