Supporting Independence with Adaptive Equipment and Assistive Technology March 12, 2012

1. Supporting Independence with Adaptive Equipment and Assistive TechnologyMarch 12, 2012 Annette Lauber Funding Specialist NC Assistive Technology Program

2. Successful transitioning to home: Safety, Comfort, Function • Planning takes time • Start early • People • Individual, family & friends, physicians, PT/OT/SLP/social worker/case manager • Solutions • Buy-in from the individual • Look at range of options (includes AT) • Know your resources

3. Questions to discuss • What is it that needs to happen for the person to live at home? • Transportation • Access • Safety • What does the person want and/or need to be able to do…? • in the same way • differently

4. Before you bought something, have you ever said…? • This looks like something my friend used. • I saw this new gadget on TV and it worked perfectly. • I’m sure I (or my relative or my friend )will use this.

5. How can I keep things from ending up on closet shelves or in junk drawers?? Contact NCATP • Ten offices in NC with knowledgeable staff and a sampling of technology • Learn more about options • Try things out • Borrow items for up to 2 weeks • Be a knowledgeable decision maker!!!

6. What is the NC Assistive Technology Program (NCATP)? • A state agency in the Community Services Section of NCDVRS in NCDHHS • Established under federal legislation, the Assistive Technology Act of 1998 as amended in 2004, to provide assistive technology services statewide to people of all ages and abilities. • http://www.ncatp.org/

7. NCATP Services • Free Services required under The Assistive Technology Act of 1998 as amended in 2004 • Device Demonstrations • Device Loans for up to 14 days • General awareness of Assistive Technology • Open-ended Loan of Devices • Technology Exchange Post • Info and assistance about community resources, funding resources and strategies • Fee-Based Services that NCATP provides to supplement and not supplant AT Act funds • Assessment, training, consultation • Referrals for fee-based services are from VR/IL, Schools, VA, Workers Comp, Medicaid, Private Insurance

8. Hertford Alleghany Northampton Camden Gates Currituck Ashe Surry Stokes Warren Rockingham Vance Person Caswell Pasquotank Granville Halifax Perquimans Watauga Wilkes Chowan Yadkin Forsyth Bertie Guilford Avery Franklin Orange Nash Durham Mitchell Alamance Caldwell Yancey Alexander Davie Edgecombe Madison Washington Dare Martin Tyrrell Iredell Davidson Burke Chatham Wake Wilson McDowell Catawba Randolph Buncombe Haywood Rowan Pitt Swain Beaufort Hyde Greene Rutherford Lincoln Lee Johnston Graham Jackson Cleveland Cabarrus Henderson Gaston Harnett Wayne Lenoir Macon Polk Stanly Moore Craven Montgomery Clay Transylvania Pamlico Mecklenburg Cherokee Sampson Jones Hoke Richmond Cumberland Union Anson Duplin Scotland Carteret Onslow Robeson Bladen Pender Columbus New Hanover Brunswick 8/24/2011

9. What is assistive technology (AT)? • Any item or piece of equipment that can be bought at stores, modified, or adapted and is used by people at home, school, work, or in the community to increase independence, save time and energy, and prevent injury

10. AT Categories • Vision • Hearing • Speech • Mobility, seating, positioning • Computer and related • Daily Living • Recreation • Learning, cognitive, developmental • Environmental adaptations • Vehicle modifications

11. Start from the Outside --- In Vehicle modifications

12. Entering the home

13. Doors • Opening and closing

14. Bathroom

15. Bathroom

16. Bedroom • Getting in and out of bed

17. Dressing aids

18. KITCHEN

19. Recreation

20. Sit to stand • Lift cushions and chairs

21. Telephones

22. Assisted Listening • Hearing and voice amplification

23. Speech communication (aac)

24. Alert systems • Vary in cost and fees

25. Who are the funders? It depends…. • Insurance • Public Programs • Private foundations • Faith based and civic groups • Individuals, friends and families

26. Who pays what? • The amount other funders will pay varies. • Alwaysask if there will be any out-of-pocket expense. • Do not rely on past experience. You can’t assume things will work the same way. • Every funder has their own eligibility criteria. • Income, age, disability, location, residence

27. Types of Insurance Programs • Public • Medicaid • Medicaid Waivers • Medicare B • Tricare • Private

28. Major aspects in all insurance plans • Medical necessity • Durable Medical Equipment • Written support information • Claims Process • Appeals Process

29. Medical necessity • prescribed by a physician; • used to restore or approximate normal function of a missing, malformed, or malfunctioning body part; • directly related to a diagnosed medical condition; • expected to improve the user’s ability to function

30. Durable medical equipment (DME) • can withstand repeated use; • is primarily or customarily used to serve a medical purpose; • generally is not useful to an individual in the absence of illness or injury; • and is appropriate for use in the home.

31. Physician’s Prescription letter of support (focused on medical necessity) Use language in the Explanation of Benefits of your plan Justify specific feature as medically necessary Will more costly episodes of care result if denied? Explain why the typically covered device will not work in this situation. Written Support Information

32. Written Support Tips continued • Other professionals (PT, OT, SLP) may also be providing information. • Provide information that is correct and consistent. • Work together and view each other as resources.

33. Claims Process • Follow the process for your plan • Submit request for prior approval if required. • Find out which providers you can use. • Claims are paid after the device has been provided.

34. Claims Process continued • Some plans only accept claims from approved providers. Those providers agree to accept the amount of reimbursement. • Some plans will reimburse the patient for a portion after the patient has paid in full.

