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Success Story: Assistive Technology and Funding
Peninsula Works One-Stop

Oftentimes when you hear a success story, the story revolves around an individual's personal accomplishments. There are many times where businesses, agencies and organizations have been successful as well. We just don't hear about them very often. When looking for a success story regarding funding assistive technology, CR4AT wanted to highlight an organization that had been successful in removing barriers to access for its clients by getting AT funded and installed in their business.

PeninsulaWorks Redwood City, a One-Stop Employment Center, is our funding success story. By law, they are required to have an accessible location to serve their clients looking for employment. They have taken further steps to ensure that they are inclusive in their accessibility for all the types of people who walk through their doors. The PeninsulaWorks Redwood City One-Stop Employment Center purchased assistive technology to provide information access for people with disabilities who are conducting job searches.

Equipment purchased included literacy software for people with reading challenges and learning disabilities (WYNN Wizard and textHELP! Read & Write). Screen Reading & Magnification software (ZoomText), a Large Print Keyboard, an ERGO CCTV (Video Magnifier) for the visually impaired, a Trackball Mouse and an Adjustable Height Workstation for people with physical disabilities.

Funding for the equipment was provided through a grant administered by the California Department of Rehabilitation and EDD. We purchased the equipment from a local AT vendor, Access Ingenuity, in Santa Rosa, CA (877-579-4380) - they also provided staff training on the use of our equipment.

The equipment was just installed at the end of October 2002 and customers are just becoming aware of the equipment. We are developing plans to educate clients and other referral agencies about our new services.

PeninsulaWorks is looking at the development of access solutions for our clients with disabilities as a long term process - one that involves both building internal staff awareness and communication skills to work with clients as well as providing access solutions (i.e. assistive technology). This approach allows us to start providing services now - and modify or enhance our services as our client needs change.

For more information on the PeninsulaWorks - Redwood City they can be reached at: 2500 Middlefield Road, Redwood City, CA 94063

Funding for Assistive Technology in California: What we know now
By Liz Arjun, M.P.H., M.S.W. and Tanis Doe Ph.D.

Introduction

As a result of our initial contacts, additional topics relevant to the use of Assistive Technology began to emerge. Difficulty in accessing the necessary funding seemed to be a common issue across all four research areas. Consumers with disabilities suggested that we disseminate what was already known about funding and work on changing existing barriers to obtaining funding. This paper is a response to that need. It will provide some clarity about the different funding streams within California and outline the difficulties that people with disabilities have when attempting to locate funding for assistive technology. We are seeking feedback on this paper and will integrate key questions about funding into the next stages of research including focus group and survey methods in the coming years.

Background

There is little data available regarding the use, need, and satisfaction of AT users. The scant information that does exist is generally derived using data from the National Health Interview Survey. One study conducted in 1992 (LaPlante, Hendershot, & Moss) found that 13.1 million persons used AT, an additional 2.5 million persons needed AT, and that of this 2.5 million, 60% could not pay for the needed AT.

Carlson, Ehrlich, Berland, & Bailey (2002) conducted a national survey regarding the use, need, and satisfaction of AT. This study was a joint effort by the NIDRR, the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA), and the University of Michigan. This study found that 64% of people with disabilities used some type of AT usage was 36% at school and or at work, 49% at home, and 50% in the community. Regarding the funding of AT, it was found that more than a third paid for AT themselves and another third received funds by public or private insurance. Finally, it was reported that only 20% of AT users received help in the selection and purchase of their AT and that of this number, 50% received the advice from their medical providers.

In 1993, The National Council on Disability (NCD) conducted a project entitled, "Study of the Financing of Assistive Technology Devices and Services to Individuals with Disabilities". This study was funded under the original 1988 Tech Act to provide recommendations to the President and to Congress on improving access to the financing of assistive technology. Many of the findings from this study in 1993 were echoed in the initial stages of the Community Research for Assistive Technology (CR4AT) project. "Current, reliable, and easy-to-understand information remains out of reach for many persons with disabilities and their family members" (National Council on Disabilities, 1993, p. 15). Significant recommendations emerged from the NCD research study in response to these findings and were made to the President and Congress.

A) "Establish the statutory authority for a federal Assistive Technology Interagency Coordination council to meet quarterly and be responsible for improved coordination of services and funding for assistive technology for Americans with disabilities" (National Council on Disability, 1993).

In many states, the government provides funding to various entities to address issues of system change to promote interagency coordination around assistive technology. The Assistive Technology Network at the California Foundation for Independent Living Centers (CFILC) has an ongoing change component built in for interagency coordination. We are providing a network that allows for more information to be disseminated regarding AT. However CFILC do not yet have collaboration with the funding agencies, including educational, vocational, and medical service providers.

