PRIVATE HEALTH BENEFIT PLANS This article is an approved, adapted excerpt from a manual entitled Accessing Assistive Technology (First Edition, 1995), written by the California Protection and Advocacy agency, with funding from the California Assistive Technology Project. The responsibility of private health benefit plans to purchase assistive technology for plan beneficiaries, is governed by the terms of the policy. There is no legal requirement that private health benefit plans cover assistive technology. Most health benefit plans are provided as a benefit of employment. They are negotiated and provided by an employer. However, the plan can still be viewed as a contract between the provider and the employee. The responsibility of the provider and the rights of the employee depend on the benefits provided in the policy. Sometimes there is a choice of plans. If access to assistive technology is a concern, it is important that the employee carefully reviews the provisions of the alternative plans to see which provides the most extensive benefits, given other considerations, such as cost. ARE THERE LEGAL REQUIREMENTS FOR THE ADMINISTRATION OF EMPLOYER-SPONSORED HEALTH PLANS? Federal law, the Employee's Retirement Income Security Act (ERISA), places certain requirements upon employer provided health plans. Employees and beneficiaries must be given access to information about the health plan, explaining benefits and requirements in plain language (29 U.S.C. 1001, 1021, 1024). The plan administrator must respond to requests for information within 30 days (29 U.S.C. 1132(c)). The "plain-language" version of the policy is normally provided to employees in the form of a "summary of benefits" or a "summary plan description" booklet. Employees are often not shown the actual benefit plan unless they ask to see it. However, if the summary that employees receive conflicts with the actual plan, the rules in the actual benefit plan apply - unless the employee can show that the plain-language version was inaccurate or slanted against the employee. The summary booklet may not provide a clear list of covered services and limitations, or adequate information about prior approval requirements, co-payments, or deductibles. The employee has a right to see the actual plan, and it is a good idea to get a copy, if the summary booklet is unclear or does not appear to be accurate or complete. It is important to carefully read the summary booklet or policy. Policies will generally not refer to specific devices or equipment as benefits. There is a good argument that necessary assistive technology is a benefit if the plan covers durable medical equipment, prosthetic devices, or equipment associated with physical or occupational therapy. Employees and beneficiaries may argue that augmentative and assistive communication devices are included under these categories, or as equipment associated with speech therapy services WHAT EVIDENCE IS NECESSARY TO DOCUMENT THE NEED FOR AN ASSISTIVE TECHNOLOGY DEVICE? How you should ask for an assistive technology purchase through a health benefit plan, and the supporting information that is required, should be written in the policy. For example, many HMO plans require that a primary physician refer the employee to a specialist (such as an orthopedist, physical therapist, or speech therapist), who would then prescribe the equipment. It is important to follow the process accurately, and to document the need for the service, as required. In some cases, the insured should request a referral to a rehabilitation service or professional from which the most thorough and accurate evaluation is likely to be obtained. Services and equipment are purchased by health benefit plans only if demonstrated to be medically necessary. The plan may provide a definition of this term. Supporting evidence, such as letters or reports from physicians or other professionals, should explain how the definition in the policy is satisfied and should address how other requirements are met. Supporting letters should also identify the services for which the device is being requested. The definition of what is "medically necessary" generally requires that the requested services or equipment cure or alleviate (make less severe) a medical condition, reduce pain, or assist a person in maintaining or achieving more normal function. For example, a wheelchair may be medically necessary if the user needs it to become more independent. Similarly, a speech device may be medically necessary if needed to communicate with other people in a manner consistent with his or her potential. The justification for the needed equipment should explain the user's impairment, his or her functional ability without the equipment, and how the impact of a disability will be reduced with the requested device. If possible, the physician or other professional prescribing the assistive technology should document similar cases in which the health benefit plan has previously provided the requested device or equipment. Benefit plans may claim that a service is educationally necessary or a convenience item, but not medically necessary. The fact that an item will be used in school, allow for access to recreational opportunities, or make life easier for the user does not mean that it is not also medically necessary. Arguments for the equipment should discuss how the impact of the individual's disability