Acknowledgements

On behalf of the Board of Directors of the Arkansas Center for Public Affairs, Inc., (ACPA) I want to extend ACPA's thanks to a number of individuals who gave generously of their time, experience and knowledge in the development of recommendations co ntained in this report. Special appreciation is given to members of the project's Advisory Committee who not only contributed their time, experience and knowledge, but also provided critical commentary and valuable suggestions.

--Senator Nick Wilson, Chairman, ACPA Board of Directors

Assistive Technology and Insurance Advisory Committee
Billy Altom
Maria Jones
Kim Baxter
Bill Knight
Alice Caldwell
Karen Lutrick
Randall Caldwell
Ken Musteen
Cliff Coates
Burt Pusch
Tim Corbitt
Frances Rayburn
Suzanne Crisp
LaNora Steiner
Jim Eakin
LaVencia Sugars
Nan Ellen East
Nancy Sullivan
Rick Fleetwood
Diane Sydoriak
Sue Gaskin
John Taylor
Ira Gerlis
Glenn Thomas
Barbara Gullett
Dale Turrentine
Howard Harper
Cheryl Vines
Donna Hartzell
Barry Vuletich
Phyllis Henry
Bettye Watts
Arnold Hurst
Ronnie Wheeler
Becky Johnson

EXECUTIVE SUMMARY:
Although the enactment of the Americans with Disabilities Act (ADA) marked significant progress toward providing equal opportunity to employment and services for persons with disabilities, it did not provide similar opportunity for access to health insurance. For persons with disabilities, concerns about access to adequate and affordable health insurance drive decisions about many aspects of life. Such concerns influence decisions on occupation, employment and living arrangements.

Consequently, lack of access to insurance coverage is a serious problem for persons with disabilities who need "assistive technology"-or devices such as wheelchairs, hearing aids or computerized equipment-in order to maintain or improve their functio nal capabilities. Recognizing the importance of addressing this issue, ICAN (Increasing Capabilities Access Network), administered through Arkansas Rehabilitation Services, commissioned the Arkansas Center for Public Affairs, Inc. (ACPA) to study insurance coverage of assistive technology and related services in the state.

A number of issues were identified during the fifteen-month initiative, which included several study approaches. A review of other states' experiences was conducted and surveys were administered among Arkansans with disabilities and providers of rehabilit ation services. Additionally, two conferences were sponsored by ACPA that featured presentations by health policy experts, insurance and state agency representatives, disability advocates and consumers of assistive technology.

The Assistive Technology and Insurance Advisory Committee developed the resulting recommendations, which are presented in this report, in 1997. This Committee is comprised of consumers, family members, business organizations, service providers and st ate agency representatives. The recommendations are grouped within three categories:

* benefits and coverage
* insurance processes and procedures
* collaboration and service integration.

COVERAGE AND BENEFITS

Issues:
Often "pre-existing condition" exclusion practices result in denials of coverage or restrictions of benefits and services. Other persons with disabilities, who are covered, must often pay exorbitant premium costs.

Limitations exist in the assistive technology services that are currently covered.

Recommendations:
* Eliminate private insurance access barriers, including basic coverage exclusions, caps, partial coverage and excessive premium costs.

* Provide coverage for related services such as evaluations, therapies, supplies, training, repairs and maintenance. Assistive technology evaluations and therapies, necessary for appropriate utilization of devices, should be considered as distinct reimbursable services.

* Develop universal definitions for "medical necessity," durable medical equipment, assistive technology and orthotics and prosthetics.

* Standardize coverage for durable medical equipment and orthotics and prosthetics.

* Implement insurance ombudsman program to assist consumers and providers in identifying problems, researching systemic issues and advocating for change.

* Develop a Medicaid waiver and/or other strategies to provide acute care rehabilitation of traumatic neurological conditions.

PROCESSES AND PROCEDURES
Issues:
Persons involved in making coverage decisions are often not aware that assistive technology devices can reduce the need for more expensive health care service utilization by persons with disabilities.

Persons requesting prior approval for assistive technology often endure lengthy waits for decisions to be made or must repeatedly submit documentation to justify the need for assistive technology as a requirement for approval.

Recommendations:
* Assure Medicaid Medical Care Advisory Committee includes representatives who are aware of consumer needs for durable medical equipment, assistive technology and orthotics and prosthetics.

* Provide ongoing training about assistive technology, durable medical equipment and orthotics and prosthetics for private and public insurance internal review professionals.

* Keep decision-and-policy-makers at all levels updated and informed about emerging rehabilitation technology.

