Source: http://aspe.hhs.gov/daltcp/reports/2006/HM-ATI.htm
Timestamp: 2014-07-29 16:46:22
Document Index: 3871696

Matched Legal Cases: ['§2100', '§3113', '§1915', '§1915', '§2100', '§3113']

Compendium of Home Modification and Assistive Technology Policy and
Practice Across the States Volume I
U.S. Department of Health and Human Services Compendium of Home Modification and Assistive Technology
Policy and Practice Across the States Volume I: Final Report Terry Moore, BSN, MPH and Beth O'Connell, MS Abt Associates, Inc. October 27, 2006 PDF Version (50 PDF
pages) This report was prepared under contract #HHS-100-03-0008 between
Officers, Gavin Kennedy and Hakan Aykan, at HHS/ASPE/DALTCP, Room 424E, H.H.
e-mail addresses are: Gavin.Kennedy@hhs.gov and Hakan.Aykan@hhs.gov. The opinions and views expressed in this report are those of the
TABLE OF CONTENTS EXECUTIVE SUMMARY 1. INTRODUCTION 2. METHODOLOGY 3. BACKGROUND 3.1. Definitions 3.2. Federal Legislation and Policies Regarding AT and HM 3.3. Medicaid Policies Regarding AT and HM 3.4. Non-Medicaid Sources for AT and HM 4. OVERVIEW OF STATE AT AND HM POLICIES AND
PRACTICES 4.1. Medicaid State Plan Coverage of AT and HM 4.2. HCBS Waiver Coverage of AT and HM 4.3. Discussion 5. STATE PROFILES OF AT AND HM POLICIES AND
PRACTICES REFERENCES NOTES APPENDICES APPENDIX 1: PROCESS TO ACCESS WAIVER
SERVICES LIST OF EXHIBITS EXHIBIT 1: Description of the State
Profile LIST OF TABLES TABLE 1: HCBS Waiver AT and HM Service
Categories TABLE 2: Medicaid State Plan Coverage: AT,
Wheelchairs and Other TABLE 3: Medicaid State Plan Access to AT and
HM Services and Service Controls TABLE 4: Coverage of AT and HM by Waiver
Type TABLE 5: Type of Coverage by Waiver Type TABLE 6: Types of Waiver Limits for AT and HM
Services Used within States EXECUTIVE SUMMARY Various studies have examined the positive benefits of assistive
technology (AT; e.g., adapted computers, powered mobility devices, augmentative
communication devices (ACDs)), and home modifications (HM; e.g., structural
changes such as widening doorways or building an access ramp) in enhancing the
abilities of persons with disabilities and the elderly to function
independently, safely, and successfully in their home environments (Mann, et
al., 1999; Verbrugge and Sevak, 2002; Calkins and Namazi, 1991). Much has
also been written about the large baby boom population, the associated rise in
sheer numbers of individuals with disabilities and the resulting need for
growth in the availability and financing of long-term care services (Merlis,
2004; National Academy of Social Insurance, 2005; OBrien, 2005). However, few studies have examined or described the financing, coverage,
and general availability of HM and AT in states, particularly through Medicaid.
Little is currently known about Medicaid state policy and practice with regard
to AT and HM, and the consequential impact on public spending and planning for
long-term care. Many state home and community-based service (HCBS) waiver
programs list AT and/or HM as covered Medicaid services. However, existing
administrative datasets cannot easily convey the degree to which consumers
access AT and HM services or the extent to which Medicaid, state-specific, or
other programs pay for these services. The absence of basic information led the
U.S. Department of Health and Human Services Office of the Assistant
Secretary for Planning and Evaluation (ASPE) to commission this compilation of
Medicaid coverage policies and practices for AT and HM services across the 50
states and the District of Columbia. ASPE seeks to understand Medicaids
role, specifically, in paying for AT and HM, as Medicaid is a major source of
payment for long-term care, accounting for 47 percent of spending for nursing
home and home care services in 2002 (OBrien, 2005). About half of
Medicaid long-term care spending is for services to the elderly; the rest is
for services to non-elderly disabled people, especially people with
developmental disabilities (OBrien, 2005) -- two populations heavily
reliant on AT and HM services. The purpose of this Compendium of Home Modification and Assistive
Technology Policy and Practice Across the States is to establish a baseline
knowledge of the scope of AT and HM services that states make available to
Medicaid-eligible adults. This study provides federal and state policymakers
with basic information to inform planning and policy development. It also
provides other stakeholders, including consumers, with valuable information
about Medicaid State Plan and HCBS waiver coverage of AT and HM. The report addresses three main questions: To what extent do Medicaid State Plans and HCBS waivers cover AT
and HM services? What are the processes available to Medicaid recipients to obtain
AT and HM services? What mechanisms -- if any -- do states use to control use and
costs of AT and HM services? Data that inform this volume were from reviews of relevant web sites,
from reviews of Medicaid provider manuals, from limited discussions with state
representatives (Medicaid State Plan Home Health/Durable Medical Equipment
(DME) and HCBS waiver personnel). In all, this report covers 51 Medicaid State
Plans and 202 HCBS waivers. Volume II of this report
includes a profile of each states coverage of HM and AT services through
Medicaid. By and large, relevant state personnel verified information contained
therein. Key Definitions There are important distinctions between equipment and services
collectively referred to as AT and those equipment and services encompassed
under the rubric of HM; thus, throughout this report, the two types of services
are categorized and discussed separately. AT is a broad term that encompasses
any technology to increase, maintain, or improve functional capabilities of
individuals with disabilities (Assistive Technology Act of 1998). As such, the
use of AT fosters a persons independence, safety, and quality of life. HM
include any change to a particular location that fosters the independence and
safety of individuals with disabilities or that allows people to carry out
their daily tasks more easily (Pynoos, et al., 1998). HM can range from
installation of inexpensive items (e.g., grab-bars) to more costly structural
changes such as widening of doorways, renovation of bathrooms and kitchens, and
installation of ramps. Key Findings The key findings stem from the three main areas of inquiry: (1) the
extent and types of AT and HM services offered by State Plans and HCBS waivers;
(2) the processes available to Medicaid-eligible recipients to facilitate
access to AT and HM; and (3) the policies and practices employed by states to
limit or restrict access to AT and HM services. The extent to which AT and HM services are offered by Medicaid
State Plans and HCBS waivers. Almost every HCBS waiver includes AT and HM as listed services, while
Medicaid State Plans more greatly limit what they include as AT and HM. Even
though most states report including AT and/or HM, considerable variation exists
in how states define and refer to AT and HM. AT services covered most frequently by Medicaid State Plans include
ACDs and power or custom wheelchairs or wheelchair adaptations. The majority of Medicaid State Plans do not cover HM, personal
emergency response systems (PERS), or vehicle modifications (VM). 173 of the 202 waivers reviewed include HM, 159 include AT, 124
include PERS, and 64 of the waivers reportedly include VM, mostly through the
mental retardation/developmental disabilities (MR/DD) waivers. Both Medicaid State Plans and HCBS waivers describe coverage of AT
services in their provider manuals. However, states almost never refer to these
services as assistive technology; rather, the services are listed
in the Medicaid coverage manuals under DME or prosthetics services. The processes available to Medicaid recipients to obtain AT and HM
services. Most HCBS waivers -- and some state plans (11) -- offer service
coordination or case management to recipients in order to facilitate access to
AT and HM services, and both types of Medicaid programs use health
professionals such as physical and occupational therapists and speech-language
pathologists or therapists to assess recipient need for AT or HM services. The
majority of state plans require physician orders for AT and HM services, while
only half of the waiver programs list that as a requirement. The mechanisms used by states to control use and costs associated
with AT and HM services. Most state HCBS waivers list many AT and HM services as available to
multiple target populations in need of these services (e.g., aged and disabled,
MR/DD, traumatic brain injury). However, the scope of this study did not permit
investigation of how and to what degree access to services might be limited
through prior authorization procedures and medical necessity or other criteria.
