1. A Review of Lesser Known Funding Sources and Funding Strategies for Work-Related Assistive Technology November 19, 2014 1

2. 2 Today’s Presenters James R. Sheldon, Jr., Supervising Attorney National Assistive Technology Advocacy Project Neighborhood Legal Services, Buffalo, NY jsheldon@nls.orgjsheldon@nls.org * 716-847-0650 ext. 262 Ronald M. Hager, Senior Staff Attorney National Disability Rights Network Washington, D.C. Ron.Hager@ndrn.orgRon.Hager@ndrn.org * 202-253-5252

3. CEUs The RESNA Catalyst Project offers CEUs for this webinar session. The RESNA Catalyst Project is an approved authorized provider for CEU credits by the International Association for Continuing Education and Training (IACET). You can receive 0.1 CEUs for a sixty to ninety minute webinar. There is a $16 fee to receive credits for each webinar. To learn more about CEUs or to apply for CEUs from an archived webinar, contact Paul Galonsky, pgalonsky@resna.org. pgalonsky@resna.org 3

4. Funding of AT to Support Work Webinar Series Today’s session is Part 5 of the 6 part webinar series. December 10, 2014 (Session 6) - Using Traditional Medicaid and Medicaid Waivers to Fund Assistive Technology to Support Work All sessions 2:00 to 3:15 p.m. Eastern & sessions will be archived at http://www.resnaprojects.org/statewide/webedarchive.html http://www.resnaprojects.org/statewide/webedarchive.html 4

5. Services of the National AT Advocacy Project A Technical Assistance and Training Project Call or email speakers for technical assistance Any topic covered in the webinars Any issue related to funding of AT We can assist you in thinking through funding issues and appeals Additional materials available on most topics Contact us for copies and/or links. 5

6. Purpose of Webinar Series Barriers to Funding AT to Support Work It can be expensive. Individuals and service providers may not be familiar with funding sources and funding criteria. Will discuss funding sources, funding criteria: Most common funders – Medicaid, special education, vocational rehabilitation Less common funding sources Special rules within programs that support funding for work, education, training. 6

7. Format for Today’s Session Walk through power point (on screen, received via email) Participants can post questions in question or chat box. Will attempt to address questions during presentation. Follow up questions can be emailed to presenters. Contact presenters for more resources on any of the content. Additional resources-This ppt and additional documents will be posted at http://www.resnaprojects.org/statewide/webedarchive.ht ml http://www.resnaprojects.org/statewide/webedarchive.ht ml 7

8. Purpose of this Session Look at Non-Traditional Ways to Fund AT to Support Work, Such As: Special ways to create eligibility for traditional funding source like Medicaid or Medicare. Variety of non-traditional funding sources, like equipment loan funds and the crime victims program. Funding strategies, like use of IRS approved flexible spending accounts. 8

9. Will Funding Source or Strategy be Available in Your State? For most part, answer is yes. Many of the programs, like Crime Victims Fund, are subject to some state options. Some programs, like Alternative Financing Programs (equipment loan funds) do not exist in every state. 9

10. Hypothetical 10

11. The Case of Mario Mario is 17 years old and a high school senior. He has cerebral palsy, uses a 7-year old power wheelchair for all mobility, and relies on accessible transportation to go to school. He will turn 18 in February 2015. He will graduate from high school in June 2015. He plans to go to college and study to become an English teacher at the high school or college level. 11

12. Mario’s Current Education Mainstreamed with some special education services: Physical therapy, occupational therapy Use of standing frame in physical therapy (allows medical benefits of standing program) Laptop with adapted keyboard, voice dictation software 12

13. Mario’s SSI and Medicaid SSI Currently, SSI benefits - $104.50 per month (Mom works and earns $2,800 gross monthly, $33,600 per year). In February 2015, at age 18, will get full SSI check of $733 as Mom’s income will no longer count. As SSI beneficiary automatically eligible for Medicaid in his state. Parents are divorced and Dad pays no child support. 13

14. AT Needed by Mario A ramp at the home, to come and go in his wheelchair Accessible van transportation, to attend college (until he gets a modified van) A modified van, with hydraulic lift, hand controls, etc. A power standing wheelchair, to replace old wheelchair, allow him to benefit from standing therapy throughout the day, to do work-related activities best done in standing position. A new laptop, with modified keyboard, voice input software 14

