Funded  through a grant from the National Institute on Disability and Rehabilitation Research,
U.S. Department of Education, under contract number H224B990002. The opinions expressed do not
necessarily reflect the position of the U.S. Department of Education, and no official endorsement by the
U.S. Department of Education of the opinions expressed herein should be inferred.

Copyright 2002 Neighborhood Legal Services, Inc.

In this issue ...
Private Insurance contracts and exclusions for preexisting conditions
Protections Under the Health Insurance Portability and Accountability Act
THE USE OF PREEXISTING CONDITION CLAUSES
HIPAA: GOVERNING LAW AND REGULATIONS269
PREEXISTING CONDITION EXCLUSIONS, WAITING PERIODS, AFFILIATION PERIODS
The Basic Rules
Application to Individual Who Works and is Covered by a Group Health Plan
HIPAA’S “SIX-MONTH LOOK-BACK RULE”
The Basic Rule, With Examples From HIPAA Regulations
Application to Individual Who Works and Is Covered by a Group Health Plan
Maximum Period of Exclusion: The “12-Month Look-Forward Rule”; Reducing Period Through “Creditable  Coverage”
The Basic Rule, With Examples From HIPAA Regulations
Application to the Individual Who Works and Is Covered by a Group Health Plan
PREEXISTING CONDITION EXCLUSIONS BARRED FOR NEWBORNS, ADOPTED CHILDREN AND PREGNANCY
THE “CERTIFICATE OF CREDITABLE COVERAGE”
Features
Hipaa Online
NEIGHBORHOOD LEGAL SERVICES TO CONTINUE AS NATIONAL AT ADVOCACY PROJECT
AT Court Watch

PRIVATE INSURANCE CONTRACTS AND
EXCLUSIONS FOR PREEXISTING CONDITIONS
Protections under the Health Insurance Portability and Accountability Act

        Health insurance is a concern of all Americans. For persons with disabilities who have high-cost medical needs, a lack of health insurance is not an option. In fact, many individuals will seek employment based on the need for a comprehensive, employer-funded health insurance plan to cover their needs or those of dependants with disabilities.

        Medicaid and Medicare remain the primary form of health insurance for many adults with disabilities. However, an increasing number of the clients served by Protection and Advocacy (P&A) agencies depend on private insurance plans to cover expensive medical care, including doctor visits, mental health treatment, prescription drugs, and assistive technology (AT)(typically covered as durable medical equipment). Private insurance has long been an issue for clients served by the PAAT programs. It is also extremely important to clients served by two new P&A programs: P&A for Beneficiaries of Social Security (PABSS) and the P&A now serving individuals with traumatic brain injury in nearly 30 states.

        Many adults with disabilities cannot take that next step toward self-supporting employment, a higher paying job, or independent living without adequate health insurance in place. Although continued Medicaid may be an option for some individuals who go to work, under either the 1619(b) or optional Medicaid buy-in programs, many will either not be eligible for those programs or will choose not to maintain resources within program limits. For them, the coverage offered through a private insurance plan will be the only realistic option. Similarly, many children with disabilities will not be eligible for Medicaid; the coverage offered by their parents' private insurance plans will be their only option. (Both 1619(b) and the Medicaid buy-in are discussed in our Funding of AT Booklet, Work Incentives for Persons with Disabilities Under the Social Security and SSI Programs (Aug. 2002), recently mailed to all P&As. It appears on our website at www.nls.org/wkboklet. htm.)

        Even when comprehensive health insurance is available through an employer, there is a widespread belief that most plans will not cover the preexisting conditions of the worker and his or her dependents. In fact, many persons with disabilities, family members, health care providers, and advocates readily assume that all such clauses are legal.

        The federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) greatly limits the use of preexisting condition exclusions in group health plans. This article will discuss HIPAA's application to preexisting condition clauses in private insurance plans, with the focus on group plans. We will discuss what plans are covered, when an exclusion is legal, and how the impact of the exclusion is either limited or eliminated when the individual was recently covered by another form of insurance. This article should be viewed as supplementing a two-part series on private insurance that appeared in the February-March 1998 and April-May 1998 issues of AT Advocate. A more comprehensive article on insurance will be published in 2003 as part of our Funding of AT booklet series.

THE USE OF PREEXISTING CONDITION CLAUSE

        Many health insurance policies contain provisions which, as a practical matter, result in certain individuals being uninsured for the life of the policy or for a designated period of time. Unless otherwise limited by law, these provisions are legal and will limit who and what is covered. Since persons who need expensive services often have longstanding disabilities, a preexisting condition clause can present a major barrier to obtaining those services.