Almost all Medicaid State Plans use medical necessity
criteria when determining coverage for AT and HM services, and half of the HCBS
waivers studied use these criteria. For those waiver programs that do not use
medical necessity criteria (n=28), some use functional
language to determine if AT or HM services should be covered, rather than
medical language or medical necessity criteria. This
functional approach to coverage determination may be more aligned with the
intent of the 1915(c) waivers to maintain the independence of the elderly and
persons with disabilities in the community. Almost all Medicaid State Plans and HCBS waivers studied require prior
authorization of some sort for AT and HM services. State HCBS waiver programs use multiple mechanisms to limit or restrict
waiver expenditures, whereas Medicaid State Plans have few limits (but less
extensive AT/HM coverage). Implications for Further Research The findings suggest that additional research would need to examine
scope of coverage and use of services. As described earlier, the scope of this
project does not include the extent to which Medicaid-eligible persons actually
receive the AT and/or HM service they might require. Such a study might require
in-depth interviews of state agency officials (e.g., utilization review
representatives, waiver case managers, coverage policy experts) and examination
of claims data to determine actual use and cost. Further research might examine
what impact the provision of AT and HM through Medicaid has on other health and
long-term care use and spending. 1. INTRODUCTION An accessible and safe living and work environment is fundamental to the
quality of life of both older adults and younger persons with disabilities and
chronic health conditions. Assistive technology (AT; e.g., adapted computers,
powered mobility devices, augmentative communication devices (ACDs)), and home
modifications (HM; e.g., structural changes such as widening doorways or
building an access ramp) can enhance the physical and sensory functioning of
persons with disabilities and the elderly, and enable them to function
independently, safely, and successfully in their home environments. AT and HM
can also help prevent secondary problems like accidents and falls, increase
safety and independence, and reduce institutionalization, thereby enhancing the
overall quality of life for people with disabilities (Mann, et al.,
1999; Verbrugge and Sevak, 2002; Calkins and Namazi, 1991). Little is currently known about Medicaid state policy and practice with
regard to AT and HM, and the consequential impact on public spending and
planning for long-term care. Many state home and community-based service (HCBS)
waiver programs list AT and/or HM as covered Medicaid services. However,
existing administrative datasets cannot easily convey the degree to which
consumers access AT and HM services or the extent to which Medicaid,
state-only, or other programs pay for these services. The absence of basic
information led the U.S. Department of Health and Human Services (HHS)
Office of the Assistant Secretary for Planning and Evaluation (ASPE) to
commission this compilation of Medicaid coverage policies and practices for AT
and HM services across the 50 states and the District of Columbia. ASPE seeks
to understand Medicaids role, specifically, in paying for AT and HM, as
Medicaid is a major source of payment for long-term care, accounting for 47
percent of spending for nursing home and home care services in 2002
(OBrien, 2005). About half of Medicaid long-term care spending is for
services to the elderly; the rest is for services to non-elderly disabled
people, especially people with developmental disabilities (OBrien, 2005)
-- two populations heavily reliant on AT and HM services. The purpose of this Compendium of Home Modification and Assistive
about Medicaid State Plan and HCBS waiver coverage of AT and HM. Section 2 provides a description of study methods.
Section 3 offers background information regarding AT
and HM definitions, a review of the literature, and relevant laws and
regulations that influence the provision of AT and HM. Section 4 presents an overview of findings regarding
Medicaid coverage policies and practices across the states, including the
degree to which Medicaid State Plans cover AT and/or HM, how consumers access
AT and HM services across state plans and HCBS waivers, and any restrictions
imposed by state programs on reimbursement for AT and HM equipment and
services. Section 5 provides a detailed explanation of the
terms used to describe each states Medicaid State Plan and HCBS waiver
program. Volume II of this report includes a profile
of each states coverage of HM and AT services through Medicaid. By and
large, relevant state personnel verified information contained therein. 2. METHODOLOGY To inform the development of the state profiles and determine the scope
of this investigation, ASPE and the project team convened a Technical Advisory
Group (TAG). Based on feedback from the TAG and a review of the literature, the
definition of AT and HM was limited to services and equipment that are used
primarily to facilitate independent living and promote health and safety. As
such, the scope of AT and HM considered included the following types of items:
Adaptive aids and equipment; Specialized medical supplies and equipment; Assistive devices; ACDs/speech-generating devices; Environmental accessibility adaptations (EAA), environmental
controls, and HM; Lifts; Personal emergency response systems (PERS); Power custom wheelchairs, scooters, etc.; Sip and puff controls and other adaptive devices for
wheelchairs; Vehicle modifications (VM). Items that are traditionally used for a medical purpose, even if they
can also be classified as AT or HM, were excluded. For example, items such as
ventilators, respirators, standard wheelchairs, canes, walkers, commodes,
specialty mattresses, hearing aids, and prosthetics were generally excluded
from this search. These were considered distinct from equipment classified as
specialized medical supplies and equipment that may enhance a
consumers ability to perceive or control their environment, such as ACDs
or environmental control devices. The information contained in the state summaries and discussed in
Section 4 is based upon Medicaid coverage policies
obtained, to the extent possible, via the internet in the form of Medicaid
Provider Manuals, HCBS waiver provider manuals, state web sites, and state
statutes and regulations. When these secondary sources of information were not
readily available, project staff contacted state officials to obtain copies of
coverage manuals and/or regulations and to clarify coverage policies and
practices. Once compiled, state-level data were validated through telephone and
e-mail inquiries to state officials. The data collection process was completed
over an eight-month period, from June 2005 through January 2006. Appropriate
state officials were identified through an extensive search and direct
telephone contact to Medicaid Agency and HCBS waiver personnel. HCBS waivers
were selected for inclusion in the state profile if they were listed in the
Waiver and Grants Management Database (WGMD) System data files for waiver years
2002-20031 as having
used waiver funds to pay for AT and/or HM. The validation process involved sending an electronic copy of the draft
state profile, or summary, to the knowledgeable state staff responsible for
State Plan durable medical equipment (DME) or Home Health services, and to the
multiple state staff identified as responsible for the various HCBS waivers
reported to cover AT and HM. State contacts were asked to review, comment
and/or validate the accuracy of the profiles. Profiles were then revised to
incorporate state comments/corrections. More than 80 percent of states
responded to our requests for data review and verification; however, it is
important to note that multiple individuals per state were asked to
respond to inquiries and to verify Medicaid policies and practices. If just one
individual in the state responded, the state was included in this count of
respondents. 3. BACKGROUND There are important distinctions between equipment and services
under the rubric of HM. These are described below. In addition, this section
presents an overview of relevant regulations, policies and funding sources for
AT and HM, organized as follows: Federal regulations that support the availability of AT and HM; Medicaid policies regarding AT and HM; Non-Medicaid funding sources for AT and HM. 3.1. Definitions AT is a broad term that encompasses any technology to increase,
maintain, or improve functional capabilities of individuals with disabilities
(Assistive Technology Act of 1998). As such, the use of AT fosters a
persons independence, safety, and quality of life. There are many types
of AT currently available, ranging from inexpensive items (e.g., grabbers), to
expensive high-tech systems (e.g., computerized communication devices). Items
as diverse as wheelchairs, power scooters, computer voice recognition software,
sip-and-puff controls, prosthetics, and speech synthesis systems are all under
the rubric of AT. HM include any change to a particular location that fosters the
independence and safety of individuals with disabilities or that allows people
to carry out their daily tasks more easily (Pynoos, et al., 1998). HM
can range from installation of inexpensive items (e.g., grab-bars) to more
costly structural changes such as widening of doorways, renovation of bathrooms
and kitchens, and installation of ramps. HM is often referred to by the more
general term environmental accessibility adaptation. In such cases,
the definition expands to include VM that accommodate a wheelchair or allow a
person with limited mobility to drive. HM and VM are sometimes considered to be
subcategories of AT. The array of AT and HM has grown dramatically over the past decade;
Freedman, Martin, and Schoeni (2004) state that the number of commercially
available AT products has grown from 6,000 in 1992 to over 20,000 in 2002. This
increase in the number of AT coincides with a demographic shift in the United
States, in which the population of elderly and people with disabilities
continues to grow. This demographic shift, coupled with the trend toward
enabling these people to live at home and be integrated into their communities,
has created an expanding need for quality of life-enhancing devices and
concomitant surge in states coverage of these products.2 3.2. Federal Legislation and
Policies Regarding AT and HM Legislation and federal policy over the last 20 years has strongly
supported the rights of people with disabilities to be integrated into their
communities. Important laws and court rulings to reduce discrimination and
improve access to education, employment, and housing services include: Fair Housing Act (1968); Architectural Barriers Act (1969); Rehabilitation Acts (1973 and 1998 amendments); Americans with Disabilities Act (1990); Individuals with Disabilities Education Act (IDEA) (1997 and 2004
amendments); Olmstead v. L.C. Supreme Court Decision (1999); New Freedom Initiative (2001). While all of these laws have important implications for access to AT and
HM as a means of enabling people with disabilities to obtain education,
employment, and housing, the Assistive Technology Act of 19983 (Public Law 105-394) and
Assistive Technology Act of 2004 (Public Law 108-364) [known as the Tech
Acts] were enacted specifically to improve access to AT devices, and to support
state grants for protection and advocacy programs related to AT. The Tech Acts establish three ways to encourage access to AT and HM:
State grant programs; Federal research and training programs; Alternative financing mechanisms for the purchase of AT and HM. The Federal Government provides grants to states for AT projects to
support public awareness programs, promote interagency coordination, provide
technical assistance and training, and provide outreach support. In addition,
states may provide technology demonstrations, participate in interstate
activities, and create public-private partnerships pertaining to AT. All
states, territories, and the District of Columbia have Assistive Technology Act
grant programs (Freiman, et al., 2006). Further, the Tech Acts authorize funding for AT and universal design,
including federal grants to small businesses, innovative research, grants for
commercial groups for research, and grants to improve the training of
rehabilitation engineers and technicians. In addition, the Tech Acts direct the
Presidents Committee on the Employment of People with Disabilities to
work with the private sector to promote the development of accessible
information technologies. Finally, the Tech Acts authorize federal grants to states to help pay
for the establishment and administration of alternative funding systems for AT
to enable more individuals to obtain needed AT and HM. Alternative funding may
include low-interest loan funds, interest buy-down programs, revolving loan
funds, loan guarantee programs, or programs operated with private entities for
the purchase or leasing of AT devices. The Assistive Technology Act of 2004 retains the structure of the
earlier act, but provides additional resources for state AT projects, and
emphasizes the needs of two specific populations: students with disabilities
receiving transition services and adults with disabilities maintaining or
transitioning to community living. The FY 2007 budget request includes $22.4 million for AT programs,
of which $21.3 would support the AT state grant program and $1.0 million would
support technical assistance required under the AT Act's National Activities.
