U.S. Department of Health and Human Services

Compendium of Home Modification and Assistive Technology Policy and Practice Across the States

Volume I: Final Report

Executive Summary

Terry Moore, BSN, MPH and Beth O'Connell, MS

Abt Associates, Inc.

October 27, 2006

This report was prepared under contract #HHS-100-03-0008 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and Abt Associates, Inc. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officers, Gavin Kennedy and Hakan Aykan, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Their e-mail addresses are: Gavin.Kennedy@hhs.gov and Hakan.Aykan@hhs.gov.

The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.

Various studies have examined the positive benefits of assistive technology (AT; e.g., adapted computers, powered mobility devices, augmentative communication devices (ACDs)), and home modifications (HM; e.g., structural changes such as widening doorways or building an access ramp) in enhancing the abilities of persons with disabilities and the elderly to function independently, safely, and successfully in their home environments (Mann, et al., 1999; Verbrugge and Sevak, 2002; Calkins and Namazi, 1991). Much has also been written about the large baby boom population, the associated rise in sheer numbers of individuals with disabilities and the resulting need for growth in the availability and financing of long-term care services (Merlis, 2004; National Academy of Social Insurance, 2005; O’Brien, 2005).

However, few studies have examined or described the financing, coverage, and general availability of HM and AT in states, particularly through Medicaid. Little is currently known about Medicaid state policy and practice with regard to AT and HM, and the consequential impact on public spending and planning for long-term care. Many state home and community-based service (HCBS) waiver programs list AT and/or HM as covered Medicaid services. However, existing administrative datasets cannot easily convey the degree to which consumers access AT and HM services or the extent to which Medicaid, state-specific, or other programs pay for these services. The absence of basic information led the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Planning and Evaluation (ASPE) to commission this compilation of Medicaid coverage policies and practices for AT and HM services across the 50 states and the District of Columbia. ASPE seeks to understand Medicaid’s role, specifically, in paying for AT and HM, as Medicaid is a major source of payment for long-term care, accounting for 47 percent of spending for nursing home and home care services in 2002 (O’Brien, 2005). About half of Medicaid long-term care spending is for services to the elderly; the rest is for services to non-elderly disabled people, especially people with developmental disabilities (O’Brien, 2005) -- two populations heavily reliant on AT and HM services.

The purpose of this Compendium of Home Modification and Assistive Technology Policy and Practice Across the States is to establish a baseline knowledge of the scope of AT and HM services that states make available to Medicaid-eligible adults. This study provides federal and state policymakers with basic information to inform planning and policy development. It also provides other stakeholders, including consumers, with valuable information about Medicaid State Plan and HCBS waiver coverage of AT and HM.

The report addresses three main questions:

• To what extent do Medicaid State Plans and HCBS waivers cover AT and HM services?
• What are the processes available to Medicaid recipients to obtain AT and HM services?
• What mechanisms -- if any -- do states use to control use and costs of AT and HM services?

Data that inform this volume were from reviews of relevant web sites, from reviews of Medicaid provider manuals, from limited discussions with state representatives (Medicaid State Plan Home Health/Durable Medical Equipment (DME) and HCBS waiver personnel). In all, this report covers 51 Medicaid State Plans and 202 HCBS waivers. Volume II of this report includes a profile of each state’s coverage of HM and AT services through Medicaid. By and large, relevant state personnel verified information contained therein.

KEY DEFINITIONS

There are important distinctions between equipment and services collectively referred to as AT and those equipment and services encompassed under the rubric of HM; thus, throughout this report, the two types of services are categorized and discussed separately. AT is a broad term that encompasses any technology to increase, maintain, or improve functional capabilities of individuals with disabilities (Assistive Technology Act of 1998). As such, the use of AT fosters a person’s independence, safety, and quality of life. HM include any change to a particular location that fosters the independence and safety of individuals with disabilities or that allows people to carry out their daily tasks more easily (Pynoos, et al., 1998). HM can range from installation of inexpensive items (e.g., grab-bars) to more costly structural changes such as widening of doorways, renovation of bathrooms and kitchens, and installation of ramps.

KEY FINDINGS

The key findings stem from the three main areas of inquiry: (1) the extent and types of AT and HM services offered by State Plans and HCBS waivers; (2) the processes available to Medicaid-eligible recipients to facilitate access to AT and HM; and (3) the policies and practices employed by states to limit or restrict access to AT and HM services.

The extent to which AT and HM services are offered by Medicaid State Plans and HCBS waivers.

Almost every HCBS waiver includes AT and HM as listed services, while Medicaid State Plans more greatly limit what they include as AT and HM. Even though most states report including AT and/or HM, considerable variation exists in how states define and refer to AT and HM.

• AT services covered most frequently by Medicaid State Plans include ACDs and power or custom wheelchairs or wheelchair adaptations.
• The majority of Medicaid State Plans do not cover HM, personal emergency response systems (PERS), or vehicle modifications (VM).
• 173 of the 202 waivers reviewed include HM, 159 include AT, 124 include PERS, and 64 of the waivers reportedly include VM, mostly through the mental retardation/developmental disabilities (MR/DD) waivers.
• Both Medicaid State Plans and HCBS waivers describe coverage of AT services in their provider manuals. However, states almost never refer to these services as “assistive technology”; rather, the services are listed in the Medicaid coverage manuals under DME or prosthetics services.

The processes available to Medicaid recipients to obtain AT and HM services.

Most HCBS waivers -- and some state plans (11) -- offer service coordination or case management to recipients in order to facilitate access to AT and HM services, and both types of Medicaid programs use health professionals such as physical and occupational therapists and speech-language pathologists or therapists to assess recipient need for AT or HM services. The majority of state plans require physician orders for AT and HM services, while only half of the waiver programs list that as a requirement.

The mechanisms used by states to control use and costs associated with AT and HM services.

Most state HCBS waivers list many AT and HM services as available to multiple target populations in need of these services (e.g., aged and disabled, MR/DD, traumatic brain injury). However, the scope of this study did not permit investigation of how and to what degree access to services might be limited through prior authorization procedures and medical necessity or other criteria.

Almost all Medicaid State Plans use “medical necessity” criteria when determining coverage for AT and HM services, and half of the HCBS waivers studied use these criteria. For those waiver programs that do not use “medical necessity” criteria (n=28), some use “functional” language to determine if AT or HM services should be covered, rather than “medical” language or “medical necessity” criteria. This functional approach to coverage determination may be more aligned with the intent of the 1915(c) waivers to maintain the independence of the elderly and persons with disabilities in the community.

Almost all Medicaid State Plans and HCBS waivers studied require prior authorization of some sort for AT and HM services.

State HCBS waiver programs use multiple mechanisms to limit or restrict waiver expenditures, whereas Medicaid State Plans have few limits (but less extensive AT/HM coverage).

IMPLICATIONS FOR FURTHER RESEARCH

The findings suggest that additional research would need to examine scope of coverage and use of services. As described earlier, the scope of this project does not include the extent to which Medicaid-eligible persons actually receive the AT and/or HM service they might require. Such a study might require in-depth interviews of state agency officials (e.g., utilization review representatives, waiver case managers, coverage policy experts) and examination of claims data to determine actual use and cost. Further research might examine what impact the provision of AT and HM through Medicaid has on other health and long-term care use and spending.