* Develop standards to assure quality; prevent fraud and abuse; avoid faulty devices and minimize duplication in approval processes.

* Refine private and public insurance prior authorization processes for obtaining durable medical equipment, assistive technology and orthotics and prosthetics.

* Streamline private and public insurance paper work and documentation processes.

* Assure private and public insurance decision- making and appeal processes are timely.

COLLABORATION AND SERVICE INTEGRATION
Issues:
Service systems often do not focus on the total needs of the individual, resulting in fragmented services and inefficient use of limited resources.

Confusion frequently exists among consumers, providers and professionals about insurance regulations and processes, rights and responsibilities.

Recommendations:
* Develop mechanisms for collaboration among various state and community-based programs--both public and private--which play a role in the provision of assistive technology to more readily assure availability of coordinated, community- based service s ystems statewide.

* Educate consumers and providers about insurance and related processes for obtaining durable medical equipment, assistive technology and orthotics and prosthetics so that they can make better-informed choices.

* Develop and conduct training for providers and evaluators regarding aspects to be considered in selecting and recommending equipment and/or services based on individualized need. Such training should include consideration of options, the environmen t in which the equipment and/or services will be used, costs and future needs of the individual.

OVERVIEW Remarkable advances have been made in the field of technology in recent decades that have revolutionized how people work, live, learn, play, communicate and interact with the rest of the world. For most people, technology offers conveniences allowing them to do things more easily. For people with disabilities, however, technology makes doing things possible and is, therefore, essential. However, access to assistive technology--for example, wheelchairs, hearing aids, augmentative communication d evices, home modifications or daily living aids--that can assist individuals with disabilities to maintain or improve functional abilities is frequently limited due to the lack of health insurance coverage.

Throughout the nation, persons with disabilities have the poorest access to private health insurance coverage due to the industry's exclusions, limitations and restrictive underwriting practices. Private insurance often seeks to minimize the risk of serious illness and, as a result, may exclude persons with disabilities from coverage. Those who do have insurance are typically underinsured with coverage packages that are oriented to acute care and that do not meet their specific chronic and long-term care needs. These needs often include assistive or rehabilitation technology devices and related services such as training, therapy, or maintenance required for persons to be able to use technology to the greatest benefit.

When unable to obtain private health coverage, persons with disabilities often seek public insurance. Public health insurance programs, such as Medicaid and Medicare, however, impose requirements and restrictions that--like private health insurance--limit access to needed services, affect decisions about employment and influence the individual's independence. The eligibility requirements of public programs for person with disabilities are typically related to an inability to work. If individuals become employed and earn more than a designated amount, they may eventually lose their eligibility for public insurance and thus, their access to needed services.

The U.S. Census Bureau estimates that almost 18 percent of Arkansans, over age 16, have work limitations due to disabilities. This figure places Arkansas among the top five states in the number of persons who cannot work or who can perform only limit ed work because of disabilities related to walking, lifting, hearing, seeing or speaking. With the passage of the Americans with Disabilities Act (ADA) and resulting provisions for workplace accommodations, employment opportunities for persons with d isabilities have increased. However, the employment opportunities and protections promised by ADA offer little for many persons with disabilities whose concern about access to adequate health insurance drives their employment decisions, including wh ether to change jobs or whether to accept employment at all.

More recent federal legislation--the Health Insurance Portability and Accountability Act (P.L. 104-191)--also improves access to insurance coverage for some persons with disabilities. The law guarantees the availability and transferability of private health insurance coverage for individuals with pre-existing conditions who had insurance coverage at a previous employer. However, the law does not improve access for persons with pre-existing conditions who have not had prior insurance coverage, si nce its provisions do not include these individuals.

Within Arkansas, one of the agencies most concerned with the issue of assistive technology and insurance is ICAN (Increasing Capabilities Access Network). Administered through Arkansas Rehabilitation Services, ICAN is a federally- funded program that has responsibility for facilitating changes in laws, regulations, policies and practices in order to furnish greater access to assistive technology for persons with disabilities.

As a part of its continuing efforts to increase accessibility to assistive technology, ICAN engaged the Arkansas Center for Public Affairs, Inc. (ACPA) to study pertinent issues of health insurance coverage for assistive technology. The primary goals of the fifteen-month study included:

* Providing information to persons with disabilities and other stakeholders-including advocates, service agencies, legislators, policy makers and insurance providers-for use in policy development and other decision-making processes related to the provision of assistive technology;

* Involving persons with disabilities who use assistive technology and/or their family members as active advisors through the project; and

* Developing a public policy position statement that focuses on access to assistive technology through public and private insurance.