Review of the state plans submitted to the Department under the AT state grant
program for fiscal year 2005 found that the majority of states will use their
formula grant funds to administer and/or operate alternative financing
activities that were initiated with funding from previous fiscal years under
Titles I and III of the AT Act. (U.S. Department of Education, 2006) The Association of Assistive Technology Act Programs notes that the
AT Act sets the minimum state grant award at $410,000. Currently, 75
percent of the programs funded under the AT Act are funded below the minimum.
Of the 75 percent of the programs receiving less than the minimum, the average
state grant program allotment is under $370,000 (Association of Assistive
Technology Act Programs, 2006). 3.3. Medicaid Policies Regarding AT and HM Medicaid is largely administered by states. As such, it is necessary to
examine each states regulations separately in order to obtain comparative
information (Sheldon and Hager, 1997). Even though Medicaid requires that
services be medically necessary, each state has flexibility in
deciding what does, and does not, fall under this determination (Sheldon and
Hager, 1997). Some states may pay for the treatment of a condition but not for
a functional need related to the condition; others may consider both types of
services as medically necessary. Since most AT and HM serve a
social or functional need created by an underlying medical condition, states
have considerable latitude in defining coverage under their Medicaid
programs. As Sheldon and Hager (1997) state, The Medicaid law and its
implementing regulations do not provide for the funding of any particular AT
devices. The law and regulations do not specify whether motorized wheelchairs
or ACDs, for example, are covered items within the scope of any particular
mandatory or optional category of coverage. Nor do they spell out a specific
test of medical necessity...or other criteria governing when a person is
eligible for a specific device. However, the federal law provides a general
framework and the individual federal regulations often spell out, in better
detail, what a particular category contemplates. (Sheldon and Hager,
1997). The following sections describe how AT and HM are covered under state
plan and HCBS waivers. 3.3.1. State Plan Services Federal law requires state Medicaid plans to cover a basic set of
mandatory services for mandatory eligible populations, which includes items
such as physician services, inpatient hospitalizations, nursing facility care,
and home health services. Federal law allows states to cover a set of optional
services to mandatory eligible populations, which includes services such as
intermediate facility care for individuals with mental retardation, personal
care services, and targeted case management. There are no explicit service categories for AT or HM, although specific
items may be covered under the mandatory or optional service categories
(Sheldon and Hager, 1997). AT, when covered through Medicaid, is most often
provided as DME under the mandatory Home Health Services benefit (University of
Washington Center for Technology and Disability Studies, 2003). DME is defined
by Medicare (Carriers Manual, §2100.1, and Intermediary Manual,
§3113.1) as equipment that: Can withstand repeated use; Is customarily used for a medical purpose; Is generally not useful to a person in the absence of an illness or
injury; Is appropriate for use in the home. However, each state can adopt its own definition of DME, as well as
determine whether a particular item falls under the states DME benefit
(Golinker, 2005). In addition, each state must include a process for
consumers/providers seeking modifications or exceptions to any lists of covered
items (University of Washington Center for Technology and Disability Studies,
2003). In a recent study, Freiman and colleagues found that State
Medicaid plans vary substantially in their coverage of AT. Roughly 80 percent
of plans cover at least some types of assistive technologies for activities of
daily living (ADLs) and for personal mobility.Only about 60 percent of
state Medicaid plans cover hearing aids, and roughly the same percentage cover
some type of augmentative communication AT. None of the state Medicaid plans
covers cognitive AT, transportation AT, or HM (Freiman et al.,
2006). 3.3.2. Waivers In addition to state Medicaid plan services, states have the option to
apply for waivers in order to provide services not usually covered by the
Medicaid program, as long as these services are required to keep a person from
being institutionalized (U.S. HHS, 2000). These waivers, commonly
referred to as HCBS waivers, are authorized by Section 1915(c) of the Social
Security Act. Section 1915(c) waivers allow states to cover certain supportive
services with respect to the frail elderly and/or people with disabilities at
risk for institutionalization. Unlike the state plan requirements, 1915(c)
allows states to limit the population served under the waiver, the scope of
waiver services, and the geographic area in which services are covered. The HCBS waiver application from CMS includes a list of additional
services that states can opt to include in their different waiver programs. If
a state chooses to include the service, the state can provide the service as
defined in the application or can alter the definition. Table
1 displays the AT and HM waiver service categories listed in the HCBS
waiver application. Recent research funded by the American Association of Retired Persons
(AARP) Public Policy Institute examined Medicaid HCBS coverage of AT and HM
services and found that, among waiver programs for older
persons and for older persons and persons with
disabilities,the one type of AT that is almost always covered is a
PERS. HM, the next most frequently listed type of AT, is found in the majority
of these waivers. However, no more than half of the waivers cover other AT
categories. Very few cover transportation AT, and waiver coverage only applies
to the limited number of persons enrolled in the waivers (Freiman et
al., 2006). Medicaid research and demonstration waivers, authorized by Section 1115
of the Social Security Act, allow states to develop and evaluate policies or
programs that have not been widely used. One such program, the Cash and
Counseling Demonstration and Evaluation Program, funded jointly by ASPE, the
Administration on Aging, and the Robert Wood Johnson Foundation, provides for
the purchase of AT and HM, at the consumers discretion, as part of a
personal care services plan (Doty, 1998). A consumer, or his/her surrogate,
decides how to spend a monthly cash allowance on needed services such as
personal care, AT, and HM. Multiple studies have reported the growth of 1915(c) waiver programs
(Lutzky, et al., 2000; LeBlanc, et al., Miller, et al.,
2001). Despite relevant findings about which populations tend to be served and
variations in per capita expenditures for different waiver populations, these
studies have not explored which waiver populations have access to AT and HM
services in particular, what AT and HM services waiver recipients can access,
nor how state cost control mechanisms (e.g., caps on spending, requirements
that all services be prior authorized) affect AT and HM service receipt among
Medicaid-eligible individuals. TABLE 1. HCBS Waiver AT and HM Service
Categories Service Type Core Definition Home
Accessibility Adaptations (also called Environmental Accessibility
Adaptations) Those physical
adaptations to the private residence of the participant or the
participants family, required by the participant's service plan, that are
necessary to ensure the health, welfare and safety of the participant or that
enable the participant to function with greater independence in the home. Such
adaptations include the installation of ramps and grab-bars, widening of
doorways, modification of bathroom facilities, or the installation of
specialized electric and plumbing systems that are necessary to accommodate the
medical equipment and supplies that are necessary for the welfare of the
participant. Vehicle
Modifications (VM) Adaptations or
alterations to an automobile or van that is the waiver participants
primary means of transportation in order to accommodate the special needs of
the participant. Vehicle adaptations are specified by the service plan as
necessary to enable the participant to integrate more fully into the community
and to ensure the health, welfare and safety of the participant. Specialized
Medical Equipment and Supplies (SMES) SMES include: (a)
devices, controls, or appliances, specified in the plan of care, that enable
participants to increase their ability to perform ADLs; (b) devices, controls,
or appliances that enable the participant to perceive, control, or communicate
with the environment in which they live; (c) items necessary for life support
or to address physical conditions along with ancillary supplies and equipment
necessary to the proper functioning of such items; (d) such other durable and
non-DME not available under the state plan that is necessary to address
participant functional limitations; and, (e) necessary medical supplies not
available under the state plan. Assistive
Technology (AT) AT device means an item,
piece of equipment, or product system, whether acquired commercially, modified,
or customized, that is used to increase, maintain, or improve functional
capabilities of participants. AT service means a service that directly assists
a participant in the selection, acquisition, or use of an AT
device. Personal
Emergency Response System (PERS) PERS is an electronic
device that enables waiver participants to secure help in an emergency. The
participant may also wear a portable "help" button to allow for mobility. The
system is connected to the participants phone and programmed to signal a
response center once a "help" button is activated. SOURCES: Application for a §1915(c) Home and
Community-Based Waiver [Version 3.3], Instructions, Technical Guide, and Review
Criteria, Appendix C. Retrieved January 23, 2006 from
http://www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/05_HCBSWaivers-Section1915(c).asp.
