Non-Traditional Funding Sources and Funding Strategies for Assistive Technology

1. Non-Traditional Funding Sources and Funding Strategies for Assistive Technology Creative Ways to Access Traditional AT Funding Sources, Some Little-Known AT Funding Sources and Funding Strategies 2010 Annual Conference of AT Act Programs Presenter : Diana M. Straube, Esq. National Assistive Technology Advocacy Project Neighborhood Legal Services, Inc., Buffalo, New York dstraube@nls.org 1

2. Background AT Advocacy has traditionally focused on 5 key funding sources: • Medicaid • Medicare • Special education programs • State vocational rehabilitation programs • Private insurance plans

3. A “Big Five” Funding Source May Not be Available Because: • Individual not eligible for program, or not eligible for special benefit within program • Eligible for program, but AT device is not covered. • Eligible for program, AT is covered by program … BUT • individual has not demonstrated “need” for the item under program criteria • i.e., not medically necessary, educationally necessary, vocationally necessary, etc. 3

4. Resolving the Big Five Funding Dilemma • Identify way to make person eligible for program. • Identify another program to fund device. • Identify an available funding strategy to cover all or part of device: • Anti-discrimination laws, like Americans with Disabilities Act • Use of tax provisions, like Flexible Spending Account

5. Ensuring Eligibility for the Traditional, Big-Five Funding Sources

6. MedicaidSeveral Paths to Potential Eligibility • Receipt of SSI = automatic eligibility in 39 states • Medically needy or “spend down” category • Home and community based services “waiver” • Child Adopted -- federal Adoption Assistance Program • Medicaid Buy-In for working people, more than 40 states

7. SSI for Child of Working Parent Darlene is a widow, with three children: Chris, age 11; Carey, age 13; Jason, age 16 • Jason has cerebral palsy • Jason gets SSI of $373 and automatic Medicaid • Medicaid covers medications, speech therapy, $10,000 power wheelchair, $8,000 communication device • Keeping Medicaid is critical! • State SSI rate is $674, with automatic Medicaid

8. Jason’s SSI Based on Darlene’s Wages Darlene earns $33,000 gross, working 60 % time ($2,750 per month) Employer wants Darlene to increase hours: • 80 percent time -- $44,000 per year/$3,667 per month • 90 percent time -- $49,500 per year/$4,125 per month • Full time -- $55,000 per year/$4,583 per month Jason will lose SSI if Darlene makes $3,495 per month.

9. Four Strategies to Keep SSI and Medicaid • Play it safe – keep working 60 percent time • Accept 80 percent time job if: • Employer “pays” Darlene $350 less • Employer pays Darlene’s $350 share for health insurance • Darlene’s taxable wages reduced to $3,317 • Jason eligible for SSI of $89 per month

10. Four Strategies to Keep SSI and Medicaid(Continued) • Accept 80 percent time job if: • Employer offers “Flexible Spending Account” • $350 deducted each month for health insurance payment • Jason eligible for SSI of $89 per month • Wait until Jason’s 18th birthday to increase pay.

11. Medicare Savings Plans: QMB, SLMB, QI-1 Qualified Medicare Beneficiaries program (QMB) • State must pay Medicare deductibles, coinsurance and premiums ($96.40), for nearly all disabled individuals ($110.50 for newly eligible) • Must have income at or below 100 percent of federal poverty level (FPL) ($903 in 2009)

12. Medicare Savings Plans: QMB, SLMB, QI-1 Specified Low-Income Medicare Beneficiaries program (SLMB) • State must pay Medicare Part B premiums only • Income between 100 and 120 percent of FPL (up to $1,083 in 2009) Qualified Individual Program (QI-1) • State must pay for Part B premiums only • Income between 120 and 135 percent of FPL (up to $1,219 in 2009)

13. How QMB Helps Pay for AT If Medicare funds a power wheelchair at approved rate of $8,000: • Medicare pays 80 percent ($6,400) • Individual must pay balance ($1,600) • Medicaid would typically pay the $1,600 If person not eligible for Medicaid or chooses not to pay a spend down: • Medicare pays the $6,400 • QMB pays the $1,600

14. State Vocational Rehabilitation (VR) Agencies Financial Need Criteria – General Rule • VR agency may use financial need criteria for most of its services. • E.g., college tuition, vehicles modifications, computers, and AT. Social Security, SSI Recipients Exempt from Needs Test • With any amount of SSI or SSDI, eligible for VR services at no cost. • Income/resources of parents, spouse do not count.

15. VR Agencies and Financial Need Criteria – The Case of Ted Ted Receives $1,500 in Social Security Benefits • This is too much to qualify for SSI. • Also too much to qualify for state’s Medicaid spend down program Ted Automatically Meets the VR Agency’s Financial Need Criteria • The VR agency can pay for expensive AT, like van modifications, access ramps at home, or adapted computer equipment • The agency cannot make Ted pay toward cost of items it provides.