B) "Amend the individual program planning requirements in multiple statutes to provide notice to individuals with disabilities and their families of the right to assistive technology devices and services in response to individualized needs in a timely manner" (National Council on Disability, 1993).

The Department of Rehabilitation and Special Education programs have addressed this recommendation by including phrasing that AT must be considered for Individual Education Programs in Special Education as well as in the Individual Plan for Employment (IPE) through the Department of Rehabilitation. The implication of this recommendation is that it promotes the use of AT in educational and vocational settings. It also promotes the consumer to be aware that such technologies are available to them in their goal setting.

C) "Reauthorize the Tech Act for an additional three years and strengthen opportunities for interagency coordination, systems change, and consumer choice and control" (National Council on Disability, 1993).

In 1998, the Assistive Technology Act was signed with the intention of increasing interagency coordination, systems change, and consumer choice and control. The passage of the Assistive Technology Act of 1998 P.L. 105-394 implemented a variety of programs and policies affecting the availability of assistive technology. Funding was made available for a variety of specific tasks at the state level to do the following: The purposes of this NCD recommendation and implementation were threefold: (a) to support states in their capacity to address the assistive technology needs of individuals with disabilities; (b) to support the investment in technology across federal agencies and departments that could benefit individuals with disabilities; (c) to sponsor micro-loan programs to individuals wishing to purchase assistive technology devices or services (RESNA, 2002). It is clear that the overall goals of this policy were to lessen barriers to obtaining assistive technology due to the lack of coordination between agencies as well as financial constraints posed to consumers by the high cost of many assistive technology devices. Unfortunately, at this time, barriers due to the lack of coordination among the different funding agencies still exist.

D) "Establish Assistive Technology Demonstration and Recycling Centers nationwide in an appropriate city of each state… to be operated by existing Centers for Independent Living or other community-based organizations that are consumer controlled and directed to enhance consumer choice and control of assistive technology services and funding (NCD, 1993).

Most users of assistive technology are unable to test the technology or device prior to its purchase. Unfortunately, this often results in the purchase of AT that is not appropriate, which leads to abandonment of the device. By providing demonstration and recycling centers, consumers have the opportunity to tryout or "test-drive" their future purchase to decide if it actually meets their individual needs and lessen retention issues (National Council on Disability, 1993).

Currently there are several Demonstration and Recycling centers in the state of California. However, these centers are located haphazardly and serve only the immediate areas in which they are located. Centers that are more geographically central and target more than one population may better serve a wider range of consumers throughout the state.

E) "Authorize by statute the establishment of a National Center on Assistive Technology Legal Advocacy to specialize in funding issues" (National Council on Disability, 1993).

The reauthorization of the Tech Act in 1998 authorized funding for state protection and advocacy systems to assist individuals with disabilities in acquiring assistive technology devices and services. This funding came jointly from the U.S. Department of Education and the National Institute on Disability and Rehabilitation Research (NIDRR) to the entity in each state to support protection and advocacy services through the Developmental Disabilities Assistance and Bill of Rights Act (RESNA, 2002) for a six-year period. In the state of California, this organization is Protection and Advocacy, Inc. (PAI). Up until March 2002 PAI had been receiving monies to provide training and a resource manual entitled, Accessing Assistive Technology, outlining the various funding streams in California. Currently, they receive a small amount of money each year to provide legal assistance regarding issues consumers may have in obtaining AT. The work of PAI has resulted in dissemination of information regarding funding decisions and the provision of technical assistance to groups and individuals regarding their right to assistive technology.

F) "Create a comprehensive set of fiscal incentives encouraging private industry to invest in the production, marketing, and distribution of assistive technology to benefit Americans with disabilities" (National Council on Disability, 1993).

One example of a fiscal incentive is Section 508 of the Rehabilitation Act which requires that when federal departments or agencies develop, procure, maintain, or use electronic and information technology, such as web sites, that individuals with disabilities have comparable access to it. Additionally, the Tech Act of 1998 requires that all states that receive federal funding be in compliance with Section 508 (National Council on Disability, 2000). The purpose of these policies is to increase the contribution of the federal government in promoting the development of assistive technology that is readily available and accessible to people with disabilities.

G) Amend Section 162 of the Internal Revenue Code to allow taxpayers with disabilities who do not itemize the option of claiming assistive technology expenses as above-the-line adjustments to income. Request that the Department of Treasury develop a cohesive set of tax policies on assistive technology for persons with disabilities that clarifies national values and goals as articulated in the ADA and the Tech Act.

