Funding and Appeals For
Under Medical Assistance
A Self-Advocacy Fact Sheet from the Minnesota Disability Law Center
This fact sheet is an introduction to the rights of people with disabilities under the Medicaid Act. The information in this fact sheet is not legal advice. Every case is different and the laws change all the time. Some of the laws may be different in other states.
* Look at the end of this fact sheet for the meaning of abbreviations and words printed in bold & italics, such as AT
1. What is assistive technology (AT)?
Assistive technology (AT) is used to mean both assistive technology devices and assistive technology services.
Assistive technology devices (AT devices) are equipment or tools that can help people with disabilities to work, learn, or move through life more easily.
Assistive technology services (AT services) include help or instruction to find, make, repair, or learn to use an AT device.
Some examples of assistive technology:
√ A test to decide if a person needs AT
√ Wheelchairs, canes, scooters or walkers
√ Items to help with bathing or personal care, and other daily living activities
√ TTY, TDD or talking computers
√ Devices to help with speaking or writing, such as a special keyboard
√ Building or changing an AT device to meet a person's needs
2. Who pays for AT?
Money for AT can come from several places.
Medical Assistance (MA) Program
Medical Assistance has money for AT. The funds are partly federal money and partly state money. The Department of Human Services (DHS) is a state agency that decides how MA money is spent. If a person is on MA and needs AT, the money for that AT comes from DHS.
Schools provide AT for students who get special education services. If the AT will help the student learn, the school district has to get it. The student may use it after school and on weekends, but it belongs to the school district. For more information, see the Minnesota Disability Law Center's fact sheet, Assistive Technology and the Schools.
Rehabilitation Services Division of the Department of Economic Security (RS) and State Services for the Blind and Visually Impaired (SSB)
If you get rehabilitation services from RS or SSB, your plan must describe all rehabilitation technology services. Those services should include any AT you need to meet your rehabilitation goals. If RS or SSB don't provide the AT, you can appeal. The Client Assistance Project (CAP) of the Minnesota Disability Law Center can help you. See the telephone numbers at the end of this fact sheet.
There are four kinds of insurance that might pay for AT. The four kinds are health, disability, worker's compensation, and liability insurance. Different insurance policies have different ways of deciding how much they will pay for AT and how you can ask for it. Most have a process like MA. Look at your insurance policies to find out how to get money for AT. If they tell you that you can't get it, appeal the decision. Your insurance policy should tell you how to appeal.
Check the STAR Directory of Funding Resources for Assistive Technology in Minnesota to learn about other ways to get money for AT.
50 Sherburne Ave., Room 309
658 Cedar Street
St. Paul, MN 55155
651-296-2771 or 1-800-657-3862 (voice)
651-296-9478 or 1-800-657-3895 (TTY)
3. What is a home- and community-based waiver?
The Federal Medicaid program allows states to be flexible in how they spend their money. Minnesota has a plan that includes home- or community-based services. This plan helps people live at home instead of in an institution. The state can use federal Medicaid money to help set up services at home.
4. What kind of AT can I get under home- and community-based waivers?
If you get services under a home and community-based waiver, the money for AT is more flexible. Waivers often cover changes to your home, such as ramps, stair lifts and grab bars. They also cover changes to your car, including ramps, lifts, and raised roofs. Ask MA for the money for AT first. If you can't get MA money, then try under your waiver.
5. How do I ask for AT under a waiver program?
If you get waiver services, you can ask the county to pay for AT under your individual service plan. Ask the county case manager for the AT. If the case manager decides the answers to all of these questions are yes, then the waiver can pay for your AT.
A. Is this the only way you can pay for the AT?
B. If you don't get this AT, will you have to live in an institution?
C. Is the AT only for your use, and nobody else's?
D. Is this AT medically necessary, and is it the right type of AT for the person asking for it? Is it good quality, and the cheapest type of AT to do the job?
E. Is this AT a good use of waiver funds?
If the county case manager decides that all answers are yes, and waiver money is available to pay for the AT, then they give prior authorization.
Once you have prior authorization, you usually need to give three different bids from different companies to the county agency. The county agency will choose which company to buy from. They will not always choose the lowest bid. They should choose the bid that gives the best service for the price. The company gives you the service or the device, and the bill goes to the county agency.