3.4. Non-Medicaid Sources for AT and HM There are several non-Medicaid sources for AT and HM funding, described
below. 3.4.1. Special Education and Public Schools The IDEA authorizes the provision of special education and related
services to students with disabilities, in the least restrictive environment
possible. Under IDEA, a public school system is required to pay for AT devices
and services necessary for a childs educational program, as specified in
the childs individualized education plan. AT devices that are commonly
used in schools include computer equipment and adaptations, augmentative
communication systems, assistive listening devices, and adaptive seating
systems (Sheldon and Hager, 1997). 3.4.2. State Vocational Rehabilitation Agencies The Rehabilitation Act establishes state Vocational Rehabilitation (VR)
agencies to provide VR to help people with disabilities to work at their
maximum levels, become as self-sufficient and independent as possible, and be
integrated into the workplace and community (Sheldon and Hager, 1997). VR
agencies cover AT, including VM, under the Rehabilitation Technology Services
benefit. In 2002, rehabilitation technology expenditures totaled roughly $96
million (Freiman, et al., 2006). A state has the option of setting
financial criteria to determine eligibility for this benefit. VR is the payer of last resort and does not pay for any service if a
comparable benefit is available through another insurer, provider, or program
(including Medicare and Medicaid). Also, VR agencies do not ordinarily serve
people aged 65 and over. 3.4.3. Medicare Medicare is available to all people over age 65, to people receiving
Social Security Disability Insurance payments, and to people with end stage
renal disease. Medicare Part A provides coverage for limited types of AT under
the DME benefit; Part B covers additional types of AT under prosthetic and
orthotic devices. For persons with severe disabilities who are dually eligible
for both Medicare and Medicaid, Medicare is the primary insurer, with Medicaid
as secondary payer of last resort. Freiman and colleagues (2006) assessed the degree to which Medicare
covers and reimburses AT services and found that Medicare provides
only limited coverage of personal AT for ADLs; items such as grab-bars and
raised toilet seats do not meet the criterion of medical necessity. Personal
mobility AT such as canes, walkers, and wheelchairs are covered when determined
to be medically necessary within the home.And cognitive AT,
transportation AT, and HM are not covered at all. 3.4.4. State Assistive Technology Projects Each state has an AT program funded through the Tech Acts, as described
in Section 3.2. Although exact services available
vary by state, most programs include lists of funding resources within the
state. State Tech Act projects may be able to assist consumers to access AT and
HM services through the following types of resources: Grants from private charities, foundations, and civic
organizations; Low-interest alternative loan programs for the purchase of AT; Equipment manufacturer rebates and discounts; Personal and home equity loans. 4. OVERVIEW OF STATE AT AND HM POLICIES AND
PRACTICES As described earlier, the purpose of this Compendium of Home
Modification and Assistive Technology Policy and Practice Across the States
is to establish a baseline knowledge of the scope of AT and HM services that
states make available to Medicaid-eligible adults. This study provides federal
and state policymakers with basic information to inform planning and policy
development. It also provides other stakeholders, including consumers, with
valuable information about state Medicaid plan and HCBS waiver coverage of AT
and HM. Research questions This study was designed to address three fundamental questions: To what extent Medicaid State Plans and HCBS waivers cover AT and
HM services? What are the processes available to Medicaid recipients to obtain
AT and HM services? For example, must a physician prescribe the equipment
or service? Must the recipient be evaluated by a rehabilitation specialist to
determine the need for the service? Does the state provide a case manager or
service coordinator to assist the recipient to obtain the service? What mechanisms -- if any -- do states use to restrict or control
use and costs associated with AT and HM services? For instance, must all AT
and HM services be prior authorized or approved by the Medicaid State Plan or
HCBS waiver prior to delivery? If so, must these services meet medical
necessity criteria and what are those criteria? Does the state limit or
place a cap on reimbursement for AT and HM services? Methods Data summarized here were obtained through internet searches, review of
Medicaid provider manuals, limited discussions with state representatives
(Medicaid State Plan Home Health/DME and HCBS waiver), and state verification
of reported findings. State response rates to our requests for data
verification were high (84 percent). However, given the number of different
individuals required to review and verify the various HCBS waivers, we rarely
received comments from each and every state representative that we contacted.
Study Limitations Missing/unverified data. As described above, some data were
not verified by the state, or some aspect of a states data on AT and HM
coverage was not verified. For example, some states were unable to verify their
Medicaid State Plan profiles (e.g., Alaska, Mississippi, North Carolina,
Pennsylvania, Tennessee, Utah, and Wisconsin). Several states were also unable
to verify the AT and HM coverage as described in their HCBS waiver profiles. In
these instances, data were considered missing, as the researchers
did not want to presume that unverified data were accurate. These missing data
(or unverified data), limit the degree to which this study can address the
research questions posed here (e.g., what are all the processes by which
consumers access AT and HM services). However, state plan and waiver data are
sufficient to present the broad array of AT and HM services offered to
Medicaid-eligible individuals nationwide, and to gain a baseline understanding
of the various mechanisms states use to control use and costs associated with
AT and HM services. Variation in terminology. One significant challenge (and
resulting limitation) of this synthesis of Medicaid State Plan and HCBS waiver
coverage policies is the wide variation in terminology for AT and HM. In order
to consistently summarize the state and waiver-level data, this report grouped
services into the following categories:4 Assistive Technology. Services or equipment or devices
considered for our purposes to be assistive technology include:
specialized medical supplies and equipment, adaptive equipment,
adaptive/assistive devices and services, adaptive aids, communication aids, and
adaptive eating utensils. Augmentative communication devices (ACDs). These
speech-generating devices are generally defined as any electric or non-electric
aid or device that replaces or enhances lost communication skills for a person
with a severe communication disability. They are available in a continuum
ranging from very simple systems, such as picture books or picture boards, to
highly complex computerized systems. Environmental accessibility adaptations/Home
Modifications. Services or equipment that were categorized as
environmental accessibility adaptations or HM include: physical
adaptations to the home and/or workplace, wheelchair ramps, environmental
control systems, plumbing modifications, turnaround space adaptations,
specialized accessibility adaptations, environmental modifications, and the
installation of specialized electrical and/or plumbing systems necessary to
accommodate medical equipment and supplies. Personal Emergency Response Systems. A PERS is generally
an electronic device that enables a person to secure help in an emergency.
Though PERS systems are a form of AT (as are ACDs and power wheelchairs), these
services were categorized in a group by themselves in order to distinguish
those states/waivers that offer only PERS from those that offer PERS and other
AT. Vehicle Modifications. Though VM (e.g., van lifts,
modifications to the primary vehicle) were often contained within a
waivers HM service definition, this report categorizes these services
separately as vehicle modifications. Wheelchairs. The mobility-enhancing devices included in
this study are power-operated wheelchairs, custom wheelchairs, custom
wheelchair seating, power-operated vehicles, scooters, adaptive devices for
wheelchairs, and sip-and-puff wheelchair controls. Study findings are summarized below by Medicaid State Plan and 1915(c)
HCBS waiver program, respectively, due to the differences in programmatic
structure and requirements between each type of Medicaid program. 4.1. Medicaid State Plan Coverage of AT and HM As stated earlier, Medicaid State Plans must offer mandatory
benefits and may offer optional benefits. The benefit categories
that states are most likely to use to cover AT are the medical equipment
and supplies or durable medical equipment categories within
the mandatory home health benefit. Forty-seven states and the District of
Columbia categorize any AT or mobility-enhancing services (e.g., power
wheelchairs, sip-and-puff wheelchair controls) as DME, while three states
classify these services under the prosthetic devices benefit
(Arkansas, Colorado and Iowa).5 4.1.1. AT and HM Services Listed as Medicaid State Plan
Services As presented in Table 2, most states cover ACD or
speech-generating devices under the Medicaid State Plan, though these services
are not referred to in states coverage guidelines as assistive
technology. All 40 states for which wheelchair coverage information was
located offer Medicaid coverage for the purchase or rental of
mobility-enhancing equipment or services. Examples of these services include
power-operated wheelchairs, custom wheelchairs, custom wheelchair seating,
power-operated vehicles, scooters, adaptive devices for wheelchairs, and
sip-and-puff wheelchair controls. Only three states (Arizona, Kansas, and
Massachusetts) and the District of Columbia list PERS as a covered Medicaid
State Plan service; two of these are 1115 Research and Demonstration Waiver
states (Arizona and Massachusetts). As stated earlier, PERS is generally
any electronic device that enables a person to secure help in an
emergency. With the exception of Arizona, no states offer HM services,
per se, as Medicaid State Plan services, though Hawaii covers wheelchair
ramps and New Jersey reportedly will cover environmental control
units in special circumstances. These data differ slightly by those
reported by Freiman et al., 2006, in which no Medicaid State Plans were
reported to cover HM. Medicaid State Plans also provide coverage under the Home Health DME
benefit for other types of mobility-enhancing equipment and supplies, or for
AT. These types of equipment and services are categorized as other
in Table 2. Examples of these services include: Specialized rehab equipment, AT, mobility-enhancing equipment
including grab-bars and handrails, automobile hand controls (Arkansas); Bathtub wall rail, bathtub rail, floor base, toilet rail, transfer
tub rail attachment, power-operated vehicle; environmental control units
permitted in special circumstances (New Jersey); AT that is limited to use in the home with a documented medical need
for the device (Texas); AT/adaptive equipment including lifts, bath chairs, wall-mounted
insulin delivery devices, and automatic feeder systems (Virginia). TABLE 2. Medicaid State
Plan Coverage: AT, Wheelchairs and Other State PERS ACD Wheelchairs Other Alabama X M Alaska M M M Arizona X X M X Arkansas X X X California X M X Colorado X X X Connecticut X X Delaware X X District of
Columbia X M X Florida X X Georgia X X Hawaii X X X Idaho X M X Illinois X X Indiana X X Iowa X M X Kansas X X M X Kentucky X M X Louisiana X X Maine X X X Maryland X X X Massachusetts X X X X Michigan X X X Minnesota X X X Mississippi X X Missouri X X Montana X X Nebraska X X X Nevada X New
Hampshire X X X New
Jersey X X X New
Mexico X X X New
York X M X North
Carolina X X North
Dakota X X X Ohio X X X Oklahoma X X Oregon X X X Pennsylvania X X Rhode
Island M X South
Carolina X X X South
Dakota X X X Tennessee X M Texas X X X Utah X Vermont X X X Virginia X X X Washington X X X West
Virginia X X X Wisconsin X X Wyoming X X Total
States Offering Services 4 37 40 39 NOTES: n = 51 (50
states and Washington, DC). M indicates missing
data.SOURCE: Abt Associates review of Medicaid State Plan coverage
policies, June 2005-February 2006. 4.1.2. How Medicaid Recipients Access AT and HM
Services In addition to reviewing the types of AT (and/or HM) services covered by
Medicaid State Plans, this study considered the process by which
Medicaid-eligible individuals access these particular state plan services.