15. Additional AT Needed by Mario A speech generating device (SGD) –We know Medicaid programs can fund dedicated devices, often costing more than $6,000. –Mario would like to get an iPad to function as an SGD. Medicaid programs reluctant to fund the tablet devices because they have uses not related to a disability. A smart phone, other hand held device –Assuming Mario also has a learning disability, with short-term memory problems. –Using built in features and apps, can set up reminders, record videos for job-related tasks. 15

16. Creative Ways to Fund AT While Retaining SSI and Medicaid 16

17. The Flexible Spending Account Authorized by section 125 of Internal Revenue Code If employer offers FSA, money set aside can be used to pay for many medical costs not covered by insurance or Medicaid. This money will not count as taxable income, not count in determining Social Security and Medicare (i.e., FICA) contributions, and not count as income in the SSI program. Tax benefit will be based on taxes and FICA avoided. E.g., if $1,000 set aside and combined tax and FICA rate would be 20 percent, savings would be $200. 17

18. Using FSA to Partially Fund AT, Keep SSI and Medicaid Mario is 17 and receives $104.50 in SSI. Household consists of Mario and his mother. As an SSI beneficiary, Mario qualifies for Medicaid. Mom earns $2,800 gross per month - $33,600 per year. Mom gets offered a promotion. Will pay $3,050 per month gross - $36,660 per year. With this pay rate, Mario will lose SSI and Medicaid. What can mom do? 18

19. Using FSA to Fund Ramp, Retaining SSI and Medicaid Mario’s mom sets aside $200 per month in Flexible Spending Account to purchase $2,400 ramp. Assuming a combined tax + FICA rate of 15 percent, $360 of ramp costs funded through tax savings. Mario retains SSI at $79.50 per month (more than $950 per year) and keeps Medicaid. With ramp, Mario will have a better way to leave home for travel to college after graduation. By time extra $2,400 starts counting against SSI, Mario will be 18 and Mom’s earnings will no longer count. 19

20. Creative Alimony Settlement to Pay for AT, Retain SSI & Medicaid The Case of Christina, Age 42: Power wheelchair user, receives $721 SSI and Medicaid. Attends college and is looking for a way to fund a van for post-college transportation to work. Not a candidate for Plan for Achieving Self Support (PASS) because no source of income other than SSI to put in PASS. Settling a divorce with working spouse. Expected to get $920 per month alimony. SSI will count $900 of alimony as unearned income. She will lose SSI and Medicaid. What can she do? 20

21. In Lieu of Alimony Christina’s Ex- Husband will Pay Directly: $10,800 van down payment and $450 van loan payment. $100 cable TV bill and $50 cell phone bill. Payments not for food or shelter, so not counted as income for SSI. Continues to get SSI of $721 plus Medicaid. State VR agency will pay for van modifications. See Disability, Divorce, SSI, and Medicaid: Using Creative Alimony, Child Support and Property Settlements to Maximize SSI, Ensure Medicaid Eligibility, and Create Funding for Assistive Technology, www.nls.org/files/Disability%20Law%20Hotlines/National%20AT%2 0Advocacy/DisabilityDivorce.pdf www.nls.org/files/Disability%20Law%20Hotlines/National%20AT%2 0Advocacy/DisabilityDivorce.pdf 21

22. Medicare Savings Plans Using SSI Budgeting to Establish Eligibility Leveraging Funding for Part B Premiums, AT, and Part D Extra Help 22

23. Medicare Savings Programs – Paying for Part B Premiums, Co-Pays The Qualified Medicare Beneficiaries (QMB) Countable income up to $973 per month ($1,311 for a couple).* $7,160 countable assets for individual. Some states allow more in assets. New York eliminated its asset test in 2008. Pays for Part B premium, deductibles and copayments Selected Low-Income Beneficiaries (SLMB) Countable income up to $1,167 per month ($1,573 for a couple). Same asset test. Pays for Part B premium only *2014 figures. 2015 figures available first quarter of year. 23

24. Medicare Savings Programs Qualified Individual (QI-1) Countable income up to $1,313 per month ($1,770 for a couple). Same asset test Pays for Part B premium only All SSI exclusion rules applied in determining countable income, including: $20 general income exclusion Additional $65 plus half of remaining earned income Impairment related work expenses, blind work expenses 50 percent of remainder excluded 24

