Suggested State Strategies for Private Health Insurance Initiatives

The RESNA Technical Assistance Project hosted a one-day meeting May 17, 2002 in Hartford, Connecticut for representatives of statewide assistive technology (AT) programs and private health insurance companies. The purpose of this meeting was to begin a dialog between these groups to: (1) promote a greater understanding of assistive technology (AT) and durable medical equipment (DME), (2) clarify current private insurance coverage of AT/DME; (3) identify information needed to broaden coverage of AT/DME, and (4) explore mechanisms for starting a long-term dialog among AT advocates and insurance industry representatives.

There were 33 participants: 20 representing the disability and assistive technology community and 13 representing the private insurance industry from 7 insurance companies (see attached Participants’ List). Aetna, Anthem/Blue Cross Blue Shield, The Hartford, Integrated DisAbility Management Resources, Kaiser Permanente, MetLife, and UnumProvident sent representatives. This group represented a mix of representatives from medical insurance as well as disability insurance carriers.

Discussion centered on several topics, including what is AT, factors, which influence AT coverage decisions, how coverage decisions are made, and strategies to increase AT coverage. From this discussion, the RESNA Technical Assistance Project has developed 17 Consensus Principles and Suggested State Strategies for Private Health Insurance Initiatives.

Following is a set of principles on which it is believed the participants in this meeting were in broad agreement.

1. Assistive technology is important in the lives of many people with disabilities, and contributes significantly to the quality of life and the opportunities available to such persons.

2. The fact that something enhances the quality of life or that it contributes to increased functional capabilities does not make the item or service medical in nature and does not establish its coverage under health insurance.

3. AT is not synonymous with the kinds of high-tech equipment that insurers typically think about when coverage for technology is discussed. Though some AT devices may be expensive, a great many are not.

4. Cost is a major factor in determining what private health insurance can cover. Insurers are not free agents in deciding what to cover, because they are obliged to keep the costs of premiums down in order to satisfy the purchasers of insurance, particularly employers.

5. Health insurers, as distinguished from disability insurers, are not generally familiar with what AT entails, with what it costs or with the ways many AT devices are equivalent to mainstream devices and services already covered.

6. Insured persons who feel their requests for AT devices and services have been rejected wrongfully or whose cases present special and unusual circumstances should seek to have their cases referred to the case management units of their insurance carriers, or should pursue the appeals process as a means for putting the necessary information before the insurer.

7. The provision of AT in special situations would have little impact on the overall cost structure of health insurance and would have a potentially great leverage value in avoiding subsequent costs.

8. Individual cases, however meritorious, can never be viewed in a vacuum. The decision by an insurer to grant a particular claim can create a precedent, whether or not the claimant or the insurer expect or want it to.

9. Assistive technology can be justified in bottom line business terms, although research data sufficient to demonstrate this, or to isolate the situations in which it is true, does not yet exist, pending the results of major AT outcomes research currently underway.

10. Insurers have to make decisions that maximize return on investment (ROI), and that reflect their fiduciary responsibilities, as well as their competitive position. Under such circumstances, extensions of coverage cannot be made based on faith but must be supported by solid data and a strong business case.

11. AT could be provided under various existing coverage rubrics.

12. Core benefits cannot readily be modified. If AT is to be covered to a materially greater extent than is generally the case, the industry believes that other strategies, including special needs funds, would need to be used.

13. Many insurers appear to believe that AT devices and services costs will be met by governmental programs, but this is not usually the case, as evidenced by the fact that the majority of AT costs are met out of the private resources of persons with disabilities, their families and communities.

14. Coordination of benefits is an issue of growing importance and complexity. Insurers need to know more about what other benefits are and are not available to insured persons with disabilities.

15. People with disabilities are frustrated, believing that their efforts to educate health insurers about AT have been largely unsuccessful.

16. The accumulation of appeals has changed insurer policy in various instances, and should be pursued here.

17. Many opportunities exist for further dialog and work between the AT sector and the health insurance industry. Possible areas for further work include:

    1. Reviewing what may be called "slam dunks," that is, those categories of AT that clearly fit within existing coverage guidelines (such as talking glucometers or blood pressure gauges);

    2. Undertaking pilot projects and small-scale experimental efforts to test a variety of theses regarding AT, including the cost-benefit implications of its expanded provisions, the intersection, in push-pull model terms, between its expanded use and medical necessity, episode-of-care reduction and other variables, and whether if given the flexibility to select it along with or in lieu of other benefits any appreciable number of insurance purchasers, once educated about AT, would do so, and at what cost;

    3. Develop reciprocal AT 101 and Private Health Insurance 101 training and education models so that members of the two communities can learn about one another's issues, concerns and frames of reference.

    4. Educating employers about AT, so that they will be able to fully evaluate it in their insurance purchasing decisions;

    5. Continuing dialog at the national level and, because insurance coverages vary somewhat according to state law and plan terms, establishing lines of communication in the states between private health insurers and state AT Act programs.

1. Identify the largest health plan(s) in your state. These will, most likely, be the state employee health plan(s). Obtain contact information for their case managers and appeals managers.



2. Identify the largest employer(s) in your state. Obtain contact information for their Human Resources (HR) benefits personnel.

   Three advisories should be heeded in working with the largest state employers: (1) The largest employer will almost certainly be a self-insured plan, and therefore will be governed by ERISA, with very little state law or state policy input. (2) If this largest employer is a national company with operations in more than one state, they cannot readily change their benefits package for one state only, except in carefully structured experimental circumstances or where some state law or where a collective bargaining agreement is required. (3) When trying to talk to the HR high-level managers in such a large company, you may not attract any interest on a state-by-state basis, as their focus is national. If possible, try contacting a regional employer contact.

3. Identify trade unions in your state, making sure you have an understanding of the difference between local and national work rules and contract provisions.



4. Identify state health officials and regulators since there is a trend of court decisions and of state legislation moving in the direction of more state oversight of private insurance. Also, state health officials and regulators should be targeted for public awareness and training regarding AT.



5. Be prepared to offer what the incentives are for the insurance companies, employers, and trade unions.



6. Formalize structured relationships with private health insurance companies, employers, and trade unions upon which both the AT Act project and one or more of these stakeholders agree.



7. Disseminate information about your project and other AT resource material (newsletters, conference notices, training, etc.) to private health insurance companies, employers, and trade unions in your state via their CEOs, case managers, medical policy directors, HR benefits personnel, etc.



8. Disseminate collection of best practices re: private insurance and AT.



9. If they have any consumer advisory boards or focus groups, request to have a key person from your project assigned to such a group.



10. Hold a meeting or special session that would provide information to health insurance representatives and HR benefits personnel on the uses and benefits of AT (e.g., "AT 101").



11. Private insurers could offer a meeting or special session to provide information to AT advocates on how private health insurance works (e.g., "Private Insurance 101").



12. Develop new private insurance "products" with funding options and new strategies. Products could offer AT as: (1) an option in a "cafeteria plan" or Individual Service Fund (ISF)—some type of "special needs" fund or a "special needs review" if an AT device or service is denied under the core benefits. Not only would this fund increase coverage, the data on what is paid for through this fund could generate some of the data desired by insurance companies on AT needs by employees; (2) an add-on to an existing health insurance policy for an additional cost or deductible; or (3) some sort of capitation arrangement for AT. For example, some health clubs offer 20 percent discounts for employees working for specific companies where the health club "eats" the 20 percent savings but they raise their volume of use. Therefore, the health club is making more of a profit. Perhaps AT vendors can do the same with health insurance companies.

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