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KATS Network > Publications > The Buck Starts Here... > Developing a Funding Strategy

The Buck Starts Here... A Guide to Assistive Technology Funding in Kentucky

I. Developing a Funding Strategy

The "quest" for the funding of assistive technology can be long and strenuous. There are many possible funding sources that might be able to help you purchase what you need depending on a variety of criteria, such as:

• Do you meet the eligibility requirements?
• Does the device fit what the funding source will pay for?
• Is there any money left in the funding agency's budget for this year?

Finding the proper funding source and getting a "yes" is seldom easy. It will take a lot of effort and perseverance on the part of you and/or your advocate. So be prepared.

The Steps to Funding Assistive Technology

One thing that will help before you depart on your quest is a funding strategy. This strategy will include the identification of what sources are most likely to assist you and how you can best convince those sources to do so. In developing your strategy for funding the assistive technology that is needed, you would best be served by taking a systematic and logical approach. This first section of the booklet will assist you in developing an effective funding strategy by offering the following steps as a method for guiding your efforts. These steps are:

1. Define the need
2. Document the need
3. Identify the equipment and/or services needed and secure necessary prescriptions and other justification
4. Determine if alternative equipment will meet the need
5. Determine funding sources
6. Collect and submit the required paper work
7. Authorization is received
8. Search for co-payment options
9. The appeals process

The next few pages will explain these steps in detail by supplying specific suggestions to help you as you move along in your quest. A checklist is provided for your use in Appendix A.

Step 1: Define the need.

This step involves the identification of that aspect in your life in which you feel technology can assist you. You probably already have some idea about where assistive technology can provide you with fuller access in society. You need to fully explore, identify and define that need in order to begin. It is important that you know in your own mind what you need. This is the time to describe that need in writing so that you can express it to the people you working with in seeking funding for your device or service.

Step 2: Document the need.

Documentation will be very important throughout the funding process. The first thing you will want to document is the need for assistive technology. It is one thing to know that you need assistive technology; it is another thing to prove that need to someone else, and that is what you will have to do. You should obtain the assistance of a professional in developing this documentation if you have not already. This professional might be a teacher, a speech therapist, a physical therapist, an occupational therapist, a teacher, an assistive technology specialist, or a rehabilitation engineer/technician. One or more of these individuals will probably assist you throughout your request, but you must begin with the documentation of need.

Step 3: Identify the equipment and/or services needed and secure necessary prescriptions and other justification.

Once the need has been identified and documented, the assistive technology and related services required to fill this need must be outlined. This will include specific recommendations from the professionals. These recommendations may come in the form of a written evaluation, a medical prescription, or whatever other justification you may need. The extent, detail and scope of this written justification may hinge on what funding sources you decide to pursue. Later in the process you may find that you will have to come back to this step and to Steps 1 and 2 for further documentation.

Part of this step also involves the pricing of the equipment and the identification of where you will be able to purchase it. This can be very important because the funding source will almost certainly be concerned with cost and also because the identified dealer of the equipment may be able to help you along in the process. Some funding sources, such as Medicaid and Medicare, only purchase equipment from designated Durable Medical Equipment (DME) dealers. If you plan to approach one of these sources, you will have to locate such a dealer.

Some questions to ask at this step are:

• What type of assistive technology and related service will achieve the targeted level of functioning?
• Where can I obtain this assistive technology? How much does it cost? Can it be rented?
• What services are needed to prescribe, train and follow-up with the aid or device?
• What professionals are available who can help justify the medical necessity for the assistive technology?
• Can the equipment manufacturer or local vendor provide any special assistance?
• Is there a case manager assigned to the case? If not, then how can one be secured?
• Are there others who can help advocate for my needs?