will be reduced if the device is provided. This is generally independent of the setting in which it will be used. Benefit plan providers may claim that requested assistive technology is not medically necessary, but merely a convenience. In these cases, it is important to document the impact of the beneficiary's disability and the amount of improvement that the requested technology will bring about. CAN A HEALTH BENEFIT PLAN PROVIDER DENY A CLAIM BECAUSE THE POLICY STATES IT IS THE PROVIDER OF LAST RESORT? Many health benefit policies have provisions stating that the health plan will not provide benefits that are the responsibility of another party or funding stream. Plan providers may attempt to rely on this provision in denying requests. The response to this may depend on the alternative program identified to provide the requested device. For example, in California, persons eligible for Medi-Cal, California Children's Services, or regional center services are required by statute to use their health plan benefits first. No health policy can contradict this, and thus any payor of last resort restriction cannot be relied on by the benefit plan provider in California. However, school districts may not require a parent to use health benefits to obtain a device that a child is entitled to through special education. If the school district refuses to provide the device (or service), the parent will need to decide whether to first ask for the device from the school district or benefit plan. If the parent decides to ask for the requested device from the health plan, a letter of denial should be obtained from the school district. The health plan should not be able to require that the parent pursue an administrative hearing with the school district prior to providing the requested equipment. (See July edition of Tech Express, article entitled Special Education, on the right to obtain assistive technology through special education.) IS THERE A RIGHT TO CONTINUED HEALTH BENEFITS AFTER LEAVING EMPLOYMENT? Under the Consolidated Omnibus Budget Reconciliation Act (COBRA), which is federal legislation, an individual who leaves employment is entitled to continue health plan coverage for 29 months if s/he has a Social Security-eligible disability, or 18 months if s/he is not eligible for Social Security. The employee must pay the premiums at the group rate paid by the employer. CAN A HEALTH BENEFIT PLAN DENY COVERAGE OR A BENEFIT BECAUSE OF A PERSON'S DISABILITY? It is fairly common for health benefit plans to deny coverage for a "pre-existing condition." In some cases, this may be discriminatory. The Americans with Disabilities Act (ADA) (42 U.S.C. 12201) and many state laws state that a benefit plan may not refuse to insure, refuse to continue to insure, limit the amount, extent, or kind of coverage available to an individual - or charge a different rate for the same coverage solely-because of a physical or mental impairment. This is true except where the disability does lead to higher costs. The health benefit plan must be able to prove the higher costs - based on facts and statistics. Figuring out whether a disability-based distinction can be supported must be done on a case-by- case basis, taking into consideration the circumstances. The benefit plan must prove that the disability-based distinction was based on legitimate risk considerations. The key question here is what is a "legitimate risk consideration." In many cases, plan providers have no data that a particular disability will, in fact, result in higher overall costs. They cannot legally deny coverage without the required data, or, alternatively, without information on a person's health history, which would lead to a conclusion of anticipated higher costs. It may therefore be possible to challenge a denial of coverage. Further, even if an individual with a preexisting disability can be denied coverage of the costs associated with that condition, treatment for illness or injuries not related to the pre-existing condition should still be a plan benefit. It is also discriminatory for a plan to make distinctions based on a perceived view of the impact of a disability in general or perceived impact of an individual's disability. For example, if powered wheelchairs are a plan benefit, it would be discriminatory for a plan provider to refuse to pay for powered chairs for all people with mental retardation, under the theory that no one has the ability to learn to operate powered chairs. Obviously, many people with mental retardation can safely learn to do so. Similarly, it is discriminatory to deny purchase of a powered chair for a particular individual who has mental retardation, unless it is proved that the nature and degree of disability makes it impossible for that person to learn to safely operate a powered chair. It is not, however, considered discriminatory for a plan to exclude provision of specific benefits, even if this would have a different impact on persons with disabilities. A plan can clearly state that it does not cover assistive communication devices, as long as this limitation is applied consistently. In addition, in a recent federal court case, Carparts Distribution Center Inc. v. Automotive Wholesalers of New England Inc. (37 F.3d 12 (1st Cir. 1994)), the court found that employer-provided health benefit plans might be considered an accommodation under the ADA, and thus