Inexpensive low tech devices like calculators, adapted knives, forks and spoons, bath seats and touch lamps may not deplete your family’s budget. Money for expensive high tech devices like home and vehicle modifications, computers and robotics may not be available in the family budget.
Maine’s mPower loan program offers low interest loans so families can borrow money to buy assistive technology, adapted vehicles or make necessary home modifications. For more information about mPower, please visit their website www.mpowerloans.org
A new regional service called Get AT Stuff provides a source for buying, selling or donating used assistive technology. For more information visit www.GetATStuff.com
Families sometimes avoid paying for pricey assistive equipment with the help of clever and creative friends, resourceful and energetic volunteers who can make devices like those described in Stephanie’s story. Parent groups, preschools and centers where children with disabilities go for therapy sometimes sponsor equipment loan programs.
The Kid’s Project, a program of Pine Tree Society , provides affordable adaptive equipment and furniture; custom-designed equipment; and modifications to existing furniture, toys and utensils for people with disabilities. This project brings together the expertise of a physical therapist, adaptive equipment specialist and the wood working and upholstery expertise of more than one hundred volunteer carpenters and upholsterers. A full line of wooden equipment and toys are available as well as consultations for custom equipment. Contact the Pine Tree Society for more information .
Few families can afford to buy all the assistive technology their children require. Families often need help paying for devices and services. Generally, families may find themselves in one of three funding possibilities:
Sometimes families get the technology their children need by using “third party payers”. A third party payer is any public or private program, agency or company that pays for the devices or services used by an individual. Public programs are sometimes a source of funding.
Some assistive technology (called “durable medical equipment”) is covered by Maine Care. To find out if your family or child is eligible for any Maine Care coverage, contact the local Department of Health and Human Services (DHHS) office nearest you.
Some “private” sources like local fraternal or community service organizations pay for assistive devices and services on a case-by-case, solicited basis. Health insurance plans can also be used to pay for devices and services.
No matter if you use a public insurance program such as Maine Care or your own health insurance plan, be sure to keep accurate records of your contacts with the program or plan. This documentation should include at least the date, person’s name, title, the reason for the contact, the results of the contact, any necessary follow-up, and who is responsible for the follow-up. Model forms for documentation can be found at Center for Community Inclusion and Disability Studies .
The cost of devices and services is sometimes covered by health insurance plans. However, paying with your health insurance plan can use up a large portion of everyday and emergency health care coverage.
The concept of maximum lifetime benefits is like a checking account. Your individual policy determines the “opening balance”. If the policy has a maximum lifetime benefit of one million dollars, that is the “opening balance”. Every time the health insurance plans pays for a service for any family members, the cost of that service is deducted from your balance.
Most health insurance plans pay up to a “maximum lifetime benefit” amount. Once your family has used up that amount, your medical expenses are no longer covered. Every time your family uses your plan to pay for health care, some of the maximum lifetime benefit is used up. Once the maximum lifetime benefit amount has been depleted regular and emergency health care will not be covered. Coverage for your family will no longer be available to help pay for regular and emergency health care bills.
Your health insurance plan policy manual explains your maximum lifetime benefit amount. You should understand the limits of your health insurance plan. Read your policy manual carefully and consider your family’s individual needs and circumstances.
If you have decided that your maximum lifetime benefit amount will not be jeopardized by using your health insurance plan to pay for assistive devices and services, be prepared to meet your plan’s requirements. Keep in mind this important “medical necessity” guideline: insurance plans are health plans. For a device or service to be covered it must affect the insured person’s health or serve a medical purpose.
Advocacy hint: private insurers and Medicaid often use the reason “not medically necessary” to deny claims for AAC and Seating, Positioning or Mobility devices.
This line of reasoning is often based, not on medical need, but on how the device may have additional uses. Even if the device allows a person to take advantage of a wide array of opportunities inside and outside of the home, it does not matter. You should consider appealing the denial.
Devices and services for physical, occupational and speech therapies may be covered entirely or partially if your insurer determines that they are medically necessary. What about other assistive technology - seating, positioning and mobility devices, for example? Unless medical necessity is demonstrated, an insurer is likely to deny coverage saying that seating, positioning or mobility devices are of social, educational or recreational necessity.
Professionals who work with your child and your family understand the medical needs that assistive technology can fill. Talk with your professionals about the medical reasons for the devices and services that your child needs. Your pediatrician, family doctor and other health specialists should write a letter of medical necessity stating the specific medical needs that the device or service will fill. It is very important for the letter to explain how the device and/or service will be used to treat the disease, illness or condition. In addition, the letter should also emphasize the following important preventive factors.
Insurance plans require a physician’s prescription for devices or services. Talk with your doctors about your child’s medical needs that can be met with the assistive device or service. Get your doctor’s written prescription.
Even if your child’s doctor writes a prescription, your insurer might deny coverage if you cannot explain how the device or service will improve or maintain your child’s health. Be sure that the letter of medical necessity supports your doctor’s prescription.
“Prior authorization” is another requirement your insurance plan might have: the insurance company won’t pay unless it has approved the purchase. Read your insurance policy manual. Know whether your health insurance plan covers the cost of the device or service your child needs. Your policy manual probably does not use the words “assistive technology.” Look for words like “durable medical equipment” or “home medical equipment.” Contact your insurance company, ask for a written verification that the device or service will be covered. Confirm your coverage before you buy assistive technology devices or services.
Get the required documentation: 1) the doctor’s prescription, 2) the letter of medical necessity and 3) the written verification of coverage, all together. Keep this documentation in a handy place.
Your health insurance company should give you written reasons if they deny your claim for assistive technology devices or services. If the denial does not include written reasons, ask for them.
Your insurance company is also required to have appeal procedures you can use when coverage is denied. In general, you are encouraged to appeal any denial. Studies show that many times upon review, the insurance company will change its mind and pay for the necessary assistive technology. Insurance companies are also required to explain to you how to use those appeal procedures. Look in your policy manual for an explanation of appeal procedures. Be sure that you follow any timelines stated in the appeals process. If you miss any deadlines, the insurance company does not need to continue the appeals process.
A “claims review” can help change the denial decision. Your claims review request should be in writing. Your request should include the reasons you think your claim is valid: tell why you believe the device or service is covered under the terms of your policy.
Your claims review request should also include any documentation - your doctor’s prescription, statement of medical necessity and any other written evidence - that supports your belief that the device or service is covered under the terms of your health insurance policy.
There is, however, an important note if your child receives benefits from both a private health insurance and Maine Care. Once the appeals process is complete and the private insurance company still denies the claim, the denial should be sent to Maine Care. Maine Care will then consider the claim and decide if coverage is available for the requested device or service.
Claims examiners at the Maine Bureau of Insurance Consumer Health Care Division can help you. They are able to review claim denials. They might be able to help if you believe your denied claim should be covered under the terms of your insurance policy. Maine people have the right to request an external review when a health insurance carrier or an HMO denies benefits. Maine has a law that gives people the right to an external review of certain kinds of treatment denials, including denials based on issues of medical necessity. Maine Bureau of Insurance contact information .