A number of issues were identified during the initiative, which included several study approaches. Two conferences were sponsored by ACPA that featured presentations by health policy experts, insurance and state agency representatives, disability advocates and consumers of assistive technology. These conferences drew participants from across the state. A review of other states' experiences with insurance coverage of assistive technology was also conducted. Members of the Advisory Committee met with representatives of the Arkansas Insurance Department and the state's Medicaid program to explore area s of concern. To more fully define public and private insurance coverage issues related to funding of assistive technology, ACPA surveyed Arkansans with disabilities, as well as providers and professionals who work with persons with disabilities.

Survey respondents perceived a number of problems with insurance coverage of assistive technology within the state. Of four hundred twelve persons who returned surveys, forty-five point five percent said private insurance would not cover their assistive technology needs and twenty-five point nine percent indicated private insurance rendered partial coverage for rehabilitation devices. Regarding public insurance coverage- Medicaid, Medicare or the Veterans Administration- -twenty-three point nine percent of those completing the surveys noted no coverage was available for their assistive technology or durable medical equipment needs, while fifteen point nine percent said partial coverage was provided.

Underscoring this lack of coverage perception was a finding obtained from responding rehabilitation services providers and professionals: 66.2 percent thought persons with disabilities who could benefit from assistive technology did not have adequate coverage for such devices. When asked for their opinions as to the major barriers with insurance coverage of assistive technology or durable medical equipment, fifty-three percent cited "no insurance coverage," thirty-three point five percent selected both "partial coverage" a nd "insurance caps or exclusions" and twenty-six point five percent checked "eligibility requirements." (Persons answering the survey could select more than one response to this question.)

Survey results also revealed limitations in insurance coverage for evaluating technology needs, fitting or adapting devices, coordinating assistive technology and durable medical equipment with other therapies or services and maintaining, repairing o r replacing equipment. Other problems noted from the surveys included the length of time and "red tape" associated with insurance processes. Also cited was the lack of professionals, involved in coverage decisions, who have adequate knowledge of the important role assistive technology plays in improving functional capacity of persons with disabilities. In terms of recommendations for changes with insurance coverage of assistive technology or durable medical equipment, only point five percent of respondents indicated "no changes are needed."

With the increased focus on improving access to assistive technology through expanded insurance coverage, several significant events occurred within Arkansas during the project's time frame. Major accessibility barriers were removed through the prom ulgation of new rules within the state's Medicaid program. As a result of these revisions, adults were granted similar access to Medicaid reimbursement for assistive technology that previously had only been allowed for children. Additionally, the 1997 Arkansas General Assembly passed resolutions calling for legislative study of the assistive technology insurance coverage issue prior to the convening of the Arkansas General Assembly in 1999.

The recommendations presented in this report have been prepared to assist state leaders, policy makers, advocates and others concerned with assistive technology. The recommendations are intended to guide the creation of more viable, affordable and "user friendly" alternatives to existing insurance coverage systems-both public and private-as they relate to assistive technology within Arkansas.

The recommendations were developed in 1997 by the Assistive Technology and Insurance Advisory Committee, which is comprised of consumers, family members, business organizations, service providers and state agency representatives. The proposals are gr ouped within three categories:

* benefits and coverage
* insurance processes and procedures
* collaboration and service integration.

ISSUES AND RECOMMENDATIONS The private health insurance system is a major potential resource for assisting people with disabilities to gain access to assistive technology and subsequently, the potential for employment, income, independence and richer, fuller lives. However, in contrast to Medicaid, Medicare, special education and vocational rehabilitation, there are no federal laws that specify what must be covered in health insurance policies. Although states regulate insurance, many variations and individual difference s in the scope of health care insurance coverage are permitted.

Private health insurance is often a part of wage and benefit packages provided by employers to their employees and their families. Health insurance is also obtained through professional or other organizations or directly by individuals. There are two ways that employers usually pay for health care coverage. The most common method is for an employer to buy a contract of insurance (insurance policy) from a commercial health insurance provider for the benefit of the employer's workers and their families. The second method is for an employer to "self-insure" or "self-fund" a plan of health benefits, using company resources to pay for employees' and their families' covered health expenses.

There is no requirement for employers to provide health insurance as a benefit to their workers or their workers' families. Employers can purchase no insurance at all, purchase insurance, or offer a self-insured benefits plan. Employers' decisions to offer health care coverage, as well as how to pay for it, are largely based on the costs of these choices.

Because of the very high costs connected with health care, private health care payments are a highly-prized benefit. A source of health care payment helps provide a measure of financial security to families.