Physician orders are a requirement for AT coverage in the majority of state
plans.6 In addition,
more than half of all Medicaid State Plans (29) require assessments by health
professionals (other than a physician) in order to document the need for the
service. This is especially true in the case of augmentative speech devices, in
which a speech-language pathologist/therapist often assesses the
recipients need for the device in order to obtain coverage for that
service, and in the case of wheelchairs, in which a physical or occupational
therapist assesses the recipient. Table 3 displays the
number of states with specific requirements regarding how Medicaid recipients
might access AT and HM services. A list of all state plan access requirements
may be found in Appendix 1. TABLE 3. Medicaid State Plan Access to
AT and HM Services and Service Controls Access Mechanisms States with
Requirement States without the
Coordination/Case Manager (n=36) 11 25 Physician
Order (n=37) 37 0 Assessment by
Other Health Professional (n=33) 29 4 Medical
Necessity (n=48) 47 1 Prior
Authorization (n=42) 42 0 One or more
vendor/supplier bids (n=37) 1 36 NOTE:
n varies due to varying response rates from states and adequacy of secondary
data. SOURCE: Abt Associates review of Medicaid State Plan coverage
policies, June 2005-February 2006. 4.1.3. Limits on Access to AT and HM Services for Medicaid State
Plan Recipients Medicaid State Plans limit use and contain costs related to AT and/or HM
services by reviewing whether the services are medical necessary,
require prior authorization, or sometimes require consumers or
providers to obtain one or more bids from potential suppliers
before the State would agree to cover the equipment or service. A brief
description of these mechanisms follows, along with a summary of findings
regarding the number of states that utilize these controls (presented in
Table 3). Medical necessity. For federally mandated services
(e.g., home health), states maymake service eligibility criteria based
upon medical necessity. (U.S. HHS, 2000), though states may develop
and implement their own definitions of medical necessity when
determining whether to cover a particular service, device or equipment. Issues
that may be relevant to determining medical necessity may be whether the
service is related to the medical condition for which the recipient is
receiving treatment, or whether the service is consistent with generally
accepted standards of good medical practice (U.S. HHS, 2000). Prior authorization. Prior authorization is commonly used in
managed care environments and requires the provider of service to submit
medical justification or rationale for the services, along with an estimate of
how much service will be required. In such a system, claims for service are
generally not reimbursed without proof of prior authorization. There is a
general interpretation that medical necessity criteria or
limitations require that services be preauthorized, or authorized
by a medical professional before the service begins. (U.S.
HHS, 2000). Bids for equipment or services. Some programs require that
either the consumer or vendor submit cost estimates or bids before
equipment or services may be obtained or authorized. This process assures that
the payor -- in this case the state Medicaid agency -- pays for only the least
costly services available. The following sections describe findings regarding the number of states
that use these controls. Medical necessity. Forty-seven of 48 states require that AT
services meet medical necessity criteria.7 The majority of state plan coverage guidelines
merely state that medical necessity is required, or that the
service must be medically necessary. Examples of more specific language
used by states regarding medical necessity of AT services include: Thedefinition of medical necessity limits health care
services to those necessary to protect life, to prevent significant illness or
significant disability, or to alleviate severe pain. Therefore, prescribed DME
items may be covered as medically necessary only to preserve bodily functions
essential to ADLs or to prevent significant physical disability
(California -- MediCal). Medical necessity must be established for each service and
documented. DME/medical supplies, orthotics, and prosthetic devices must
be: Functionally appropriate, Adequate for the intended medical purpose, For conventional use, and For the exclusive use of the recipient (Florida). A certificate of medical necessity is required for some
specific items; the physician must determine medical necessity
(Wyoming). Prior authorization. Forty-two state plans require prior
authorization for AT equipment or services. The scope of this review did not
include an investigation of the process by or frequency with which services are
authorized, nor did it include analysis of data regarding the volume of AT
services authorized or denied through states prior authorization
programs. Bids for equipment or services. Most state plans do not require
the provider or recipient to obtain vendor/supplier bids for the service, and
more than half (29) do not impose special reimbursement limits on these
Medicaid State Plan services (they generally reimburse for these services
according to the Medicare DME schedule). 4.2. HCBS Waiver Coverage of AT and HM Using the WGMD file extracts, CMS internet information on HCBS waivers,
and interviews with HCBS waiver representatives, 202 HCBS waivers were
identified in the 50 states and the District of Columbia that reportedly cover
AT and/or HM. The number of waivers per state that were reported to cover these
services ranged from one (Arizona, an 1115 Research and Demonstration Waiver
state) to ten (Pennsylvania). Table 4 shows states coverage of AT and HM
by waiver type. Consistent with previous reviews of 1915(c) HCBS waivers
(Lutsky, et al., 2000), most states had one or more Aged and
Disabled waivers, and one or more Mentally Retarded/Developmentally
Delayed waivers. Twenty-one states studied offered a Traumatic Brain
Injury (TBI) waiver and seven offered HIV/AIDs waivers. TABLE 4. Coverage of Assistive
Technology and Home Modification by Waiver Type Waiver Type Number of States* (n=51) Aged and
Disabled 49 Mentally
Retarded/Developmentally Disabled (MR/DD) 46 Traumatic
Brain Injury (TBI) 21 HIV/AIDS 7 Other** 5 NOTES:
* Some states have more than one waiver of each type. ** The other waiver
types found to cover AT and/or HM include a chronically ill waiver, a
technology dependent waiver, New Jerseys 1115 Personal Preference Program
waiver, and Vermonts two 1115 waivers. SOURCE: Abt Associates
review of Medicaid HCBS waiver coverage policies, June 2005-February
2006. 4.2.1. AT and HM Services Listed as HCBS Waiver
Services Table 5 provides a summary of waiver types across
all states and the District of Columbia according to whether PERS, AT, HM and
VM services are covered in those waiver types. These data suggest that AT and
HM are broadly covered across the Aged and Disabled and MR/DD waivers, but that
VM are most often offered only to Medicaid recipients served by the MR/DD
waivers. Of the 173 waivers studied that offer HM (the most frequently offered
of the four services), 159 cover AT, 124 cover PERS, and 64 of the waivers
reportedly cover VM. More than half of the state HCBS waivers cover AT under the term
specialized medical equipment and supplies. Examples of services
that fall under this category across the states and across different waiver
types include: Van lifts/adaptations for vehicles (Maine); Specialized wheelchairs and wheelchair modifications (Michigan);
Ramps, grab-bars, porch lifts, electronic door openers, ACDs, and
sip-and-puff controls for wheelchairs (Montana); Vehicle adaptations and AT (Nevada); Widening of doorways and modification of bathroom facilities
(Washington). TABLE 5. Type of Coverage by Waiver
Type Waiver Type PERS
Covered AT Covered HM Covered VM Covered Aged and
Disabled (n=90) 65 59 72 16 Mentally
Retarded/ Developmentally Disabled (MR/DD) (n=79) 40 71 72 37 Traumatic
Brain Injury (TBI) (n=21) 14 20 20 8 HIV/AIDS
(n=7) 2 6 5 1 Other
(n=5) 3 3 4 2 Total
(n=202) 124 159 173 64 SOURCE: Abt Associates review of Medicaid HCBS waiver coverage
policies, June 2005-February 2006. Some of these same services are categorized as environmental
accessibility adaptations or as HM by other states and waivers. For
example, the State of Washington considers the installation of ramps and
grab-bars and the widening of doorways to be EAA in the Basic MR/DD
waiver, while grouping those services under SMES in the Community Options
Program Entry System Aged and Disabled waiver. Other examples of EAA
services across the states and different waiver types include: Ramps, grab-bars, minor home improvements (California); Alarm systems/alert systems including auditory, vibratory, and
visual; stair mobility devices; shatterproof windows (Delaware); Visual fire alarms; lifts; ramps; grab-bars or handrails; stair
glides; widening of doorways; modification of bathroom or kitchen facilities to
make them physically accessible; lock, buzzer, or other device on a doorway to
prevent or stop wandering (Maryland). 4.2.2. How HCBS Waiver Recipients Access AT and HM
Services Appendix 1 summarizes the process by which waiver
recipients access AT and HM services for all 202 waivers examined in this
study. In all states for which we have complete data -- with the exception of
Tennessee -- waiver policies require that recipients be assessed by a health
professional such as a physical or occupational therapist in order to determine
the need for at least one AT or HM service or supply. Tennessee does not
require such an assessment in the states three Aged and Disabled waivers,
but does require a health professional assessment in its MR/DD waivers. Without
exception, all states and the District of Columbia offer a case manager or
other service coordinator to assist recipients with accessing waiver services
and/or assessing the recipients need for the services. Few states seem to
require a physicians order as a condition of coverage of the AT/HM
service. However, these data should be interpreted with caution, as information
about the need for physician orders was unable to be obtained in more than half
of the waivers studied. HCBS waiver manuals were often silent regarding this
coverage requirement. 4.2.3. Limits on Access to AT and HM Services for HCBS Waiver
Recipients Like Medicaid State Plans, HCBS waivers may limit use and contain costs
related to AT and/or HM services by reviewing whether the services are
medical necessary, may require prior authorization, and
sometimes require consumers or providers to obtain one or more bids
from potential suppliers before the waiver would agree to cover the equipment
or service. A brief summary of findings regarding HCBS waiver limits to
coverage and/or cost containment mechanisms follows. Medical necessity. Unlike the Medicaid State Plans, in which the
majority use medical necessity criteria to determine coverage of AT
and HM services, only about half of the HCBS waivers studied report
medical necessity as a requirement for coverage, while 28 waivers
did not require medical necessity.8 There were 75 of the 202 waivers in which
information about medical necessity requirements was unable to be verified with
state personnel, or data were missing from the coverage manuals. The
specification of the requirement varied across state waiver programs, and
within state waiver programs. For example, Connecticut does not use
medical necessity criteria in any of the four HCBS waivers studied,
while Florida does not use the criteria in one of three of its waivers. To further our understanding of state policy and practice in the area of
medical necessity requirements, we examined some of the terms that state waiver
programs use when describing what AT or HM service might be covered. Some
states use terms that are more functionally oriented than
medically oriented when describing requirements for AT and/or HM
coverage. For example, In the Connecticut Home Care Program for Elders waiver,
the [home] modifications must be necessary because of a physical
disability. In the Connecticut Comprehensive Supports waiver, HM and VM
must be necessary to improve the individuals independence and
inclusion in the community and to avoid institutionalization. The Florida Channeling Services for Frail Elderly waiver
states that, physical adaptations to the home [must] ensure the health
[and] welfare of the individual. In Hawaiis Nursing Home without Walls waiver, EAA or HM
must be necessary to ensure the health, welfare, and safety of the
individual, or must enable the individual to function with greater independence
in the home, and without which, the individual would require
institutionalization. Prior authorization. As with the Medicaid State Plans, almost all
HCBS waivers studied require that at least one AT and HM service be prior
authorized. The scope of this review did not include an investigation of the
process by or frequency with which services are authorized or denied through
the HCBS waiver prior authorization programs. Bids for equipment or services. About half of the HCBS waiver
programs require the provider or recipient to obtain vendor/supplier bids for
the service. Limits on AT and HM services. Many of the HCBS waivers described
cost caps or limits to the amount the state would reimburse for AT and HM
services. Many states set an annual or lifetime limit on the amount that could
be spent on HM and AT, while others set a total waiver cap per
recipient per year or per the life-of-the-waiver. Some of the state
representatives stated that they calculated an average cost per person, and
that services must be managed within that average cost (e.g., Montana).