16. Alternative and Little Known Programs for Funding AT

17. Alternative Financing Programs(AFPs) - A Source of Loans for AT An AFP can make a loan available by: • A revolving loan fund • A loan guarantee • An interest buy down

18. The Most Common Items Purchased with Loan Funds • Vehicles modifications • Computers, costs for computer access • Mobility equipment, such as wheelchairs, scooters • Equipment for daily living, like environmental control devices • Hearing aids, vision aids • Home modifications See www.resnaprojects.org/AFTAP for AFP information in 40 States.

19. AFPs - Advocacy Tips The AFP loan: An excellent way to cover out-of-pocket costs related to AT purchase: • Amounts that exceed the payment limitations of private insurance • The 20 percent co-payment required under Medicare Part B • Any share of cost requirement charged by a state VR agency • Any AT-related costs that exceed the amount available for purchases under an SSI Plan for Achieving Self Support (PASS) • Amounts not otherwise covered by charity payments • Through an appeal process.

20. The Federal Adoption Assistance Program Help for parents who adopt a “Child with Special Needs” • Includes cash assistance and other special services Assistance with AT Funding through Automatic Medicaid: • If “child with special needs” criteria met and “adoption assistance agreement” in effect (i.e., a federal adoption) • At state option if child receives state or local adoption assistance program

21. The Federal Adoption Assistance Program Additional Payments for AT, at State Option, with State/Local Funds: • Covered through Minnesota’s adoption program: • Specialized communications equipment • Ramps • An accessible shower, elevated bathtubs and toilets • Blinking lights and tactile alarms as alternate warning systems • Lowered kitchen work surfaces • Disability-related modifications to a vehicle

22. Related Benefits • Kinship guardianship assistance payments when relative foster parent has chosen not to pursue adoption • Foster care maintenance payments = payments for food, clothing, shelter, daily supervision, school supplies, a child's personal incidentals,etc

23. In NY, Foster Care Agency Paid for: • Van lift including installation, accessories and equipment • Bathroom renovations • Rehab wet vest for swimming • Special recreational items (swing, beneficial for respiration)

24. Funding Strategies That Do Not Involve a Program That Funds AT In a Conventional Sense

25. The Flexible Spending Account (FSA)Under Federal Tax Law Known as “flex plans,” “cafeteria plans” or “125 plans” • Employee contribution deduction from pay, pre tax • Reduces taxable wages Types of expense covered • Uncovered medical: insurance premiums, co-payments, uncovered services, AT devices • Non-medical: child care, adoption fees, parking fees, public transportation costs

26. Using Flexible Spending Account for AT- Back to Darlene & Jason Green Darlene Pays $350 Share of Insurance Premium • Taxable income reduced by $4,200. Taxes reduced. • Reduced income for SSI eligibility. Jason keeps SSI. By Keeping SSI, Jason Also Keeps Medicaid • Medicaid pays for new wheelchair • Medicaid pays for new communication device

27. Creative Structuring or Restructuring of a Child Support to Obtain or Retain SSI and Medicaid Purpose of Strategy is Twofold: • Disability-related and other needs met through the child support without decreasing the SSI amount. • By obtaining or retaining eligibility for SSI, we ensure eligibility for Medicaid (in most states). • Both support dollars and Medicaid can fund AT.

28. Creative Structuring of Child Support- Back to Darlene & Jason Green Works 80 Percent Time, Earns $3,667 Per Month • Wages reduced by $350 through FSA contribution. • Jason gets $89 SSI check plus Medicaid. Jason’s Dad to Pay $450 in Monthly Child Support • SSI program would count two thirds, $300. • Extra income makes Jason ineligible for SSI. • Jason will also lose Medicaid.

29. Alternative Child Support Settlement for Jason Darlene’s Dilemma: No Adequate Transportation • Cannot afford van for travel with wheelchair. • Drives used car. Two adults must lift Jason in and out of car. Instead of Cash, Dad Pays Directly to Vendors: • $400 to bank for loan on accessible van • $50 to car insurance company toward $150 monthly insurance

30. How Creative Child SupportAgreement Helps Jason Jason Keeps Same Amount of SSI • Money paid to vendors not available for food or shelter • Not counted by SSI Jason Keeps Medicaid • Getting $1 or more in SSI keeps Medicaid in 39 states. • Medicaid pays for power wheelchair, communication device. Darlene Get Van and Insurance • Child support arrangement makes it possible for Darlene to get a van with insurance to transport Jason.

31. Thank you…. • Other materials available on each topic through National AT Advocacy Project. Contact Diana Straube (dstraube@nls.org). • Check out National AT website (www.nls.org/natmain.htm) • Materials by James R. Sheldon, Supervising Attorney National Assistive Technology Advocacy Project Neighborhood Legal Services, Inc., Buffalo, New York