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You have defined your needs, identified the technology that can help, gathered all the documents needed, determined the costs, listed your potential funding sources and completed all the paperwork and sent in the request. Now comes the hard part... waiting for a response. It bears repeating, finding the proper funding source and getting a “yes” is seldom easy. With time and perseverance, you will receive an answer. Your answer will typically be in writing and should list the amount of money that has been authorized toward the purchase of the specified assistive technology.
If you receive the amount in full, the vendor will then be able to process the order and secure the device. If funding is denied, you can look for other funding options (see Step 7), or you may choose to begin the appeal process. Not all funding sources will have an appeal process. For example some community groups or foundation funds may simply make a final decision. However insurance or public money will have an appeal process and should notify you in writing, along with the rejection letter, of your right to appeal the decision.
If you plan to appeal, be very careful to to submit the appeal within the deadlines for that funding source. Appealing funding decisions is quite common. Often, denial for funding is not because the device was unimportant or unnecessary, but rather because of a lack of understanding or knowledge by the reviewers at the funding sources. Appeal processes invariably demand extensive written evidence to support your claims. From the beginning of your search for funding, keep copies of all correspondence and written notes from all phone calls related to your case.
When you begin an appeal, find out whether your request was denied because of a lack of funds or because of a lack of information. If your request has been denied because of a lack of information find out what additional information is needed. Get this information to the person handling your request (for example, case manager or a durable medical equipment vendor). Don’t leave it to chance that the right person will get it. Make certain of it.
Agencies, insurance companies and other traditional funding sources are cautious when it comes to paying for devices or services that are the least bit questionable from their perspective. You should not give up just because you get a “no” for an answer. You may very well have to exercise self-advocacy in order to create a policy change. It may be necessary to demonstrate to funding sources that a certain assistive device or service will not only benefit you, but will also be cost-effective in the long run. The quest for success in funding does not promise to be quick and easy. Persistence is the key.
The Client Assistance Program (CAP) provides information and assistance to individuals with disabilities who are seeking or receiving services from certain government-funded programs funded under the Rehabilitation Act of 1973. The Client Assistance Program (CAP) assists people who are seeking or receiving services from Michigan Rehabilitation Services, Consumer Choice Programs, Michigan Commission for the Blind, Centers for Independent Living, and Supported Employment and Transition Programs. The CAP program is part of Michigan Protection and Advocacy Service, Inc. For more information call: 1-800-292-5896 or 517-487-1755.
Checklist for Appeals
Prepare a letter requesting an appeal.
Make sure you submit the letter within the required time period.
Make sure you have all the documents and materials you need for your hearing:
Letters and reports from medical provider: Information, brochures, pictures, etc., about the assistive technology you are requesting
If possible, have the requested device on site for the hearing
Copies of similar appeals decisions
Copies of all other related documents
Witness preparation to be done:
Identify witnesses on your behalf
Make sure witnesses are available for the hearing. If not available, get their statements in writing.
Prepare witness for hearing:
Provide information on what was denied and why
Provide witness with documents supporting your request
Be sure you have proven the need: Before the hearing make sure you can clearly demonstrate that the assistive technology you are requesting is medically necessary to address or accommodate a medical condition, and it is the least expensive, appropriate option. Be sure you have proven that the assistive technology you are requesting is:
Medically necessary as determined by prevailing medical community standards or customary practice and usage
Appropriate and effective to meet the medical needs of the recipient
Timely, considering the nature and present state of the recipient's medical condition
Furnished by a provider with appropriate credentials
The least expensive, appropriate alternative health service available.
An effective and appropriate use of funds
Tips for Specific Types of Funding Sources
Group Health Insurance Plans
Employees who have disabilities often turn to their group health insurance plan to provide or at least assist with funding. If you have been denied on the first round:
Double-check to see if you have provided them with the required medical documentation and appropriate forms. If something has been filled out incompletely or incorrectly, the insurance company may not voluntarily notify you.
Assuming everything was correct, you can ask for an administrative review by a staff physician or nurse. However, keep in mind that a general physician employed by an insurance company may not necessarily be knowledgeable about these devices and how they can assist you in staying healthy or employed. Do not be afraid to ask that a specialist in rehabilitation medicine review the claim.
Remember that there is always a chance for full or partial funding if the policy coverage does not specifically exclude a device or piece of assistive equipment. It is not uncommon for the claimant to eventually learn that he/she is better informed than the personnel with the group health plan.
Workers’ Compensation Claims
If a disability was acquired through a work-related accident or illness, you may seek funding through the employer’s Workers’ Compensation Insurance carrier. It is advisable not to be too hasty in settling the claim. When there is permanent disability involved, Workers’ Compensation carriers generally want to settle the claim as soon as possible. It is recommended that you wait until the full extent of the injury or disability is known in order to determine what kind of assistive devices or equipment will be needed and for how long. Let the insurance personnel know that you will not settle the claim or sign any waivers or release forms until there is sufficient medical evidence that the disability is permanent and unchanging. If there is an attorney involved, make sure she or he understands why the client may need certain assistive devices and the terminology associated with them. Be sure you know how the Workers’Compensation benefits are structured.
If you apply for funding from a state agency and have been told that you do not qualify for assistance or if the particular device does not qualify, you may appeal this initial decision. All government agencies have internal appeal procedures and you can have your claim reviewed by mid-level management or, eventually, an agency director. In considering an appeal, you should ask the following:
How does this device enable me to enter employment, receive vocational training, live more independently or otherwise improve my functioning in society? You undoubtedly built a case for this earlier when you first approached the source, but you need to look for ways to strengthen it. You can construct an appeal if you can demonstrate how the device will help you.
Do the agency’s guidelines specifically exclude the device or has it been funded in some cases before? If an agency has funded a device in the past, thereby setting a precedent, it will be more difficult to deny your appeal.
Do you meet the agency’s financial requirements and other criteria? If it is obvious that you do not meet their criteria, an appeal would be fruitless. On the other hand, if you can provide evidence that disputes someone’s determination of your eligibility, it will greatly improve your chances.
The contents of this web page were developed under a grant from the Department of Education. However those contents do not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the Federal government.