Similarly, Connecticuts Home Care Program for Elders monthly cost
cap determines whether funds are available for HM. Some states also reported
that they at times had the flexibility within the waiver to shift funds toward
clients who were needier. Table 6 presents the mechanisms that states use to
limit reimbursement for AT and HM services in any of their waivers. Note that
depending on the waiver type, the same state may have differently-defined
service limits. For example, Iowa has a mix of annual expenditure limits for HM
and lifetime benefit limits for HM, depending on the waiver. Some specific
examples of state waiver limits are as follows: States with a lifetime limit or a life-of-the-waiver limit on AT
and/or HM expenditures: Arkansas -- $7,500 per person limit for the life-of-the-waiver
for HM, Georgia -- $10,000 per person lifetime limit for HM, Iowa -- $1,000 lifetime limit for HM (Elderly Waiver), Iowa -- $5,000 lifetime benefit limit for HM (Mental Retardation
Waiver), Kansas -- $7,500 lifetime benefit for AT, HM and VM. States with an annual limit on AT and/or HM expenditures: Alabama -- $5,000 per year for SMES, $5,000 per year for HM,
Iowa -- $6,000 per year limit for HM, New Mexico -- $300 per year limit for HM
maintenance, North Carolina -- $10,000 per year limit for ACDs, Virginia -- $5,000 per year for AT. States with a waiver limit over multiple years on AT and/or HM
expenditures: Alaska -- $10,000 every three-years for HM, Florida -- $20,000 over five years for EAA, Illinois -- $15,000 over five years for all HM, VM, and adaptive
equipment, Oklahoma -- two residences in five-year period (HM); one vehicle
in five-year period (VM). States that report a total waiver cap, inclusive of AT, HM and
other waiver services: Montana -- Must fit into annual [waiver] budget for all
beneficiaries, Tennessee -- Total budget for all waiver services cannot exceed
$36,000 per year (including Emergency Assistance services). TABLE 6. Types of Waiver Limits for AT
and HM Services Used within States State Lifetime or life of waiver limit Annual service cap or limit Limit over multiple years Total waiver cap Alabama X X Alaska X Arizona X Arkansas X X California X X Colorado X Connecticut X Delaware X X District of
Columbia M M M M Florida X X Georgia X X Hawaii Idaho M M M M Illinois X X Indiana X X Iowa X X Kansas X Kentucky X Louisiana X Maine X X Maryland X Massachusetts* Michigan* Minnesota X Mississippi M M M M Missouri X X Montana X X Nebraska X Nevada X New
Mexico X X New
Dakota M M M M Ohio* X Oklahoma X X Oregon X Pennsylvania* X X Rhode
Carolina X X South
Dakota* Tennessee* X X X X Texas X X Utah* Vermont X X Virginia X Washington* X West
Virginia X Wisconsin M M M M Wyoming NOTES: * These
states have limits other than those reflected here (e.g., Massachusetts caps
reimbursement at the average per person expenditure in the previous year; South
Dakota imposes monthly caps; Utah has total reimbursement limits per service).
M indicates missing data. SOURCE: Abt Associates
2006. 4.3. Discussion The extent to which AT and HM services are offered by Medicaid
State Plans and HCBS waivers. There is coverage of AT and HM services in the waiver programs, and more
limited coverage of AT in the state plans. There is wide variation in
definitions and terminology used by states when referencing AT and HM services.
Specifically, AT services covered most frequently by Medicaid State Plans include
ACDs and power or custom wheelchairs or wheelchair adaptations. Almost no Medicaid State Plan reports coverage of HM, PERS, or VM.
173 of the 202 waivers reviewed offer HM, 159 cover AT, 124 cover
PERS, and 64 of the waivers reportedly cover VM, mostly through the MR/DD
waivers. Though all states offer HCBS waivers that reportedly cover AT and/or
HM, considerable variation exists in how states define and refer to AT and HM
services. Both Medicaid State Plans and HCBS waivers describe coverage of AT
services in their provider manuals. However, state plans almost never refer to
these services as assistive technology. The processes available to Medicaid recipients to obtain AT and HM
MR/DD, TBI). However, the scope of this study did not include how and to what
degree access to services might be limited through prior authorization
procedures and medical necessity or other criteria. Almost all Medicaid State Plans use medical necessity
extensive AT/HM coverage). 5. STATE PROFILES OF AT AND HM POLICIES AND
PRACTICES Profiles of each states Medicaid policies and practices with
regard to AT and HM were developed based upon the review and synthesis of
Medicaid coverage policies obtained, to the extent possible, via the internet
in the form of Medicaid Provider Manuals, HCBS waiver provider manuals, state
web sites, and state statutes and regulations. Profiles are included for all
states and for the District of Columbia (see Volume
II of this report). The first page of each profile starts with an overview
of the states Medicaid coverage for AT and HM and then describes the
state plan coverage in detail. The following pages describe AT and HM policies
and practices as implemented in the states HCBS waivers, with each waiver
on a separate page. The profiles are arranged alphabetically, by state.
Exhibit 1 illustrates a state profile and explains each
field. Exhibit 1: Description of the
State Profile Overview A brief description of AT and HM services offered by the Medicaid
State Plan and the states relevant HCBS waivers.9 (This section appears only on the first page
of the profile.) Program Name Agency Name Agency that administers the program. Phone Phone number for general information. Web site Web site for general information. Summary of State Plan Coverage For the state plan, this section describes AT and HM services that
are available and the benefit categories under which these services are
covered. For the HCBS waivers, this section summarizes the waivers
services. Populations Served Individuals who qualify for services. The phrase
Medicaid-eligible individuals refers to the populations served by
the Medicaid State Plan, as this study did not collect data on each
states criteria for Medicaid eligibility. Terminology for HM and AT Terminology that is used in the states Medicaid regulations
and/or provider manuals to refer to covered types of AT and HM.
Examples of Covered HM and AT Services Examples of items that are covered, within the different types of
AT and HM. Process to Access Benefit ServiceCoordination/Case Manager MD OrderRequired
byOther HealthProfessional MedicalNecessityRequired PARequired
BidsRequired
X X X X X X In these
fields, the symbol X is used to indicate that the program requires this process
in order for the recipient to receive the service; a blank indicates that the
process or procedure is not required in order to obtain services; and N/A
indicates that the data was not available or not verified by the state. Note
that X in a box indicates that at least one type but not necessarily all types
of AT/HM meet the criteria for inclusion. The data fields are defined as
follows: Service Coordination/Case
Manager. A person, such as a case manager, assesses a client's overall
health care needs, may design a service plan, and coordinates services.
MD Order Required. A physician or
other licensed medical provider (e.g., physicians assistant, nurse
practitioner) must write a prescription or order for an AT/HM service.
Assessment by other health
professional. A specialized therapist (such as a physical, occupational or
speech-language) must perform an assessment before an item can be covered.