        A preexisting condition clause can also create a major barrier to employment for many of our clients, including Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) beneficiaries. Often facing high-cost medical expenses, if they are uncertain about coverage of an existing condition, they may elect not to take a job that offers a health insurance policy with a preexisting condition exclusion. Any significant exclusion, even if limited in time, could cost the person hundreds or thousands of dollars. Although some provisions are still legal, their use in group health plans has been limited by HIPAA.

HIPAA: GOVERNING LAW AND REGULATIONS

        HIPAA applies to plan years beginning after June 30, 1997. The law appears in two places with nearly identical language. See 29 U.S.C. §§ 1181 et seq. (Labor Law provisions); 26 U.S.C. §§ 9801 et seq. (Internal Revenue Code provisions). Implementing regulations appear in three places with nearly identical language. See 26 C.F.R. §§ 54.9801-1T et seq. (IRS regulations); 29 C.F.R. §§ 2590.701-1 et seq. (Dept. of Labor regulations); 45 C.F.R. Parts 144 and 146 (Centers for Medicare and Medicaid Services regulations). Unless otherwise noted, all references are to the Labor Law or the Department of Labor regulations. The part of HIPAA we will discuss applies to group health plans and health insurance issuers offering group plans. 29 C.F.R. § 2590.701-1. Its major impact is the elimination of most preexisting condition exclusions in group health insurance plans. (Similar, though less extensive protections exist for individual health insurance plans. See, e.g., 45 C.F.R. Part 148.)

PREEXISTING CONDITION EXCLUSIONS, WAITING PERIODS, AFFILIATION PERIODS

The Basic Rules

        It is important to distinguish a period of exclusion due to a preexisting condition and a waiting period or affiliation period. A preexisting condition exclusion "means a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the first day of coverage ...." Id.
§ 2590.701-2. A waiting period is "the period that must pass before an employee or dependent is eligible to enroll under the terms of a group health plan." Id. If a waiting period applies equally to all beneficiaries, it is permitted under HIPAA. An affiliation period is "a period of time that must expire before health insurance coverage provided by an HMO becomes effective, and during which the HMO is not required to provide benefits." Id. An affiliation period is legal under HIPAA.
Application to Individual Who Works and is Covered by a Group Health Plan

        The distinction between a waiting period and a preexisting condition exclusion is best illustrated by two examples. The first involves a waiting period which is permitted by HIPAA.

Example 1. Janice receives $900 in SSDI benefits. She is covered by Medicare and Medicaid (subject to a $246 Medicaid spend down based on New York's program rules). She goes to work, despite severe multiple sclerosis, in a job which is covered by an employer-funded group health plan that would cover her $1,200 monthly medication expenses. Under the terms of the plan, however, Janice must be employed for nine months before she can enroll in the plan. The same waiting period applies to all new employees.

        Since the nine-month period applies to all new employees, it is a waiting period and is permitted by HIPAA. Janice must look to options other than the health insurance plan to cover her first nine months of employment. (E.g., if her state offers the Medicaid buy-in with or without a monthly premium, that program may cover her prescriptions. Under the spend down program, Janice's share of cost for Medicaid will either increase significantly or the spend down may no longer be available because she no longer meets the federal, SSI definition of disability because she is working and performing substantial gainful activity.)

        The second example involves a preexisting condition exclusion and will be subject to the limitations imposed by HIPAA.

Example 2. Same facts as example 1, except that the employer's health plan takes effect on Janice's first day of employment. Under the terms of the plan, Janice must be employed for nine months before it covers treatment for any condition that existed before she started employment. This rule would apply to any new employees.

        This would meet HIPAA's definition of a preexisting condition and be subject to the rules discussed below.

HIPAA'S "SIX-MONTH LOOK-BACK RULE"
The Basic Rule, With Examples From HIPAA Regulations

        "A preexisting condition exclusion must relate to a condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending with the enrollment date." Id.  2590.701-3(a)(1)(i). If there is no advice, diagnosis, care or treatment recommended or received within the 6-month look-back period, the preexisting exclusion will not be legal. The rule is best understood by looking at the four examples contained in the regulations [see  2590.701-3(a)(1)(i)(c)], three of which are reproduced verbatim:

"Example 1. (i) Individual A is treated for a medical condition 7 months before the enrollment date in Employer R's group health plan. As part of such treatment, A's physician recommends that a follow-up examination be given 2 months later. Despite this recommendation, A does not receive a follow-up examination and no other medical advice, diagnosis, care, or treatment for that condition is recommended to A or received by A during the 6-month period ending on A's enrollment date in Employer R's plan.

