Developing a Funding Strategy
AT Funding Strategy
Finding the proper funding source and getting the financial help you need is seldom easy. Many funding sources might be able to help you purchase the assistive technology (AT) you need depending on whether or not you fit a variety of criteria. It will take a lot of effort and perseverance on the part of you and/or your advocate to get the AT device you need.
This is why you need a funding strategy. Having a funding strategy allows you to approach, in an appropriate manner, the funding sources most likely to assist you. This booklet will help you develop an effective funding strategy.
The Steps to Funding Assistive Technology
We offer nine steps as a method for guiding your efforts. These steps are:
- Step 1: Define the need.
- Step 2: Document the need.
- Step 3: Identify the equipment and/or services needed and secure necessary prescriptions and other justification.
- Step 4: Determine if alternative equipment will meet the need.
- Step 5: Determine funding sources
- Step 6: Collect and submit the required paperwork.
- Step 7: Authorization is received.
- Step 8: Search for co-payment options.
- Step 9: The appeals process.
This step involves the identification of activities in which you would like to participate or cannot currently complete. You need to describe the difficulty encountered as you try to perform a task. For example: unable to produce legible handwritten communication, unable to hold the telephone handset to your ear, or unable to get out of your home in your wheelchair. (Return to Steps)
Documentation is very important throughout the funding process. First, document your need for AT. It is one thing to know that you need AT; it is another thing to prove that need to someone else. You should obtain the assistance of a professional when developing this documentation. This professional might be a teacher, a speech therapist, a physical therapist, an occupational therapist, an assistive technology technician, or a rehabilitation engineer. The necessary documentation should include input from one or more of these professionals.
The AT and related services required to fill your documented need must be outlined with recommendations from the professionals you consulted.
These recommendations may come in the form of a written evaluation, a medical prescription, or any other justification you may need. The funding sources you decide to pursue may dictate how detailed your written justification will need to be. (Later in the funding process you may need to come back to Step 2 and 3 for further documentation.)
Part of this step also involves finding an equipment vendor and pricing equipment. The funding source will almost certainly be concerned with cost, and many times equipment vendors can help you in the funding process. If you plan to obtain funding from Medi-Cal or Medicare, you need to locate and purchase equipment from designated Durable Medical Equipment (DME) dealers.
No matter which funding sources are being approached, you should demonstrate and document your need. The following is a list of supportive materials that are often required by funding sources:
- Physician's prescription for AT (equipment, device and/or services). For Medicare, Medi-Cal and some other funding sources, medical necessity of the AT must be established to receive authorization for payment. This necessity exists when the item is a part of the physician’scour se of treatment and when a physician is supervising its use directly. (Note: a therapist or other appropriate individual may be providing the treatment, but the treatment has to be prescribed by a physician.) The physician is required to provide a signed prescription. It is strongly recommended, and usually required, that the physician also write a letter substantiating this medical necessity.
- Letter of medical necessity from the physician(s).
- Letters of medical necessity from the other professionals involved in the case (physical therapist, occupational therapist, speech therapist, etc.).
- Photograph of the individual if it helps to demonstrate the need.
- Literature concerning the requested AT (with specifications that pertain to this individual).
- Explanation of the individual's current functional skills and how they will be improved with acquisition of AT.
- Specifications of the equipment, including cost and photograph or catalog picture.
Some key questions to consider at step 3 are:
- What type of AT do I need to achieve the targeted level of function?
- Where can I obtain the requested AT? How much does it cost? Can it be rented?
- What services are needed to train me how to use the device? Will there be any follow-up after the initial training?
- Can the equipment manufacturer or local vendor provide any special assistance?
- Are there others who can help advocate for my needs?
Based on past funding patterns and AT funding denials, you may need to consider alternative equipment and/or services. You should investigate alternatives to your requested AT before applying for assistance. This will help prepare you for questions from potential funding sources.
The funding source might have to be convinced that the requested AT is cost effective. To determine if a request is reasonable, consider the following:
- Is there an inexpensive way to build/fabricate the AT?
- Can it be borrowed from an "Equipment Loan Closet" or library?
- Is the expense reasonable when compared to the therapeutic benefit?
- Is the equipment or service more costly than another option or alternative?
- Does the item serve the same purpose as equipment that is already available to the consumer?
If you cannot find alternative devices that will meet your particular need, make sure to document that fact. Remember, do not let the cost of AT preclude the selection of the right aid, device, or adaptation. The process of matching the technology to the needs and abilities of the individual is crucial to the successful implementation of the technology. Trials with desired equipment and alternative equipment are the best way to determine a match. Document the results of each trial.
Now that you have determined what AT you need, you can begin searching for funding sources. Depending on the cost of the AT, you may choose to pay for it yourself, if you are able. On the other hand, you may be unable to contribute anything toward the purchase of technology. However, there may be sources with the responsibility or the willingness to help you, so an investigation of the funding landscape may be worthwhile.
Do you have private insurance? Insurance coverage differs on a policy-by-policy basis. To find out if your policy fully or partially covers AT, check your policy regarding the qualifying criteria or contact your insurance agent.