Be sure to include this list of supportive materials that are often essential in documenting these needs when submitting a request to a funding source:

• Physician's prescription for the assistive technology (equipment, device and/or services). For Medicare, Medicaid and other sources, there must be a determination of medical necessity in order to receive authorization for assistive technology. This necessity exists when the item is a part of the physician's course of treatment and will be supervising its use directly. (Note: a therapist or other appropriate individual may be providing the treatment, but the treatment has to be prescribed by a physician.)
• Letter of medical necessity from the physician(s). It is strongly recommended, and usually required, that the physician also write a letter substantiating this medical necessity.
• Letter of medical necessity from other professionals involved in the case (physical therapist, occupational therapist, speech therapist, etc.).
• General discussions by the involved professionals of medical diagnosis that may further provide specific medical information and needs.
• Photograph of the individual if it helps to demonstrate the need.
• Literature concerning the assistive technology with specifications as they pertain to this individual.
• Explanation of the individual's functional skills without the equipment and how they will be improved with the assistive technology.
• Specifications of the equipment including cost and photograph or catalog picture.

No matter which funding sources are being approached for securing assistive technology, it is of the utmost importance to demonstrate and document the need.

Step 4: Determine if alternative equipment will meet the need.

Based on the past funding patterns and denials to authorize monies for required assistive technology, you may need to see if there are any alternatives. You should investigate such alternatives in advance of applying for assistance. You want to be as prepared as possible in order to facilitate the process.

When deciding what equipment and/or services are to be secured, it must be determined if the charge is reasonable and at a customary rate. The funding source might have to be convinced that the assistive technology is cost effective.

To assist in determining if a request is reasonable, consider the following:

• Is there a way this piece of equipment can be made or fabricated?
• Can it be borrowed from an Equipment Loan Closet or library?
• Is the expense reasonable when compared to the therapeutic benefit?
• Is the equipment or service more costly than another option or alternative?
• Does the item serve the same purpose as equipment that is already available to the consumer?

If there are no alternative devices that can be found that will meet your particular need, be sure that you have that fact well documented. Remember; do not let the cost of the assistive technology preclude the selection of the right aid, device, or adaptation for the person with a need. This process of matching the technology to the needs of the individual is crucial to the successful use of the technology once it is acquired.

Step 5: Determine funding sources.

Now that you have determined what you need, you can begin to look for help in paying for it. You may choose to pay for it yourself, if you are able, but there may be sources with the responsibility or the willingness to help you, so do not act too hastily. On the other hand, you may be unable to contribute anything toward the purchase of the technology.

Listed below are strategies to consider when approaching the following funding sources.

Private Insurance

Do you have private insurance that will it pay for some or all of the technology? What insurance will pay for differs on a policy-by-policy basis. Section II of this booklet explains how to approach your insurance carrier in obtaining the assistive technology needed.

For assistive technology to be fully or partially covered by an insurance company, it usually must meet the following basic criteria:

1. The client's condition is the result of illness or accident and is not a "pre-existing" condition prior to the effective policy date.
2. A physician must prescribe the assistive technology and services required to instruct and assist the individual with a disability.

If the insurance carrier denies your claim, see Appendix C - Private Insurance on how to file an appeal.

Public Sources of Funding

Are you eligible for public funding and If so from what agencies? Do these agencies have restrictions on what they will pay for and how much they will contribute? Does your particular disability qualify? Section II of this booklet provides information on government agencies that provide funding for technology. Studying this information will help you determine which public sources, if any, are most likely to help you. This information can save you time by helping you to narrow down the number of entities you should approach. Under the Americans with Disabilities Act (ADA), employers and some other entities may have some responsibilities to provide assistive technology to individuals as "reasonable accommodations". These responsibilities are outlined in Appendix C - ADA of this manual.

Private Source of Funding

Are there private sources out there that can help? Sometimes in the funding maze people must turn to private funding sources, such as local community groups, trusts or foundations to help meet the financial cost of technology. These alternate sources can, and do provide financial assistance to individuals and families. Local community groups and foundations can provide money for a broader scope of services than publicly funded programs. They can range from purchasing equipment, to sponsoring a child's summer camp tuition or even building a ramp for an older adult. Before contacting any private organization for funding, there are a few things you must know about your request. Specifically, you need to know exactly what you want/need, why you need it and why you cannot afford to pay for it. You also need to know where you can get it, how much it costs (if you have to order it, be sure to include shipping costs) and when you need it. Section III of this booklet contains information on a variety of private sources, but it is only a sampling. There might be many others. Keep in mind, however, that private sources often have very narrow eligibility requirements and limited funds.

