About WVATSPathways To Funding For Adults & Seniors:
A Handbook for WV's Older Residents
Section 4. How to Organize your Funding Request
Step 1: Get an Evaluation and Choose the Right AT
Get an evaluation by a person with professional experience.
Health insurance, government or private, has to have a doctor make the decision on whether a person needs assistive technology (AT). Other professionals, including speech/language pathologists, and physical or occupational therapists (PTs or OTs) may evaluate the person, but you must still get an AT prescription from a doctor.
The Evaluation/Diagnosis will drive the entire funding process. You must have a good evaluation that is clear about the person's AT needs.
You can start by collecting the information below. You may need to get more specific information once you speak with the funding source. To get a good start, you should gather the following:
- Your background and history. You should include your level of ability and what AT device will improve your condition. Include your age, disability/medical diagnosis, and your goals for the future.
- Your income, its source, whether you are covered by private insurance, and if you are working.
- Information about other money sources or programs you may be using or have used.
- The name, maker and/or vendor of the assistive technology and it's cost.
Choosing the right AT is hard. Many kinds of AT are available at different prices. Here are a few questions that will help.
- What type of AT will increase your level of independence?
- Who sells the AT?
- How much does the AT cost? Can it be loaned or rented to try out?
- Is there a professional person such as a case manager who can help you write a funding request?
What other services are needed to train you and others in how to use the AT, to follow-up to see if it works right, and to teach you how to take care of the AT?
- Is there a professional person such as a speech pathologist or occupational therapist who can help with training and follow-up?
- Can the AT vendor provide follow-up help?
Once all the above information is collected, it's time to write a justification for funding. The justification should not be based on why the AT is needed but on what the AT does for the person.
A good funding justification should include the following: (see Appendix A)- Details about what type of help the AT will provide for the person
- Evidence that the AT is useful to the person
- Why this AT was chosen. Include other AT choices that you tried, but that did not work. Explain why the AT is the ONLY real answer to your problems and why other AT did not work.
- Pictures or videotapes of the person with and without the AT.
Step 2: Find out what Funding is Available
You can start by answering the questions below.
- Can you pay for the assistive technology? Do you have private insurance? If so, will it pay for the AT? Does the private insurance have limits or caps on what it will pay?
- Do you qualify for Medicaid or Medicare?
- Are there private funding sources or grants? What are the requirements of each? How can I apply? How long is the wait? Are funds easily available?
- Can I get a loan? Do local banks give AT loans? Do I qualify for the West Virginia Revolving Loan Program?
- Does the AT vendor have a special way to finance the AT?
You don't have to find the funding source on your own. This would be a perfect time to get professional advice from your case manager, an advocate, a health care professional, or a social worker. They can help you tackle the following questions based on their experiences.
- Will the AT vendor order the AT knowing funding has not been approved yet, and then submit billing to the funding source?
- Will the AT vendor be able to help with any financing? For example, will the supplier accept a lesser payment and finance the remainder or write it off as payment in full?
- How can the possible funding source be convinced that the AT will help the person work or continue working and/or help him/her to live more independently?
- Have you reviewed what information the funding source needs and what AT they will cover? (Medicare, Medicaid, private insurance, etc.)
- Is it possible to combine two funding sources that will equal 80% or more of the total cost? Private insurance funding sources may only pay up to 80% or less. For example, if your private insurance paid less than 80%, Medicaid could pay the difference up to 80%.
- If disabled through a work-related accident, is worker's compensation insurance responsible for the cost of the AT?
- Are there charitable groups in your area that can help raise the necessary funds? (Lions Club, Kiwanis, etc.)
Step 3. Funding Approval
What happens when your request is approved?
The amount of funding that was approved from your request will be stated in writing. Hopefully, your request was approved for the full amount that was needed. If this is the case, the vendor will order the AT.
What do you do if the request was approved but for less money?
If the approval was for less than the amount you asked for, then you must think about some other things to do. Go to your records on all the possible funding sources that you have found and look over this information before moving on to Step 4.
What do you do if the request was turned down?
If the funding source called to say the request was turned down, you have the right to ask for that information in writing. The funding source must also tell you in writing why the request was turned down. Go to Step 5.
Step 4: Seek funds
Seek funds to make up the difference between what was requested and what was approved.
If you are not happy with the amount of funding that was approved, there are other options that you can try before paying for the AT on your own. You may choose either option or both.
- Look for other funding sources
- File an appeal to try and increase the amount of funding
After you have looked into the two options above without success, it is possible that you may have to pay for the amount of the funding that was not approved.
- Can you get a bank loan or possibly a home equity loan?
- Are there any other funding sources, for example, community agencies or local clubs that can help in covering the difference?
Step 5: Attacking the Appeals Process
If your request for funding was turned down or not fully funded, it is time to ask for an appeal. Look over your funding request package and ask the following questions.
- Was my request clear?
- Did I include all the necessary information?
- Was it well-organized?
If you don't think your request was as clear, thorough or well-organized as it could hae been, you should address the problems, make changes, and resubmit the funding request.
If you answer yes to all of the above questions, however, you have the right to file an appeal. All funding sources have an appeals process. Funding sources often say no to funding requests because of a lack of evidence that the AT meets your needs. You have the right to request an appeal to have your request reviewed, and to submit more information. Keep these things in mind while preparing your appeal:
Understand the reason for the denial. You should receive a letter from the insurer that explains the reason for your claim being denied. Examine the reason, and review your original request to see how it can be improved.
Ask your doctor to write a letter on your behalf. A letter that includes a short medical history, diagnosis, and a doctor's explanation of why the assistive technology is necessary should help.
Keep detailed records. Organization is key. Use a file folder or a computer to keep records of your correspondence with your insurer, medical records and bills. When sending letters, use certified mail and request a return receipt, so you can be sure that the letters were received.
Pay attention to deadlines. If your insurer says you have 60 days to file an appeal, make sure you meet the deadline. If you miss it, you could lose your right to appeal. If you're waiting for more information (such as a letter from a doctor), state in your letter to the insurer that you're expecting more information and will submit as soon as you can.
Ask for an independent review. Some insurers contract with doctors or other experts to review claims disputes. If you decide to go that route, try to present new information that wasn't included in your first appeal.
Key elements in successful funding are:
- Determination.
- Self-advocacy
- Educating funding sources about the advantages of the AT chosen
- Looking for other funding sources, if necessary
Remember that knowledge is power. By educating funding sources you are paving the way for other people in the future. Other individuals may benefit from your efforts.