There are a variety of tax incentives to assist persons with disabilities in the purchase of AT. For example, many AT items such as home and vehicle modifications are deductible on personal income taxes as medical expenses. However the option to claim assistive technology as a deduction to income that is taken before calculating the tax remains an option to leaving it as a regular medical expense.

H) "Authorize by statute universal product design guidelines for application in the manufacture of electronic equipment and other products to enhance accessibility by individuals with disabilities" (National Council on Disability, 1993).

The Television Decoder Circuitry Act of 1990 (Arizona Technology Access Program, 2002) that employed the use of universal design as a means by which to provide assistive technology has met part of this recommendation. This Act required that all televisions with a 13 inch or larger screen manufactured in the United States be built with close-captioning decoder chips (Mendelsohn, 1997). In addition, the passage of the 1996 Telecommunications Act (Arizona Technology Access Program, 2002) requires that telecommunications equipment and services are accessible where possible, or compatible when not. This is to ensure that manufacturers and service providers consider access to assistive technologies in the design of new products. However, to date, no legal guidelines have been established.

A few NCD recommendations have yet to be acted upon. These are burning issues that, a decade later, still pose barriers for consumers who need funding for AT:

A) "Mandate by statue the development of a national classification system for assistive technology devices and services and establish and collect uniform data sets across public programs" (National Council on Disability, 1993).

The implementation of this recommendation would allow for better tracking regarding the use and success of assistive technologies to better understand the needs of consumers. It would also allow more informed resource allocation. The implementation of this recommendation is dependent upon a national classification system of assistive technology across the potential funding programs (National Council on Disability, 1993). Currently, each agency has different definitions and classifications of AT.

B) Add the complete definition of assistive technology devices and services adopted in the Tech Act to the following programs of the Social Security Act: Title II, Social Security Disability Insurance; Title V, Maternal and Child Health Block Grant; Title XVI, Supplemental Security Income; Title XVIII, Medicare; and Title XIX, Medicaid.

While many of these agencies have definitions for assistive technology, there is still no uniformity as to what is considered AT and what is considered "medically necessary" or "durable medical equipment". This recommendation is similar in scope to the recommendation regarding a national classification system.

C) Develop statutory authority that requires private health insurance to apply medical necessity standards to durable medical equipment, prostheses, and orthotics that enhance function in activities related to health, safety, and activities of daily living (ADLs).

There has been no progress on this issue; in fact, private health plans operate largely under their own auspices and the provision of much assistive technology is dependent on the individual policy. Private insurance is an important source of funding for assistive technology, yet there are difficulties in accessing it as a source because of variability within plans, limitations of various services and devices, and the use of terms such as "medically necessary". The hope of this recommendation was to promote the use of private insurance as a more reliable and comprehensive funding source for assistive technology beyond the health care setting on a long-term basis. Currently the CFILC is working with representatives of various HMO's regarding comprehensive inclusion of AT coverage in their health plans.

The Current Funding Situation in California

There has been progress on many of these recommendations that were made by the NCD study. However, it is also clear that the progress is not comprehensive or well coordinated: issues of conflicts between federal and state statutes, interagency coordination, and private and public funding sources create a situation that still make locating the necessary funds for assistive technology difficult. "The two biggest barriers identified by consumers were lack of information and knowledge about appropriate AT and lack of funding to purchase AT" (National Council on Disability, 2000). In the first year of research conducted by CFILC we found similar priorities among consumers and experts. People with disabilities want more information and knowledge about AT and need access to funding to get it. The NCD 2000 information was taken from "Federal Policy Barriers to Assistive Technology," a federal report required as part of the 1998 Assistive Technology Act (National Council on Disability, 2000). This report found that many of the barriers identified in the 1993 study remain barriers today. An overview of the various funding resources in the state of California demonstrates the barriers and funding gaps that exist for consumers trying to obtain AT.

Three basic funding streams are available for assistive technology, medical, educational, and employment-based funding. Within these streams AT can be obtained through a variety of mechanisms. We have chosen to focus on the medical and employment based streams since these two areas are most applicable to the overall goal of the research project in addressing the role of AT in health, employability, function, and independent living.

Medically-Based Sources of Funding for AT

Private Health Plans
What they are and who is eligible:
Private health plans have no (legal) requirement to cover assistive technology; self-insured employers must follow the Employee's Retirement Income Security Act (ERISA), which covers employer-provided health plans, whether an HMO (Health Maintenance Organizations) or conventional insurance plan. Regarding assistive technology, most private health plans do not list specific devices or equipment as plan benefits. Health plans will only buy technology services that are deemed medically necessary, often implying that the requested service or equipment must cure or alleviate a medical condition, reduce pain, or help maintain or obtain more normal function.

