OAC is an independent nonprofit organization that provides legal advocacy services for people with disabilities anywhere in Oregon. OAC is designated under federal law as the protection and advocacy system for Oregon, but it is not a government agency. OAC has attorneys and advocates who assist people with disabilities.
Assistive Technology (AT) is equipment or devices that make it easier for someone who has a disability to maintain or increase functioning in a major life activity (such as seeing, learning, walking, speaking, etc.). It includes services that help someone choose and learn to use the devices best for them.
Some examples of AT covered under the Oregon Health Plan (OHP) are:
Under the Oregon Health Plan, AT I usually referred to as Durable Medical Equipment (DME). DME is an item that you can use for a long time which meets your medical needs.
The Oregon Health Plan is Oregon's publicly-funded health insurance program. It provides health insurance coverage for individuals who are eligible for Medicaid because they are poor or disabled and other individuals with limited financial resources.
This pamphlet contains general information about legal issues and legal rights and is not a substitute for legal advice. For specific information about how these laws affect you, contact OAC or your attorney. Sources of legal assistance are suggested in this pamphlet.
This pamphlet is for individuals with disabilities who already have OHP coverage either through a managed care plan like ODS or HMO Oregon or through fee-for-service ("an open card"). If you want to learn more about the OHP and apply for it, you should contact one of the resources listed in this pamphlet.
If you think you have been denied OHP eligibility unfairly, you can contact one of the advocacy organizations mentioned in this pamphlet.
This pamphlet includes references to Oregon Health Plan criteria and procedures which are described in Oregon Administrative Rules (OARs) and managed care plan policies. If you get OHP coverage through a managed care plan, you should be able to get copies of OARs and policies from your plan's administrator. If you have fee-for-service coverage, you can get copies of the OARs from your local Senior and Disabled Services Division (SDSD) or Adult and Family Services (AFS) office. You also can get copies of OARs by calling the Office of Medical Assistance Programs (OMAP) Provider Relations office at (503) 945-6505.
If you want to get a certain piece of AT, you and your health care providers
should:
1. Identify the specific AT which will help you maintain or improve your functioning and is medically appropriate for you.
The first step to getting AT coverage is to identify the type of AT you think is medically appropriate for you. (See below for a discussion about the term "medically appropriate.") One way to identify AT that is right for you is to meet with your local Technology Access for Life Needs (TALN) specialist to get more information about the types of AT available. Although TALN specialists cannot recommend a particular piece of AT, they can provide you and your health care providers with information and referrals about categories of AT, such as wheelchairs and voice output computers. TALN centers in Oregon are listed in this pamphlet.
2. Make sure that the AT you identify is medically appropriate.
The OHP only covers AT which is medically appropriate. If you want to get a certain piece of AT covered by OHP, you must show that the AT meets your medical needs. For example, if you are visually impaired you should identify whether AT exists that will allow you to see better. Your doctor or other health professional should help you do this.
The OHP does not cover AT that is only for your convenience or that does not
serve a medical purpose. Before you try to get OHP coverage for AT, you should
make sure that you and your health care provider can demonstrate that the AT
is medically appropriate. The OHP defines "medically appropriate"
as medical services and supplies that are:
For clarification see OAR 410-141-000.
If you are on a managed care plan and have health care needs requiring several different doctors or coordination of health care services, you probably are eligible for the services of an Exceptional Needs Care Coordinator (ENCC). You can ask your plan to provide you with an ENCC. An ENCC should help you get AT. "To Your Health: Choosing the Health Care that is Right for You" (see below) describes in more detail how to get an ENCC and the various ways an ENCC can help you manage your health care needs.
3. Make sure that you can meet the applicable OHP managed care plan or fee-for-service criteria for the AT you want to request.
In addition to the "medically appropriate" criteria, OHP managed care and fee-for-service coverage have other specific requirements you must meet to get a specific type of AT. Be sure to ask about the additional criteria when talking to your managed care plan or to an OHP administrator. You also should find out whether the OHP covers the type of AT you want to request. Sometimes, even if you and your health care providers think that a certain type of AT is medically appropriate for you, the OHP will not cover it. However, an alternative type of AT might exist that OHP does cover.
To avoid a denial because you do not have proper information, get a copy of the requirements you must meet for the type of AT you and your health care providers want to request. Once you have the criteria, work with your health care providers to show that you meet the criteria. As part of your request for AT, you will need to present detailed written information to demonstrate you meet these criteria.
Example: If your physical therapist and doctor want to recommend a certain type of motorized wheelchair, you should find out whether criteria exist for the specific type of motorized wheelchair you want and whether you meet the criteria. If you meet the criteria, ask your health care provider for written documentation of your need.
4. Make your request to your managed care plan or, if you have fee-for-service coverage, to your SDSD case manager or OMAP.
After you and your health care providers collect the information that demonstrates the AT is medically appropriate for you and meets the relevant criteria, you should present the request with accompanying documentation to your managed care plan, your SDSD case manager or OMAP. After you make the request, the plan, SDSD or OMAP may ask for additional information about the AT and why you need it.
You or your health provider should receive written notice explaining whether your request for AT was granted or denied, and if it was denied, the reasons for the denial. Managed care plans are required to give written denial notices. If you have fee-for-service coverage, OMAP is required to give written notice to you and your provider.
If your managed care plan, SDSD or OMAP denies your request for AT you have the right to appeal and have an administrative hearing office decide whether the denial was correct. You must file an administrative hearing request within 45 days of the date of your denial notice. At the hearing you can explain to an independent hearing officer why you think you need the AT. In response, the plan, OMAP and/or SDSD will explain why it denied the AT. The hearing officer will make a decision about whether the denial of coverage was correct. The hearings officer will make the decision based on all information presented at the hearing. You can represent yourself at the hearing or ask someone else to represent you. The representative can be a lawyer, advocate, friend, family member, or anyone else who you want to represent you.
As soon as you ask for a hearing, you should contact one of the advocacy organizations listed in this pamphlet to help you decide whether you should have the hearing. If, after you review your situation with an advocate, you find out that it is not worth your time to have a hearing, you can withdraw the request. If you decide to proceed with a hearing, the advocate can help you prepare for your hearing even if the advocate cannot represent you.
If you are covered by a managed care plan you can make a complaint to the managed care plan and should receive a response in writing about reasons for the denial. You do not have to make a complaint to the plan before you request an administrative hearing.
You can also contact the OHP Ombudsperson (1-800-365-8135, TTY 503-945-5895) for help. The Ombudsperson can help people who have managed care or fee-for-service coverage. The Ombudsperson tries to resolve OHP members' problems without a hearing. Even if you already have requested a hearing or made a complaint through the plan, the Ombudsperson can try to help you.
If the hearing officer decides that you do not meet the necessary criteria to get the type of AT you requested, you have the right to appeal the hearing officer's decision. You can appeal by asking the hearing officer in writing to "reconsider" the decision or you can file an appeal in the state court of appeals. If you want to appeal a hearing decision, you should contact a lawyer immediately.