DISCUSSION OF FUNDING SOURCES FOR ASSISTIVE TECHNOLOGY

            This article will discuss the following potential funding sources for AT:

1         the public schools, including their special education programs and obligations under section 504 of the federal Rehabilitation Act

2         state vocational rehabilitation agencies

3         Medicaid

4         Medicare

5         SSI's Plan for Achieving Self Support

For each funding source, we will go through the key criteria to obtain funding for AT, including:

1         How one becomes eligible for the program or service

2         The criteria that program follows for covering AT devices and services, and the likelihood that the program would fund the devices sought by Sharon

3         Any appeal procedures for challenging a denial of funding

I.                   The Public Schools: Special Education Programs and Section 504 Obligations

A.                 The Special Education System

1.                  Eligibility for Special Education Services

            The special education rights of children and parents, as well as the responsibilities of school districts, are spelled out in a major federal law, the Individuals with Disabilities Education Act (IDEA).⁸  The IDEA guarantees, in every state, that all eligible children with disabilities receive a free appropriate public education, which is designed to meet their unique needs.  It must be at no cost to the parents or student.  Since there can be no income test for special education services, it does not matter, for example, that Sharon's parents have an annual income of $60,000.  The income could be half that amount or double that amount and she would be eligible for the same services.

            The IDEA applies to all students aged 3 through 21, or until the student receives a regular high school diploma.  To qualify for special education services, a child must have a disability, such as a speech, mobility, orthopedic, health, hearing or visual impairment, mental retardation, or a learning or emotional disability, because of which the child requires special education and related services.  Special education is defined as specially designed instruction to meet the unique needs of the child.  Related services are defined as developmental, corrective and other support services required to assist a student with a disability to benefit from an education and include occupational therapy, physical therapy, speech pathology, counseling, health services, and parent training.  Sharon is eligible for special education and related services (i.e., speech pathology, occupational therapy and physical therapy), even though she attends all regular classes.  This is because she needs the extra services to adequately benefit from her education.

            The IDEA also requires that students receive their special education assistance in the least restrictive environment appropriate to meet their needs.  This means that removal from regular education classes occurs only when a student cannot be successfully educated in regular classes, even with “supplemental aids and services.”  When a student is removed from the regular educational environment for part of the day, the student must still be educated with nondisabled peers as much as possible.

            The needs of the student and the services to be provided must be designated, in writing, on an individualized education program (IEP).  The IEP must be developed at a meeting with a group of people, including the parents and teachers.  The IEP must specify all of the educational services planned for a child, including the child's placement, the special education services, and any supplementary aids or related services.  The IEP will also indicate how often these services will be provided.  The IEP Team must review the IEP at least once per year and more often if requested by a parent or teacher.

2.                  Eligibility for AT Through Special Education Programs

            In 1990, the IDEA was amended and the definitions of AT were added. AT may be considered as special education, related services or supplementary aids and services to ensure placement in the least restrictive environment.  The services are to be decided upon by the IEP Team and indicated in the IEP.⁹

            Any request for special education services, including AT, should be made, in writing, to the IEP Team.  This starts the process to determine what, if any, AT may be necessary to meet the child's educational needs.  Before the IEP Team can determine a child's need for AT, it is required to obtain an appropriate evaluation.  If the parent disagrees with the findings of the school district's evaluator, the parents can request that the school pay for an independent evaluation.

            The key question is whether the AT is needed to ensure that the student receives a free appropriate public education.  The decision must always be made based on the individual needs of the student as determined by the participants at the IEP Team meeting.  AT can be approved if it is needed to assist the child to achieve meaningful educational progress, remain in the least restrictive setting, or prepare him or her for the transition to adult life.  AT should always be considered before a decision is made to place a student in a more restrictive setting.

