In blog one and two of this series reviewing the process to obtain complex rehab technology (CRT) we reviewed the importance of preparing for your evaluation, as well as knowing the team members and their roles. You may now be wondering how to get the recommended equipment funded by your insurance. In this blog post, we will answer some common questions about the funding process and the challenges you may face along the way.
What is the funding process for CRT in the U.S.?
Based on your evaluation findings, the prescribing OT or PT will provide clinical justification for all the mobility and seating/positioning equipment necessary to meet your medical and functional needs. The CRT equipment provider will submit all clinical notes, equipment specification details, and signed paperwork from your physician to your insurance to obtain prior authorization.
Unfortunately, getting CRT funded is not always easy or straightforward. You may encounter some obstacles or barriers that delay or deny your access to the equipment you need. A few common challenges include:
- "Least costly alternative": This is a term used by insurance companies to ensure they meet your medical needs for the least possible cost. In theory this seems reasonable; however, people who require complex rehab equipment often have advanced needs that cannot be adequately accommodated with less expensive products. This is important to know because whatever equipment you receive will have to last a minimum of five years, and less expensive does not always equate to the most appropriate outcomes for you.
- Capped rental items: Products such as SmartDrive (a power assist device that attaches to the rear of a manual wheelchair) and manual tilt in space wheelchairs are billed to insurance as capped rental items. These devices are reimbursed differently than other complex rehab equipment because they are generally paid as a capped rental versus a lump sum purchase. The capped rental period is 13 months. During this period, your provider still owns the device and is responsible for any repairs and/or maintenance. Your provider will bill your insurance each month and you will be billed for your monthly coinsurance. Once the capped rental period is complete, ownership of the device is transferred to you from the provider and your insurance will begin covering repairs on your behalf.
- Denials and appeals: A denial does not necessarily mean you will not get your equipment, but it does add time to the process. There are several levels of appeal available that allow for further information to be provided to the insurance company for reconsideration. Your provider and clinical team can assist with this process. If you have questions regarding the appeal process for equipment that has been denied, please feel free to email Permobil.
What are examples of alternative funding resources?
In cases where your insurance does not cover the prescribed equipment, or you have a high deductible or coinsurance, you may want to explore other funding options. There are many organizations and programs that offer grants, loans, or donations for people who need CRT. Some of these are:
- State vocational rehabilitation agencies: These are state-funded programs that help people with disabilities find and maintain employment. They may provide funding for CRT if it is necessary for your work or education goals. You can find your state agency here.
- Medicaid waiver programs: These are state-specific programs that provide additional services and support for people who are eligible for Medicaid. They may cover some CRT items that are not covered by regular Medicaid. Click here to find out more about these programs.
- Veterans Affairs: If you are a veteran or a service member, you may be eligible for CRT benefits through the VA. The VA has a comprehensive program that provides evaluation, prescription, delivery, and maintenance of CRT equipment. You can find out more about the VA program.
- Non-profit organizations: There are many non-profit organizations that offer financial assistance or equipment donations for people who need CRT. Some examples are United Spinal Association, Muscular Dystrophy Association, ALS Association, National MS Society, and Christopher and Dana Reeve Foundation.
What is the funding process in Canada?
In Canada, government funding for mobility equipment is organized on a provincial level. That means that every province has different rules and criteria for eligibility and coverage. Some provinces have generous funding programs that cover various products, while others have limited or no funding opportunities. In some areas, funding assistance is based on your income, while in others, it is not. Your best bet is to talk to your clinician, equipment provider, and any other professional that is assisting you with rehab and mobility equipment. They can help you navigate the funding process and direct you to the available agencies and sources.
Aside from government assistance, there are other options to help you finance your equipment. You might be able to access funds through private insurance, Workplace Safety and Insurance Board, or other worker compensation organizations. If you are a veteran or a service member you may be eligible to benefits through Veterans Affairs Canada. You might also be eligible for alternative funding sources, such as charities and service groups. These organizations might have different requirements and application processes, so make sure you do your research and contact them for more information.
Getting CRT funded can be a complex and challenging process, but it is by no means impossible. With the right information, support, and advocacy, you can get the equipment you need to live your life to the fullest. If you have any questions or concerns about the funding process, please do not hesitate to contact us at US_Funding@permobil.com. We are here to help you navigate the system and get the best possible outcomes. Thank you for reading and stay tuned for our next blog post on the fitting, training, and maintenance of your new equipment.
Catherine Sweeney, PT, ATP/SMS
Regional Clinical Education Manager
Catherine Sweeney, PT, ATP/SMS joined Permobil as Regional Clinical Education Manager in 2019. Prior to this, she spent the bulk of her career at Providence Portland Medical Center, where she co-founded the outpatient seating clinic program in 2004. As lead seating specialist, Catherine worked to expand access to wheeled mobility services through staff education in OP satellite clinics, home health, and outlying Providence hospitals.
Catherine served as the RESNA PT SIG co-chair, and is co-founder of the Northwest Assistive Technology Access Coalition with a passion for improving Oregon Medicaid recipients access to assistive technology. She has presented at both the RESNA and International Seating Symposium conferences 2021.
Stefan Morin, OT
Regional Clinical Education Manager
Stefan Morin, OT, is a registered occupational therapist who graduated from the University of Toronto in 2008 with a master’s degree in Occupational therapy. Stefan joined Permobil in July 2021 as a Regional Clinical Education Manager for the Atlantic Provinces and Quebec. From 2008 – 2012 Stefan practiced at the Lyndhurst Centre Brain and Spinal Cord Rehabilitation Program, located in Toronto, Canada working both as an inpatient OT as well as in the outpatient Seating Clinic providing complex seating and mobility solutions for a variety of clientele. In 2013 Stefan moved to Moncton, New Brunswick Canada and worked in the community, providing complex seating and mobility solutions, home modification solutions, as well as working with veterans with mental health and addictions issues.