25. Medicare Savings Programs – Did You Know? MSP will pay for any Part B late enrollment penalties. If eligible for QMB ($973 countable income or less), it can pay 20 percent co-pay on expensive wheelchair. Saving Money in Medicare Part D Prescription Program MSP is considered a Medicaid program, making person “dually eligible” for Medicaid and Medicare. Dually eligible individual automatically qualifies for full Part D low-income subsidy program. 25

26. Medicare Savings Programs – Work, AT Funding and Part D The Case of Larry, Age 35 Injured in car accident 2 years ago Settled lawsuit and used settlement money to pay off mortgage, modify home for wheelchair use. Approximately $9,500 remains from settlement. Gets $650 Social Security Disability Insurance (SSDI) Lost SSI because of resources above $2,000 Just qualified for Medicare, will enroll in Parts B and D Starting job as part time dispatcher, 3 days per week, 5 hours per day, $10 per hour (paid $300 every 2 weeks). 26

27. Work Incentives Apply to Larry’s QMB Eligibility Step 1:$650.00 SSDI - 20.00 General income exclusion $630.00 Countable unearned income Step 2:$ 648.00 Gross monthly wages ($300 x 2.16 weeks) - 65.00 Earned income exclusion $ 583.00 - 291.50 Additional 50% exclusion $ 291.50 Countable earned income + 630.00 Countable unearned income $ 921.50 Total countable income (below $973 QMB limit) 27

28. Larry’s QMB Eligibility – Managing His Assets Larry’s $9,500 is $2,340 above asset limit. He spends about $2,500 on new doors and rugs for his home and better clothing for work. With assets now at $7,000, he qualifies for QMB. The Medicaid agency will pay his $104.90 Part B premium each month. 28

29. Larry’s QMB Eligibility – Leads to Full Part D Extra Help Larry gets full low-income subsidy because he is “dually eligible” for Medicaid and Medicare. QMB and all MSPs are considered a Medicaid benefit. As dually eligible, he pays little or no monthly premium, modest co-pays for drugs, and has no contributions in the “donut hole.” Larry could earn about $650 per month more and still qualify for QI-1 to pay the Part B premium only. 29

30. QMB Can Pay Medicare Co-Pay on Power Wheelchair Larry will obtain an $8,000 power wheelchair: Medicare Part B will pay 80 percent of an approved rate or $6,400 (if $8,000 represents the approved rate). Local Medicaid agency, through QMB, will pay the $1,600 copayment. 30

31. Alternative and Little Know Programs for Funding AT 31

32. 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 32

33. 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 http://resnaprojects.org/allcontacts/allafpcontacts.htmlhttp://resnaprojects.org/allcontacts/allafpcontacts.html for AFP information in 40 States. 33

34. 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 34

35. 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 35

36. 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 36

37. The US Department of Veterans Affairs (VA) Requirements for the VA as a funding source Generally, all veterans who enlisted after 1980 must have served 24 continuous months. Certain exceptions may apply. Must be enrolled in VA healthcare system. Injury must be service connected, not due to willful misconduct. Applicant must be unable to pay the cost of services. 37

38. Assistive Technology and the VA Funding for electronic equipment has been approved for people who are blind or visually impaired. Funding has also been approved for the veteran engaged in/served through –Vocational rehabilitation services –Employment services –Independent living services 38

39. Funding AT to Support Work through the VA Look to link the need to one of the provisions that allow for funding of specialty equipment, such as: the references for people who are blind or visually impaired, those involved in vocational rehabilitation, employment services, or independent living services as referenced above). The VA has history of funding tablet devices to support employment efforts of veterans with cognitive problems. 39

40. Independent Living Services Background The Rehabilitation Services Administration provides funding to establish a State Independent Living Council (SILC) and Centers for Independent Living (CILs). Funding passes through the State VR agency to the SILC and the CILs. CILs are required to provide "core IL services" to individuals with significant disabilities - information and referral, IL skills training, peer counseling, and individual and systems advocacy. The CIL may provide "as appropriate, a combination of any other independent living services." 29 USC 796f-4(5). 40

41. Non-Core IL Services Categories that Could Fund AT Include: Adaptive housing services, including home modifications Needed prostheses and other appliances or devices Rehabilitation technology services Accessible transportation services; and “[A]ny other services" to improve ability to function, continue functioning, or move toward functioning independently. 41