3.                  Sharon's Need for AT

            The AAC device is an item that special education programs have frequently funded.  It would meet the definition of AT device as a supplementary aid or special education service.  As her only effective means of communicating with teachers and peers, it will ensure that Sharon can effectively participate in the regular classroom.  If specialized software is needed, or if training is needed to learn how to use the AAC device, those items would be AT devices and services, respectively, and could also be approved by the special education system.  Finally, in order to fully learn to use the device and benefit from its use, Sharon should be allowed to take it home, despite any increased chances of damage to this expensive item.¹⁰

            The laptop computer with specialized keyboard and voice input software are items that can be funded through a special education system.  They will become important to Sharon as she and the special education system plan her “transition” from the public school system to college and eventual employment.  The school may argue that she does not need the laptop to benefit from her education, as she can use the computers in the school library.  Sharon may counter that the laptop is needed to meet the increased homework demands during her last two years of high school.  Since the special education program has an obligation to prepare Sharon for the transition to higher education, her later need for the laptop will be an added argument for providing it while she is still in high school.  Based on the limited facts we are given, it appears that Sharon will have a strong case for the computer and accessories, which may depend on how well she is able to both succeed in high school and prepare for the transition to college without them.

            Since both the AAC device and the laptop (or one dual purpose device) will be very important to Sharon as she enters college, it will be very important that any devices she receives during high school stay with her as she leaves.  This can be a problem, as most special education programs around the country will retain ownership of equipment purchased by them and the equipment will remain with the school when the student graduates.  For this reason, Sharon may wish to investigate funding of these items by another entity, such as Medicaid or her state's vocational rehabilitation (VR) agency, that will allow her to retain ownership.¹¹

            The special education program will probably not be responsible for purchasing the ceiling track lift, the access ramp, or the modified vehicle as they are not directly connected to whether Sharon benefits from her education.  Nor are they needed, as special education or related services, to prepare her for the transition to adult life.  However, a special education system will be responsible to provide Sharon with accessible transportation to and from school, including any off site programs that are part of her curriculum.  Based on the facts presented, it would also not appear that the school is responsible for the power wheelchair, as it is not needed for Sharon to benefit from her education.  Special education programs have been required to pay for mobility equipment, like wheelchairs, under limited circumstances.¹²  In Sharon's case, it appears that she can propel her manual wheelchair to meet her needs in the public school.  Her problem will occur when she goes to Cornell University or another college.

4.                  Appeals  -- What if the Parent Disagrees with the IEP Team?

            Any time a parent or guardian disagrees with the services proposed on the IEP, a hearing can be requested.  The parent has the right to be represented by an attorney or other advocate and can present witnesses and other evidence in support of the appeal.

            The current program is to remain in place while any appeal is pending.  For example, if last year's IEP provided for use of a special computer and this year's IEP eliminated that provision, a hearing request would guarantee that the computer is provided during the course of the appeal.  Additionally, if a student moves from one school district to another in the State, and the new school district refuses to recommend the computer and the parents request a hearing, the new school district must provide the computer until the case is resolved.

B.                 The Public Schools and Section 504

            The rights of children whose disabilities do not meet the criteria for special education, but who still may need some specialized assistance, including AT, are covered by section 504 of the Rehabilitation Act of 1973 (section 504).¹³  Under section 504, schools must take reasonable steps to ensure that these students have access to the full range of programs and activities offered by the school.

            To determine a student's eligibility and needs, school districts may choose to simply use the IEP Team procedures and IEP.  If other procedures are used, they must include the following:

1         the student must be provided with a comprehensive, individualized evaluation of his or her needs, with regular reevaluations;

2         the decision about eligibility and services must be made by a group of people, including the parents, knowledgeable about the child, the evaluation information, and the placement options;

3         the student's needs must be specifically identified in writing; and

4         parents have due process rights if they disagree with the district's recommendations, including the right to an impartial hearing.

