The Future of Disability in America (2007) / Chapter Skim
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9 Coverage of Assistive Technologies and Personal Assistive Services
9 Coverage of Assistive Technologies and Personal Assistive Services
Pages 253-286
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From page 253... ...
This chapter focuses on the second issue in health care financing included in the committee's charge: health insurance coverage of assistive technologies. Because personal assistance services sometimes serve similar purposes for people with disabilities, this chapter also examines coverage of these services.
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From page 254... ...
; or securing assistance from vocational rehabilitation, assistive technology, or other special public or private programs, some of which are described below. Neither this chapter nor the previous one offers a comprehensive examination of health care financing issues relevant to people with disabilities, a task that would demand a report in itself.
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From page 255... ...
Along with inadequate professional education, they can contribute to the problems that people with disabilities often report in finding health care professionals who understand their medical condition and its nonmedical dimensions, who appreciate their need for routine health promotion and primary care services, and who have accessible facilities and equipment. The committee also recognizes that rising health care costs, particularly costs for Medicare and Medicaid, make some of the changes proposed in this chapter difficult.
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From page 256... ...
Medical necessity criteria have proved particularly troublesome for people with disabilities seeking coverage of assistive technologies and personal care services. They may be invoked to deny payment for nonmedical services, such as assistance with bathing, or products, such as bathroom grab bars, that help people manage daily life or protect their health (e.g., by avoiding falls)
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From page 257... ...
that will be reimbursed; • caps on total reimbursement (e.g., $1,000 for home medical equipment) ; • restrictions on who can provide a service (e.g., excluding coverage for personal care provided by a family member)
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From page 258... ...
As described by Iezzoni and O'Day (2006) , assistive technology "re 4A recent Government Accountability Office report cited an estimate by the Centers for Medicare and Medicaid services that Medicare made about $700 million in improper payments for durable medical equipment, prostheses, orthotics, and supplies between April 1, 2005, and March 31, 2006 (GAO, 2007)
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From page 259... ...
observed that, although most health plans cover some assistive technology, "its predominant use in daily functioning rather than for therapeutic purposes has contributed to ambiguity in health insurance coverage. Coverage policies are typically stringent, and coverage disputes in this area are among the most common and problematic" (Wolff et al., 2005, p.
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From page 260... ...
, and limited to certain geographic areas of a state; some = although some items are covered, a significant portion of the assistive technologies in this category are not covered; ADL = Activities of daily living; AT = assistive technology; VA = U.S. Department of Veterans Affairs.
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From page 261... ...
Unfortunately, based on the statutory reference to durable medical equipment used in the home, the memorandum focused on individual needs related to ADLs, which are primarily performed in the home, rather than instrumental activities of daily living, which include some activities (e.g., shopping and traveling) that occur outside the home.
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From page 262... ...
. In a paper that outlines the many financial obstacles to accessible assistive technologies, the American Academy of Physical Medicine and Rehabilitation observed that "to be fair, Medicare is often asked to approve coverage and reimbursement of assistive technology with little clinical data [or]
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From page 263... ...
(The State Children's Health Insurance Program [SCHIP] option, which covers many children with special health care needs, does not include EPSDT benefits as such.)
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2 THE FUTURE OF DISABILITY IN AMERICA BOX 9-1 Medicaid's Early Periodic Screening, Detection, and Treatment Benefits (as required under Section 1905(r) of the Social Security Act)
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From page 265... ...
Priate Health Insurance The committee found little specific information on private health plan coverage of different kinds of assistive technologies.12 In general, people covered by private health plans will often encounter problems with coverage restrictions and medical necessity determinations similar to those that that Medicare beneficiaries face (Iezzoni, 2003; Iezzoni and O'Day, 2006)
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From page 266... ...
Medicare rules define homebound to mean that a beneficiary has "a normal inability to leave home," such that trips outside the home require "a considerable and taxing effort by the individual" (such as relying on personal assistance or assistive technology) and are "infrequent or of relatively short duration" (see 42 U.S.C.
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From page 267... ...
. The committee found no systematic information on employer-sponsored or private health insurance coverage of personal assistance services.
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From page 268... ...
Use of such waivers has expanded substantially since publication of the 1991 IOM report, in part as a result of the U.S. Supreme Court's 1999 decision in Olmstead .
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From page 269... ...