(ii) In this Example 1, Employer R's plan may not impose a preexisting condition exclusion period with respect to the condition for which A received treatment 7 months prior to the enrollment date.

Example 2. (i) Same facts as Example 1, except that Employer R's plan learns of the condition and attaches a rider to A's policy excluding coverage for the condition. Three months after enrollment, A's condition recurs, and Employer R's plan denies payment under the rider.

(ii) In this Example 2, the rider is a preexisting condition exclusion and Employer R's plan may not impose a preexisting condition exclusion with respect to the condition for which A received treatment 7 months prior to the enrollment date.

Example 3. (i) Individual B has asthma and is treated for that condition several times during the 6-month period before B's enrollment date in Employer S's plan. The plan imposes a 12-month preexisting condition exclusion. B has no prior creditable coverage to reduce the exclusion period. Three months after the enrollment date, B begins coverage under Employer S's plan. Two months later, B is hospitalized for asthma.

(ii) In this Example 3, Employer S's plan may exclude payment for the hospital stay and the physician services associated with this illness because the care is related to a medical condition for which treatment was received by B during the 6-month period before the enrollment date."

Application to Individual Who Works and Is Covered by a Group Health Plan

        Let us go back to Janice to consider how these rules apply to her.

Example 1. In the six months before she starts work, Janice sees her neurologist twice and takes daily medication to treat her multiple sclerosis. She is immediately covered by the health insurance plan when she starts work, but the plan has a nine-month preexisting condition exclusion and will not cover treatment related to multiple sclerosis during her first nine months of work.

        Since Janice received care and treatment for this condition during the six months preceding her enrollment in the plan, HIPAA would allow this provision. As we shall see below, however, if Janice was continuously covered by either Medicare or Medicaid in the year prior to starting the job, this period of "creditable coverage" should effectively eliminate the nine-month wait for her private insurance plan to become available.

        Now, let us add a few facts to get a different result when Janice seeks treatment for a new condition.

Example 2. Shortly after she starts working Janice seeks treatment for depression. She visits a psychiatrist and begins taking anti-depressant medication. Janice received treatment for depression 10 years earlier when she was first diagnosed with multiple sclerosis, but did not receive nor have treatment recommended during the six months before she started work and enrolled in the group health plan. She is told that the preexisting condition clause means she will not be eligible for mental health treatment until she has been employed for nine months.

        Under the HIPAA regulations, this would not be a legal preexisting condition exclusion. Since Janice did not receive mental health treatment and no treatment was recommended in the six months preceding her enrollment in the plan, this exclusion is not legal.

MAXIMUM PERIOD OF EXCLUSION: THE "12-MONTH LOOK-FORWARD RULE";
REDUCING PERIOD THROUGH "CREDITABLE COVERAGE"

The Basic Rule, With Examples From HIPAA Regulations

        "A preexisting condition exclusion is not permitted to extend for more than 12 months (18 months in the case of a late enrollee) after the enrollment date." Id.
§ 2590.701-3(a)(1)(ii). For example, using an enrollment date of August 1, 2002, the maximum exclusion under the 12-month look-forward rule would be through July 31, 2003. A "late enrollee" is a person who enrolls after the earliest date on which coverage can become effective or after a special enrollment date established for that individual. Id. § 2590.701-3(a)(2)(iii).

        "The period of any preexisting condition exclusion that would otherwise apply to an individual under a group health plan is reduced by the number of days of creditable coverage the individual has as of the enrollment date ...." Id. § 2590.701-3(a)(1)(iii). The "enrollment date" is the "first day of coverage or, if there is a waiting period, the first day of the waiting period." Id. § 2590.701-3(a)(2).

"Creditable coverage" includes a wide range of public and privately funded health coverage, including any of the following [id. § 2590.701-4(a)(1)]:

• A group or individual health insurance plan
• Medicare or Medicaid
• Certain health insurance plans offered to federal employees, members of the armed forces, and members of the Peace Corps
• A medical care program of the Indian Health Service of a tribal organization
• A state health benefits risk pool

        In order to count past coverage, there must be no "significant break" in coverage. This is defined as a break of 63 consecutive days. Id. § 2590.701-4(b)(2). Neither a waiting period nor an affiliation period is taken into account in determining a significant break in coverage. This rule is best understood by looking at the eight examples contained in the regulations [these appear following § 2590.701-4(b)(2)(iv)], several of which are reproduced verbatim:

"Example 1. (i) Individual A works for Employer P and has creditable coverage under Employer P's plan for 18 months before A's employment terminates. A is hired by Employer Q, and enrolls in Employer Q's group health plan, 64 days after the last date of coverage under Employer P's plan. Employer Q's plan has a 12-month preexisting condition exclusion period.