Section 504 does not include the right to an independent evaluation at school district expense.¹⁴  However, it does include the right to “status quo,” i.e., the continuation of existing services pending an appeal.¹⁵

            In the event that Sharon did not meet the criteria as a special education student, section 504 would still be available to ensure that she has full access to the school and its services.  For example, to allow Sharon to move about the school, section 504 may require the installation of access ramps to allow her to enter and leave the building.  It may also require the installation of an elevator to allow her to reach various locations in the school.  If the school provides computers in its library to all students, section 504 would require that adaptations be provided to allow Sharon to use the computers despite her severe disability.

II.                Vocational Rehabilitation Agencies

A.                 Eligibility for VR Services

            State vocational rehabilitation (VR) agencies can play a critical role in assisting people with disabilities to enter the work force.¹⁶  VR services are to empower individuals to maximize employability, economic self-sufficiency, independence and integration into the work place and the community through “comprehensive and coordinated state-of-the-art programs.”¹⁷  The comments to the 2001 regulations reaffirm this “maximization” requirement.  They note that States must “look beyond options in entry-level employment for VR program participants who are capable of more challenging work.”¹⁸

            An eligible individual must be disabled and require VR services “to prepare for, secure, retain or regain employment.” Persons must show a mental, physical or learning disability that interferes with the ability to work.  It need not be so severe as to qualify the person for SSDI or SSI benefits.  It need only be a substantial impediment to employment.   Recipients of SSDI or SSI disability benefits are presumed to be eligible for VR services, if they intend to achieve an employment outcome.  Although VR services may be denied if a person cannot benefit from them, a person is presumed capable of employment, unless the VR agency shows by clear and convincing evidence they cannot benefit.  Any service an individual is to receive from the VR system must be connected to an ultimate employment goal.

            The written Individualized Plan for Employment (IPE) lists the employment goal and the specific services to be provided.  This plan is to be developed by the consumer, with assistance from the VR counselor if requested, and approved by the VR agency.  Prior to developing the IPE there must be a comprehensive assessment, to the extent necessary to determine the employment outcome, objectives and nature and scope of VR services.  It may also include a referral for the provision of rehabilitation technology services, “to assess and develop the capacities of the individual to perform in a work environment.”

            The VR agency must ensure that all necessary services are provided to equip the individual for employment.  It cannot choose to provide only some services to eligible individuals to save costs.  The “severity of an individual's disability or the cost of services can have no bearing on the scope of services the individual receives.”¹⁹

            The services available from the VR system are incredibly broad and varied.  The following are representative VR services under which AT could be funded: (1) an assessment by someone skilled in rehabilitation technology (i.e., AT); (2) services needed for the diagnosis and treatment of physical or mental impairments, including prosthetic and orthotic devices, eyeglasses and visual services; (3) transportation, including the purchase and repair of vehicles, including vans; (4) interpreter services, readers, rehabilitation teaching, and orientation and mobility services; (5) AT, including vehicular modification, telecommunications, sensory, and other technological aids and devices; (6) transition services for students with disabilities; (7) other goods and services determined necessary to achieve an employment outcome; and (8) post-employment services necessary to assist an individual to retain, regain or advance in employment.

            States need not consider financial need when providing VR services. However, any financial needs test must take into account the individual's disability-related expenses.  The individual's level of participation must not be so high as to “effectively deny the individual a necessary service.”  SSI and SSDI recipients are totally exempt from any financial needs test.

            The following services must be provided without regard to financial need: (1) diagnostic services; (2) counseling, guidance and referral services; (3) job placement; (4) personal assistance services; and (5) “any auxiliary aid or service,” such as interpreter or reader services, that the individual needs to participate in the VR program and which would be mandated under section 504 of the Rehabilitation Act or the Americans with Disabilities Act.

            VR agencies will not pay for a service if a comparable benefit is available through another provider.  For example, if an applicant qualifies for personal assistance services through Medicaid, the VR agency will not provide them.  But, loans, which must be repaid, are not similar benefits.²⁰  A Plan for Achieving Self Support (PASS) is not a comparable benefit.²¹  Additionally, AT is exempt from the comparable benefit requirement.