Sometimes, the county case manager will look at a request and decide that the answers to one or more of Questions A-E are no. Then s/he will deny your request. The county agency has to tell you what the decision was. If the request was denied, the county has to tell you how to appeal the decision.
6. What kinds of AT will Medical Assistance pay for if I'm not on a waiver program?
MA funds AT that is "medically necessary durable medical equipment and prosthetic and orthotic devices."
Durable medical equipment is something to correct or help with a physical disability. It must hold up well with heavy use, and it must be something that can be used in the person's home.
Prosthetic and orthotic devices are tools or equipment to take the place of a body part that doesn't work correctly, or to give support for a body part that is weak.
7. What are some examples of AT that Medical Assistance will pay for?
√ Walkers and hospital beds;
√ Wheelchairs (Medical Assistance may pay for both a power and a manual wheelchair, because they are used for different kinds of activity.);
√ Bath equipment, including shower chairs and bath lifts;
√ Standing equipment of all kinds, including standing wheelchairs;
√ Special car seats for children with all kinds of disabilities, including behavioral disorders; and
√ Augmentative communication devices
√ This includes all different kinds of machines to help with communication if you have trouble speaking. MA will pay for entire systems and related parts. MA will also pay for the costs of putting different devices together to meet your individual needs.
8. How do I ask for Medical Assistance funding for AT?
Medical Assistance has to authorize the AT before you get it. Your medical provider has to convince Medical Assistance that you need the AT for your medical problem. They also have to show that the AT you are asking for is the least expensive appropriate option. In other words, it has to be the cheapest way to do the job right. Your medical provider needs to write a letter of medical necessity explaining why you need the AT.
A good letter of medical necessity is very important if you want Medical Assistance to pay for AT. You will find an example of one at the end of this fact sheet. You may want to give a copy to your medical provider.
9. When DHS looks at my request for Medical Assistance funding, how do they decide if I should get it?
The Department of Human Services has six questions to look at. To give prior authorization, they have to be sure that all six answers are yes.
1. Is the AT medically necessary? (See Question #10)
2. Is the AT the right device or service for your individual needs?
3. Is the AT right for your medical condition at the time of the request?
4. Does the AT come from a company with all of the licenses or certifications it needs to do business legally?
5. Is the AT the cheapest device or service that can do the job right?
6. Is the AT a good and appropriate use of the program's money?
DHS will ask you for information about your request. The information they need depends on the kind of AT you want. For example, if you want to buy a wheelchair, they need information about the wheelchair. If you want to hire someone to teach you to use a special computer, they will need information about the teacher and the computer.
Some kinds of general information, though, are always needed.
√ You always need a doctor's letter or order saying why the device or service is medically necessary.
√ You need a test to show that the AT will work for you, and you can use it. For example, if you want a motorized wheelchair, you have to show that you can make it work.
Your request must include written reports from medical providers. Sometimes, these reports will be very long. Submit all of your information to DHS.
You may need reports from several different people. For example, if you want a communication device, you may need a report from a speech therapist that talks about your need for help to speak. You may also need a report from a physical therapist that describes your arm strength and your ability to use that particular device.
10. When is AT medically necessary?
AT devices or services are medically necessary if your doctor or therapist thinks anyone with the same condition would need it, whether or not they had Medical Assistance. For AT to be medically necessary, a medical provider must be able to say yes to these three questions:
1. Is the AT needed because of a medical condition?
2. Would the doctor order the same AT for someone else with the same needs?
3. Would the AT allow the person to function the way the doctor would expect anyone else with the same condition to function?
The doctor or therapist should use their experience and knowledge about your medical condition, and about people with a condition like yours, to answer the questions.
11. How do I know what the Department of Human Services decides about my request?
DHS has to give you a written notice of the decision. The notice must include:
√ A statement that they approve or reject your request;
√ The reasons why they approve or reject your request;
√ The specific rules they used to make their decision;
√ Information about how to get an appeal hearing, and an explanation that you have a right to the hearing and you have a right to a lawyer or advocate to help you at the hearing; and
√ An explanation of your rights to continue getting AT until the question is settled. Many AT services must continue during the hearing, and DHS must explain this to you.