Are you eligible for public funding? Under the Americans with Disabilities Act (ADA), employers, state agencies, local governments and other places of public accommodations may have a responsibility to provide assistive technology to individuals as "reasonable accommodations and to otherwise make their services and programs accessible." Post-secondary educational institutions that receive federal funds are included in this mandate. Other common examples of public funding sources include: Medi-Cal, Department of Rehabilitation, School Districts, etc. If you find that you are eligible for public funding, take time to research the sources’ restrictions on what and how much they will pay for a particular device.
Private sources may be able to help, but they can be difficult to find and even harder to access. Keep in mind that private sources often have very narrow eligibility requirements and limited funds.
Are you willing to take out a personal loan for the technology? This could be done as a last resort or to avoid a lot of bureaucracy and red tape.
Before you approach any one source, make a prioritized list of all possible sources. This will give you other options to contact should you have difficulty with your primary choice.
You may want to seek assistance as you begin to identify and approach funding sources. Possibilities include the Durable Medical Equipment (DME) dealer (when you purchase the equipment from a dealer, they should be more than willing to help), a social worker, a case worker, a health care professional, or one of the professionals that helped you identify the technology in steps 2 and 3.
Some questions to ask at this stage are:
- What is the most likely source of funding?
- Have you dealt with this source before? Were you successful? What problems did you encounter? Who was the contact person?
- Is there possibly more than one source of funding available?
- Will a vendor be an advocate and provide pre-approval and billing services?
- Are there individuals with disabilities who can be contacted for hints and suggestions? Have they been successful in receiving payment for assistive devices?
- Will the device or service enable you to enter or to continue employment (this is a prerequisite for funding from Vocational Rehabilitation and helps with private insurance and some other sources), live more independently or improve your overall health? Depending on the funding source, you may have to prove one or more of these benefits.
- Is it possible for two different funding sources to coordinate payment that will equal or approach the total cost?
- If you became disabled through a work-related accident, is the cost of the device or service the responsibility of worker's compensation insurance?
- Is there a local civic or charitable organization, foundation or association in your area that can help raise the necessary funds?
It is important to note that no specific method exists to assure funding. If the AT is new to the marketplace, funding sources may not be willing to provide funding. However, traditional funding sources are currently undergoing a period of adjustment and "precedence setting.” Consequently, It is important to plan your communication strategy and show patience and respect when dealing with prospective funding sources. If your argument is convincing, they may fund your device, even if they have never done so before. Some helpful hints are:
- Be polite and pleasant, but always be businesslike.
- Communicate in writing whenever possible and keep a copy for yourself. Thoroughly document all written and verbal communication. Keep records of names of people you spoke to, what was said when and who you were referred to next.
- Maintain a routine connection with the funding source and do not permit communication gaps of three months or more.
- Encourage a positive working relationship by directing letters or calls to the same person each time.
- Offer your cooperation and willingness to provide proof of medical necessity.
- Never threaten with legal action, unless you know that you are being discriminated against. A common threat, it will not intimidate any agency or insurance company.
- When someone (a case manager, therapist, DME dealer, etc.) goes out of her or his way to help, express your sincere thanks and appreciation.
The case manager, DME dealer or advocate will typically gather and complete the required paperwork. However, you should remain closely involved. You should understand exactly what is needed prior to submitting the request. Try to include all the paperwork upon first request. Don't be surprised if the funding source requires you to resubmit with changes, particularly on expensive items. Only after your submitted, written request has met all the necessary criteria can you wait for the decision on whether your funding application was approved or denied.
Gathering the right information is essential to developing your funding strategy. The following information should be included:
- Information about the individual needing the AT including: age, disability/ medical diagnosis, employment status, income level, etc.
- Information about the individual's family status including: parents, children, private insurance coverage, family physician, etc.
- Information about the individual’s educational level including the highest-grade level reached, special education services, etc.
- Public services that have been accessed previously such as Medi-Cal, Medicare, local school districts, social services, vocational rehabilitation, etc.
- AT recommendations including the name and manufacturer of the equipment, the cost, the amount that the individual or family can contribute, why a particular piece of equipment was selected, and how the equipment will improve the individual’s function.
You should receive written approval for the authorized funding amount. If the funding source pays the equipment vendor in full, the vendor will be able to process the order and secure the equipment. If the required amount of money is not approved, you can look for other options. If funding is denied, you may choose to begin the appeals process.
If the funding source only provided partial funding for the requested device, you still have options. You may have to personally pay for a portion of the desired AT. A personal bank loan or home equity loan may help you do so.
You may consider approaching additional funding sources. Typically, private insurance companies will not cover costs that can be covered by public systems (i.e. Medicare, Veterans' Administration, etc.) If you receive partial funding or are denied funding, it is a good time to seek assistance from private community and philanthropic organizations. Often, these organizations consider themselves "funders of last resort" and require written documentation of previous funding denials from traditional funding sources. Please see our handout “How to fund AT devices” for contact information of philanthropic organizations serving Californians.