(ii) In this Example 1, because A had a break in coverage of 63 days, Employer Q's plan may disregard A's prior coverage and A may be subject to a 12-month preexisting condition exclusion period.

Example 2. (i) Same facts as Example 1, except that A is hired by Employer Q, and enrolls in Employer Q's plan, on the 63rd day after the last date of coverage under Employer P's plan.

(ii) In this Example 2, A has a break in coverage of 62 days. Because A's break in coverage is not a significant break in coverage, Employer Q's plan must count A's prior creditable coverage for purposes of reducing the plan's preexisting condition exclusion period as it applies to A.

Example 3. (i) Same facts as Example 1, except that Employer Q's plan provides benefits through an insurance policy that, as required by applicable State insurance laws, defines a significant break in coverage as 90 days.

(ii) In this Example 3, the issuer that provides group health insurance to Employer Q's plan must count A's period of creditable coverage prior to the 63-day break.

Example 4. (i) Same facts as Example 3, except that Employer Q's plan is a self-insured plan, and, thus, is not subject to State insurance laws.

(ii) In this Example 4, the plan is not governed by the longer break rules under State insurance law and A's previous coverage may be disregarded.

Example 5. (i) Individual B begins employment with Employer R 45 days after terminating coverage under a prior group health plan. Employer R's plan has a 30-day waiting period before coverage begins. B enrolls in Employer R's plan when first eligible.

(ii) In this Example 5, B does not have a significant break in coverage for purposes of determining whether B's prior coverage must be counted by Employer R's plan. B has only a 44-day break in coverage because the 30-day waiting period is not taken into account in determining a significant break in coverage."

Application to the Individual Who Works and Is Covered by a Group Health Plan

    Let us go back to Janice to consider how these rules might apply to her.

Example. Janice was covered by Medicare and Medicaid during the 12 months immediately before starting a job. Medicaid covered her $1,200 per month prescription drug costs and covered the three-year old power wheelchair that needs to be replaced in the next two years. After starting this job, she will lose her right to continue on the Medicaid spend down program and her state does not offer the optional Medicaid buy-in program. Medicare does not cover prescription drugs, but will cover up to 80 percent of the cost of her replacement wheelchair.

        The employer's health insurance plan will cover the prescription drugs, subject to a $10 per prescription co-payment. The plan is also expected to cover the replacement power wheelchair. However, the group health plan offered by the employer includes a 12-month preexisting condition exclusion period.

        This exclusion is legal under HIPAA, as it is limited to a 12-month period. In Janice's case, however, this period of exclusion is reduced by the period of "creditable coverage" which she had as of her enrollment date. Since she was continuously covered by Medicare and Medicaid for 12 consecutive months prior to enrollment, with no significant break in coverage, the exclusion period will be eliminated (i.e., reduced to zero) and Janice will be immediately covered by the group health plan. Importantly, this allows Janice to immediately take advantage of the plan's prescription drug and durable medical equipment benefits.

PREEXISTING CONDITION EXCLUSIONS BARRED FOR NEWBORNS,
ADOPTED CHILDREN AND PREGNANCY

        HIPAA disallows preexisting condition exclusions in three instances [29 C.F.R.  2590.701-3(b)]:
Newborns: It prohibits exclusion of newborns, who would otherwise be covered by the policy, so long as the child is covered by some form of creditable coverage within 30 days of birth.

        Adopted children: It prohibits the exclusion of an adopted child (i.e., one adopted or placed for adoption before age 18) who is covered under creditable coverage within 30 days of the adoption or placement for adoption.
Pregnancy: Neither a group health plan nor a health insurance issuer offering group health insurance may impose a preexisting condition exclusion relating to pregnancy.

THE "CERTIFICATE OF CREDITABLE COVERAGE"

        HIPAA envisions that a person will establish past creditable coverage by producing a certificate or certificates. Generally, the entity providing the past creditable coverage has an obligation to provide a "certificate of creditable coverage." See 29 C.F.R. §§ 2590.701-5(a)(1)(i)(obligation of group health plans and health insurance issuers) and 2590.701-5(a)(6)(i) & (ii)(obligation of other entities).