subject to stricter anti-discrimination mandates than health benefit providers in other contexts. This case has not yet fully worked its way through the courts, but does present an approach which should be discussed with an attorney. If a person's disability does result in a non-discriminatory denial of benefits, many states have an alternative to enroll in the state's specialized high risk pool for persons who are otherwise ineligible. These are state-administered programs which provide coverage for persons who, generally because of a pre-existing condition, are not eligible for other health benefits. WHAT APPEAL PROCESS IS AVAILABLE IF A HEALTH BENEFIT PLAN REJECTS A REQUEST TO PURCHASE ASSISTIVE TECHNOLOGY? Almost all health benefit policies provide for an internal appeal. Persistent applicants can succeed in having decisions reversed, especially if additional documentation of medical necessity, or information that the health benefit plan has purchased similar devices in the past, can be provided. The appeal is often informal and consists of explaining the need and justification for the device in writing. Copies of supportive documents should be provided. Since health benefit policies are established by the plan provider and not negotiated by the beneficiary, discrepancies will be resolved in favor of the beneficiary if a court is asked to decide. Pointing out portions of the policy or summary plan description that could be interpreted to cover assistive technology may assist in convincing a plan to provide assistive technology, even when the requested device or equipment is not specifically mentioned in the policy. If the policy contains a provision for arbitration, it must be followed. In this case, arguments by the plan and beneficiary are presented to a third party, who issues a decision. Complaints against an employer-provided health plan, alleging discrimination in violation of the ADA, can also be made with the Equal Employment Opportunity Commission. Such complaints would be made against the employer, not the health benefit plan provider. Finally, ERISA provides that claims against an employer- provided health plan may be brought in federal court. The complaint may claim that the health benefit plan is not providing services as required under the policy, or that the plan or the employer did not follow required procedures. For example, failure to provide a clear summary plan description, or a clear and complete description of why a requested benefit was denied, is actionable (29 U.S.C. 1001, 1021, 1024). A court can order provision of the requested device if it finds that it is a plan benefit. Some courts have also ordered provision of benefits because the summary plan description was unclear. This is because the beneficiary was given the "benefit of the doubt." ACTION STEPS For information on your state's specialized high risk pool, contact the office of your state insurance commission. You should be able to find this information in the state government pages of your phone book. For information about filing an EEOC complaint, contact your local EEOC office. This information should be listed in the in the state or local government pages of your phone book. For persons who wish to secure the full document, Accessing Assistive Technology, contact: Protection and Advocacy, Inc., 100 Howe Avenue, Suite 185N, Sacramento, California 95825, Phone: 800-776-5746 (V/TTY). To secure general information on the project, contact: Assistive Technology Funding & Systems Change Project, 1660 L Street, NW, Suite 700, Washington, DC 20036 Tel: (202) 776-0406 Fax: (202) 776-0414 Email: atfscp@aol.com. To secure information & individual assistance on AT funding issues, contact: 1-800-827-0093 (voice) 1-800-833-8272 (TDD), or (404) 919-8305 (fax) The opinions expressed herein do not necessarily reflect the position or the policy of the U.S. Department of Education, and no official endorsement by the U.S. Department of Education of the opinions expressed herein should be inferred. ---------- ASSISTIVE TECHNOLOGY FUNDING BY PRIVATE HEALTH CARE REIMBURSEMENT SOURCES By Lew Golinker, Esq. November, 1995 INTRODUCTION This article provides an overview of funding issues related to assistive technology (AT) and private health care reimbursement. It makes broad, general statements about the duty of private health care sources to provide equipment and devices. While private health care is an important resource for AT device funding, it will become more important with predicted changes to the Medicaid program. Many variations and individual differences in the scope of health care coverage are permitted in private health care. As a result, this document should not take the place of personal assistance in interpreting individual health insurance policies or health benefit plans. This assistance might be provided by an occupational therapist, physical therapist, or speech language pathologist. It may be provided by staff of your Protection & Advocacy program, a private attorney, or other advocacy services/providers. A list of resources appears at the end of this article. TYPES AND CATEGORIES OF PRIVATE HEALTH INSURANCE Private health insurance in the United States is often a part of wage and benefit packages provided by employers to their employers and their families. Health insurance is also obtained through professional or other organizations (e.g., labor