The provision of assistive technology using private insurance plans is made available under the "durable medical equipment" category (Mendelsohn, 1997). Assistive technology is customarily considered durable medical equipment, prosthetic devices, or equipment associated with occupational or physical therapy. However, private insurance plans often impose modest dollar coverage on durable medical equipment (DME), rendering this source of funding often unavailable in supporting an individual's ability to function independently (National Council on Disability, 2000). This means that insurance companies may only be willing to fund the AT for DME for the duration of a hospital stay.

What they don't cover/Coordination with Other Agencies:
Many health plans do not cover benefits that are the responsibility of another organization such as Medi-Cal. However, if a person is eligible for Medi-cal, California Children's Services, Regional Centers, or another type of government program, the law requires that the person use the private health plan benefits first. This creates a paradox of who is responsible for payment of devices and services. The main exception to this is that the education system cannot require a person to use their medical plan first (Protection and Advocacy, 2000).

Medicaid (Medi-Cal)
Who they are and who is eligible:
Medi-Cal is the State of California's Medicaid program, a federally funded matching program that is administered at the state level. This means that the Medi-Cal program is funded by a combination of federal dollars that are matched to the amount of dollars California is willing to spend on it's state-sponsored health care program. Medi-Cal serves approximately 6 million people in California (Medi-Cal Policy Institute, 2002). Individuals who receive Supplemental Security Income (SSI) or In-Home Support Service (IHSS) are automatically eligible for Medi-Cal and account for approximately 1.5 million of those who receive Medi-Cal (Medi-Cal Policy Institute, 2002). After an individual pays a certain amount each month, Medi-Cal may provide services for a limited amount of time, or may pay part or all of the premiums for Medicare. For a more detailed description of these eligibility requirements, please refer to the Accessing Assistive Technology Handbook, (Protection and Advocacy, 2000).

What Medi-Cal funds:
Because Medi-Cal is a federally funded matching program, it is required by federal law to provide services including emergency room visits, treatment for most chronic illnesses, and home health services to persons aged 21 and over. California has chosen to provide other "medically necessary" services relevant to the provision of assistive technology. Assistive technology can fit under a variety of services including medical supplies, durable medical equipment, or prosthetic devices; however, there are often restrictions placed on services such as physical and occupational therapy.

Medi-Cal's definition of Medically Necessary:
The Medi-Cal definition of medically necessary includes those services, medicines, supplies, and devices necessary to protect life, to prevent a significant illness or disability, or to alleviate severe pain (CA Welf. & Inst. Codes §§ 14059.4, 14133.3, as cited in Protection and Advocacy, 2000, p/10-17). Medically necessary services include rehabilitation and other services needed to attain or retain the capability for normal activity, independence, or self care. Medi-Cal will not pay for services that it considers "experimental," which might include new therapies for treating autism, for example.

Medi-Cal's definition of Durable Medical Equipment:
It is defined under Medi-Cal as equipment prescribed by a licensed practitioner to meet the medical equipment needs of the patient and includes such equipment as: canes, crutches, walkers, oxygen therapy equipment, basic and custom wheelchairs, and other devices (Title 22 C.C.R. §§ 511601, 51521, as cited in Protection and Advocacy, 2000, p. 10-21). All items must be medically necessary and Medi-Cal states "Durable medical equipment items are covered only as medically necessary, and only to preserve bodily functions essential to activities of daily living or to prevent significant physical disability" (Medi-Cal Policy Institute, 1992, 82-21). Medi-Cal has argued that a device used for social or educational purposes is not medically necessary. However, this is not in agreement with the California Welf. & Inst. Code § 14059, which emphasizes that the purpose of Medi-Cal services are "for conditions that cause suffering, endanger life, result in illness or infirmity, interfere with capacity for normal activity, including employment, or for conditions which may develop into some significant handicap" (Protection and Advocacy, 2000, 10-22). Medi-Cal has provided funding for a wheelchair or scooter to be used in the home, but has refused to pay for a wheelchair or scooter to enable an individual to get out and participate fully in community life.

Medicare
Who they are and who is eligible:
Medicare is a federally administered health insurance plan for those over the age of 65 and for certain individuals with disabilities who receive Social Security Disability Benefits. Most people who are eligible for Medicare are also eligible for Medi-Cal. If a person receives both Medicare and Medi-Cal, Medi-Cal is responsible for those expenses that require payment (Protection and Advocacy, 2000).

