1. Non-Traditional Funding Sources and Strategies for Assistive Technology Creative Ways to Access Traditional AT Funding Sources, Some Little-Known AT Funding Sources and Strategies June 2011 NDRN Network Conference Presenter: James R. Sheldon, Jr., Esq. National AT Advocacy Project Neighborhood Legal Services Buffalo, NY * jsheldon@nls.orgjsheldon@nls.org 1

2. 2 Background AT Advocacy Traditionally Focused on 5 Key Funding Sources: Medicaid Medicare Special education programs State vocational rehabilitation programs Private insurance plans

3. Individual not eligible for program, or not eligible for special benefit within program Eligible for program, but AT device is not covered Eligible for program, AT is covered by program … BUT  Not demonstrated “need” for item under program criteria  I.e., not medically necessary, educationally necessary, vocationally necessary, etc. Why “Big Five” Funding Source May Not be Available 3

4. 4 Resolving Big Five Funding Dilemma Identify way to make person eligible for program Identify another program to fund device Identify funding strategy fund all or part of device:  Anti-discrimination laws, like Americans with Disabilities Act  Use of tax provisions, like Flexible Spending Account

5. 5 Ensuring Eligibility for the Traditional, Big-Five Funding Sources

6. 6 Medicaid- Several Paths to Eligibility Receipt of SSI = automatic eligibility in 39 states Medically needy or “spend down” category Home and community based services “waiver” Child Adopted - federal Adoption Assistance Program

7. 7 Medicaid – Paths to Eligibility (Cont.) Section 1619(b) – lost SSI through work Medicaid Buy-In for working people, 43 states DAC Medicaid –Lost SSI upon eligibility for Social Security “Disabled Adult Child’s” (DAC) benefits –Also known as Childhood Disability Benefits Pickle Medicaid –Lost SSI through receipt of SSDI –Ignore more recent SSDI cost-of-living increases

8. 8 SSI for Child of Working Parent Darlene is a widow, with three children: Chris, age 11; Carey, age 13; Jason, age 16 Jason has cerebral palsy Jason gets $373 SSI, automatic Medicaid Importance of Medicaid Covers medications, speech therapy, $10,000 power wheelchair, $8,000 communication device Keeping Medicaid is critical! State SSI rate is $674, with automatic Medicaid

9. 9 Jason’s SSI Based on Darlene’s Wages Darlene Earns $33,000 Gross Works 60 percent time ($2,750 per month) Employer Wants to Increase Hours: 80 percent time -- $44,000 per year/$3,667 per month 90 percent time -- $49,500 per year/$4,125 per month Full time -- $55,000 per year/$4,583 per month Jason loses SSI if Darlene makes $3,495/month

10. 10 Four Strategies to Keep SSI and Medicaid # 1: Play it safe – keep working 60 percent time # 2: Accept 80 percent time job if: Employer “pays” Darlene $350 less Employer pays Darlene’s $350 share for health insurance Darlene’s taxable wages reduced to $3,317 Jason eligible for SSI of $89 per month

11. 11 Four Strategies to Keep SSI and Medicaid (Continued) # 3: Accept 80 percent time job if: Employer offers “Flexible Spending Account” $350 deducted each month for health insurance payment Jason eligible for SSI of $89 per month # 4: Wait until Jason’s 18 th birthday to increase pay.

12. 12 Medicare Savings Plans: QMB, SLMB, QI-1 Qualified Medicare Beneficiaries program (QMB) Medicaid agency pays Medicare Part B deductibles, coinsurance and premiums: –$115.40 (first eligible, 2011) –$110.50 (first eligible, 2010) –$96.40 (first eligible, 2009 or earlier) Countable income at or below 100 percent of federal poverty level (FPL) ($908 in 2011)

13. 13 Medicare Savings Plans (Cont.) Specified Low-Income Beneficiaries Medicaid agency must pay Medicare Part B premiums only Income between 100 and 120 percent of FPL (up to $1,089 in 2011)

14. 14 Medicare Savings Programs (Cont.) Qualified Individual Program (QI-1) Medicaid agency pays for Part B premiums only Income between 120 and 135 percent of FPL (up to $1,226 in 2011) QI-1 can be dependent on funds allocated year-by-year

15. 15 How QMB Helps Pay for AT If Medicare funds power wheelchair at approved rate of $8,000 Medicare pays 80 percent ($6,400) Individual must pay balance ($1,600) Medicaid would typically pay the $1,600 If person not eligible for Medicaid or chooses not to pay a spend down: Medicare pays the $6,400 QMB pays the $1,600

16. 16 State Vocational Rehabilitation (VR) Agencies Financial Need Criteria – General Rule VR agency may use financial need criteria for most services. E.g., college tuition, vehicles modifications, computers, and AT. Social Security, SSI Recipients Exempt from Needs Test With any amount of SSI or SSDI, eligible for VR services at no cost. Income/resources of parents, spouse do not count.