When applying for Private Funding Sources, please keep the following in mind:

• What is the Organization's Giving Priority? Most philanthropic organizations have special causes for which they like to target their grants. These might include a specific group (i.e., people with disabilities, Hispanics or religious organizations) or certain types of social issues (i.e., education, empowerment or cultural) or within a specific geographic area (i.e., inner city, county or state). Make sure your application matches the organization's giving priorities.
• What is the Groups Average Grant Amount? If you want $1,000 to purchase a communication device for your child and you apply to a group that usually gives $500 (or $50,000) as its average grant, the likelihood of getting a "yes" is slim. Find an organization that usually gives about how much money you need.
• What is the Application Process? Some organizations have printed brochures that outline each step of the process whereas others try to make the application process very difficult. You will then need to ask around to find out the best way to approach your potential funder. You will need to do some sleuthing, if the organization does not have printed material available. Make sure you follow the application procedures that the organization specifies. That always helps make a good impression.
• When Does the Group Review Applications? Some funders review and vote on applications as they arrive. You usually hear from them within 30-45 days. Some wait and review applications quarterly, semiannually or even annually. It will help in planning to know when they review applications.
• What Does the Funder Want Out of the Deal? Some funders want publicity. Others may just want a tax break. Find out ahead of time. If the funder wants publicity, make sure you mention it in the application. If they don't (and some do not want any publicity) honor and mention that preference too!
• Other tips that can help you in getting that "yes":
  • If applying to a community group, have a case manager, social service or other professional, friend or family member apply on the behalf of the family or individual.
  • Send a photo or videotape of the person to make the person real, in their eyes.
  • Have documentation that verifies the need for the equipment.
  • Send literature about the technology.
  • Include a picture if you can.
  • Be sure to include any add-ons too if you request those.
  • Be sure to include a complete price list.
  • Describe how the technology will enhance the user’s life. Give examples of what life is like without the technology and how the technology will improve life.
  • Be sure to mention how you fall within the specific group, issue, or geographic area the organizations serves.

Loan Programs

You may want to consider a special loan to purchase the technology you need. As an alternative to private insurance, government programs or difficult to obtain conventional bank loans, special loan programs are being designed to make low interest or affordable loans available to qualified borrowers. Kentucky has developed a low interest loan fund which is designed to provide a choice to consumers who have encountered funding barriers due to coverage gaps in private insurance plans or eligibility requirements of specific government programs to consumers who simply do not want to get involved with bureaucratic procedures or to some as a last resort. Kentucky Housing also has loans available for individuals with disabilities, and there is a national loan program for Kentuckians with visual impairments. These programs are outlined in Section IV of this book.

Some questions to ask at this stage are:

• What is the most likely source of funding? (For example: personal health insurance, Medicaid, Vocational Rehabilitation, the Veteran's Administration, other public sources of funding, loan programs etc.) The following sections of this booklet contain information on the most common funding sources that will help you determine the most likely source or sources.
• Have you dealt with this source before? Were you successful? What problems did you encounter? Who was the contact person?
• Is there possibly more than one source of funding available?
• Will a vendor be an advocate and provide pre-approval and billing services?
• Are there individuals with disabilities who can be contacted for hints and suggestions? Have they been successful in receiving payment for assistive devices?
• Will the device or service enable you to enter or continue employment (this is a prerequisite for funding from Vocational Rehabilitation and helps with private insurance and some other sources), live more independently or improve your overall health? Depending on the funding source, you may have to prove one or more of these benefits. How can the potential funding source be convinced of this advantage?
• Are the written policy coverages of the primary sources available? (For example: Medicare, Medicaid, Blue Cross/Blue Shield, HMO, etc.)
• Is it possible for two different funding sources to coordinate payment that will equal or approach the total cost?
• If you became disabled through a work-related accident, is the cost of the device or service the responsibility of workers' compensation insurance?
• Is there a church, local civic or charitable organization, foundation or association in your area that can help raise the necessary funds?

Before you approach any one source, it would be helpful to make a list of all possible sources and then prioritize it. This will give you ready options to go to should you have difficulty with your primary choice. The key, again, is to be well prepared, with choices, documentation, and determination.