For people with disabilities and their families, the value of this benefit is unique. Health insurance coverage may be the controlling factor between treatment that supports independent functioning in the home or dependency and institutionalization. Assistive technology is another unique need of people with disabilities. It is a benefit that has special meaning: in general, assistive technology "treats" various conditions by reducing or eliminating their residual handicapping effects.

Assistive technology is now one of the treatment methods being applied to a wide variety of persons with disabilities. It is replacing other types of care, and extending the benefits of treatment to persons who previously were thought beyond assistance. Through technology, these persons are now able to see significant improvement in their abilities to function.

Unfortunately, there is no mandate for "universal coverage," either for people or for services. There is no "common benefits list" that applies to all insurance polices or health benefit plans. Consequently, there are a number of barriers to health i nsurance for persons with disabilities, particularly in two major areas: who is insured and what benefits are covered.

BENEFITS AND COVERAGE

Issues: Individuals with "pre-existing conditions" are frequently denied access to health coverage, or have limitations placed on their coverage. Pre- existing condition clauses are limits to benefits in both health insurance policies and benefit plans. They limit coverage for care or treatment- related conditions that occurred before the person became covered. Usually there are specific time limits and exclusion periods, after which coverage will be provided. It is also possible, however, that a policy or plan will limit continuing coverage of treatment for these conditions.

Disabilities are often defined as "pre-existing conditions" by insurance plans; therefore, individuals with "pre-existing conditions" are frequently denied access to health insurance coverage. Furthermore, if the person with a disability or a pre-existing condition is insured, there may be significant limitations in coverage. Persons who may obtain coverage often find they must pay exorbitant premiums to maintain coverage, resulting in yet another barrier to insurance accessibility.

Private health insurance pays for assistive technology--which is typically referred in insurance plans as "durable medical equipment"-- based on the criteria for coverage listed in the policy. Assistive technology devices must meet criteria for "medic al necessity" and "durable medical equipment."

There are no standard definitions for these terms. Typically, however, "medical necessity" means the device is prescribed by a physician; is used to restore or approximate normal function of a missing, malformed, or malfunctioning body part; is directly related to a diagnosed medical condition and is expected to improve the user's ability to function.

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

Most health insurance polices require prior approval for durable medical equipment, although prior approval is not a guarantee of payment. Additionally, the degree to which services or devices are medically necessary is not solely the decision of th e prescribing physician. Most policies contain a statement similar to the following:

The fact that a provider may recommend, prescribe, order or approve a service or supply does not, of itself, make the service or supply medically necessary.

In many states, advocates are recommending changes to the traditional definition of "medical necessity" with the newer focus based on maintaining or improving functional capacity and preventing worsening of an illness, condition or disability. States are also passing legislation that calls for stronger consumer advocacy mechanisms as they relate to insurance coverage.

Another major issue is the fact that reimbursement for assistive technologies may be limited. For example, some policies may pay for an assistive technology device, but fail to provide coverage for maintenance, repairs or for associated therapies, training or services that are necessary for the individual to be able to use the technology to the greatest benefit. Other policies may limit purchase of modifications to the home-- for example, ramps, lifts, stair glides, bathroom grab bars or environ mental control units--by classifying them as "convenience items."

A further coverage issue is that many health benefit policies contain provisions stating that the health plan will not provide benefits which are the responsibility of another party or funding stream. As a result, there is often confusion and debate over the payor of first versus last resort.

Recommendations:

* Eliminate private insurance access barriers, including basic coverage exclusions, caps, partial coverage and excessive premium costs.

* Provide coverage for related services such as evaluations, therapies, supplies, training, repairs and maintenance. Assistive technology evaluations and therapies, necessary for appropriate utilization of assistive devices, should be considered as distinct reimbursable services.

* Develop universal definitions for "medical necessity," durable medical equipment, assistive technology and orthotics and prosthetics.

* Standardize coverage for durable medical equipment and orthotics and prosthetics.

* Implement insurance ombudsman program to assist consumers and providers in identifying problems, researching systemic issues and advocating for change.

* Develop a Medicaid waiver and/or other strategies to provide acute care rehabilitation of traumatic neurological conditions.