Medical Necessity Required. The
state's Medicaid regulations state that the AT/HM service must be medically
necessary in order to be covered. PA
(Prior Authorization) Required. An AT/HM service must receive prior
authorization from the program in order to be covered.
Bids Required. A case manager,
service coordinator or consumer must obtain one or more bids from an equipment
supplier/vendor for an AT/HM service. Benefit Limits Cost caps or service limits that the program
imposes. Training on Use and Repairs The availability of training on the use of AT/HM*. Coverage
for repair of AT/HM*. NOTE: * When coding these services, we indicated that these
services were covered if they were bundled with the equipment cost (and were
not a separate charge.) We also included training and repairs that were billed
separately. SOURCE: Abt Associates review of Medicaid State Plan
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Assistance for Disability. Journal of Gerontology, 57B (6):
S366-S379. APPENDIX 1. PROCESS TO ACCESS WAIVER
SERVICES Access to Services -- HCBS Waiver
Requirements State Waiver Category Waiver Name MD Order Support Coordination/ Case Manager Prior Approval Medical Necessity AL MR WAIVER Home &
Community-Based Waiver for Persons with Mental Retardation X X X X AL MR WAIVER Home &
Community-Based Living at Home Waiver for the Mentally Retarded X M X AL PHYSICAL DISABILITIES
WAIVER Home &
Community-Based Services for Individuals Under the Technology Assisted Waiver
for Adults X X X X AL PHYSICAL DISABILITIES
WAIVER Alabama Independent
Living Waiver X X X X AK AGED
AND/OR DISABLED Older
Alaskans M X X X AK MR/DD
WAIVER People
with Mental Retardation & Developmental Disabilities M X X X AK PHYSICAL DISABILITIES WAIVER Adults
with Physical Disabilities M X X X AZ AGED AND/OR
DISABLED Arizona Health Care Cost
Containment System X X X AR PHYSICAL DISABILITIES WAIVER Alternatives for Adults with Physical Disabilities M X X X AR MR/DD
WAIVER Alternative Community Service X X X X CA AGED AND/OR
DISABLED In-Home Medical Care
Waiver M X X X CA AGED AND/OR
DISABLED Nursing Home Facility A/B
DISABLED Nursing Facility Subacute
DISABLED Multipurpose Senior
Service Program M X X M CA MR AND/OR DD Home &
Community-Based Services Waiver for Persons with Developmental
Disabilities M X X M CA HIV/AIDS
WAIVER AIDS Waiver X X X X CA AGED AND/OR
Waiver M X X M CO AGED
AND DISABLED WAIVER Home
& Community-Based Services for the Elderly, Blind, &
Disabled M X X X CO MR/DD
& Community-Based Services for Persons with Major Mental
Illness M X X X CO MR/DD
& Community-Based Services for the Developmentally Disabled X X CO TBI
& Community-Based Services for Persons with Brain Injury M X X X CO DD
WAIVER Supported Living Services M X X X CT AGED AND/OR
DISABLED Connecticut Home Care
Program for Elders X X X CT MR AND/OR DD Comprehensive Supports
Waiver X X CT TBI WAIVER Acquired Brain
Injury X X CT MR AND/OR DD Individual & Family
Support Independence Plus X X DE MR
AND/OR DD Mental
Retardation/Developmental Disability Home & Community-Based
Waiver X X X DE AGED
AND/OR DISABLED Elderly
& Disabled Home & Community-Based Waiver M X X M DC MR AND/OR DD Mental Retardation &
Developmental Disabilities Waiver X M M M DC AGED AND/OR
DISABLED Elderly & Physical
Disabilities Waiver M M M X DC HIV/AIDS
WAIVER HIV/AIDS
Waiver M M M M FL MR
AND/OR DD Developmental Services Home & Community-Based Services
Waiver M X X X FL AGED
AND/OR DISABLED Channeling Services for Frail Elderly M X M M FL AGED
& Disabled Waiver M X M M FL HIV/AIDS WAIVER Project
Aids Care M X X X FL AGED
AND/OR DISABLED Nursing
Home Diversion M X X FL MR
AND/OR DD Family
& Supported Living Waiver M X X X FL TBI Home
& Community-Based Services Waiver for Traumatic Brain Injury & Spinal
Cord Injuries M X X X FL AGED
AND/OR DISABLED Adult
Cystic Fibrosis Waiver M X X X FL AGED
AND/OR DISABLED 1915(c)
Alzheimer's Disease Program M X M M GA MR/DD WAIVER Mental Retardation Waiver
Program X M X M GA MR/DD WAIVER Community Habilitation
& Support Services M X X X GA PHYSICAL DISABILITIES
WAIVER Independent Care Waiver
Program M X X M HI MR
AND/OR DD Developmentally Disabled/ Mentally Retarded M X X HI AGED
Home Without Walls M X X HI HIV/AIDS WAIVER HIV
Community Care Program M X X M ID AGED AND DISABLED
WAIVER Aged & Disabled
Waiver M X X ID MR/DD WAIVER Developmentally Disabled
Waiver M X X X ID TBI WAIVER Traumatic Brain Injury
Waiver M X X X IL TBI Waiver
for Persons with Brain Injury M X X M IL AGED
AND/OR DISABLED Supportive Living Waiver M M M M IL AGED
Waiver M X X M IL HIV/AIDS WAIVER Home
& Community-Based Services Waiver for Persons Diagnosed with
HIV/AIDS M X X M IL AGED
AND/OR DISABLED Home
& Community-Based Services Waiver for Persons with Physical
Disabilities M X X M IL MR
AND/OR DD Home
& Community-Based Services Waiver for Adults with Developmental
Disabilities M X X M IN AGED AND/OR
DISABLED Aged & Disabled
Waiver M X X M IN TBI WAIVER Waiver for Persons with
Traumatic Brain Injury M X X M IN MR AND/OR DD Waiver for Persons with
Developmental Disabilities M X X M IN MR AND/OR DD Support Services for
Mentally Retarded/Developmentally Disabled M X X M IN MR AND/OR DD Autism Waiver
M X X M IA MR
Retardation Waiver M X X X IA TBI
WAIVER Traumatic Brain Injury Waiver M X X X IA AGED
AND/OR DISABLED Physically Disabled Waiver M X X X IA MR
AND/OR DD Ill and
Handicapped Waiver M X X X IA AGED
Waiver M X X X KS TBI WAIVER Traumatic Brain Injury
Waiver M X X KS MR/DD WAIVER Mental Retardation/
Developmentally Disabled Waiver M X X KS AGED AND/OR
DISABLED Frail Elderly
Waiver M X X KS PHYSICAL DISABILITIES
WAIVER Physically Disabled
Waiver M X X KY AGED
&Community-Based Waiver for Elderly & Disabled Individuals X X KY MR
AND/OR DD Supports for Community Living Waiver X X X X KY TBI
WAIVER Brain
Injuries Waiver M X X X LA AGED AND/OR
DISABLED Elderly & Disabled
Adult Waiver X X X X LA MR AND/OR DD New Opportunities Waiver
-- Independence Plus Waiver M M M M ME PHYSICAL DISABILITIES WAIVER Physically Disabled Waiver X X M ME MR/DD
WAIVER Mental
Retardation Waiver X X X X ME PHYSICAL DISABILITIES WAIVER Disabled Adults Under 60 X X X ME AGED
Waiver X X X MD AGED AND/OR
DISABLED Waiver for Older
Adults M X X M MD AGED AND/OR
DISABLED Living At Home: Maryland
Community Choices M X X M MD MR AND/OR DD Waiver for Individuals
with Mental Retardation/Developmental Disabilities -- Community
Pathways X X X MD MR AND/OR DD Waiver for Individuals
with Mental Retardation/Developmental Disabilities -- New
Directions X X X M MA AGED
& Community-Based Services Waiver for Elders M X X MA MR
Retardation/Developmental Disability Waiver M X X MA TBI Traumatic Brain Injury M X X MI DD WAIVER Habilitation Supports
Waiver M X X X MI AGED AND DISABLED
Choice X M X MN AGED
AND DISABLED WAIVER Elderly
Waiver M X X X MN PHYSICAL DISABILITIES WAIVER Community Alternatives for Disabled Individuals Waiver M X X X MN TBI
WAIVER Traumatic Brain Injury Waiver M X X X MN MR/DD
Retardation/Related Conditions M X M X MN CHRONICALLY ILL Community Alternative Care Waiver M X X X MS AGED AND/OR
DISABLED Elderly and Disabled
Waiver M X X M MS ADULTS WITH
DISABILITIES Independent Living
Waiver M X X M MS MR AND/OR DD Mental
Retardation/Developmental Disability Waiver X M X M MS AGED AND/OR
DISABLED Assisted Living for the
Elderly Waiver M M M MS TBI Traumatic Brain Injury
Waiver M M M M MO PHYSICAL DISABILITIES WAIVER Physically Disabled Waiver M X X X MO MR/DD
WAIVER Mentally Retarded/ Developmentally Disabled Waiver M X X X MO MR/DD
WAIVER Independent Living Waiver M X X M MT AGED AND DISABLED
WAIVER EPH M M X MT MR/DD WAIVER Mentally Retarded/
Developmentally Disabled M X X X MT DD WAIVER Developmental
Disabilities Aged 18 & Older M X X X NE AGED
AND DISABLED WAIVER Aged
& Disabled Waiver M X X X NV PHYSICAL DISABILITIES
Community-Based Waiver for the Physically Disabled X X X X NV AGED AND DISABLED
WAIVER Waiver for the Frail