17. 17 VR Agencies and Financial Need Criteria – The Case of Ted Ted Receives $1,500 in Social Security Benefits This is too much to qualify for SSI. Too much to qualify for state’s Medicaid spend down Ted Automatically Meets the VR Agency’s Financial Need Criteria VR agency can fund expensive AT, like van modifications, access ramps at home, or adapted computer equipment Agency cannot make Ted pay toward cost of items.

18. 18 Alternative and Little Known Programs for Funding AT

19. 19 Alternative Financing Programs (AFPs) - A Source of Loans for AT An AFP can make a loan available by: A revolving loan fund A loan guarantee An interest buy down

20. 20 Most Common Items Purchased with Loan Funds Vehicles modifications Computers, costs for computer access Mobility equipment, such as wheelchairs, scooters Equipment for daily living, like environmental control devices Hearing aids, vision aids Home modifications See www.resnaprojects.org/AFTAP for AFP information in 40 States.www.resnaprojects.org/AFTAP Vehicles modifications Computers, costs for computer access Mobility equipment, such as wheelchairs, scooters Equipment for daily living, like environmental control devices Hearing aids, vision aids Home modifications See www.resnaprojects.org/AFTAP for AFP information in 40 States.www.resnaprojects.org/AFTAP

21. 21 AFPs - Advocacy Tips The AFP loan: Excellent way to cover out-of- pocket costs related to AT purchase: Amounts that exceed the payment limitations of private insurance Medicare Part B 20 percent co-payment Share of cost requirement charged by a state VR agency AT-related costs exceeding amount available under SSI’s Plan for Achieving Self Support (PASS) Amounts not otherwise covered by charity payments Pending an appeal

22. 22 Federal Adoption Assistance Program Help for parents who adopt “Child with Special Needs” Includes cash assistance and other special services Assistance through Automatic Medicaid: If “child with special needs” criteria met and “adoption assistance agreement” in effect (i.e., a federal adoption) At state option, if child receives state or local adoption assistance

23. 23 Federal Adoption Assistance Program Additional Payments for AT, at State Option: Covered through Minnesota’s adoption program: –Specialized communications equipment –Ramps –Accessible shower, elevated bathtubs and toilets –Blinking lights and tactile alarms as alternate warning systems –Lowered kitchen work surfaces –Disability-related modifications to a vehicle

24. 24 Funding Strategies That Do Not Involve a Program That Funds AT In a Conventional Sense

25. 25 Flexible Spending Account (FSA) Under Federal Tax Law Known as “flex plans,” “cafeteria plans” or “125 plans” Employee contribution deduction from pay, pre tax Reduces taxable wages Types of expense covered Uncovered medical: insurance premiums, co-payments, uncovered services, AT devices Non-medical: child care, adoption fees, parking fees, public transportation costs

26. 26 Using Flexible Spending Account for AT - Back to Darlene & Jason Darlene Pays $350 Share of Insurance Premium Taxable income reduced by $4,200. Taxes reduced. Reduced income for SSI eligibility. Jason keeps SSI. By Keeping SSI, Jason Also Keeps Medicaid Medicaid pays for new wheelchair Medicaid pays for new communication device

27. 27 Creative Structuring or Restructuring of Child Support to Obtain/Retain SSI and Medicaid Purpose of Strategy is Twofold: Disability-related and other needs met through the child support without decreasing the SSI amount. By obtaining or retaining eligibility for SSI, we ensure eligibility for Medicaid (in most states). Both support dollars and Medicaid can fund AT.

28. 28 Creative Structuring of Child Support - Back to Darlene and Jason Works 80 Percent Time, Earns $3,667 Per Month Wages reduced by $350 through FSA contribution. Jason gets $89 SSI check plus Medicaid. Jason’s Dad to Pay $450 in Monthly Child Support SSI program would count two thirds, $300. Extra income makes Jason ineligible for SSI. Jason will also lose Medicaid.

29. 29 Alternative Child Support Settlement for Jason Darlene’s Dilemma: No Adequate Transportation Cannot afford van for travel with wheelchair. Drives used car. –Two adults must lift Jason in and out of car. Instead of Cash, Dad Pays Directly to Vendors: $400 to bank for loan on accessible van $50 to car insurance company toward $150 monthly insurance

30. 30 How Creative Child Support Agreement Helps Jason Jason Keeps Same Amount of SSI Money paid to vendors not available for food or shelter Not counted by SSI Jason Keeps Medicaid Getting $1 or more in SSI keeps Medicaid in 39 states. Medicaid funds power wheelchair, communication device. Darlene Get Van and Insurance Child support arrangement makes it possible for Darlene to get a van with insurance to transport Jason.

31. 31 Thank you….  Other materials available on each topic through National AT Advocacy Project. Contact Jim Sheldon (jsheldon@nls.org).jsheldon@nls.org  Check out National AT website (www.nls.org/natmain.htm)www.nls.org/natmain.htm