What Medicare covers:
Medicare's Medical Insurance Part B covers most of what is considered assistive technology, including durable medical equipment, physical, occupational, and speech therapy, and prosthetics. Medicare only pays for services and equipment that are considered reasonable and necessary. The justification for any item to be paid for by Medicare is dependent on the individual service provider's report. Explanations for durable medical equipment are similar to those outlined by Medi-Cal in that they are to be primarily used for medical purposes, can withstand repeated use, and are necessary to treat an illness or injury, or improve function (Protection and Advocacy, 2000). , It is possible to get a power wheelchair Medicare approved for use outside of the home, but only with great medical justification.

A common occurrence when using funding streams such as Medi-Cal or Medicare is the gulf between need versus want. For example a consumer may have received an electric wheelchair purchased by Medicare. He also wanted a manual wheelchair to aid him in becoming more independent. However, Medicare will only assist in purchasing the electric wheelchair. If the consumer's wants are not compatible with the guidelines Medicare has established he must find other means of obtaining another wheelchair that fits his needs.

Regional Health Centers and AT
Who they are and who is eligible:
Regional centers are nonprofit corporations under contract with the State Department of Developmental Services (DDS) to provide assessment and case management services for people with developmental disabilities. Additionally, regional centers buy necessary equipment and services based on individual needs (Protection and Advocacy, 2000, p.4-1). The Lanterman Act established regional centers and the services they provide. Regional centers serve people who have developmental disabilities, women at high risk of giving birth to a child with a developmental disability, and infants at high risk of acquiring a developmental disability.

Regional centers define developmental disabilities as including mental retardation, autism, cerebral palsy, and "other disabling conditions" which are related to mental retardation or require similar treatment to that received by people with mental retardation. The condition must begin before the person is 18 years of age, most likely to continue indefinitely, and constitute a substantial disability. The Lanterman Act defines high-risk infants as a child less than 36 months of age whose genetic, medical or environmental history predicts a much greater risk for developmental disability than the general population (Protection and Advocacy, 2000, p.4-1).

What Regional Health Centers fund:
Assistive technology such as adaptive equipment and supplies and transportation services is part of the support offered by regional centers that can help in social, personal, physical, or economic habilitation or rehabilitation. The Lanterman Act specifies "wheelchairs, hospital beds, communication devices, and other necessary appliances or supplies" (Protection and Advocacy, 2000, p.4-2). Although there is no comprehensive list of assistive technology, the regional centers are required to provide the necessary assistive technology to help an individual meet the goals of the Lanterman Act. The Lanterman Act includes the equipment, supplies, and transportation services to:
This third goal of the Lanterman Act gives Californians offers hope the maintenance of independence is sufficient cause to fund assistive technology to developmentally disabled individuals. Since this goal is already established in legislation expansion in other programs to ensure other disabilities have access to assistive technology across lifespan.

California Children's Services and AT
Who they are and who is eligible:
California Children's Services (CCS) is a statewide program for children under the age of 21 who have a physical disability and meet specified financial requirements. Families who have a gross income of less than $40,000 per year are eligible for medical treatment services through CCS. The Director of the Department of Health Services may authorize treatment services and equipment for children in families with higher income if the cost of care is expected to exceed 20% of the family's adjusted gross income. Children do not have to be a citizen or permanent legal resident of the state of California to receive services; but your child must be a resident at the time. CCS receives its funding from the state and county level. This is common in other states too, but it puts an arbitrary age limit on eligibility. Disability does not end at 21 and many people with developmental disabilities spend a great deal of their adult life learning basic skills not mastered in childhood (Protection and Advocacy, 2000).

What CCS funds:
CCS provides medically necessary services and assistive technology related to a child's CCS eligible condition, including durable medical equipment, medical supplies medical appliances, electronic communication devices, and medications.

Medically necessary is defined as "those services, equipment, tests, and drugs which are required to meet the medical needs of the client's CCS-eligible medical condition as prescribed, ordered, or requested by a CCS physician"(22 C.C.R. § 41518, as cited in Protection and Advocacy, 2000, p.5-7). Services include evaluations and purchases of medically necessary assistive technology that includes medical supplies, durable medical equipment (such as wheelchairs), medical appliances (artificial limbs), and electronic or manual communication devices. CCS also provides the repairs, maintenance, and upkeep on appliances and equipment. Specific examples of the types of medical supplies, durable medical equipment, medical appliances, and electronic or manual communication devices that CCS will fund are given in the Accessing Assistive Technology handbook (Protection and Advocacy, 2000).