B.                 Eligibility for AT

            Most of the items listed in the Sharon scenario, above, can potentially be funded through a state VR agency if she can establish: i) that she needs the item to reach her vocational goal; and ii) that she meets the VR agency's financial need criteria, if any.²²  Generally, she would also need to show that she has exhausted any comparable benefits that may be available to pay for the item.  However, since each of the items sought should meet the definition of an AT device or service, their funding is exempt from the comparable benefit requirement.

            More than likely, the VR agency will refer Sharon to either Medicaid or Medicare (if she is eligible for those programs) to fund the power wheelchair and AAC device, even though those items are exempt from the comparable benefit requirements. Both Medicaid and Medicare will routinely fund those items when they are medically necessary.  Sharon should be encouraged to foster good will with the VR agency by first seeking Medicaid or Medicare funding for these items.

            The laptop computer, with accessories, and the access ramps are items that are likely to be funded through the VR agency if Sharon can show they are necessary for the success of her vocational plan.  It is less likely that Medicaid or Medicare will be able to fund these items.²³  Sharon need not exhaust SSI's PASS as a potential funding source as that is not considered a comparable benefit.

            The ceiling track lift is a more difficult argument.  A VR agency can fund home modifications, under the category of rehabilitation technology, when necessary to allow a person to leave the house to attend a training program, set up a home business, or go to work.  The ceiling track lift, which is typically used to get a person to and from the bed or bath, may be viewed more like a personal hygiene aid.  Sharon's best approach is to argue that the ceiling track lift, like the access ramp and the van modifications, is necessary to get her out of the house and to school.

            In a few states, the VR agency will fund a vehicle lease or purchase if needed to participate in a VR program. It is clear that the federal VR regulations permit a state to fund vehicles, but less clear whether it would require that they do so in all cases.²⁴  Under the facts presented, however, one should argue that since the purchase or lease of a vehicle would be less expensive than a private transportation service to and from college for four years, a vehicle should be purchased or leased for Sharon.  In all states, the agency should pay for the modifications to allow Sharon to get into the van and drive it from her wheelchair.

C.                 Hearing and Appeal Rights

            Anyone dissatisfied with a decision by the VR agency has the right to appeal.  Appeals can be pursued through mediation or an administrative hearing before an impartial hearing officer.  The Client Assistance Program (CAP) is available in every state to assist individuals who have questions or who are appealing a VR decision.

            At a hearing, the individual has the right to be represented by an attorney or other advocate.  The individual can present evidence and cross examine witnesses.  The hearing decision is final and must be implemented, unless appealed.  Either party may appeal a final administrative decision to court.  However, pending review in court, the final administrative decision must be implemented.

III.             Medicaid

A.                 Eligibility for Medicaid

            Medicaid, also known as Medical Assistance, is a cooperative federal-state program authorized by Title XIX of the Social Security Act.²⁵  It is a health insurance program, designed to serve persons with limited income and resources.  Although every state has the option of whether or not to have a Medicaid program, every state has exercised that option.  Administration of Medicaid will occur at the state level, with the state Medicaid agency often delegating decision making to other state agencies, to county or local Medicaid units, or to managed care organizations.  Medicaid can pay for a wide range of health-related costs for both children and adults with disabilities, including many of the items sought by Sharon.

            Medicaid is typically the only or primary health insurance plan for persons with disabilities who have limited income.  Additionally, an increasing number of individuals with disabilities are looking to Medicaid as their primary health insurance plan, notwithstanding higher levels of income.  Medicaid may be available to those individuals through state-specific Medicaid waivers, through optional Medicaid buy-in programs, or through the section 1619(b) provisions.

            Medicaid eligibility will vary somewhat from state to state.  Generally, the majority of persons with severe disabilities will become Medicaid-eligible in one of two ways: through the SSI program or through the medically needy program.  In 39 states and the District of Columbia, an individual eligible for SSI is automatically eligible for Medicaid.  If the SSI check is as little as $1, Medicaid eligibility is guaranteed.²⁶  In most of these states, an SSI application is also a Medicaid application and no additional action is needed to ensure Medicaid eligibility.  However, the following states require a separate Medicaid application: Alaska, Idaho, Kansas, Nebraska, Nevada, Oregon, Utah, and the Northern Mariana Islands.