12. What if DHS doesn't give me a decision? What if they ask for more information?
Sometimes, instead of making a decision, DHS will ask you for more information. This is called a pending decision. Usually DHS will tell you exactly what information they want. If they don't, ask them to explain what else they need. If the missing information is medical, ask your doctor or therapist to give the information to DHS.
If you think DHS is taking too long to give you a decision, you can complain. Sometimes, they keep asking and asking for more information. If this happens, tell them you want an appeal hearing. A disability advocate can help you.
13. What if they say I can get the AT, but they don't give me enough money?
Sometimes DHS approves your request, but they don't give you enough to buy the AT you want. They call it an approval, but really it's a denial. If this happens, appeal. In a case like this, you should definitely get help from an advocate.
14. What if they deny my request?
Do not take no for an answer! Ask for an appeal. Ask in writing. A sample appeal letter is at the end of this fact sheet.
At this point, there are some things you must do:
· Keep all written notices from DHS or the county. Don't throw anything away.
· Get the first and last name of everyone you talk to. Write down the person's name, title, and who they work for. Keep these notes with your other papers.
· Make copies of anything you send. Keep those copies with your other papers.
· Keep track of any phone conversations. Write down the date and time, and write down what is said.
· Keep track of any money you spend.
· Keep all of your papers together in one folder. Don't lose anything.
· Call the Minnesota Disability Law Center and see if you can get an advocate.
· With or without an advocate, you need to keep all of your papers, and keep them together. This is very important.
15. How do I appeal?
Don't wait. You only have 30 days from the day you got the denial letter. DHS must get your letter within 30 days. If something keeps you from sending the letter on time, tell DHS. If DHS thinks your reason was a good cause, they will give you 90 days from the day you got your denial. Examples of good cause are: a death in the family, or if you were ill or hospitalized during the 30-day period.
Send your request for an appeal to:
Chief Appeals Referee
Appeals and Regulations Division
Minnesota Department of Human Services
444 Lafayette Road
St. Paul, MN 55155-3813
Send a copy of DHS's written denial along with your appeal letter. That notice of denial includes the name of the person who is supposed to get the AT, and their address and identification number. In the letter, say that you are appealing the denial. Say that you want a hearing in person to argue about the denial.
Be sure to keep a copy of your letter and of DHS's written denial.
16. What happens after I submit my letter asking for an appeal?
DHS will choose an Appeals Referee to hear your appeal. DHS will send you a written notice that tells who the Referee is. The notice will also give the time and date of your hearing.
The Referee may tell you that it will be a telephone hearing. If they do, ask for an in-person hearing. You have a right to a hearing in person, and it is usually better for you. That way, the Appeals Referee can meet you, and you can talk face-to-face. If the hearing is in person, you can bring along all of your proof that you need the AT. You and the Referee can go over your proof together.
17. Where will the hearing be?
The hearing will be in the county you live in. Usually, it is in a conference room in the county's Social Services or Human Services building.
18. What is a hearing?
The hearing is your chance to explain why you should get assistive technology, and why Medical Assistance should pay for it. You can show any proof, including letters, reports, and pictures. You can have witnesses come and explain why they think you need the AT. Answer all of the questions that DHS had about why you need the AT.
The Minnesota Medical Assistance program must have a neutral hearing process. The Appeals Referee works for DHS, but s/he was not involved in the decision about you. The Referee should listen to both sides and consider the question fairly.
19. What if I don't have an advocate? Can I handle my case by myself?
If you can, you should get an advocate. Call the Minnesota Disability Law Center for help. We may have an advocate who can help you at no charge. We can't help with every case, but we may be able to help you.
If we can't provide an advocate, we can give you advice over the phone or send you some written advice. Or, we can suggest other people you can call for help.
If you can't get an advocate, use the advice in this fact sheet to prepare for your hearing. Questions #20-31 give detailed information about hearings. This will help if you are going to handle your case by yourself. Call MDLC (Question #32) and ask for all of our fact sheets about appeals.
Preparing for a Hearing
You will have many details to remember when you prepare for a hearing. Please read this section carefully. At the end of this fact sheet, you will find a Checklist for Appeals to help you remember everything.
20. What will I need for the hearing?
Get together everything you have about your case. Find all of the letters and reports from doctors or therapists. Get written information about your medical condition. Get information about the AT you want. Ask DHS for copies of everything in your file. If you have brochures or pictures of the AT, bring those. If possible, bring the AT device to the hearing.