• Required home health services include skilled nursing care, home health aide services, medical supplies, and medical equipment. • Optional home health services include occupational therapy, physical therapy, audiology services, and speech pathology services.
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From page 270... ...
The waiting times for people with traumatic brain injuries and children with special needs averaged over 20 months. Collectively, HCBS waivers accounted for 30 percent of Medicaid longterm care spending in 2001 (up from 15 percent in 1992)
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. (Some children may also be eligible for direct services under the Maternal and Child Health Bureau's Title V state grants program [Markus et al., 2004]
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From page 272... ...
a cash allowance or budget based on a needs assessment. They allow the consumer to direct his or her own personal care and certain other services.
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From page 273... ...
. The federal Assistive Technology Act does not directly fund the provision of equipment but, rather, supports technology development, training for rehabilitation engineers and technicians, technical assistance and advocacy, and research on needs for assistive technology.
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From page 274... ...
In addition, the National Institute on Disability and Rehabilitation Research has funded a number of relevant research and data collection programs, including the Center for Personal Assistance Services at the University of California at San Francisco (UCSF, undated)
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From page 275... ...
Others focus on particular chronic conditions or disabilities, such as spinal cord injuries, multiple sclerosis, and cerebral palsy. One example is The Wheelchair Recycler, whose founder received Christopher Reeve's first wheelchair from the Christopher Reeve Foundation and recycled the parts to at least three different people whose chairs needed replacement parts and repairs (New Mobility Magazine, 2006)
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From page 276... ...
For all the difficulties and problems that have thus far confronted this country's system of financing health care services, including services for individuals with disabilities, the situation will surely become more challenging in the future. Although some challenges stem from those with philosophical opposition to government- or employer-based health insurance programs, the most widely understood threat relates to health care costs that continue to rise at rates higher than general inflation.
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From page 277... ...
who are in mandatory Medicaid categories are exempt, adult beneficiaries with disabilities may be affected. The Deficit Reduction Act also allows the mandatory or voluntary enrollment of beneficiaries in "benchmark" health plans that are not required to offer the benefits traditionally required for Medicaid beneficiaries.
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A recent analysis suggested that "more than half of the decline in [health insurance] coverage rates experienced over the 1990s is attributable to the increase in [private]
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From page 279... ...
offering health insurance coverage has dropped in recent years.
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. More recently, the use of disease management programs have been promoted as a way to improve outcomes and reduce costs for people with specific chronic health conditions that collectively account for a significant share of health care costs.21 The programs, which are quite variable, typically emphasize education and other means to increase patient adherence to diet, medication, exercise, or other regimens supported by clinical evidence.
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From page 281... ...
First, decisions about the share of societal resources that should be allocated to publicly funded health insurance programs such as Medicare and Medicaid are critical and are intimately related to overall tax and fiscal policies. In addition to the direct taxes that help support Medicare and Medicaid, tax subsidies for private health insurance and health care in general must be considered as part of the total resource allocation picture for governments.
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From page 282... ...
Government officials have proposed making cost-effectiveness a consideration in Medicare decision making but have, so far, put the proposal aside after negative public reaction. Acceptability is, to various degrees, an issue for employers who see health insurance as a recruitment and employee relations asset (as well as a cost)
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From page 283... ...
. Finally, although the committee did not examine the principles that should be used to determine the expansion of health insurance coverage more generally, it notes that another recent IOM report set forth such principles (IOM, 2004d)
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From page 284... ...
Likewise, the statutory requirements that durable medical equipment be suitable for "use in the home" and its narrow interpretation by CMS are inconsistent with the emphasis on independence and community integration exemplified in the Americans with Disabilities Act and other policies. At the same time, as described in this chapter and Chapter 8, recent years have brought some progress in expanding health insurance coverage of assistive services and technologies.
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From page 285... ...
At the same time that outmoded restrictions are discarded, continued efforts to prevent and detect fraudulent wasteful practices by providers and vendors remain important, but such efforts must be made with care to avoid actions that limit access. This committee's recommendations are directed primarily at the Medicare and Medicaid programs, but the committee encourages private health plans to make similar adjustments in their policies relating to durable medical equipment.
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From page 286... ...
This chapter and preceding chapters have suggested a number of specific topics for research. The next chapter considers more generally the organization and financing of disability and rehabilitation research.
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