            In 11 states, known as section 209(b) states, Medicaid eligibility is not automatic for SSI recipients.  These states use their own Medicaid eligibility criteria which differs from SSI eligibility criteria.²⁷  The states which exercise the 209(b) option are: Connecticut, Hawaii, Illinois, Indiana, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, and Virginia.²⁸

            Four separate categories of former SSI recipients can retain automatic Medicaid eligibility as if they were still receiving SSI.  These include:

1         Recipients of Social Security Widow's/Widower's Benefits.  If a person loses SSI when he or she becomes entitled to widow's or widower's benefits under Social Security, the person will remain automatically eligible for Medicaid if SSI eligibility would continue in the absence of the widow's or widower's benefits.  Eligibility continues only for so long as the person remains ineligible for Medicare, a period of 24 months following the first month of Social Security eligibility.²⁹

2         Recipients of Social Security Disabled Adult Child's Benefits.  Recipients of Social Security Child's Insurance Benefits, often referred to as Disabled Adult Child's (DAC) benefits, can continue eligibility for automatic Medicaid if, after July 1, 1987, the person lost SSI due to entitlement to or an increase in DAC benefits.³⁰

3         The Pickle Amendment.  This protects certain persons who lost SSI because of cost of living increases in Social Security benefits since April 1977.  Automatic eligibility continues if the person would be eligible for SSI under present eligibility standards if Social Security cost of living expenses since April 1977 are disregarded.³¹

4         The Section 1619(b) Program.  This provides Medicaid for individuals who lose SSI benefits because earnings become too high to continue receiving cash benefits.  Under 1619(b) criteria, automatic Medicaid will continue if the person would continue to be eligible for SSI if the wages were ignored and if annual income is less than a specified income threshold.³²  The 1619(b) eligibility thresholds will usually change each year and will vary state by state.³³

            The Medically Needy Program, often referred to as a spend down, is an option exercised by approximately two thirds of the states.  Medically needy individuals are those who would qualify for Medicaid, including individuals who are disabled, but have income or resources above limits set by their state.³⁴  Since Medicaid eligibility workers often do not explain the spend down program to applicants or recipients, it is important that you find out if your state offers this option and take steps to educate yourself on how it works.  At a minimum, you should keep up to date on your state's medically needy income eligibility levels for various sized families.

            How does the spend down work?  Each state will set its own medically needy income level based on family size.  All individuals meeting the federal (i.e., SSI) definition of disability, who have income and resources below their state's medically needy level, automatically qualify for Medicaid.

            Individuals with income above the medically needy level do not automatically qualify for Medicaid.  They must first meet a “spend down” or “share of cost” test.  The spend down is the amount by which the individual's income exceeds the medically needy level after subtracting allowable deductions.  Consider this example: In New York, which has a 2002 one-person medically needy level of $634 per month, a single adult with a disability receives a monthly SSDI check of $754.  Since this exceeds the state's medically needy level of $634, the Medicaid agency will disregard the first $20 as an unearned income exclusion and the individual will face a $100 spend down (i.e., their countable income exceeds the medically needy level by $100).  The spend down acts like a deductible or insurance premium that must be paid or incurred before the insurance program, i.e., Medicaid, begins coverage.

            The optional Medicaid Buy-In Program is an important way for individuals with disabilities to obtain or retain Medicaid coverage when they are working.  It is designed to provide health insurance to working people with disabilities who, because of relatively high earnings, cannot qualify for Medicaid under another provision. The buy-in was originally made available as part of the federal Balanced Budget Act of 1997.  The enhancements to this optional program have been touted as some of the more important provisions of the Ticket to Work and Work Incentives Improvement Act of 1999.  As this document is written, approximately 15 states had adopted and were implementing buy-in programs, with an additional 20 or more states at various stages of pre-implementation (including several that had been adopted and were awaiting federal approval, and several pending in state legislatures).  You may wish to check the status of the buy-in program in your state.