You may want to seek assistance in identifying and approaching funding sources. Possibilities would include the Durable Medical Equipment (DME) dealer (since you will be purchasing the equipment from this dealer, they should be more than willing to help), a case manager, a social worker, a case worker, a health care professional, or one of the professionals who helped you identify the technology in steps 1 and 2. It is important to involve as many support people as possible.

When approaching funding sources, it is important to note that there is no one specific method to assure funding. Traditional sources that have provided funding for assistive technology in the past are currently undergoing a period of adjustment. This is clearly a time when "precedence setting" may occur. A strategy that might be effective in California may not be so effective in Kentucky. If the assistive technology is new to the marketplace, the funding source may take a conservative "hands-off" attitude. Knowing these things, it will be important to plan your strategy and show patience and respect when dealing with prospective funding sources.

Some helpful hints are:

• Be polite and pleasant, but always be business-like.
• Communicate in writing whenever possible and keep a copy for yourself.
• Maintain a routine connection with the funding source and do not permit time gaps of three or more months between communications.
• Encourage a positive working relationship by directing letters or calls to the same person each time.
• Offer your cooperation and willingness to provide proof of medical necessity and to show how the technology will benefit the consumer and the funding source.
• When questioned, try to educate and inform in an assertive fashion, emphasizing long-term monetary benefits to the funding source.
• Never threaten with legal action, unless you know that you are being discriminated against. This is an often-heard threat and will not intimidate any agency or insurance company.
• When someone (a case manager, therapist, durable medical equipment (DME) dealer, etc.) goes out of her or his way to help, express your sincere thanks and appreciation.
• Thoroughly document all written and verbal communications.
• Remain patient and diplomatic while being persistent and enduring.
• Document, document, document. Keep records of names of people you spoke to, what was said and where you were referred to next.

Step 6: Collect and submit the required paperwork.

The case manager, DME dealer, or advocate will typically gather and complete all the required paperwork. It is important to coordinate this activity with the funding source, however, and to remain closely involved. You will want to understand exactly what is needed prior to submitting the request. Try to include all the paperwork upon first request. But don't be surprised if the individual funding sources require you to resubmit with changes, particularly on expensive items. If the request for assistive technology has met all the necessary criteria and you have submitted all of the necessary paperwork, you can now wait for the decision on approval or denial.

Gathering the right information is essential to developing your funding strategy. The following information should be included:

• Information about the individual needing the assistive technology including age, disability/medical diagnosis, employment status, income level, etc.
• Information about the individual's family status including parents, children, private insurance coverage, family physician, etc.
• Information about the educational level of the individual including the highest-grade level reached, special education services, etc.
• Public services that have been accessed previously includingMedicaid, Medicare, local school districts, Social Services, Vocational Rehabilitation, etc.
• Assistive technology recommendations including the name and manufacturer of the equipment, the cost, the amount that the individual or family can contribute why a particular piece of equipment was selected, and how the equipment will improve the functioning of the individual.

Step 7: Authorization is received.

When this occurs, written approval will be given for the amount of money that has been authorized toward the purchase of the specified assistive technology. If the amount is received in full, the vendor will then be able to process the order and secure the equipment. If the required amount of money is not approved, you can look for other options. If funding is denied, you may choose to begin the appeals process.

Step 8: Search for co-payment or alternative funding options.

If the funding source has not authorized for the full amount of the cost of the technology, what are your options?

• If you have to personally pay for a portion of the assistive technology, where will it come from?
• Is there any money available?
• Can you secure a personal bank loan or home equity loan?
• Have you considered additional funding sources.

Typically, private insurance companies will not cover costs simultaneously being covered by the public systems, for example, Medicare, Veterans' Administration, etc. This is a good time to seek out assistance from private community and philanthropic organizations.

Step 9: The appeals process (... and what if they say no?).

What if the funding source denies your request altogether? The appeals process is a fairly common practice when it comes to securing funding for assistive technology. Often, denial for funding is not due to equipment not being important or necessary, but rather a lack of understanding or knowledge by the reviewers at the funding sources.