CCS and other sources of funding:
CCS only provides amenities that are not the responsibility of a private health plan or Medi-Cal. CCS eligible conditions are serious and severe physically handicapping conditions. Children with mental retardation are not eligible for services based on that diagnosis alone.

Medi-Cal and CCS can be coordinated; a child eligible for both CCS and Medi-Cal is considered "dual-eligible" and in this case should have more access to providers than a child eligible for Medi-Cal alone. However, this process is often haphazard and riddled with obstacles because of unresolved coordination issues between the agencies (Protection and Advocacy, 2000). For these children:

Veteran's Affairs (VA) and AT
Who they are and who is eligible:
VA services are for individuals who leave active military duty with an honorable or general discharge and are eligible for VA benefits. The Department of Veterans Affairs (VA) has responsibility for providing federal benefits to veterans and their dependents. The VA health care system consists of over 850 hospitals and outpatient clinics (Department of Veterans Affairs, 2002).

What VA funds:
There are four potential ways to obtain AT within the VA health care system including vocational rehabilitation and education programs, prosthetics and other medical supplies, grants for automobiles and automobile adaptation, and loans and grants for adapted homes or adaptations to existing homes (Protection and Advocacy, 2000).

Employment-Based Funding and AT

Vocational Rehabilitation and AT
Who they are and who is eligible:
The Department of Rehabilitation (DOR) in the state of California is the agency responsible for providing vocational and independent living rehabilitation services to people with disabilities. These services are available through the Federal Rehabilitation Act (Protection and Advocacy, 2000, p.7-1). and states that choose to participate in the program receive federal money to provide services and must operate under the federal mandate.

Assistive technology is a vocational rehabilitation service and eligible people can get the tools they need from DOR to achieve employment goals. Following 1998 congressional amendments to the Rehabilitation Act, rehabilitation technology includes telecommunications aids and devices, sensory aids and devices, and other technological aids and devices.

A person is eligible for rehabilitation services under the Act if: What DOR funds:
Just as Regional Centers determine what assistive technology is fundable by the Individual Program Plan (IPP), the Department of Rehabilitation will fund the assistive technology necessary to achieve employment goals outlined by the Individualized Plan for Employment (IPE). Assistive technology services and items are available when they are necessary to help one become employable.

Rehabilitation technology is defined by the Rehabilitation Act as "the use of technology, engineering, or scientific principles to meet the needs of and address the barriers faced by people with disabilities. This can include education, rehabilitation, employment, transportation, independent living, and recreation." Rehabilitation technology is divided into three categories: rehabilitation engineering, assistive technology devices, and assistive technology services" (Hager, 1999, p.9). Assistive technology devices are any "item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities" (Hager, 1999, p.8). Assistive technology services are any services that directly help a person to select, acquire, or use and assistive technology device such as an AT evaluation provided by an Occupational Therapist (Hager, 1999, p.8).

DOR and other Programs:
If a comparable service is available through another program, DOR is the payer of last resort for many services. The items must not be available through other free or less costly sources or through Medi-Cal, Medicare, or other funding sources including private health plans. It is also possible that someone who became disabled as an adult might see this program as a first resort- if they have no insurance. Because he or she was not a disabled child, does not have a developmental disability and might not be eligible for medical, DOR has a larger role to play. Non-disabled people are perhaps more likely to HAVE insurance but not a guarantee. This is easily seen when comparing the percentages of those who are non-disabled without insurance (57%) and individuals with disabilities without insurance (17%).

DOR as the funder of the loan guarantee program:
The California State Treasury has a permanent revolving fund called the Rehabilitation Revolving Loan Guarantee Fund. This program is available to eligible persons to buy vans, automobiles, and special equipment.

Loan Guarantee Eligibility:
Loans are available to those who are adults with a disability, the parent of a child with a disability, or the private employer of a person with a disability. The individual must also be ineligible for vocational rehabilitation services or independent living services. However, the items purchased must be necessary for employment or to enable an individual to live more independently and a physician must certify them or by DR. Additionally this is a loan of last resort. The applicant must have been turned down by all other available sources before they are eligible to apply for this loan. Currently this loan is underutilized in California due to a high interest rate (13%) and an unwillingness of banks to participate for fear that they will have to repossess someone's AT device if they default on the loan.

Social Security Work Incentives and AT

Who they are and who is eligible:
Social Security itself does not provide any assistive technology, but has many work incentive programs that allow an individual to shelter income to purchase employment-related assistive technology so that benefits are not affected. The two social security programs applicable to people with disabilities are the Supplemental Security Income (SSI) and Social Security Disability Income (SSDI). SSI provides a guaranteed grant to people who were disabled before they had a substantial work history, while SSDI is a federal pension for those who became disabled after working for some time and paying into the Social Security trust fund.