What if the funding source denies your request altogether? The appeals process is a fairly common practice. Contact the funding source to learn whether your request was denied because of inadequate information or whether is was due to a lack of available funds. If your funding was denied because of a lack of information, find out what additional information is needed. Submit this new information to the person who is handling your request. Don't leave it to chance that the right person will get it. Make certain of it.
The appeals process can be time consuming. Nothing can be more discouraging than to be told repeatedly that the assistive device or service needed is "not medically necessary” or "not covered." Agencies, insurance companies, and other traditional funding sources are conservative when it comes to paying for devices or services that they consider the least bit questionable. You may need to demonstrate to these potential funding sources that a certain assistive device or service will not only benefit you, but will also be cost effective in the long run.
New technology is marketed at a much faster rate than funding becomes available. Because of its cost, the need for many AT devices will continue to be questioned by funding sources, and denials are likely to increase. Consumers need to know about existing AT options despite the poor prospect of getting a device funded.
Despite the obstacles, you should not give up. Investigate and exhaust all possible funding avenues and alternatives. You may need to challenge some decisions in the process. Everyone has the right to legally and ethically advocate for oneself. If you have been denied funding, there are many things you can still do. Here are a few suggestions:
Working with State Agencies
If you apply for funding from a state agency and have been told that you do not qualify for assistance or that the requested device does not qualify, you can consider appealing the initial decision. All government agencies have internal appeal procedures. You can have your claim reviewed by mid-level management and, if they continue to deny your claim, an agency director. In considering an appeal, you should ask yourself the following question:
How will this device enable me to enter employment, receive vocational training, live more independently, or otherwise improve my functioning in society?
You addressed your need when you first approached the source, but now you need to strengthen your case. You can construct an appeal if you can demonstrate how the device will help you. If an agency has funded a device in the past, thereby setting a precedent, it will be more difficult for them to deny your appeal for the same device.
If it is obvious that you do not meet the agency's financial requirements and other criteria, an appeal will be fruitless. On the other hand, if you can provide evidence that you do meet their established criteria, your chances of winning the appeal greatly increase.
Workers' Compensation Claims
If a disability was acquired through a work-related accident or illness, you may seek funding through the employer's Workers' Compensation Insurance carrier. However, don’t be too hasty to settle the claim. When there is permanent disability involved, workers’ compensation carriers generally want to settle the claim as soon as possible. Let the disability maximize in order to know what kind of assistive devices will be needed and for how long. Also, inform the insurance personnel that you will not settle the claim or sign any waivers or release forms until there is ample medical evidence that the disability is permanent and unchanging. If there is an attorney involved, make sure s/he understands why the client may need certain assistive devices and the terminology associated with the devices. Take time to learn how workers' compensation benefits are structured.
Health Insurance Plans for Groups
Employees who have disabilities often turn to their group health insurance plan to provide, or at least assist, with funding. If you have been denied funding on the first round, double check to see if you have provided your insurance carrier with the required medical documentation and appropriate forms. If something has been completed incorrectly, the insurance company may not voluntarily notify you. Assuming everything was correct, you can ask for an administrative review by a staff physician or nurse. However, keep in mind that a general physician employed by an insurance company may not necessarily be knowledgeable about AT devices and how they can assist you in staying healthy or employed. Do not be afraid to ask that a specialist in rehabilitation medicine review the claim.
Remember that there is always a chance for full or partial funding if the policy coverage does not specifically exclude a particular device. It is not uncommon for a claimant to eventually learn that he is better informed than the personnel with the group health plan.
Advocates/Protecting your rights
In the case of state agencies, if you have totally exhausted the appeals process without success, a few more options are available to you. Two state agencies exist specifically to support your interest when you are having problems with certain other state agencies. The Client Assistance program (CAP) will pursue your interest if you are in conflict with state vocational rehabilitation agencies. Protection and Advocacy (P & A) protects the rights of and advocates for persons with disabilities in disagreements with state agencies, private insurances, and others.
If you have been through the appeals process with a federal agency or program and still have not received authorization for funding, you may want to consider contacting your United States Senators and Congresspersons for assistance. Federal agencies or programs include the Social Security Administration, Medicare, and the Veteran's Administration.
The most important thing to remember throughout the entire process is to be persistent. If you believe that you are entitled to the technology that can enable you to achieve a higher quality of life, DO NOT GIVE UP!
Using the nine steps as your structure, you should be able to develop a comprehensive strategy for funding assistive technology. Persistence and preparation will be the keys to obtaining the equipment you need. Lewis Golinker, an attorney and funding expert from New York, put it this way:
"The formula for success in cases involving technology devices and services has three essential ingredients:
- A heartfelt commitment by a professional (such as a physician, an occupational physical and/or speech-language therapist) to the potential of an assistive technology device or service to provide real benefits to a person with disabilities;
- A refusal by the person with disabilities and the professional to take an initial "no" for a final answer; and
- A willingness of the professional to participate in any administrative appeal, where high quality information is supplied.
In the final analysis, applicants who follow this formula are the ones most likely to be rewarded for their perseverance in the form of a favorable decision."
The STAR Program Fourth Edition 2000
Directory of Funding Resources for Assistive Technology
Revised by Ability Tools, August 2004