            The buy-in program is most important to those individuals with disabilities who have significant health care needs that cannot be met through employer-sponsored health benefits plans and have no ability to obtain or retain Medicaid when working for significant wages.  Most often, the group that will benefit most will be recipients of SSDI, who were not simultaneously eligible for SSI and, thus, cannot qualify for Medicaid under the section 1619(b) program.  Many of these individuals currently receive Medicaid through medically needy programs and could not afford to work if it meant giving up Medicaid as the source of payment for expensive items like prescription drugs, personal assistance services, and durable medical equipment (i.e., AT).  In those states that have implemented buy-in programs, eligibility for Medicaid can continue in many cases at annual wage levels exceeding $40,000.

            Subject to federal criteria, a state can choose to structure the buy-in as it sees fit.  Largely due to fears of rising Medicaid costs, only five or six states had initiated buy-in programs when the Ticket to Work and Work Incentives Improvement Act (TWWIIA) was signed into law in December 1999.  TWWIIA sought to make the program more attractive to states.

            Key federal eligibility criteria for the original, 1997 buy-in include:

1                   Eligible individuals must be in a family whose net income is less than 250 percent of the federal poverty level.  A single individual is in a family of one.

2                   Except for the individual's earnings, the person with a disability would be considered eligible for SSI benefits.  This includes the definition of disability.

3                   Each state determines its own definition of a “family.”

4                   All SSI exclusions apply to the determination of family income, including the earned income exclusions.

5                   Individuals are not required to have been on SSI to be eligible for this new Buy-In provision.

6                   The State must make a disability determination if an individual was not an SSI recipient.

7                   Substantial gainful activity (i.e., in 2002 earnings in excess of $780 monthly) is not an eligibility consideration.

8                   States can increase the resource limits to as high as $14,000.

9                   States can charge premiums or other cost-sharing charges.

            The 1999 TWWIIA legislation builds on the 1997 legislation, adding provisions that make it more attractive to states:

1                   It allows states to offer a Medicaid buy-in to persons with disabilities who work and have earnings between 250 and 450 percent of the federal poverty level.

2                   Participating states are allowed to set income limits and require cost-sharing and premiums, based on income, on a sliding scale.  A state could require some individuals to pay the full premium as long as the premiums do not exceed 7.5 percent of the individual's total income.

3                   States must require a 100 percent premium payment for individuals with adjusted gross incomes greater than $75,000 unless states choose to subsidize the premium using their own funds.

B.                 Eligibility for AT Through Medicaid

            The categories of service covered by Medicaid will vary greatly from state to state.  This is because the majority of Medicaid service categories are optional.  A state must cover all “required” categories of service, such as inpatient hospital care and home health care services for persons eligible for skilled nursing services.  A state may choose which of approximately 30 “optional” categories of service to cover.

            Typically, state Medicaid programs have covered AT under one or more of the following coverage categories: home health care (which includes medical supplies and equipment, commonly referred to as “durable medical equipment”), prosthetic devices, physical therapy (PT), occupational therapy (OT), speech therapy,³⁵ rehabilitative services, and transportation.  With the exception of home health care, all of these categories are optional for adults, meaning that some states will cover them and some will not.