unions) or directly by individuals. There are four common types of health insurance programs. The freedom to choose a health care provider is different in each of these programs. Indemnity programs allow enrollees free choice of health care providers, who are reimbursed on a fee-for-service basis. Preferred Provider Organization or PPO plans encourage enrollees to use providers who contract with the plan and who are paid on a discounted fee-for-service basis. The plan requires lower co-payments (out-of-pocket expenses to meet part of the costs of the service). Enrollees are permitted to use other providers, but at higher costs. Point of Service plans provide enrollees with a primary care physician ("PCP"), who arranges referrals to specialist care and provides strong financial incentives to use providers who contract with the plan. Health Maintenance Organizations or HMOs require enrollees to use only providers who contract with the plan. These programs are available to people who get insurance through an employer, association, or by individually purchasing them. Medicare and Medicaid, government- funded programs, also fit in these categories. They can be described as primarily "indemnity" (reimbursement programs). HMOs are often used by enrollees in federal government programs. There are two ways that employers usually pay for health care coverage. The most common is for an employer to buy a contract of insurance (insurance policy) from a commercial health insurance provider (e.g., Blue Cross/Blue Shield, Aetna, Travelers). This policy is for the benefit of an employer's workers and their families. The second method is for an employer to "self-insure" or "self-fund" a plan of health benefits, using company resources to pay for employees' and their families' covered health expenses. There is no requirement for employers to provide health insurance as a benefit to their workers or workers' families. Employers can purchase no insurance at all, purchase insurance, or offer a self-insured benefits plan. Employers' decisions to offer health care coverage, as well as how to pay for it, will largely be based on the costs of these choices. THE IMPORTANCE OF HEALTH CARE PAYMENT COVERAGE FOR PERSONS WITH DISABILITIES Private health care payments are a highly prized benefit in modern American society. This is because of the very high costs connected with health care. A source of health care payment (insurance or a health benefits plan), helps provide a measure of financial security to families. For people with disabilities and their families, the value of this benefit is unique. Health insurance or benefits plan coverage may be the difference between treatment that supports independent functioning in the home, and dependency and institutionalization. These issues are not shared by the public as a whole; they are unique to the life experiences of people with disabilities and their families. Assistive technology is another unique need of people with disabilities. It is a benefit (or health care payment source) that has special meaning to them. Health insurance and benefits plans have been, and will likely continue to be, a major supplier of assistive technology devices in the United States. These sources have provided coverage for alternative augmentative communication devices (AAC); bath-safety equipment (e.g., shower and bath chairs, lifts); hospital beds; environmental control devices; hearing aids; individual lifts; mobility devices (e.g., walkers, manual wheelchairs, and scooters); and seating and positioning devices (e.g., custom seating systems, standing frames, seat-lift chairs). This equipment is a sample of devices provided through private health care coverage. Unfortunately, there is no mandate for "universal coverage," either for people or for services. There is no "common benefits list" that applies to all insurance policies or health benefits plans. As a result, this document cannot make general statements that all people with a particular need can get a particular device, from any payment source. Instead, each person must review his/her own health care coverage documents. Some hints for helping you read these documents are provided below. HOW TO TELL WHAT IS COVERED BY A HEALTH CARE POLICY OR BENEFITS PLAN In reviewing a health insurance policy, benefits booklet, or health benefits plan description, you should have expectations of positive results. You should expect the health insurance policy or benefits plan to be reasonable, and to cover the assistive technology devices needed. This expectation should be held by any person who is given an excuse by an insurer or plan administrator (e.g., a requested device is not covered, not treatment, not medically necessary, not medical equipment, a convenience item). The most simple and straightforward response is to ask: "Why not?" ASKING "WHY NOT?" These two words - "why not?" - are the most powerful of all possible responses to a denial. Insurers and plan administrators may not be expecting to be asked questions about their decisions, and may not want to provide responses. However, expecting the answer to be "yes" should push you to be insistent. If you are requesting an AAC device and are given any of the excuses listed above, the following questions should be asked: Where, specifically, in the policy or benefits plan is the term (AAC device) found? Where, specifically, is it defined? You