The three main work incentive programs that allow an individual receiving these benefits to access assistive technology are the Plan to Achieve Self Support (PASS), Impairment Related Work Expense (IRWE), and the Blind Work Expense (BWE) (Sheldon, 1999). The goal of Social Security's work incentive programs is to encourage people with disabilities to seek employment without the fear of losing their social security benefits.

What they fund:
While Social Security work incentive programs do not fund assistive technology, it is these programs that make it possible for a person with a disability to accrue money without being penalized in their income received by SSI/SSDI. Each of the work incentive programs has guidelines for the type of assistive technology available.



Barriers to funding AT through the various funding streams

The assortment of funding sources for assistive technology is uncoordinated, convoluted and incompatible often leaving the consumers of assistive technology to flounder in funding gaps and systemic barriers. Varying eligibility requirements due to age, type of disability, purpose, and need make obtaining the necessary technology to cover all the realms of an individual's life and life span difficult at best. For example, various California Children's Services only cover someone until the age of 21, or the Department of Rehabilitation is only a possibility if one is employed or seeking employment. The funding problem seems to be a reflection of three issues; the lack of coordination of the service systems involved, differences in the underlying assumptions about disability from within these various systems and, finally the unique connection between employment and access to health care in the United States. Mendelsohn (1997) stated:

"Vesting one agency or service system with the responsibility for meeting educational needs, another for vocational needs, and still a third for medical needs transcend the conceptual boundaries between system, or where they fall between the cracks. Perhaps nowhere are the inherent limitations proposed by current policy more dramatically illustrated than in the area of assistive technology. Devices provided by one system may need to be forfeited when someone comes under the jurisdiction of another, or the availability of needed technology from one may preclude the provisions of other needed devices by another" (p. 38).

Mendelsohn continues to state that there are three main reasons that assistive technology remains incomprehensive and inadequately funded including the following:



These three reasons refer to the absence of a common language between the various funding agencies for assistive technology. The lack of a shared language makes it incredibly difficult to keep track of data regarding the use, funding, and satisfaction of AT. Furthermore, it leads to insufficient communication and understanding of the relationship between mainstream and assistive technology.

Deficit Model

"So long as we utilize program models that predicate access to assistive technology on the deficits arising from disability rather than on the values of technological literacy and use, this disparity will not be altered" (Mendelsohn, 1997, pp. 36).

An example of this deficit model at work is the "medically necessary" language used by Medi-Cal and private health insurance, and the qualifiers in place to access assistive technology through Vocational Rehabilitation. Essentially the provision of assistive technology is based upon an individual deficit in the person that requires something more qualified by the term "medically necessary" or in the context of the individual's vocational goals in order to be considered healthy or employable.

"The old perception of people with disabilities in society, which derives from the medical sciences, is based upon the assumption that disability is a physical or mental deficiency that is not desirable. Under this individual deficit paradigm, people with disabilities are regarded as in need of special care or services that will cure them or else help them to adjust to their 'affliction'"(Doe & Noakes, 2002).

The use of this deficit model not only reinforces the concept that people with disabilities are in need of assistance, but also allows the patchwork of funding sources for assistive technology to continue. An example of this is that a doctor or health professional must agree the desired AT is needed for medical reasons, even if the device is a captioning decoder so a deaf person can watch a television! It is somewhat out of the realm of medicine that someone may need AT to perform a job duty or listen to the radio. When the funding comes through a medical source; either through a private health plan or one of the government funded health programs, it forces the AT to be considered "medically necessary." The difficulty in obtaining funding however, arises in that individuals need AT not simply because it is "medically necessary," but because it is "necessary for life." In a Connecticut court appeal regarding Medicaid's denial of AT for an individual, the court upheld that the individual seeking coverage for an unlisted item of AT would have to show that the failure to cover that item through Medicaid "would make DME coverage inadequate to the Medicaid population as a whole" (Allan, 1998). Essentially if it's not on the list, then one must prove that everyone on Medicaid needs that item.