            Children under age 21 are covered under a special mandatory program, known as the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program.  Under federal Medicaid law, a state is required through its EPSDT program to cover all of the required and optional services for Medicaid-eligible children under age 21 even if some of those optional categories are not covered for adults.³⁶  The statutory language, governing EPSDT, would seem to support a very expansive view of when a child will receive AT under the EPSDT program.  A service must be covered for a child if it is among the required or optional services and is “necessary . . . to correct or ameliorate defects and physical and mental illnesses and conditions.”³⁷

C.                 Sharon's Eligibility for AT

            Sharon will become eligible for SSI disability benefits at age 18.  Her parents' income and resources will no longer be counted against her and her SSI payment will be based on her own income and resources.  She will then become Medicaid-eligible in those states in which Medicaid is automatic for SSI recipients.  In other states, she may be eligible under the medically needy program, with or without a spend down.  Once eligibility is established, she will be eligible through EPSDT for coverage under all of the required and optional service categories.  This will provide the maximum possibilities for coverage of the AT-related items she is seeking.

            Every state's Medicaid program should cover the power wheelchair and AAC device if Sharon can show that they are medically necessary. Typically, these items would be covered as durable medical equipment.  The AAC device has also been covered in some states as a prosthetic device or under the equipment clause of the speech therapy category.  Some Medicaid decision makers will balk at approving the power wheelchair, claiming that she can get around in most environments with her lightweight, manual wheelchair.  In some states, Sharon may need to appeal (see below) to establish that the power wheelchair is needed to meet all of her mobility needs, particularly as she begins spending time on a college campus within a hilly community.

            The ceiling track lift could also be covered under Medicaid's durable medical equipment category.  The controversy here will not focus on whether a lifting device is needed; instead, some Medicaid programs may argue that a less costly, stationary lifting device can meet her needs.  Again, Sharon may need to appeal to establish her right to the preferred ceiling track lift.  In any case in which a Medicaid agency seeks to limit the person to the less expensive device, it will be critical to have the supporting documents from doctors and other health professionals address why the lesser item falls short of meeting the person's needs.  If a Medicaid-funded personal care aide is needed to operate the stationary lift, but is not needed to operate the ceiling track lift, that may help show that the stationary lift is actually a more expensive alternative in the long run.

            The access ramp for the home is an item that many Medicaid programs will balk at funding.  A typical response will be to say that it is not primarily medical in nature or is a matter of convenience rather than a medical necessity.  The authors are aware of several cases, in different states, in which access ramps or stair glides within the home have been approved following a hearing.  In some states, a separate Medicaid waiver program may cover a range of home modifications as an exception to general rules for those who qualify for the waiver.

            A Medicaid program would not be expected to pay for a laptop computer, its accessories, or the van.  These are not items one thinks of as meeting a medical purpose or as being medically necessary.  Keep in mind, however, that there are several dual purpose AAC devices on the market that double as laptop computers.  Often, these are no more expensive and sometimes less expensive than dedicated AAC devices that meet the same communication needs.  Unlike Medicare,³⁸ most state Medicaid programs will pay for dual purpose devices, especially when they are the least costly alternative for meeting the individual's communication needs.  We can also expect state Medicaid programs to balk at paying for the van modifications.  However, we are aware of two hearing decisions from New York and an unreported court decision from Colorado in which vehicle modifications were approved to meet the needs of either a driver or a passenger with a disability.

Medicaid Waivers Can Fund AT

            Individuals with disabilities and their advocates should not be too quick to rule out potential funding of items which appear to fall outside the scope of Medicaid.  Every state will have one or more special waiver programs, typically referred to as Home and Community Based Services Waivers.  These waivers, which are optional, will vary greatly from state to state.  When approved by the federal Health Care Financing Administration (HCFA),³⁹ a state is permitted under a waiver to provide a range of services, to special populations, that are not available to Medicaid recipients generally.⁴⁰

            Many states, through Medicaid waivers, will provide a range of very expensive services if they are necessary to keep a person in the community and out of an institution.  These typically include a range of home modifications, including ramps, lifts, stair glides, and other items, that are a challenge to obtain through the standard Medicaid program.  One of New York's waiver programs will, under limited circumstances, pay for van modifications if they are needed for the transport of a child with a disability in a van owned by the parent or parents.⁴¹  Since no two states will operate identical waiver programs, the individual or their advocate must investigate to determine what waivers are available in their state.

D.                Appealing Medicaid Decisions