Make copies of everything. Make three folders – one for you, one for the Referee, and one for the witnesses. Put a copy of everything in each folder. This way, everyone can look at the information at the same time. You will want to leave one set of these copies with the referee so s/he can look them over again later. See Question #29 for information on copying costs.
Figure out who your witnesses should be. Witnesses may include you, the person who needs the AT (if that is someone other than you), doctors, therapists, psychiatrists, etc.
Arrange to have the witnesses come to the hearing. If they can't come, talk to the witness and the Appeals Referee. Sometimes a witness can be part of the hearing by telephone.
21. Where do I get copies of all the papers I need?
Ask DHS for the prior authorization file. This will have all the papers on your case, including the request and the denial. If you are on a waiver, ask for documents from the county.
If DHS or the county won't give you the file, ask the Appeals Referee to order them to do it. The agencies have rules they have to follow about giving out information.
22. What if the denial says my medical information wasn't good enough, or asks medical questions?
If the written denials from DHS or the county have a question or problem that your doctor could answer, get your doctor to help you. If the doctor needs time to get information together, ask the Appeals Referee for more time. Anytime you get denied because of a medical question, it's best to have a medical professional answer. You can get written testimony, or you can have your medical provider come to the hearing.
23. What if someone else has had the same problem? How can I find out about that?
DHS has a file on all agency decisions. Call the Appeals and Regulations Division of the Department of Human Services at 651-296-7087. Ask for a copy of the index of agency decisions. Look through that and see if any cases were similar to yours. If so, you can get copies of the decisions from DHS. If you find any that support your case, make copies along with your other paperwork. The Appeals Referee will need to see them.
24. How do I get my witnesses ready for the hearing?
Tell them what AT you asked for, and why you were turned down. Tell them you need their help. Give them copies of all the paperwork. Tell them the date and time of the hearing, and make sure they can come. If they can't come in person, ask if they can call in by phone. If not, ask if they will write a letter to the Appeals Referee. If you want witnesses to testify by phone, be sure to let the Appeals Referee know well ahead of time.
25. What if a witness says they won't testify?
First, ask the witness to come. If they work for DHS or the county, ask them in writing. Get their answer in writing. Keep copies of everything. If they won't agree to come, or join by phone or write a letter as testimony, then you need a subpoena.
Ask the Appeals Referee for a subpoena. Call the appeals office and give them all of the information about who you want to come, and when and where your hearing is.
If the witness is from DHS or the county, the Referee will give them the subpoena. You will not have to pay anything.
For anyone else, you have to give them the subpoena yourself. The Referee will send it to you. When you get the subpoena, either you or someone helping you has to give it to the witness. Do not send it in the mail. You also have to give them $20.00 for a witness fee, and money for mileage to come to the hearing. You have to pay for that yourself.
26. What will the hearing be like?
The hearing is tape-recorded. The Appeals Referee will swear in the witnesses. If both parties have lawyers, the hearing will be like an informal trial. The Referee will probably ask to hear both sides of the story before anyone asks any questions. Often, no one from DHS will come to the hearing. They will just send in a written statement. If someone from DHS does come, either party can talk first. Often, the Referee will start by having DHS explain why they denied your request. You will get a chance to show all of your evidence.
If a question comes up at the hearing that you can't answer, you can ask the Referee for more time. Then, you can give the information to the Referee later.
27. What evidence can I use?
Generally, the Appeals Referee will look at or listen to any evidence related to your need for the AT.
28. How much evidence will I need to win my case?
You have to look at the authorization criteria (see Question #9). You have to prove that the answer to each of those six questions is yes. You prove it by giving substantial evidence on every question. You can't just give a little bit of evidence, or part of the evidence. You have to show, without question, that the answer is yes.
If you can show that, you have established a prima facie case. Once you have that, if no one argues any of your points, then you win.
To prove that you're wrong, the county or DHS has to prove that the answer to one of the questions is no. They have to give evidence that shows your evidence is wrong. They have to justify and prove the reasons for their denial.
For example, if DHS says that you can't have the wheelchair you want because a cheaper one would do the job, they have to prove that. They have to find the cheaper chair, and show that it can do everything you need.