must show that the term is not in the policy or plan at all, or that it is not defined. REVIEWING AND USING YOUR INSURANCE PLAN In order to be effective, as well as insistent, you must be educated about some of the rules that apply to health insurance policies and benefits plans. Legal rules govern the operation of health insurance policies and benefit plans. Disagreements about what is covered can be reviewed by courts. Over time, courts have established rules to settle disagreements about the range of coverage. Rules state that health insurance policies and benefits plans must be specific about: The range of services covered; and What is excluded from coverage. The basis for a decision to deny a funding request must be stated clearly in the policy or health plan documents themselves. If not, the denial may not be upheld. For example, a person may need an augmentative communication device (AAC). The insurance policy covers "medical equipment," but does not give a specific definition of that word. Is the AAC device covered? To answer this question, an "interpretation" of the term "medical equipment" will be needed. This will mean an interpretation by medical staff and insurance claim staff. If other plans (e.g., Medicaid and Medicare) interpret this term to include the device, these interpretations can be presented. The insurer, plan administrator, or a court may use this information to approve the device or equipment. The general rule is that any uncertainties will be interpreted against the insurer or health plan provider. Some examples of how this rule can be applied are provided in this article. You should also expect that there will be clearly written instructions or directions describing the type of evaluation needed to support a funding request. There should be clearly written decision-making rules. This includes definitions of various-covered services and terms such as "medical need." The decision- making process should be described clearly. This expectation of "yes" also should be expressed to all who have central roles in preparing and explaining funding requests. This includes evaluation and service professionals, and the person's treating physician. The greater the commitment of these professionals to their recommendations and/or prescriptions, the greater the likelihood a "yes" answer will be provided. Another way that these professional services providers can help, is to agree to take responsibility for whatever ongoing communication and persuasion that may be necessary with the decision-maker in the health plan. This will take a significant burden off of the shoulders of the person with a disability or a family member. As a practical matter, it is the best way for any of the decision-maker's questions about the information submitted in support of the request to be answered. The first test of this expectation should occur in a careful review of the documents describing the health care benefits package. This may mean some benefits manual, booklet, or the actual insurance policy. This information should be provided by the health insurer or benefits plan administrators. These documents should identify and define - in plain English: The services covered; All important terms that will affect the procedure for submitting claims (e.g., required evaluations, prior approval requirements); and All important terms that will affect the decision-making process (e.g., medical need, coverage limitations, exclusions). In addition, the documents describing the benefits should be written in plain English. The policy or benefits plan may provide a definition, or rules, applied to funding requests. Therefore, evaluation reports and prescriptions supporting those requests should use the same language that has been written in the policy or benefits plan as closely as possible. However, the information provided may not be clear, complete, or concise. While this may be frustrating, it should not be seen as a disadvantage. As noted above, where the policy or plan documents are incomplete or confusing (in "legalese"), or where information has not been supplied, the omissions and lack of clearness will be interpreted against the insurer or employer. ---------- THE ROLE OF PRIVATE INSURANCE IN FUNDING ASSISTIVE TECHNOLOGY IN SCHOOLS by Susan Goodman, Esq. December, 1995 BACKGROUND Private insurance is often considered as a funding source for assistive technology devices in schools. It is possible to use insurance benefits to pay for devices. However, there are often "costs" associated with using it, in terms of increased premiums or reduction in lifetime benefits. Parents are often told by school district personnel that they must pay for devices and services that their children need to benefit from their educational programs. This violates the free, appropriate, public education requirement (FAPE) of the Individuals with Disabilities Education Act (IDEA). The federal Office of Special Education Programs (OSEP) has addressed the issue of school districts' requests that parents use insurance to pay for technology, including both private insurance plans and/or Medicaid. The issue was addressed in a 1993 policy letter from the OSEP, to the South Carolina State Department of Education. INQUIRY In this inquiry, the following questions were answered: 1. Is it appropriate for a public agency to bill the costs of special education services to Medicaid, or any other third- party insurer? 