CONCLUSION

        As individuals with disabilities and their families seek ways to cover high-cost medical care, private insurance plans will often be in the picture. However, that coverage could be limited by preexisting condition exclusions found in many policies. Fortunately, many of the exclusions are now either eliminated or limited by the federal HIPAA law. As applied to the worker or worker's dependent with a severe disability, HIPAA protects against gaps in insurance coverage, allowing the freedom to move from one job to another, or the freedom to move from SSI or SSDI status to the ranks of the employed.

HIPPA ONLINE

http://cms.hhs.gov/hipaa/online
This interactive tool, provided by the federal Centers for Medicare and Medicaid Services (CMS), helps answer questions about health coverage and a person’s rights and protections under HIPAA.

*  *  *  *  *  *  *

SAVE THE DATE

Bridges to Better Advocacy Conference • April 2nd, 3rd and 4th, 2003

        Planning is nearly done for our annual conference, again scheduled for the Crowne Plaza Hotel (formerly Sheraton) in downtown Austin, Texas. We will have two full-day pre-conference sessions, one on Medicaid, the other on special education. We will also run two concurrent tracks during part of our traditional two-day conference, in an effort to meet the needs of both advocate and attorney, seasoned litigator and new attorney. Registration forms, with early bird rates will be available by the time you get this newsletter. Check our website at www.nls.org/natmain.htm or contact Wilma Castro(wcastro@nls.org or 716-847-0650 x.271) if you need the registration forms.

NEIGHBORHOOD LEGAL SERVICES TO CONTINUE AS NATIONAL AT ADVOCACY PROJECT

        In September 2002, the National Institute on Disability and Rehabilitation Research, U.S. Department of Education awarded Neighborhood Legal Services, Inc. of Buffalo, N.Y. a new three-year grant to continue as the national technical assistance center serving Protection and Advocacy for Assistive Technology advocates. Our National AT Advocacy Project, established in May 1996, is now funded through September 2005.

        We will continue our core services to support AT advocates:

• Technical Assistance - by phone, fax or email
• Resource Libraries - collecting court documents (pleadings, briefs) and administrative decisions as part of two separate libraries
• Materials Preparation and Dissemination - our quarterly, AT Advocate newsletter; updating Funding of AT booklets and publishing new ones
• Training - annual Bridges to Better Advocacy conference; sessions at NAPAS conference; work with NAPAS to deliver multi-part training by phone conference; work with P&As, other entities to train at their conferences, if travel, lodging expenses are covered
• Project Website, www.nls.org/natmain.htm - a wealth of AT-related materials, including newsletters, booklets, past conference handouts, links to other resources
• Conduit for Communication Within the P&A Network - Medicaid and Medicare Work Groups, each meeting by phone conference 4 times per year; National AT List Serve, with attorneys, advocates able to communicate with the whole network via email

        Jim Sheldon will continue as project director, Ron Hager as staff attorney, Marge Gustas as staff paralegal, and Wilma Castro as secretary and desktop publisher. All will work part-time with the project. Shortly after the first of the year, we expect to have another part-time staff attorney, primarily working with us on newsletters and major publications. Call Jim or Ron with questions regarding Medicaid, Medicare, special education, vocational rehabilitation, private insurance, ADA, sections 504 or 508, Social Security/SSI work incentives, Fair Housing Act, and other issues. Call Marge for help locating hearing decisions. Call Wilma if you seek specific documents already identified.

AT COURT WATCH

U.S. Supreme Court denies cert in the Westside Mothers and Antican Cases

        In early December, 2002, the state defendants’ Petition for Certiorari in Westside Mothers was denied by the Supreme Court. In Westside Mothers v. Haveman, 133 F. Supp. 2d 852 (E.D. Mich. 2001), the lower court held that the federal courts were not available to enforce the Medicaid Act and its Early Prevention, Screening, Diagnosis and Treatment provisions. In a May 2002 decision, the Sixth Circuit reversed, allowing the lawsuit to go forward. 289 F.3d 852 (6th Cir. 2002).

        On October 21, 2002, in Antican v. Odom, the Supreme Court refused to grant a Petition for Certiorari and let stand a North Carolina lawsuit which challenges the states’ Medicaid reimbursement rates for dentists, claiming they are so low that most of the state’s dentists will not see covered patients. The state argued without success in the lower courts that it cannot be sued on claims that the state is not following federal Medicaid law. Many Medicaid advocates were very concerned that the Supreme Court might agree to hear one of these cases and issue a holding that would limit Medicaid lawsuits under 42 U.S.C. § 1983.