29. Who pays for the costs of the hearing?
If you are on a waiver and the county gave you the denial, they have to pay for certain costs. Examples are transportation, childcare, copying costs, and witness fees. Ask MDLC for a reimbursement form. If the denial comes from DHS, then you have to pay your own costs.
30. How does the Referee make the decision?
The Appeals Referee will go over all of the information from the hearing. Then, s/he writes a decision. The written decision is not just a review of the county's original decision. It must say what the Referee learned at the hearing, and how they decided to apply that information to your case.
Then, the Appeals Referee gives the decision to the Chief Appeals Referee. If the Chief Appeals Referee agrees with the decision, then s/he signs off on it. If the Chief Appeals Referee does not agree, then s/he makes an amended decision and attaches it to the Appeals Referee's decision. Then, the decisions are sent to both sides.
You will get the decision in the mail. You should get it within 90 days of the date you first asked for a hearing. If the Chief Appeals Referee disagrees with the Appeals Referee's decision, then both sides have 10 days to respond. If you don't agree, send a letter and say why you think the Appeals Referee's decision was right and the Chief Appeals Referee's amended decision is wrong.
31. What if I lose?
If you lose, you have 30 days from the date the decision was approved by the Chief Appeals Referee. In those 30 days, you can ask him/her to reconsider the decision. The Chief Appeals Referee might say no.
Within 30 days of the final decision, you can petition the State District Court for review. You do not have to pay a filing fee. If you asked the Chief Appeals Referee to reconsider and s/he did, then you have 30 days from that reconsidered decision.
If you are going to file an appeal with the District Court, you should definitely try to get help from a lawyer.
*** Definitions ***
Advocate – Someone who is on your side and will help you understand the law and fight for your rights. An advocate can be a lawyer or anyone else who understands your problem and can help you.
Appeal – A formal request for an official to review your case. This is a chance to give more information and bring other people in to support your case.
Appeals Referee – An official in the Department of Human Services, unconnected to your case. S/he will listen to your appeal, consider both sides of the case, and make a decision.
Assistive technology (AT) – AT can be used to mean both AT devices and AT services.
Assistive technology devices – Equipment or tools that can help a person with a disability to work, learn, or move through their life more easily.
Assistive technology services – Help or instruction to find, make, repair, or learn to use an AT device.
Augmentative communication device – Machine to help a person communicate.
Durable medical equipment – Equipment to correct or help with a physical disability. Must hold up well with heavy use.
Home- and community-based waiver – A program that helps people with disabilities to live in their own homes. It allows more flexibility in how Medical Assistance money is spent.
Medical provider – Doctor, nurse, therapist, home health care nurse, etc.
Medically necessary – Needed for a medical problem. A medical provider must say that anyone with the same problem would need a similar device or service. The device helps the person function or do things they could not do without the device.
Prima facie case – A case that, on the surface, looks complete and obvious.
Prior authorization – Permission from a funding agency to buy assistive technology.
Prosthetic and orthotic devices – Tools or equipment to take the place of a body part that doesn't work correctly, or to give support for a body part that is weak.
Substantial evidence – Enough evidence that any reasonable person can accept it.
Subpoena – A written demand from the court for a person to show up at a hearing.
This fact sheet may be reproduced in its entirety, with credit to the Minnesota Disability Law Center. The legal content of this fact sheet was updated in March 2004, and it was re-written by MDLC for the Minnesota Governor's Council on Developmental Disabilities in June 2004.
Minnesota Disability Law Center (MDLC)
430 First Ave. North, Suite 300
Minneapolis, MN 55401-1780
Web Address: www.mndlc.org
New client intake: 612-334-5970
Toll Free: 1-800-292-4150
Preparation of this Fact Sheet was financed in part by grant number 90DNO133 from the US Department of Health and Human Services, Administration on Developmental Disabilities, Projects of National Significance, under provisions of Public Law 106-402. The content of this Fact Sheet does not necessarily reflect the position of policy of the Administration on Developmental Disabilities or the Minnesota Department of Administration.
Checklist for Appeals
If your request for AT has been denied:
· Send a letter requesting an appeal within 30 days of the denial.
You will need to gather these materials for the hearing:
· Letters and reports from your medical providers;
· Information about the AT you want (brochures, pictures, etc.);
· If you can, bring the AT with you to the hearing;
· Copies of the decisions of other appeals like yours where the person ended up getting the AT they wanted;
· Be sure to make a folder for the Referee that includes copies of everything.