Elderly X X X X NH MR
& Community-Based Care for Developmentally Disabled X X X M NH AGED
& Community-Based Care for the Elderly & Chronically Ill M X X X NH AGED
& Community-Based Care for Acquired Brain Disorders X X X M NJ TBI WAIVER Traumatic Brain Injury
Waiver M X X X NJ DD WAIVER Community Resources for
People with Disabilities Waiver M X X X NJ 1115 R&D Personal Preference
Program X X X NJ AGED AND DISABLED
WAIVER Enhanced Community
Options Waiver M X X X NJ MR/DD WAIVER Community Care
Waiver M X X X NM AGED
& Disabled Waiver M X X M NM MR
AND/OR DD Developmental Disabilities Home & Community-Based
Waiver X X X X NY AGED AND/OR
Waiver M X X M NY MR AND/OR DD Mental
Retardation/Developmental Disability Waiver M M X M NY TBI WAIVER Traumatic Brain Injury
Waiver M X M M NC AGED
AND/OR DISABLED Community Alternatives Program for Disabled Adults M X X M NC AGED
AND/OR DISABLED Community Alternatives Program for Persons with AIDS X X X M NC MR
AND/OR DD Community Alternatives Program for Persons with Mental
Retardation/Developmental Disability M X X X NC MR
AND/OR DD 1915(b)/(c) Consumer Directed Care for Behavioral Health-Innovations
& Piedmont Cardinal Health Plan M M M M ND AGED AND/OR
Waiver M X X M ND TBI WAIVER Traumatic Brain Injury
Waiver M X X M OH AGED
AND/OR DISABLED Ohio
Home Care Waiver X X X X OH MR
AND/OR DD Transitions Waiver X X X X OH AGED
AND/OR DISABLED Passport Waiver X X X X OH AGED
AND/OR DISABLED Choices
Waiver X X X X OH MR
AND/OR DD Individual Options Waiver X OH MR
AND/OR DD Level
One Waiver X OK MR AND/OR DD Community
Waiver M X X M OK AGED AND/OR
DISABLED Advantage X X X X OK MR AND/OR DD In-Home Supports for
Adults M X X M OK MR AND/OR DD Homeward
Bound M X X M OR MR
AND/OR DD Waiver
for Individuals with Developmental Disabilities M X X OR AGED
AND/OR DISABLED Seniors
& People with Disabilities M X X OR MR
AND/OR DD Support
Services Waiver for Adults X X X X PA MR AND/OR DD Consolidated Waiver for
Individuals with Mental Retardation X X M PA HIV/AIDS
WAIVER AIDS Waiver M M M M PA PHYSICAL DISABILITIES
WAIVER OBRA Home &
Community-Based Waiver M M M M PA AGED AND/OR
DISABLED Attendant Care
Waiver M X M M PA AGED AND/OR
DISABLED Pennsylvania Department
of Aging Waiver M X M M PA AGED AND/OR
DISABLED Independence Home &
Community-Based Waiver M X M M PA MR AND/OR DD Person/Family Directed
Support Waiver X X M PA TBI COMMCARE Waiver
Program M X X M PA OTHER Michael Dallas
DISABLED Elwyn Waiver M M M M RI AGED
AND DISABLED WAIVER Aged/Disabled Waiver M X X X RI AGED
AND DISABLED WAIVER Department of Elderly Affairs Waiver M X X X RI MR/DD
WAIVER Mentally Retarded/ Developmentally Disabled Waiver M X X X RI PHYSICAL DISABILITIES WAIVER People
Actively Reaching Independence/Severely Handicapped Waiver M X X X RI ADULTS
WITH DISABILITIES Assisted Living Waiver M X X X RI TBI
WAIVER Habilitation Waiver M X X X SC AGED AND DISABLED
WAIVER Elderly & Disabled
Waiver M X M M SC MR/DD WAIVER Mentally Retarded &
Developmental Disabilities Waiver M X M M SC TBI WAIVER Head & Spinal Cord
Injury Waiver M X X X SC MR/DD WAIVER Mechanical Ventilator
Dependent Waiver M X X M SC HIV/AIDS
Waiver M X M M SC PHYSICAL DISABILITIES
WAIVER South Carolina Choice
Waiver M M M M SD AGED
Waiver X X M M SD MR
AND/OR DD Intermediate Care Facility for the Mentally Retarded
Support Program X X X M TN MR/DD WAIVER Mental Retardation
Waiver X X X X TN MR/DD WAIVER Self-Determination Waiver
Program X X X X TN MR/DD WAIVER Mental Retardation
Waiver X X X X TN AGED AND DISABLED
WAIVER Adapt X X X X TN PHYSICAL DISABILITIES
WAIVER Disabled Individuals over
21 Waiver X X X X TX AGED
AND DISABLED WAIVER Consolidated Waiver Program X X X X TX MR/DD Home
& Community-Based Wavier X X X X TX MR/DD
WAIVER Community Living Assistance & Support Services
Program X X X X TX AGED
AND DISABLED WAIVER Community-Based Alternatives X X X X TX AGED
AND DISABLED WAIVER CBA-STAR+PLUS M X M X TX ADULTS
WITH DISABILITIES Waiver
for People with Deaf-Blindness & Multiple Disabilities X X X TX MR/DD
WAIVER Consolidated Waiver Program X X X X TX MR/DD
Home Living Program X X X UT MR/DD WAIVER Developmental
Disabilities/Mental Retardation Waiver M X M M UT AGED AND/OR
DISABLED Aged Waiver M X M X UT TBI WAIVER Acquired Brain Injury
Waiver M M M M UT MR/DD Nursing Facility Level of
Care Waiver M M M M VT 1115
Vermont Global Commitment Waiver M X X VT 1115
Choices for Care Medicaid Waiver M X X VA MR/DD WAIVER Mental Retardation
Waiver M X X X VA AGED AND DISABLED
WAIVER Elderly or Disabled with
Consumer Direction Waiver Services M X X X VA MR/DD WAIVER Individual & Family
Developmental Disabilities Support Waiver M X X X WA AGED
AND DISABLED Medically Needy Residential Waiver M X X X WA AGED
AND DISABLED WAIVER Medically Needy In-Home Waiver M X X X WA AGED
AND DISABLED WAIVER Community Options Program Entry System Waiver M X X X WA MR/DD
WAIVER Basic
Waiver M X X X WA MR/DD
Plus Waiver M X X X WA MR/DD
WAIVER Community Protection Waiver M X X X WA MR/DD
WAIVER Core
Waiver M X X X WV MR/DD WAIVER Mentally Retarded/
Developmentally Disabled Waiver M X M WI AGED
AND DISABLED WAIVER Community Options Waiver X M X M WI MR/DD
WAIVER Mentally Retarded/ Developmentally Disabled Waiver X X X X WI AGED
& Disabled Waiver X X X WI TBI
WAIVER Traumatic Brain Injury Waiver M M M M WI DD
WAIVER Wisconsin Community Integration Program X M M M WY MR/DD WAIVER Adult Developmental
Disability Waiver X X X M WY TBI WAIVER Acquired Brain Injury
Waiver X X X M WY AGED AND DISABLED
Waiver M X X X Total with Requirement 202 Waivers 50 180 163 99 n = 51 (50
states and Washington, DC). NOTES: X=Required, Blank=Not
Required, M=Missing Data SOURCE: Abt Associates review of
Medicaid HCBS waiver coverage policies, June 2005-February 2006. NOTES The Centers for Medicare and Medicaid Services
(CMS) granted ASPE and Abt Associates access to the WGMD and authorized Medstat
to create and deliver to Abt Associates analytic file extracts of the WGMD
specifically for HM, VM and AT expenditures. The 2002-2003 data were the most
recent data available at the time of information gathering for this
Compendium. In 1999, HM, specialized medical equipment or
PERS were the most commonly offered services among all HCBS waivers (Lutsky,
et al., 2000). The Tech Act of 1998 was a reauthorization of
the Technology Related Assistance for Individuals with Disabilities Act of 1988
Public Law 100-407 [29 USC 2201]. These categories were adopted in part from the
CMS HCBS waiver application (see
http://www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/05_HCBSWaivers-Section1915(c).asp).
Note that most state plans do not refer to
any services as assistive technology; this is a
categorization imposed by the project team for purposes of classifying Medicaid
coverage policies. Federal guidelines require that Medicaid home
health services be ordered by a physician. Arizona's coverage guidelines do not contain the
phrase medical necessity. Though no explanation was obtained for
this from the state, it may be that Arizona utilizes service criteria other
than medical necessity to limit utilization, since Arizonas Medicaid
State Plan services are capitated and operate under an 1115 Research and
Demonstration waiver. It was assumed that the state did not have a
requirement for medical necessity (or other coverage limits) if the HCBS waiver
coverage manual was silent with regard to medical necessity. This investigation of waiver coverage policies
was limited to those waivers identified by the WGMD file extracts obtained for
the project from Medstat that reportedly offer AT and/or HM services. Compendium of Home Modification and Assistive
Technology Policy and Practice Across the States Volume I: Final Report --
http://aspe.hhs.gov/daltcp/reports/2006/HM-ATI.htm
Volume II: State Profiles (Alabama through Missouri) --
http://aspe.hhs.gov/daltcp/reports/2006/HM-ATII.htm
Volume II: State Profiles (Montana through Wyoming) --