2. Before engaging in third-party billing for special education services, must a public agency seek parents' permission and inform parents about all of their rights in the process? TEXT OF RESPONSE The text of the response referred to a December, 1980 notice of interpretation issued by the federal Secretary of Education, entitled "Notice of Interpretation on Use of Parent's Insurance Proceeds." The response read as follows: The requirement that a free, appropriate, public education be provided 'without charge' or 'without cost' ... means that an agency may not compel parents to file an insurance claim, when filing the claim would pose a realistic threat that the parents (of children with disabilities) would suffer a financial loss not incurred by similarly situated parents (of non-disabled children). Financial losses include, but are not limited to, the following: 1. A decrease in available lifetime coverage or any other benefit under an insurance policy; 2. A decrease in available lifetime coverage or any other benefit under an insurance policy; or, 3. An out-of-pocket expense ,such as payment of a deductible amount incurred in filing a claim. 45 Fed. Reg. 86390 (December 30, 1980). Therefore, public agencies may access parents' insurance to pay for required special education and related services, in circumstances where the parents would incur no realistic threat of a financial loss. However, in circumstances where parents would incur a realistic threat of a financial loss, use of parents' insurance proceeds must be voluntary. In your second question, you asked if the school district must seek the permission of the parents and inform them of all their rights in the process (including the fact that there may be loss of potential lifetime benefits). Public agencies must obtain parental consent for the filing of an insurance claim, including informing parents of any potential financial losses they could incur. However, public agencies may not condition the provision of special education and related services on parental consent to the filing of an insurance claim. Therefore, parents may refuse to sign an consent form without jeopardizing receipt of services to their child ( 20 IDELR 629, letter to Spann). INTERPRETATION It is important to note that this reasoning would apply to any situation in which school districts ask parents to pay for technology through private insurance policies (or Medicaid). For example, consider the case of a parent's requesting payment for a device from an insurance company. She finds out that the insurance company will increase the family's monthly premiums because of the high cost of the device. Or, the lifetime amount of money that they have available for health insurance will be less, because of this purchase. This is considered to be a cost to the parent. The child would not be receiving a free, appropriate, public education (FAPE), at no cost to the parent. Therefore, the parents may request reimbursement from the insurance company, but it is not necessary for them to do so. If they choose not to do so, the school is still required to provide the device or service. ACTION STEPS 1. Share this letter with other parents and groups interested in assistive technology issues. Encourage them to use the letter where the school district has requested use of private insurance or Medicaid to pay for devices and services. 2. If your school district has asked you to use your insurance to pay for a device, share this letter with them. Include a letter that you have written about how this applies to your own request. 3. If an attorney or advocate is involved in your case, share the letter with him or her. INTERPRETATION It is important to note that this reasoning would apply to any situation in which school districts ask parents to pay for technology through private insurance policies (or Medicaid). For example, consider the case of a parent's requesting payment for a device from an insurance company. She finds out that the insurance company will increase the family's monthly premiums because of the high cost of the device. Or, the lifetime amount of money that they have available for health insurance will be less, because of this purchase. This is considered to be a cost to the parent. The child would not be receiving a free, appropriate, public education (FAPE), at no cost to the parent. Therefore, the parents may request reimbursement from the insurance company, but it is not necessary for them to do so. If they choose not to do so, the school is still required to provide the device or service. ACTION STEPS 1. Share this letter with other parents and groups interested in assistive technology issues. Encourage them to use the letter where the school district has requested use of private insurance or Medicaid to pay for devices and services. 2. If your school district has asked you to use your insurance to pay for a device, share this letter with them. Include a letter that you have written about how this applies to your own request. 