Try to determine if your request was denied due to a lack of funding or due to inadequate information. If it is a lack of information, persist and find out what additional information is needed. Submit this new information to the person who is handling your request (for example, case manager or DME dealer). Don't leave it to chance that the right person will get it. Make certain of it. The appeals process can be time-consuming and you want to find every possible way to lessen the waiting period. Nothing can be more discouraging than to be told repeatedly that the assistive device or service needed is "not medically necessary" or "not covered". Agencies, insurance companies, and other traditional funding sources are conservative when it comes to paying for equipment, products, and other devices or services that are the least bit questionable from their perspective.

Assistive products and devices are becoming available at a much faster rate than are the funds to pay for them. Much of this new and innovative technology can be very costly. The need for it will continue to be questioned by funding sources and denials are likely to increase. Consumers need to know about the assistive technology options that exist for them despite the cost and the poor prospect of getting a device funded. As a result of this knowledge, however, frustration will mount when it becomes obvious that the lack of funds are the only thing that stand between the consumer and an assistive device or service that will allow her or him to live more independently, receive an education or gain employment.

You should not give up just because you get a "no" for an answer. You may very well have to exercise self-advocacy in order to affect a policy change. It may be necessary to demonstrate to funding sources that a certain assistive device or service will not only benefit you, but will also be cost-effective in the long run.

The quest for success in funding does not promise to be quick and easy. Persistence is the key. You must investigate and exhaust all possible avenues and alternative methods for funding. It may be necessary to challenge some decisions in the process. Everyone has the right to legally and ethically advocate for him or herself. If you get "no" for an answer, there are many things you can still do. Here are a few suggestions.

Working with State Agencies

If you apply for funding from a state agency and have been told that you do not qualify for assistance or that the particular device does not qualify, you can consider appealing this initial decision. All government agencies have internal appeal procedures and you can have your claim reviewed by mid-level management or, eventually, an agency director.

In considering an appeal, you should ask yourself the following:

• How will this device enable me to enter employment, receive vocational training, live more independently, or otherwise improve my functioning in society? You undoubtedly built a case for this earlier when you first approached the source, but you need to look for ways to strengthen it. You can construct an appeal if you can demonstrate how the device will help you.
• Do the agency's guidelines specifically exclude the device or has it been funded in some cases before? If an agency has funded a device in the past, thereby setting a precedent, it will be more difficult to deny your appeal.
• Do you meet the agency's financial requirements and other criteria? If it is obvious that you do not meet their criteria, an appeal would be fruitless. On the other hand, if you can provide evidence that disputes someone's determination of your eligibility, it will greatly improve your chances.

Workers' Compensation Claims

If a disability was acquired through a work-related accident or illness, you may seek funding through the employer's Workers' Compensation Insurance carrier. It is advisable not to be too hasty in settling the claim. When there is permanent disability involved, worker's compensation carriers generally want to settle the claim as soon as possible. Let the disability maximize in order to know the duration and the kind of assistive devices or equipment will be needed. Let the insurance personnel know that you will not settle the claim or sign any waivers or release forms until there is ample medical evidence that the disability is permanent and unchanging. If there is an attorney involved, make sure she or he understands why the client may need certain assistive devices and the terminology associated with them. Be sure you know how the workers' compensation benefits are structured. For more information, please contact the Department of Workers Claims at (502) 564-5550

Group Health Insurance Plans

Employees who have disabilities often turn to their group health insurance plan to provide or at least assist with funding. If your health care claim is denied, you have the right to request an internal appeal of the denial. Also once you have exhausted the internal review process within the private insurance company, you can request an external review be done to see if the assistive technology can be funded. Remember, there is always a chance for full or partial funding if the policy coverage does not specifically exclude a device or piece of assistive equipment. It is not uncommon for the claimant to eventually learn that he is better informed than the personnel with the group health plan.

To learn more about Health Insurance Appeals, the KY Office of Insurance offers a fact sheet, “What You Should Know about Health Insurance Appeals”. You can download this fact sheet, along with several others at: http://doi.ppr.ky.gov/kentucky/fpubs.asp .