How to prepare your witnesses:
· Make a list of all witnesses who will testify for you;
· Give each witness the information on what AT you wanted and why it was denied;
· Give each witness copies of all the documentation (letters from medical providers, etc.) that supports your request;
· Make sure each witness can either come to hearing or participate by phone. If they can't, get a written and signed statement from them.
Before the hearing, be sure you can show that the AT you want is medically necessary. You also need to show that it is the least expensive AT that can do the job right. Be ready to prove these things:
· The AT is medically necessary, according to common medical standards;
· The AT is right for the person who needs it, and will help with the medical need;
· The AT is right at this time for the person's condition;
· The provider of the AT has the needed certification or credentials;
· The AT is the least expensive needed to do the job;
· The AT is a good and appropriate use of the program's money.
This is a form to help you write your own letter. Wherever you see this type of print, replace it with your information. See the sample letter below.
Be sure to include a copy of your notice of denial from DHS. Keep a copy of the notice and of this letter for yourself. If you have any questions, call the Minnesota Disability Law Center.
Chief Appeals Referee
Appeals and Contracts Division
Minnesota Department of Human Services
444 Lafayette Road
St. Paul, MN 55155-3813
Dear Chief Appeals Referee:
I am appealing a denial of prior authorization for assistive technology. Name of person who needs the AT is a resident of county where the person lives County in the State of Minnesota.
A prior authorization request was submitted for Medical Assistance reimbursement for a assistive technology requested. By notice dated date that you received the notice from DHS denying prior authorization, the state agency denied this request. A copy of the notice is attached.
I would like an in-person hearing on this matter in county where the person lives county.
Dear Chief Appeals Referee:
I am appealing a denial of prior authorization for assistive technology. My son Bill Smith is a resident of Hennepin County in the State of Minnesota.
A prior authorization request was submitted for Medical Assistance reimbursement for an electric wheelchair. By notice dated October 2, 2004, the state agency denied this request. A copy of the notice is attached.
I would like an in-person hearing on this matter in Hennepin County.
RE: Ms. Jane Doe
Clinic #: 4-124-109
TO WHOM IT MAY CONCERN:
Ms. Jane Doe is a 30-year-old woman with C5-6 quadriplegia related to a motor vehicle accident in 1985. Despite her significant disabilities, she had been able to achieve independent living with the assistance of a personal care attendant. However, she continues to have difficulties with environmental controls within her home due to her impaired upper extremity function.
Due to Ms. Doe's high level of injury, she is unable to use her upper extremities to control her environment. She is in need of being provided with appropriate technology for permanent use. I recommend that a voice recognition system from Advanced Speech Interface Systems, Inc. be purchased and installed in Ms. Doe's present residence. This company has demonstrated their equipment to us and will be able to provide ongoing service of their product.
This system is medically necessary and is accepted among the medical community because it provides persons with C5-6 quadriplegia (like Ms. Doe) independent living to generate self-care and self-esteem as mandated under federal law. In order to maximize Ms. Doe's functional independence, an environmental control system is medically necessary. She would benefit from a voice-controlled system that allows her the ability to control many functions within her home such as opening doors to exit her residence in emergency situations such as a fire since she is currently unable to do this without the assistance of a personal care attendant. This system will also allow her to change the room temperature to prevent hypothermia since a person with C5-6 quadriplegia has difficulty maintaining a normal body temperature. In addition, it will provide her with the means to dial a phone by using voice commands in the event of an emergency. Because of her condition, this system will increase her functional capabilities and decrease her need and use for a personal care attendant.
Ms. Doe needs this system immediately. She is not going to recover nor regain any of her functional ability due to her disabling condition which occurred nine years ago. I recommend that this system be provided by Advanced Speech Interface Systems, Inc. This company has been in this field of expertise for ten years. They are a recognized medical assistance provider, and they are supported by the medical community. The system provided by Advanced Speech Interface Systems, Inc., will be customized to Ms. Doe's medical needs. Because this system will be specifically catered towards her health needs, it represents an effective and appropriate use of program funds.
If you have any questions, please contact me.
Philip Physician, M.D.
Physical Medicine and Rehabilitation Specialist