35. Appeals • It’s not unusual for claims to be denied. • Speak to a case manager or someone in claims processing (not the customer service representative) • Try to talk with the same person • Ask why the claim was denied • Provide additional information

36. Appeals continued • Additional information may be needed on : • benefits of one device over another • medical necessity of specific features • costly episodes of care will be reduced

37. Medicaid • provides medical assistance for certain individuals and families with low incomes and resources. • within guidelines, states determine eligibility, scope of services and payment rates • in NC, contact local DSS to apply

38. Examples of groups covered by Medicaid • Medicaid programs for children under 18 years of age • Income limits vary. • Medicaid for Aged (65 and older), Blind and Disabled Persons. • The income limit is equal to 100% of the poverty level. • There is a limit on resources.

39. How does Medicaid fund AT? • listed on the authorized fee schedule • medically necessary • durable medical equipment • appropriate for use in the home • enrolled Medicaid DME provider • Medicaid Certificate of Medical Necessity and Prior Approval (CMN/PA) signed by physician

40. Medicaid and evaluation for DME • The evaluation for DME is covered by regular Medicaid. • Provider Classifications • Other Specialized Therapies (only when provided by home health providers, hospital outpatient departments, physician offices, and area mental health centers) - adults • Equipment (including dedicated speech generating devices) as listed under codes in the DME policy 5.3.23 are now covered under regular Medicaid . Go to http://www.dhhs.state.nc.us/dma/dme/dmepdf.pdf

41. What about evaluation services to adults on Medicaid? • Outpatient hospitals, home health agencies, and physician services can reimburse for services of an SLP/ OT /PT  • Independently enrolled therapists can not see adults and be reimbursed by Medicaid.  • Check with the hospitals, home health agencies, and MD offices in your county.  These services are covered in Clinical Coverage Policy 10A  http://www.ncdhhs.gov/dma/mp/8f.pdf  on the DMA website.

42. INCLUDES: AAC device http://www.dhhs.state.nc.us/dma/fee/dme_rates_010710.pdf software (including software upgrades necessary to expand or improve the function of the AAC device), mounting system, accessories, repairs, Technical assistance from a qualified augmentative communication technology professional, Technical assistance may not duplicate evaluation and services provided by licensed speech, occupational, or physical therapists. training on use of the AAC equipment and is included in the total purchase price for the AAC device. Ask what is covered in the cost of the device. For example, AAC Cost: not over $9,500 for a 2-year period

43. Repairs of AAC devices must not exceed $500 annually. Requests for repairs in excess of the capped amount must be approved in advance. See Section 5.8 for details. • The lifetime expectancy for all AAC devices is three years

44. for speech generation only, not for other forms of communication. only used by person with medical problem –not the general public. The device should have a HCPCS code. CMS does not consider a computer to be a medical device, therefore a computer is not covered under any Medicaid program. Major points to remember when submitting claims to NC Division of Medical Assistance (NC Medicaid)

45. DME Requests from Medicaid Waiver Recipients go to Medicaid.  • CAP-C : Community Alternative Program for Medically Fragile Children • CAP-ID/DD: Community Alternative Program for Individuals with Intellectual Disabilities of Developmental Disabilities • CAP-DA: Community Alternative Program for Disabled Adults

46. For CAP-ID/DD and CAP-C If it is on the DME fee schedule, it does not count against the waiver amount. Make sure the case manager is aware of items requested through Medicaid. For CAP-DA If it is on the DME fee schedule, it does count against the waiver amount. Most CAP-DA budgets are very small and DME can throw a recipient over their budget It is very important to work with the case manager for those recipients.  DME and Medicaid Waiver Budgets

47. CAP-ID/DD and DME • Talking with the CAP case manager and the family is critical. • The device needs to be written into the Personal Care Plan and authorized by the following LME: • Eastpoint (800) 513-4002: Robeson, Pitt and Craven • Pathways LME (704) 884-2501: Jackson • http://www.ncdhhs.gov/mhddsas/servicedefinitions/servdefupdates/dmadmh12-21-10update84-revised.pdf shows the complete list. • Training for the individual/family/ caregiver • Specialized Consultation Services which trains the CAP Worker

48. CAP-I/DD http://www.ncdhhs.gov/mhddsas/ Possibly under supplies and equipment, home mods and vehicle mods in the Person-Centered Plan CAP-DA http://www.ncdhhs.gov/dma/cap/CAPContactList.pdf Home modifications : wheelchair ramps, safety rails, grab bars, non-skid surfaces, handheld showers, and widening of doorways for wheelchair access Medicaid http://www.ncdhhs.gov/dma/medicaid/index.htm health (medically necessary); Will not cover adapted car seats, home and van ramps; van tie downs; and most OTC meds Examples of possible public funding sources

49. Vocational rehabilitation http://www.ncdhhs.gov/dvrs/pwd/employment.htm • employment goals • Independent Living http://www.ncdhhs.gov/dvrs/pwd/ils.htm • maintain independence in the community • EDS through DSDHH http://www.ncdhhs.gov/dsdhh/services/telecommunications.htm • Devices for people with hearing loss or speech difficulties in order to use the phone

50. Possible public funding sources • VA Benefits http://www.vba.va.gov/vba/benefits/factsheets/#BM2 • Tricare (military insurance) http://www.tricare.mil/mybenefit/jsp/Medical/IsItCovered.do?kw=Durable+Medical+Equipment • For retirees, item must be on the fee schedule • Medicare B ( includes durable medical equipment) http://www.medicare.gov/publications/pubs/pdf/11045.pdf • Monthly premium applies ($99.90 for most people)* • $140 yearly deductible applies* • Covers 80% of Medicare approved amount* • * MQB-Q applies for some http://www.ncdhhs.gov/dma/medicaid/medicare.htm#medicareaid • Must process claim through Medicare participating vendor