For more information, please contact the Department of Insurance’s Consumer Protection Information at (800) 595-6053 or visit their website at http://doi.ppr.ky.gov/kentucky

Public Funding Sources

In the case of state agencies, if you have totally exhausted the appeals process and still are getting that "no", there are a few more options available to you. Two state agencies exist specifically to support your interest when you are having problems with some state agencies. The Client Assistance Program (CAP) will pursue your interest if you are in conflict with state vocational rehabilitation agencies. Protection and Advocacy (P & A) protects the rights of and advocates for persons with disabilities. In addition, the Cabinet for Families and Children has an ombudsman who will review legitimate complaints from citizens against all state agencies. The Department for Medicaid Services and the Division of Mental Retardation Services are two possible sources of funding for assistive technology in the Cabinet for Health Services.

For more information you may contact:

Client Assistance Program (CAP)

209 St. Clair St., 5th Fl
Frankfort, KY 40601
Toll Free - (800) 633-6283
Website: http://kycap.ky.gov/

Office of the Ombudsman

Cabinet for Families and Children
275 East Main St.
Frankfort, KY 40601
(502) 564-5497 or (800) 372-2973
Website: http://chfs.ky.gov/omb

Protection and Advocacy

100 Fair Oaks Lane, 3rd Fl
Leestown Square
Frankfort, KY 40601
Toll Free -(800) 372-2988
Website: http://www.kypa.net/

One more option to consider is to contact your local elected officials concerning your complaint or disagreement. These officials depend upon you for your support and will almost always check into your situation to see if your complaint is legitimate. If they feel that it is, they may attempt to rectify it for you or at least get you another hearing with the agency. The governor, lieutenant governor, state representatives or local officials should be contacted if the issue involves a state agency.

To get a listing of state representatives or local officials, contact the Legislative Research Commission at:

Legislative Research Commission

700 Capitol Ave.
Frankfort, KY 40601
Local - (502) 564-8100
Toll Free Legislative Message Line - (800) 372-7181
Website: http://www.lrc.state.ky.us/

Federal Agencies

If you have been through the appeals process with a federal agency or program and still have not received authorization for funding, you may want to consider contacting your United States Senators and Congresspersons for assistance. Federal agencies or programs include the Social Security Administration, Medicare, and the Veteran’s Administration. You can also obtain the address and phone numbers of your federal legislators from the Legislative Research Commission (see above).

Summary

The most important thing to remember throughout the entire process of obtaining funding for assistive technology is to be persistent. If you believe that you are entitled to the technology that can enable you to achieve a higher quality of life, DO NOT GIVE UP!

Using the nine steps as your structure, you should be able to develop a comprehensive strategy for funding assistive technology. Persistence and preparation will be the keys to obtaining the equipment you need. Lewis Golinker, an attorney and funding expert from New York, has put it this way:

"The formula for success in cases involving technology devices and services has three essential ingredients:

1. A heartfelt commitment by a professional (such as a physician, an occupational, physical and/or speech-language therapist) to the potential of an assistive technology device or service to provide real benefits to a person with disabilities;
2. A refusal by the person with disabilities and the professional to take an initial 'no' for a final answer; and
3. A willingness of the professional to participate in any administrative appeal, where high quality information is supplied."

Those applicants who follow this formula are the ones most likely to be rewarded for their perseverance in the form of a favorable decision.

You can use the rest of this booklet as a tool in developing that strategy. Specifically, it can provide you with the information you can use in selecting the funding sources that you should approach to help you meet your particular need.

The following sections of this booklet contain detailed information about specific funding sources. This information includes:

• The type of equipment or device the source will fund,
• The types of disabilities served, the eligibility requirements, instructions on how to apply,
• And other hints and tips concerning the source.

The quest for funding of assistive technology can be difficult, prolonged and frustrating. We hope this guide can help make that quest less difficult, not quite so prolonged, and not nearly as frustrating.

• Next Section: Public Sources of Funding
• Back to Funding Book Index

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Copyright © 2008 KATS Network
The contents of this website were developed under a grant from the U.S. Department of Education, Rehabilitation Services Administration (Grant #H224A060017A), Assistive Technology Act of 1998, as Amended
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