42. Can IL Services be Used to Fund the iPod Touch or iPad Mini? The best answer is a qualified “maybe.” Considerable discretion is provided to CILs to decide how to best allocate the limited dollars available for these non-core services. Given modest $200-$250 price tag one might be able to convince the CIL that this independence-producing investment that can make a remarkable difference in the person’s employability. 42

43. The Crime Victims Compensation Fund Operated by each state through a federal grant, is authorized by the Victims of Crime Act of 1984 (VOCA), as amended, 42 U.S.C. § 10601. Authorizes federal financial assistance to states (up to 40 percent reimbursement for approved expenditures) for the purposes of –compensating and assisting crime victims, –funding training and technical assistance, and –serving victims of federal crimes. See links for federal crime victims site, http://ojp.gov/ovc/ and to statehttp://ojp.gov/ovc/ crime victims sites, http://www.nacvcb.org/index.asp?sid=6.http://www.nacvcb.org/index.asp?sid=6 43

44. Crime Victims Compensation - Compensable Crimes States must include crimes whose victims suffer death or physical injury as result of: Terrorism Driving while intoxicated Domestic violence Intentional or attempted defacement of any religious real property because of: –its religious character; –or the race, color or ethnic characteristics of any individual associated with the religious property. 44

45. Crime Victims – Compensable Expenses Mandated expenses States must award compensation for a list of expenses when they are attributable to a physical injury resulting from a compensable crime: –Eyeglasses, other corrective lenses, dental services, prosthetic or other devices (no definition of "prosthetic and other devices" appears in the law or guidelines) –Mental health counseling and care –Lost wages –Funeral expenses 45

46. Crime Victims – Compensable Expenses Optional Allowable Expenses: May offer compensation for other types of expenses as authorized by state law, regulation, or established policy. These include "[n]ecessary building modification and equipment to accommodate physical disabilities resulting from a compensable crime." VOCA Guidelines, part IV.B.2.(b)(ii). (No definition for terms.) Compensation program is the payor of last resort "with regard to federal or federally financed programs." 46

47. Crime Victims Compensation – Funding for Mario’s AT? Assume his injury is due to violent crime. The standing wheelchair and speech generating devices fit most durable medical equipment definitions and should fit mandated “prosthetic or other devices” category. Look to see if state has adopted optional category for “building modification” (should include ramps) or “equipment to accommodate disability” (could cover modified van, smart phone/hand held devices). Look for dollar limits on equipment in your state policies. Remember, under payor of last resort criteria, may have to look to Medicaid/other funders first. 47

48. Worker’s Compensation Employees injured on the job receive reimbursement for lost wages and medical care, without the need to show employer fault or negligence. In return employees generally lose their right to sue the employer for damages, subject to certain exceptions that may vary from state to state. See “Worker’s Compensation and AT,” from Did You Know series, with citations to court decisions awarding AT. http://www.nls.org/Disability/NationalAssistiveTechnologyProject/ DidYouKnow/WorkersCompDidYouKnow/WorkersComp. 48

49. Worker’s Compensation – Examples of AT Awarded Louisiana Laird v. Highpoint Southwest Services (therapeutic mattress, therapeutic shoes, and a shower massage device). Cottonham v. Rockwood Ins. Co of Rockwood (emergency telephone device, and ramp and hand controls for his van, for rehabilitation and safety). Missouri Hall v. Fru Con Const. Corp. (held that if “artificial devices” included wheelchairs, it logically follows that home modifications needed to make a home wheelchair accessible were also covered). 49

50. Worker’s Compensation – Examples of AT Awarde d Compare two cases regarding modified vehicles: North Dakota Meyer v. North Dakota Workers Compensation Bureau (not responsible for purchasing a van, but was responsible for the adaptive equipment and the increased cost associated with the price of a van compared to the price of an average vehicle of the same year) Arizona Terry Grantham Co. v. Industrial Com’n of Arizona (held that in claimant’s case, a specially equipped van was not merely a form of transportation, but was “other apparatus” needed to restore any mobility) 50

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52. Thank you! Please use your chat box to ask questions James R. Sheldon, Jr., Supervising Attorney jsheldon@nls.orgjsheldon@nls.org * 716-847-0650 ext. 262 Ronald M. Hager, Senior Staff Attorney National Disability Rights Network Ron.Hager@ndrn.orgRon.Hager@ndrn.org * 202-253-5252 52