+++

Vermont Supreme Court Rules That Medicaid Program Cannot Maintain a Categorical Exclusion for Partial Dentures

        In Cushion v. Department of PATH, 807 A.2d 425 (S.Ct. Vt. 7/2/02), Vermont’s Supreme Court ruled that the state Medicaid agency’s exclusion of all coverage for partial dentures was an impermissible limitation of services under the optional dental services provision. 42 U.S.C. § 1396d(a)(10); 42 C.F.R. § 440.100. The program had covered full dentures and oral surgery, but did not cover partial dentures. The state unsuccessfully argued that it had discretion, under federal Medicaid law, to cover the optional dental services category and then limit the scope of services it covered under that category.

        The court extensively cited its 1997 decision in Brisson v. Dep’t of Social Welfare, 167 Vt. 148, 702 A.2d 405 (1997)(refusal to cover a closed circuit television (CCTV), under optional vision services category, was held to be impermissible). The court held that the state’s pre-1997 limitation on vision services was an impermissible limitation on the amount, duration and scope of that service category because the state failed to provide for those in greatest need of that service. 702 A.2d at 408; 42 C.F.R. § 440.230(b). Similarly, the court in Cushion held that “the Department’s exclusion of partial dentures fails to provide service to those in the greatest need.” 807 A.2d at 428, citing White v. Beal, 555 F.2d 1146, 1151 (3d Cir. 1977).

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Connecticut Lawsuit Challenges Medicaid Agency’s Reliance on Medicare Manual for Outright Exclusion of Medically Necessary DME

        The New Haven Legal Assistance Association (Sheldon V. Toubman, Esq.), in collaboration with Connecticut Legal Services (Kevin Brophy, Esq., Mary Jean Schierberl, Esq.), has filed a class action, Pragano, et al. v. Wilson-Coker, in the U.S. District Court for Connecticut. The lawsuit challenges a policy and practice which results in the categorical denial of many items of durable medical equipment (DME). Plaintiffs contend that if an item of DME is not on the agency’s pre-approved list, the practice is to deny coverage if the requested DME is excluded for coverage under Medicare. They contend that in making this determination the agency relies exclusively on Medicare’s Durable Medical Equipment Regional Carrier (DMERC) Manual, rejecting claims that are specifically excluded in the DMERC manual for Medicare coverage. Under this approach to decision making, the agency denied the individual plaintiffs’ claims for a low air loss mattress, a stair glide lift system, and an environmental control unit.

        The plaintiffs claim, among other things, that this use of Medicare standards to determine Medicaid coverage for DME: violates the Medicaid Act’s reasonable standards requirement [see 42 U.S.C. § 1396a(a)(17)(A); 42 C.F.R. § 440.230(b)]; denies recipients a reasonable and meaningful opportunity to obtain medically necessary DME that is not on the agency’s pre-approved list [citing the well-known CMS policy guidance of September 4, 1998]; denies payment for items of DME necessary for recipients to attain and maintain independence and self-care within the Medicaid Act’s goals [see 42 U.S.C. § 1396]; and illegally limits the scope of coverage based on the recipients’ specific medical conditions [see 42 C.F.R. §§ 440.210, 440.220].

        For copies of the plaintiffs’ complaint, preliminary injunction brief, or class certification brief, contact Jim Sheldon (jsheldon@nls.org, 716-847-0650 ext. 262) or Wilma Castro (wcastro@nls.org, ext. 271).

If you would like the AT Advocate Newsletter sent to you in a large-print or other alternative format, please let us know.

        We have designed a word-searchable digest, using computer technology, to store and retrieve hearing decisions and other administrative documents. We also have indexed more than 400 documents from more than 100 pending and decided court cases. All documents are available through our AT Resource Library. Please send us your hearing decisions, briefs and other documents involving AT.

Please send information to:
Attn.: Jim Sheldon                                                                                 TEL: (716) 847-0650
Neighborhood Legal Services, Inc.                                                        FAX: (716) 847-0227
Ellicott Square Building                                                                          TDD: (716) 847-1322
295 Main Street, Rm 495                                                                      e-mail: atproject@nls.org
Buffalo, NY 14203                                                                                Web Page: www.nls.org

The AT Advocacy Project will provide nationwide services to PAAT projects including technical assistance to advocates wanting to access funding for assistive technology for individuals with disabilities.

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