PROCESSES AND PROCEDURES

Issues:
Although primarily driven by a focus on containing or reducing costs, current insurance policies and procedures often have the opposite results. Findings from the ACPA survey among Arkansans who are familiar with submission of requests for coverage o f assistive technology reveal several issues. Evaluators and providers reported increased costs due to the time often required for approval processes; professionals experience loss of productivity or work time while waiting for approval or responding to denials for devices or needed services. Survey respondents also described concerns about duplicative review processes. Consumers cited experiences with both private and public insurers in which they encountered waiting periods of a year or longe r for decisions to be made regarding acquisition of assistive devices or equipment. In short, the "red tape" and paper work often required in obtaining assistive technology- even low-cost items-can present as many barriers as the lack of coverage.

Members of the Advisory Committee believe several of the problems associated with current processes and procedures can be best addressed through a process of mutual education with representatives of the insurance industry. Additionally, it appears to the Committee that claims processors and others involved in making reimbursement decisions are not familiar with assistive technology and how these devices can make a difference in the lives of persons with disabilities.

Recommendations:

* Assure Medicaid Medical Care Advisory Committee includes representatives who are knowledgeable about consumer needs for durable medical equipment, orthotics and prothestics and assistive technology.

* Provide ongoing training about durable medical equipment, assistive technology and orthotics and prosthetics for private and public insurance internal review professionals.

* Keep decision-and-policy makers at all levels updated and informed about emerging rehabilitation technology.

* Develop standards to: assure quality; prevent fraud and abuse; avoid faulty devices and minimize duplication in approval processes.

* Refine private and public insurance prior authorization processes for obtaining durable medical equipment, assistive technology and orthotics and prosthetics.

* Streamline private and public insurance paper work and documentation processes.

* Assure private and pubic insurance decision- making and appeal processes are timely.

COLLABORATION AND SERVICE INTEGRATION

Issues:
Within Arkansas, a variety of state and community- based agencies and programs work with individuals with disabilities who either use or could benefit from durable medical equipment or assistive technology. Such programs include hospitals, home heal th programs, nursing facilities, Rehabilitation Services, Workers Compensation, Special Education, Developmental Disabilities, Spinal Cord Commission, Easter Seals and specialized services for persons with visual and hearing impairments, traumatic head injuries or other disabilities.

However, as is common with many service delivery systems, funding and services are often defined by categorical eligibility requirements and/or limitations that focus on only one problem or disability rather than on an individual's total needs. As a result, services are fragmented, evaluation or approval processes are duplicated and limited resources are inefficiently utilized. The lack of coordination among various service systems also contributes to delays in timely acquisition of assistive technology devices and services.

Because the field of assistive technology is one of such rapid change, often persons assisting individuals in accessing needed devices or equipment have limited awareness of advancements in assistive technology. These individuals also frequently have few opportunities for expanding their levels of awareness about new technologies. Moreover, even among those agencies or individuals who may have updated information, limited resources prohibit their ability to provide ongoing training or education sufficient to inform the variety of stakeholders involved.

Recommendations:
* Develop mechanisms for collaboration among various state and community-based agencies--both public and private--which play a role in the provision of assistive technology to more readily assure availability of coordinated, community- based service s ystems statewide.

Suggested collaborative mechanisms to be explored include developing common definitions, standardized processes, guidelines and forms, as well as sharing personnel and resources across agencies in the conduct of evaluations and provision of training and education.

* Educate consumers and providers about insurance and related processes for obtaining durable medical equipment, orthotics and prosthetics and assistive technology so that they can make better informed choices.

Suggested mechanisms for education include the development of consumer handbooks, brochures and/or information sheets that explain coverage, processes, timeframes and consumer rights. It is also recommended that all educational materials be written in "user friendly," understandable language, and that these materials be developed jointly by insurance, provider and consumer representatives.

* Develop and conduct training for providers and evaluators regarding aspects to be considered in selecting and recommending equipment and/or services based on individualized need. Such training should include consideration of options, the environment in which the equipment and/or services will be used, costs and future needs of the individual.

CONCLUSION

Although technology plays a valuable role in the lives of all people, it serves critical and vital purposes for many persons with disabilities in particular; access to technology for individuals with disabilities can assist in improved functional cap ability, encouraging employment, independence and community participation. The recommendations presented in this report are aimed at promoting equal access to assistive technology through health insurance coverage for persons with disabilities, ther eby enhancing their abilities to live independently and productively in their communities.

The recommendations are designed to frame questions that need to be addressed in Arkansas. They are also intended to serve as a compass to guide change. In making these recommendations, Advisory Committee members recognize that change must be made pr udently, realistically and with due consideration of a variety of viewpoints. Whether the thousands of Arkansas children and adults who need assistive technology will be able to gain equal access to it will depend on the willingness of policymakers a nd key stakeholders to take action towards elimination of barriers that exist within public and private insurance systems.

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