3. If an attorney or advocate is involved in your case, share the letter with him or her. ---------- FUNDING AAC DEVICES: ANSWERS TO A COMMON EXCUSE Adapted by Susan Goodman, Esq., March, 1996, from an article written by Lew Golinker, Esq., entitled "The Role of Private Insurance in Funding Assistive Technology in Schools," 1995. In the Early Winter edition of Tech Express we included an article on excuses that insurance companies use to deny funding for assistive technology devices and services. An often-used excuse not reviewed in that article is: Alternative augmentative communication devices (AAC) are excluded because they are computer-based devices. Computer-based devices are not approved because of a general exclusion for computers. This article covers responses to that excuse, which should help you if you are seeking funding for devices and encounter this excuse. AAC DEVICES THAT ARE COMPUTER-BASED Some types of AAC devices are built specifically as AAC devices. Others are laptop computers with AAC software. Some insurers or plan administrators say that computer-based devices are not covered because of a general exclusion for computers. Some definitions of medical need include a rule that states that the device may not be useful in the absence of illness or injury. It may state that the device can be used only for medical purposes. The individual requesting the device should focus on how it is to be used - and how it will be of benefit. In response to such an excuse, you should ask whether there is a general exclusion for computers, or whether the decision is based on the "failure" of the device to meet the definition of medical equipment. If it is because of the medical equipment definition, look to see whether the plan covers prosthetic devices. If it does, the definition of durable medical equipment (DME) becomes irrelevant. This is how Medicare approved a computer-based AAC device: it first examined DME, ruled it out, then agreed that the device was a prosthesis. If the denial is because of a general plan exclusion for computers, a different approach is needed. First, note that the decision can be supported only if the AAC device request is taken apart, with each part examined independently. The request needs to be for an AAC device or system, NOT for a computer. What entitles the funding source to examine each part, and make an independent judgment about whether the part meets the standards for "medical equipment" or "computers?" What if this reasoning were applied to other devices? Won't wheelchairs be held together at least in part by screws that have "dual uses?" Power wheelchairs often have joysticks that can control speed, range of motion, etc. - does that make them computers? Under either circumstance, are they excluded from funding? Of course not. Examination of individual parts provides a convenient excuse for funding to say "no" to AAC devices, but it is not a standard that can be applied to other equipment. Therefore, it is both inconsistent and amounts to making a decision based on diagnosis, which is a violation of the ADA. WHAT SHOULD YOU DO? First, you should ask whether the policy or plan administrator will approve devices built for a particular purpose. If so, then ask the decision-maker to explain what makes a device a computer. If it is the presence of chips, a storage device, software, a screen, a keyboard, a battery, etc., these components are present in other devices built for a special purpose, such as a speech synthesizer. In addition, a device such as a speech synthesizer in a computer will have general uses, so how can they be approvable separately? Again, the point is that the process of disassembly is an excuse, not a standard. Overall, AAC devices are far more similar on their insides than their outsides may appear. Second, look to other funding programs as another source of support. The specific Medicaid AAC funding criteria in Indiana, Maine, New Hampshire, New York, and Ohio all include computer-based AAC devices in the range of their funding guidance. The Medicaid AAC model policy makes no distinction about the way the device is constructed. It cites as examples of AAC devices: Communication boards or books, electro-larynxes, speech amplifiers, and electronic devices that produce speech and/or written output. AAC devices include devices that are constructed for use as communication devices, as well as systems that may include a computer, when the primary use of the computer will be as the beneficiary's communication device. The Medicare program also supports computer-based AAC device funding. CONCLUSION If the decision is to exclude only the "computer" from the funding request, it is important to point out that the remaining items (e.g., software) are useless to the individual without the computer. The suggestion that the policy or plan can carve up a request for a service or device into components - and approve parts separately that do not make up a meaningful whole - should not be upheld. The response outlined in this article should be used if the insurance company uses the excuse that they will not fund a device that is computer-based. To secure general information on the project, contact: Assistive Technology Funding & Systems Change Project, 1660 L Street, NW, Suite 700, Washington, DC 20036 Tel: (202) 776-0406 Fax: (202) 776-0414 Email: atfscp@aol.com. To secure information & individual assistance on AT funding issues, contact: 1-800-827-0093 (voice) 1-800-833-8272 (TDD), or (404) 919-8305 (fax) The opinions expressed herein do not necessarily reflect the position or the policy of the U.S. Department of Education, and no official endorsement by the U.S. Department of Education of the opinions expressed herein should be inferred