From: gtrapp@abq.com
Subject: Medical Insurance
NOTE: The following is informational only, and does not constitute
legal advice.  Only an attorney licensed in your state will be able
to give you legal advice.  Your state's Protection & Advocacy
System may be able to help you, or give you the names of lawyers in
your state who are familiar with disability law.
Dear Peter, Rene, and NFB-Talk Listers,
Peter Donahue commented on an article I wrote which appears in the
November Braille Monitor.  The article deals with acquiring medical
insurance funding for a CCTV.  Peter asks if the reasoning allowing
for medical insurance funding of a CCTV could also apply to other
types of adaptive technology, such as speech synthesizers or
braille display devices.  Unfortunately, since insurance companies
generally consider such items to be "convenience" items, they are
normally not within the scope of medical insurance coverage. 
I first want to preface my remarks by saying that I have been the
Protection & Advocacy for Assistive Technology Attorney in New
Mexico for the last 3 years.  I would like to think that I am on
the cutting edge of the law as it relates to the funding and
acquisition of assistive technology.  Also, since I have only light
perception and cannot use a CCTV myself, I have no personal bias in
favor of a CCTV.
I would like to applaud Peter for his creative suggestion in
wanting to have a wider range of adaptive technology covered by
medical insurance.  Unfortunately, it would presently be very
difficult, if not  virtually impossible, to accomplish such a goal. 
Indeed, at present, even persons seeking medical insurance funding
of a CCTV can usually expect to have to appeal through numerous
levels of appeal stages, even though a CCTV should  clearly be a
covered item.
It is my belief that medical insurance funding of most items of
adaptive technology  should usually be a payer of last resort,
especially if there is a lifetime cap on the amount of insurance
coverage.  For most persons, it will be much easier to obtain
funding from a vocational rehabilitation agency, from an employer
as a reasonable accommodation, or from a school district as a part
of an IEP.  Others may decide to pursue private funding from civic
groups or pay from their own personal resources, especially if the
adaptive technology is less expensive, such as the CCTV's that hook
up to an existing television.  Yet, for some persons, such as an
elderly person who does not have an employment goal, the only
practical funding source may be medical insurance. 
Under Medicare, for a device to be covered as durable medical
equipment (DME), it must be able to withstand repeated use, be
primarily and customarily used to serve a medical purpose, be
generally not useful to an individual in the absence of an illness
or injury, be appropriate for use in the home, and be necessary and
reasonable for the treatment of an illness or injury or to improve
the functioning of a malformed body member.  The Medicare
requirements are typical of most insurance carriers.
However, most items of adaptive technology cannot be an item of DME
because they do not meet all of the required criteria.  For
instance, a reading machine, an item of adaptive technology which
is similar to a CCTV in purpose, is not primarily and customarily
used to serve a medical purpose.  The primary use of a reading
machine is not medical.  Doctors do not prescribe reading machines,
doctors do not supervise their use, and reading machines are not
sold by drug stores or medical supply companies.  If a reading
machine serves a medical purpose, than so could light probes, money
identifiers, tape recorders, speech synthesizers, braille watches,
braille printers, and a host of other adaptive aids and appliances. 
By contrast, a CCTV is similar to cataract lenses in that it
enhances available vision, giving it a more obvious medical
purpose.
  The question really gets tricky when it comes to looking at the
criteria that it be "necessary and reasonable for the treatment of
an illness or injury or to improve the functioning of a malformed
body member."  Setting aside the requirement that it serve a
medical purpose, the best argument is that a reading machine is a
"prosthetic device" which "substitutes for the functioning of a
malformed body member."  It may be useful at this point to consider
how augmentative communication devices are often funded.  What
typically happens is that the issue turns on the requirement of the
person to communicate their medical needs.  Thus, an augmentative
communication device substitutes for the functioning of the voice
box, and is "medically necessary" for the treatment of the
individual.  Without an augmentative communications device, a
person who cannot otherwise communicate could try in vain for hours
to communicate an urgent  medical need.  By contrast, while a
reading machine might be used to read a drug information sheet,
that same information could be communicated in a few seconds by the
doctor, pharmacist, reader, or relative.  For these reasons, most
items of adaptive technology are considered to be "convenience"
items, and not covered by medical insurance.  However, to confuse
matters more, the argument that a particular device is medically
necessary because it allows communication of medical needs should
not be determinative, as the real issue is the function that is
served, not the material that is read or communicated.
My purpose in writing the CCTV article was to expand the types of
CCTV funding options that are available to blind persons.  It is my
ultimate hope to expand the range of assistive technology that can
be funded through medical insurance.  As funding of CCTV's becomes
more accepted, perhaps other types of adaptive technology can also
be funded by medical insurance.  In the meantime, some persons may
by chance be able to obtain medical insurance funding of an item of
adaptive equipment such as a reading machine.  However, my
preference would be to first lay a solid foundation.  Establishing
routine medical insurance funding of CCTV's would help lay such a
foundation.
Greg Trapp
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