"As a practical manner, streamlining of AT funding is a challenge because there are so many players, each of which has divergent statutorily-defined objectives" (California Foundation for Independent Living Centers, 2001). To gain an understanding of the patchwork of funding sources for assistive technology, it may be helpful to examine the roles and goals of the various players in the game of requesting and denying funding for AT. It is clear that most roles are adversarial. For example, a consumer's goal is to obtain the needed technology to work, play or live more independently, whereas an insurance company's goal is to spend as little as possible and still comply with the law. From the insurance company's point of view, the most restrictive definition of a disability best serves their purpose. Hence, the industry adopts a medical model of disabilities that relies on a definition based on "medical necessity." "We regard technology in society as a tool of great usefulness, but treat AT as a form of therapy or discretionary benefit that has to be justified" (Mendelsohn, 1996, p.36).

This is not a new issue in the funding of assistive technology. The different use of language in different programs was the main target of many of the recommendations from the 1993 National Council on Disability study. The call for a universal classification system and common data sets were recommendations based on the needs for common language regarding assistive technology and disabilities. It is only after this type of dialogue happens will there be the potential for a system of seamless comprehensive assistive technology that encompasses the health, educational, vocational, and functional needs of people with disabilities. The development of such data sets and a universal classification system will allow policymakers to better understand consumer needs regarding AT as well as to understand issues of cost/benefits that AT provides and promote a more seamless system of AT provision.

On the other hand, a funder may find itself in an adversarial position as to other funders (Mendelsohn, 1996, p.37). Medi-Cal, for example, may adopt qualification rules as to its payer position with regard to Medicare. The people with disabilities who are the lowest income earners are eligible for Medicare but often not eligible for continuing coverage with Medi-Cal due to income restrictions. There exists an economic difference between medical coverage for those who work and those who do not. For those who are unable to work, much of their medical care is covered by Medi-Cal, such as prescription coverage. However, for those who are employed, or the working poor, they earn too much money to qualify for coverage through Medi-Cal, but do not earn enough money to cover all their AT needs. These adversarial relationships do not bode well for the development of cooperation and coordination of agencies and may perpetuate persons with disabilities "falling through the cracks."

Health Insurance and Employment

Another issue relevant to addressing the gaps in funding for AT is the relationship between employment and access to healthcare. Approximately 72% of people who had insurance in the United States in 1999 were covered by a private insurance plan, 64% of which were plans (U.S. Census Bureau, 2002). However, specifically related to people with disabilities, it is important to note that approximately 22% of people with disabilities are unemployed (U.S. Census Bureau, 2002). This is a significantly lower number than was found in a survey regarding the use and need of assistive technology conducted by NIDDR, RESNA and the University of Michigan in 2001, (Carlson, et al, 2002) which found that 52% of people with disabilities were unemployed because of their disability. In addition, a 2000 National Organization on Disability/ Harris Survey (Rossheim) found that only 32% of people with disabilities worked full or part-time compared with 81% of people without disabilities. Specifically, in the state of California, Census data show that 54.9% of individuals with a disability between the ages of 25 and 64 are employed compared with 80.0% of individuals without a disability who are employed (U.S. Census, 2002). An even more alarming statistic related to workplace benefits, was that in 1997, it was found that 2.3 million people with disabilities who were actually employed, were without health insurance (Rossheim) meaning that they were working too much to qualify for state sponsored health care, but not enough to qualify for employer-based health plans. It is this kind of statistic that explains why so many people with disabilities are forced to make the choice between not working and keeping health care coverage.

One answer to this crisis is the passage of the Work Incentives Act, which allows people with disabilities the opportunity to earn more without fearing the loss of their government-sponsored health care as well as the option to buy-into Medicaid while earning up to 250% of the federal poverty line. This has yet to be phased into practice in the state of California. It is hoped that through passage of this act, more people needing assistive technology will be able to get it through employer-based health plans.

The Americans with Disabilities Act (ADA), which was passed in 1990 was another piece of federal legislation that sought to remove barriers to people with disabilities participating in the life of their community and in seeking employment. However, a major issue concerning this legislation as well as the Tech Act, is the lack of education and information regarding the benefits of AT and ways to purchase it that are not prohibitive for consumers. The findings of Carlson, et al (2002) regarding usage of AT and funding demonstrate two important points. First, the two main sources of funding, medically- based and vocationally- based, do not meet the need of consumers using assistive technology in the larger community. Second, the majority of information provided about AT is based on health care providers' own experience; not only is their knowledge regarding the use and need of AT limited, but it is reasonable to assume that their knowledge about potential sources of funding for assistive technology may be solely medically-based.

Conclusion

Without an integrated systemic funding process that includes a universal definition of assistive technology, spans the lifecycle, and covers more than basic medical needs, consumers will be continue to struggle to obtain all but the most basic devices that allow them to live independently. Funding agencies need to expand the provision of AT from equipment and services that are "medically necessary" to that technology which will help individuals lead productive and independent lives.

References

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